News Brief 5/07/2021

Safety Investigations news brief for 5/07/2021


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21-05-07 News

This is your safety investigations news brief for May 7th, 2021. I’m your host Charles Current. And here are the week’s headlines. National discount. Retailer faces 265,000 in penalties for repeat violations. Federal judge finds Florida behavioral health care center exposed workers to more than 50 attacks by residents and allowed destruction of video evidence, Mexico city, subway overpass collapses, killing at least 24 and injuring dozens.

[00:00:29] CSB holds public board meeting to adopt final report into 2019 hydrogen sulfide release in Odessa, Texas, a Piper 600 Aerostar crashed near LaBelle, Florida with one fatality. The NTSB is investigating the crash of a Robinson  helicopter near Monroe, North Carolina, also the crash of a Cessna T two 10 M airplane near Oxford, Iowa.

[00:00:53] And the crash of a Mitsubishi U  60 airplane in Hattiesburg, Mississippi NTSB issues, a preliminary report for the accident that killed a BNSF conductor near Louisiana, Missouri, and the NTSB reports that lack of continuous monitoring is at issue in a shipyard fire. And the UK is AIB B reports. Biocide fuel contamination was the cause of an a three 21 emergency at London Gatwick airport.

[00:01:21] And Canada’s TSB says unstable approach led to a dash eight, 300 hard landing and tail strike

[00:01:36] Oh, HSA sites, Beverly Hills dollar tree for exposing workers to safety hazards. They say dollar tree workers across the country continue to face the same hazardous working conditions at the national discount chain as they have for many years, since 2016, the occupational safety and health administration has inspected company locations more than 300 times.

[00:01:57] Following an October, 2020 inspection at dollar tree store in Beverly Hills, Florida. OSHA determined the company exposed workers to fire and traveling and struck by hazards blocked exit routes and improperly strapped boxes and other materials that might fall or injure workers. OSHA proposed $265,265 in penalties.

[00:02:17] They say since 2018 inspections at dollar tree stores in Alabama, Florida, Georgia, and Tennessee have resulted in proposed penalties of more than 1.3 million nationwide dollar tree inspections in the past five years have resulted in proposed penalties of more than $9.3 million tree stores have a history of not taking the safety of its workers and customer seriously said OSHA area director, Danielle Jindra in Tampa, Florida.

[00:02:44] Until appropriate precautions are taken to protect their employees from these well-known and frequent hazards. OSHA will continue to hold them accountable. The company has 15 business days from the receipt of citations and penalties to comply request informal conference with OSHA’s area, director, or contest the findings before an independent occupational safety and health review commission.

[00:03:08] Headquartered in Chesapeake, Virginia dollar tree, Inc is the leading operator of discount variety stores serving North America. For more than 30 years, the company employs about 193,000 associates and operate stores under the dollar tree, family dollar and dollar tree, Canada brands. In Bradenton, Florida, a federal administrative law judge has determined that Brandon 10 behavioral healthcare center and its management company exposed workers to more than 50 attacks in two and a half year period, when residents kicked pinched bit scratched polled and use desk scissors as a weapon.

[00:03:44] And that both entities deserve to be sanctioned for destroying surveillance videos, showing this workplace violence. In a 170 page decision U S department of labor administrative law. Judge Dennis Phillips found UHS of Delaware, Inc. A hospital management company and premier behavioral health solutions of Florida, Inc exposed workers to workplace violence and showed bad faith and allowing the destruction of videos that showed instances of workplace violence at the facility.

[00:04:13] Premier operates as Suncoast behavioral health center in Bradenton UHS. One of the nation’s largest healthcare service providers manages Suncoast behavioral and more than 300 other behavioral health facilities nationwide. The judge’s decision follows an occupational safety and health administration investigation at Suncoast in 2017.

[00:04:36] After a patient jumped over a nurses station and stabbed an employee with a pair of scissors. OSHA determined UHS of Delaware and Suncoast exposed employees to workplace violence hazards that included physical assaults and attacks on staff. OSHA cited, premiere behavioral health solutions and UHS and proposed penalties totaling $71,137 violence, particularly against healthcare workers is a leading cause of injury in the workplace.

[00:05:06] The U S department of labor will pursue all available legal actions to hold him accountable and ensure they take all feasible steps to keep employees safe, said regional solicitor Tremmel Howard in Atlanta in April and August, 2019. The department’s regional office of the solicitor in Atlanta conducted a 13 day hearing in on the merits during which 15 direct care workers testified at about their experience with violence at the facility.

[00:05:35] Department attorneys established that between January of 2016 and July, 2018, at least 55 incidents of patients attacking staff occurred as part of his decision. Judge Phillips held UHS and Suncoast, liable for the citation and found existing measures taken to address the hazard of patient on staff violence, woefully inadequate.

[00:05:58] The judge assessed a penalty of. $12,934. In addition, the judge ordered the employers to pay 9,600 in attorney’s fees as a sanction for the employers, bad faith destruction of relevant video surveillance evidence. The judge found that UHS and Suncoast should implement abatement measures that include, but are not limited to the following, developing and implementing a comprehensive workplace violence program.

[00:06:26] Hiring staff with specialized training insecurity to be available on all shifts and on all units for the sole purpose of monitoring patients and responding to acts of patient aggression, performing practice drills on how to respond to acts of patient aggression and reconfiguring the nurses station.

[00:06:43] So patients are not able to jump over or into it. This was the fourth trial against a UHS Inc subsidiary brought by regional solicitor’s offices. And the second in which solicitor of labor and OSHA named UHS of Delaware as an employer, in addition to the subsidiary facility, Suncoast behavioral health center is an acute psychiatric facility in Bradenton.

[00:07:08] And facilities provide inpatient and outpatient treatment for children, adolescents, adults, and mature adults who are experiencing emotional and behavioral issues and overpass carrying a subway train collapsed in Mexico city, late Monday, killing at least 24 people, including children, according to local government officials, at least 79, people have been hospitalized.

[00:07:29] Officials added. The collapse happened near all of us station at 10:25 PM. Local time, according to Mexico city interior minister Alfonzo, Suarez Del Rio, the train was traveling on an elevated part of the city’s rapid transit system on the newest line 12, also known as the golden line when part of the overpass collapsed onto traffic below Mexico’s secretariat of risk management, and several protection said.

[00:07:59] International engineering experts will be called to help determine the cause of the collapse, which the country’s foreign minister Marcello abroad called the most terrible accident we’ve ever had in the public transport system. Mayor Claudia Scheinbaum told a news briefing on Tuesday that alongside an investigation by the attorney general, we will hire an international company certified in metros and instructional matters to conduct an external technical investigation.

[00:08:29] The secretary of foreign affairs Marcello abroad said he will fully cooperate with all investigations into Mondays, deadly subway, overpass collapse. And Berard who served as mayor of Mexico city. At the time, the subway line was constructed, said I’m at the complete disposal of all relevant authorities, as I’ve always been for everything that is needed.

[00:08:51] Mayor Scheinbaum said the public prosecutor’s office will carry out all the investigations. We’ll make all the expert reports to find out what happened in this accident. Online 12 of the subway Mexico’s present Andres Manuel Lopez Obrador. Offered his condolences to the families of those killed at the press briefing.

[00:09:12] He added the investigation into the cause of the collapse should be done quickly and that nothing should be hidden from the public. There is no impunity for anyone he said on May 4th, 2021, the U S chemical safety board adopted its final report into the October 26, 2019 hydrogen sulfide release at ag horn operating waterflood station in Odessa, Texas.

[00:09:35] The release, fatally injured, an egg horn employee who was working at the facility that evening, as well as his spouse, who attempted to locate him at the facility after he did not return home. The CSB report details. The following safety issues at ag horn non-use of personal hydrogen sulfide detectors non-performance of lockout tagout, confinement of hydrogen sulfide inside the pump house, basically lack of proper ventilation.

[00:10:03] Lack of safety management program, non functioning, hydrogen sulfide detection, and alarm system deficient site security. As a result of its investigation, the CSB is making several recommendations to ag horn operating Inc for safety improvements at all waterflood stations where the potential exposure to dangerous levels of toxic hydrogen sulfide gas exists.

[00:10:27] These include mandate the use of personal hydrogen sulfide detection devices. Develop site-specific formalized and comprehensive lockout tagout program for each facility commission and independent and comprehensive analysis of each facility to examine ventilation and mitigation systems develop and demonstrate the use of safety management program.

[00:10:49] That includes a focus on protecting workers and non-employees from hydrogen sulfide. Ensure that hydrogen sulfide detection and alarm systems are properly maintained and configured and develop site-specific detection and alarm programs and associated procedures ensure that hydrogen sulfide detection and alarm system designs employ multiple layers of alerts, unique to hydrogen sulfide and develop and implement a formal written site-specific security program to prevent unknown and unplanned entrance of those not employed by ag horn.

[00:11:23] In addition to recommendations to the company, the CSB made recommendation to OSHA to issue a safety information product that addresses the requirements for protecting workers from hazardous air contaminants and from hazardous energy and a recommendation to the railroad commission of Texas to develop and send a notice to operators, to all oil and gas operators that fall under its jurisdiction that describes the safety issues described in the CSPs report.

[00:11:53] The audio from the meeting was posted to this podcast feed. Last Wednesday, a copy of the video is available on the safety investigations podcast, YouTube channel. If you want to check that out, a Ted Smith Aerostar 600 impacted the train North East of LaBelle municipal airport in Hendry County, Florida.

[00:12:15] Following the loss of engine power, the twin engine airplane sustained substantial damage. And one occupant was fatally injured. The other occupant onboard received serious injuries, no word from the NTSB at the time of this recording as to whether they are traveling to the scene or not. The NTSB is investigating the May 2nd crash of a Robinson R 44 helicopter near Monroe, North Carolina.

[00:12:39] NTSB investigator expected to arrive on scene May 3rd, 2021. According to their tweet, the NTSB also said it is investigating the May 2nd crash of a Cessna T two 10 M airplane near Oxford, Iowa. NTSB investigator is traveling to the scene and they are also investigating the May 4th crash of a Mitsubishi  airplane in Hattiesburg, Mississippi.

[00:13:06] Two NTSB investigators are traveling to that scene. The NTSB issued a preliminary report. Tuesday, May 4th for its ongoing investigation of the April 7th, 2021 accident that killed a BNSF conductor on an industry track near Louisiana, Missouri on April seven, 2021 at 3:30 PM. Local time. A BNSF railway conductor was killed while dropping off and picking up cars in an industry facility outside of Louisiana, Missouri.

[00:13:37] The train BNSF, local eight three seven consisted of two locomotives, 21 cars and a modified flat car. The train crew consisted of one engineer, one conductor and one brake man, immediately before the accident, the engineer was moving the train Southeast on dyno, Nobel ink, industrial track at a speed of less than nine miles per hour.

[00:14:01] With the conductor controlling the movement with the engineer by radio while standing on the ground. The brakemen was riding the North side of the eighth rail car preliminary information indicates that during the movement, radio communication between the conductor and the locomotive engineer ceased, the engineer stopped the movement.

[00:14:20] At which point, the brakeman observed the conductor lying on the ground next to the rail on the South side of the car, the NTSB investigative team examine the accident, location collected and gathered preliminary information. Conducted interviews and obtain drone video footage of an accident.

[00:14:38] Reenactment conducted while on scene anti-air speeds. Investigation into this accident is ongoing. Future investigative activity will focus on causal factors and railroad worker safety in industrial facilities, parties to the investigation include the federal railroad administration BNSF. Brotherhood of locomotive engineers and train men and the international association of sheet metal, air rail and transportation workers, a 2020 shipyard fire aboard the iron maiden was able to start and spread without notice because no one was continually monitoring the vessel while fire detectors were shut off.

[00:15:19] During repairs, the national transportation safety board said in a report issued on Tuesday. Marine accident, brief 2111 details. The NTSB is investigation into the April 16, 2020 fire aboard the dive support vessel docked at the LA shipyard in a low roast Louisiana. The fire cost $900,000 in damage.

[00:15:41] There were no injuries while the fire caused extensive damage throughout the generator room, the NTSB found fire pattern and damage indicating the fire started near the forward bulkhead. Because the battery charger, alarm panel and generator push button start stop panel. We’re in the area of the fire ignition identified by fire investigators and electrical short from one of these components may have been the source of the fire.

[00:16:04] However, the exact location of the source of the fire could not be identified by fire investigators. There was no crew member or ship yard worker staying on board. The iron main during the night of the fire, the vessels fire detection system was shut off while work was being conducted within the vessel to prevent false alarms from smoke and dust.

[00:16:23] In addition, there was no shipyard policy or vessel owner policy in place to have the shipyard personnel or vessel crew members conduct safety rounds after hours, when there was no work being done on the vessel. Fire and flooding are risks for both crude and unattended vessels. The report said to protect personnel property and the environment, it is good maritime practice for owners operators and shipped our managers to coordinate and implement some form of continuous monitoring for vessels undergoing maintenance in a shipyard in layup or in some inactive period without regular crew aboard.

[00:16:57] Continuous monitoring can consist of scheduled security rounds and or active monitoring with sensing and alarm systems. The Marine accident brief 2111 is available. Online links will be in the show notes. The UK is air accidents, investigation, branch AIB released a report that says biocide fuel contamination was the cause of a February, 2020 Airbus, a three two, one emergency at London Gatwick airport.

[00:17:26] As part of scheduled maintenance, overseas golf, Papa, Oscar whiskey, November underwent a biocide shock treatment on his fuel system using cath on biocide to treat microbial contamination aircraft returned to the UK on 24, February, 2020. Once the maintenance was complete. In the 24 hours proceeding the serious incident, there were abnormalities with the operation of both engines, across four flights on the flight.

[00:17:57] Before the fourth event flight, the crew reported momentary indications of number two, right engine stall. After the aircraft landed. This was investigator using it inappropriate procedure obtained from an aircraft troubleshooting manual, not applicable to golf Papa, Oscar whiskey, November, but no fault was found.

[00:18:19] The aircraft took off from London Gatwick airport runway two six left at zero nine hours on 26, February, 2020, but around 500 feet AGL, the number one left engine began to surge the commander, declared a Mayday and turned right down when for the immediate return to the airport. But shortly afterwards, the crew received indications that the number two engine had stalled.

[00:18:44] The crew established that the engines were more stable at low thrust settings. And the thrust available at those settings was sufficient to maintain a safe flight path. They continued the approach and the aircraft landed at zero 20 hours. Investigation identified the following causal factors, one golf Papa, Oscar whiskey November’s fuel tanks were treated with approximately 38 times the recommended concentration of on.

[00:19:13] The excessive cath on level in the aircraft fuel system cause contamination of the engine, hydro mechanical units, or H M use resulting in a loss of correct H M U regulation of the aircraft engines. A troubleshooting procedure was used for the engine. Number two, stall that applied to the Lea P one eight 32 engines, but golf, Papa, Oscar with ski November.

[00:19:38] Was fitted with CFM 56 five B three three engines. The procedure for the CFM 56 five B3 three engines required additional steps that would have precluded popper, Oscar whiskey November’s departure on the incident flight. The investigation identified the following contributory factors, the aircraft maintenance manual AAM.

[00:20:02] Procedure did not provide enough information and enable maintenance engineers to reliably calculate the quantity of cath on required. And the specific gravity value of Catherine was not readily available. There were no independent checking procedures in place at the base maintenance approved maintenance organization to prevent or reduce the likelihood of calculating and administering an incorrect quantity of biocide.

[00:20:30] There were organizational factors at the base AMO that contributed to the incorrect cath on quantity calculations. In particular, the workload was high for the available facilities and personnel, and there was no internal technical support function for engineers to consult when they were uncertain.

[00:20:48] Number four, the manufacturer recommended method of searching The. Troubleshooting manual was not used to find the applicable procedure relating to the number two engine stall. Following the serious incident safety action was taken by regulators, the international air transport association, the manufacturers of aircraft engines and biocide, the AMS involved and the operator, the specific action taken is detailed in section 4.2 of the report.

[00:21:19] Redundancy and safety critical systems is one of the principles supporting the safety of commercial air transport, but fuel contamination undermines that redundancy because it can affect all engines. Simultaneously. It is essential that maintenance systems are resilient to errors that can lead to fuel system contamination.

[00:21:39] Therefore five safety recommendations have been made in this report to promote the classification of biocide. Treatment of aircraft fuel systems as a critical maintenance task, which will require that an air capturing method is included as part of the task. And I’ll have a link to that report in the show notes, the transportation safety board of Canada or TSB found that the January 20, 20 hard landing and tail strike of a DHC dash eight dash 300 in Shaffer avail Canada was the result of an unstable approach.

[00:22:15] On 20 January, 2020, a DHC dash eight dash three 14. Operative by air in you. It was conducting a flight from Quebec, John lifts, Sage airport to Schaefer Ville airport with three crew members and 42 passengers on board. During the landing, the rear fuselage struck the runway. As the wheels touched down after landing the aircraft, taxi to the terminal to disembark the passengers.

[00:22:41] There were no injuries. However, the aircraft sustained substantial damage. The investigation found that the flight crew for, to perform the descent checklist and realize this at an inopportune time while the captain was providing a position report, given ambiguities and contradictions in the company’s stabilized approach guidelines, the captain interpreted that he was allowed to continue the approach below 500 feet above aerodrome level elevation.

[00:23:08] Even though the aircraft had not been fully configured for the landing. When the aircraft passed this altitude, the pilots who were dealing with heavy workload didn’t notice and continued the approach, which was on stable at the time of the landing, the aircraft no longer had enough energy to arrest the descent rate solely by increasing pitch attitude.

[00:23:30] The pilots instinctive reaction to increase the pitch two during the flare combined with the hard landing results in the rear fuselage striking the runway causing substantial damage to the aircraft structure. The investigation also made findings as to risk related to air Inuits standard operating procedures and training and to transport Canada’s oversight, transport Canada assessed.

[00:23:57] Air Inuits, SLPs, but did not identify any specific issues with the upper, your stabilized approach guidelines. If TC does not assess the quality consistency, accuracy, conciseness, clarity, relevance, and content of SLPs, the procedures may be ineffective, increasing risks to flight operations. Additionally, the captain had not received many of the required training elements during his recurrent training.

[00:24:26] If required training elements are not included in recurrent training. And if TCS surveillance plan does not verify the content of crew training, there may be procedural, deficiencies, or deviations, increasing risks to flight operations. Following the occurrence area. And he went and took a number of safety actions, including the revision of all of its SLPs, to improve guidelines on several subjects, including stabilized approaches and the revision of its training program.

[00:24:54] To ensure that all training elements are covered within the two year recurrent training cycle, you can see the investigation page for more information, and the link will be in the show notes. That’s it for this week’s safety investigations news brief. Thanks for listening and check back next week for more.

[00:25:14] Bye.


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