News Brief 5/28/2021

Summary

Safety Investigations news brief for 5/28/2021

For full show notes with links and to subscribe to this audio podcast go to safetyinvestigations.net 

NTSB_Newsroom (@NTSB_Newsroom) 

Preliminary report crash of a Bell 429 helicopter near Eden, North Carolina

NTSB Opens Public Docket in Scandies Rose Sinking

Failure to Adhere to Restricted Speed Requirements Caused Fatal Arizona Train Collision

Early Communication, Fast Action, Aids Rescue of Fishing Vessel Crew

Medical Incapacitation Led to Fatal I-75 Crash

Press Release – FAA Completes Rule Establishing Pilot Records Database to Increase Safety

Federal Aviation Administration Announces Results of Mexico’s Safety Assessment

Press Release – Boeing to Pay at Least $17 Million to Settle Enforcement Cases on 737

Air transportation safety investigation report A20C0037

19 May 2021 – Marine news release 

Investigation: AO-2020-032 – Pilot incapacitation involving Cessna 208B, VH-DQP, near Brisbane Airport, Queensland, on 2 July 2020

Investigation: RO-2020-006 – Safeworking occurrence involving NSW TrainLink 283D and outer handsignaller, Dora Creek, New South Wales, on 9 May 2020

Investigation: AO-2018-057 – Collision with terrain involving BK117 helicopter, VH-JWB, near Ulladulla, New South Wales, on 17 August 2018

Investigation: AO-2018-019 – Fuel exhaustion and forced landing involving Cessna 441, VH-LBY, 39 km east of Broome Airport, Western Australia, on 2 March 2018

Learjet 31a Performed Roll on Descent to Faro Portugal

OSHA cites two Michigan companies after demolition collapse at Killen Power Plant in Manchester, Ohio, kills two workers | Occupational Safety and Health Administration

US Department announces OSHA rule proposal to clarify handrail, stair rail system requirements in general industry Walking-Working Surfaces standard | Occupational Safety and Health Administration 

Transcript

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Transcription

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21-05-28 News

This is your safety investigations news brief for May 20th, 2021. I’m your host Charles Current. And here are this week’s headlines. The NTSB announced it is investigating eight new aviation incidents in the last week. They also issued a preliminary report for, uh, ongoing investigation of the fatal crash of a bell four 29 helicopter near Eden, North Carolina, and they opened the public docket in these candies rose  rose sinking.

[00:00:29] They say failure to adhere to restricted speed requirements caused a fatal Arizona train collision, and they also say early communication and fast action aided rescue of fishing vessel crew, and the medical incapacitation led to fatal ISE 75 crash. The FAA finally completes its rule establishing pilot record database.

[00:00:52] And they have downgraded Mexico safety rating and they say Boeing is to pay at least 17 million to sell enforcement cases. On the seven 37. The Canadian TSB say continue to perch below required. Airdrome operating visibility led to runway excursion in April of 2020, and they call for mandatory risk mitigation measures for passenger vessels operating in Canadian Arctic.

[00:01:20] The Australian B says fatigue and mild hypoxia likely led to pilot incapacitation involving a Cessna two oh eight B near Brisbane airport on July 2nd, 2020. They also say an unimproved track work authority practice caused a near hit of a railway worker by a passenger train in new south Wales on May 9th, 2020.

[00:01:43] They say an incapacitating medical event likely caused a collision with terrain involving a B K one, one seven helicopter in new south Wales in 2018 and an undetected water contamination led to fuel exhaustion and forced landing of a Cessna four 41 in Western Australia in 2018 German, BFU says a Learjet 31 eight performed a role on descent to a farro Portugal.

[00:02:13] And back in the U S OSHA cites to Michigan companies after demolition collapse at killin power plant kills, two workers. And they have proposed a rule to clarify hand rail and stair rail system requirements in general industry.

[00:02:36] don’t forget. You can find this podcast on almost all podcasting apps and@safetyinvestigations.net. You can also find full show notes with links to all stories discussed@safetyinvestigations.net. Well, she going to start off with the U S NTSB, is it announced this week? That is investigating several accidents.

[00:02:55] They are investigating the May 21st crash of a Piper, PA 31 airplane near Myrtle beach, South Carolina, the May 22nd crash of a flight design, CT SW airplane near Winterville north, North Carolina. The May 23rd crash of a Sanex J S S J S X dash two airplane near Shreveport, Louisiana, the May 24th, 2021 crash of a vans, R B eight airplane in Ben cleave, Kentucky, the May 24th crash of a desalt aviation Mirage F1 in Las Vegas.

[00:03:31] The May 25th crash of a Gulf stream, a five in Crossville, Tennessee, the May 25th crash of a, B H I H 60 helicopter in Leesburg, Florida. And just announced before this recording, the May 27th crash of an early bird, Jenny airplane in Reidsville, North Carolina investigators are traveling to all of those scenes.

[00:03:55] The NTSB also issued a preliminary report for its ongoing investigation of a fatal April 28th, 2021 crash of a bell four 29 helicopter near Eden North Carolina on April 28th, 2021. About 1324 Eastern standard time. A bell four 29 helicopter, November five, three Delta x-ray. Was destroyed when it was involved in an accident near Eden, North Carolina, the commercial pilot was fatally injured, and two passengers were seriously injured.

[00:04:24] The helicopter was operated as a title 14 code of federal regulations, part 91 power line patrol, preliminary FAA, ADSL B data indicated the helicopter departed the steam station, patrolling the transmission power lines to the north, then returned. On the west side of the power lines heading south, as the helicopter approached the intersection of the north, south and east west power lines, the pilot began to reverse course by turning to the right as the helicopter turned, right.

[00:04:55] Witnesses reported hearing a pop followed by a helicopter descending into an impacting a tree, a Lyman onboard the helicopter seated in the forward left seat recalled the pilot was reversing course and the helicopter was banking to the right. When he heard a very loud noise, which he described as almost Canon, like very deep within a second or two, we were headed into the trees.

[00:05:19] He said the accident flight was witnessed by bystanders located near the steam station. One witness driving westbound, observed the helicopter cross the road, heading south. Flying low over the trees along power lines. The helicopter made a right turn before it disappeared behind the trees. Two other witnesses observed the helicopter flying from east to west over the trees before making a steep left turn, the witness stated they could see the underside of the helicopter and the skids before it slid at an angle downward and disappeared into the woods.

[00:05:54] The helicopter came to rest on the right side of the fuselage, about 393 feet from the power lines at an elevation of 570 feet. All major components of the helicopter were accounted for at the accident site. The debris path was 183 feet long on a 245 degree heading flight control. Continuity was not confirmed due to a post-crash fire that consumed the cockpit of the helicopter.

[00:06:19] Remnant carbon fiber layup was present on the area of the upper cowlings fuselage skin and doors. The cockpit cabin floor and transmission and engine deck were present, but sustained heavy thermal damage. The avionics and wiring were strewn outside. The no section with pieces of wood branches embedded within the wiring.

[00:06:43] The main rotor hub remained attached to the main rotor mast. The two YOKA semi’s remain installed with the mass nut and tact. The main rotor blades remained installed to their respective grips via blade pens. All blade attachment hardware was present and secured. All four blade tips, exhibited impact damage and their spars exhibited a broom straw appearance.

[00:07:08] Three separated, leading edge pieces near the tip end, including the tip cap lip joint were found in the debris field surrounding the main wreckage, all four main rotor blade pitch horns remained intact and all four pitch change links were connected to their respective pitch horns and the rotating swash plate.

[00:07:31] The main rotor gearbox was partially separated from the airframe due to impact and thermal damage. The tail rotor was hanging to one side of the gearbox due to fracturing of the output shaft and bending of the pitch control rod. The two tail rotor yolks remained installed on the tail rotor output shaft, and were whole the tail rotor blades remained installed on the yolks.

[00:07:57] Each blade’s entire span was present. The Yar hydraulic actuator remained attached to both the air frame and its control bell crank within the tail. Boom, the control tube. After the yacht, hydraulic actuator was fractured in multiple locations. The forward tail rotor shaft assembly was continuous to the cooler fan shaft.

[00:08:20] The cooler fan remained attached to the airframe, but was crushed from impact. The tail rotor drive train was fractured in multiple locations. After the cooler fan, the helicopter was configured with only the pilot flight controls installed on the right cockpit seat, various thermally degraded control, clevis connections and bell cranks were found in the main wreckage site.

[00:08:43] But the majority of the cockpit flight control system was consumed by the post-crash fire. The left and right hydraulic pumps were found separated from the main gearbox and were thermally damaged. The helicopter was equipped with two Pratt and Whitney P w two oh 71 engines. Both of which remained installed on the engine deck.

[00:09:05] The engine data monitors, electronic controls and health and usage monitoring system units were recovered and retained for data. Download the helicopter wreckage was recovered in retain for further examination. The NTSB also opened a public docket Monday as part of its ongoing investigation in the sinking of the fishing vessel.

[00:09:26] Scandi is rose Scandi is rose sank, December 31st, 2019 2.5 miles south of Sedwick island. Alaska. The vessel had a crew of seven, two were rescued and five others missing after the accident were never found. The docket for this investigation includes more than 4,500 pages of factual information, including interview transcripts, photographs, and other investigative materials.

[00:09:50] The docket contains only factual information collected by NTSB investigators. No conclusions about how or why the Scandi is rose sank should be drawn from the information within the docket. The probable cause analysis and recommendations will be released at a public board meeting on the scanners rose scheduled for June 29th.

[00:10:10] The full final report will be released in the weeks. Following the board meeting. The NTSB determined Thursday, the failure of a BNSF train crew to operate an intermodal train within restricted speed requirements caused the fatal June 5th, 2018. Collision between the intermodal train and a BNSF work train near Cayman, Arizona.

[00:10:32] The collision occurred when a westbound BNSF, intermodal train operating, operating in centralized traffic control territory collided with the rear of a slow moving eastbound work train. The work train was moving in reverse to drop off an employee before traveling west to exit the main track one employee was killed and another was seriously injured in railroad accident report 21 slash oh one NTSB investigators noted the crew members of the intermodal train operated at a speed that did not allow their train to stop within half the range of vision as required.

[00:11:07] The NTSB concluded. The current training and oversight by railroad supervisors are ineffective in ensuring the operating crews use of restricted. The use of restricted speed. FRA regulations require roadway workers who lay track to use a form of on-track safety. However FRA is interpretation of its regulation allows railway workers on work trains to lay track without using a form of on-track safety.

[00:11:37] And this interpretation contributed to the cause of the collision. According to the NTSB report, Robert Hall director of the NTSB office of railroad pipeline and hazardous materials investigation says it is extremely important. The railroad industry is in full compliance with established federal regulations.

[00:11:55] There is no room for misinterpretation of the requirements. As this tragic accident demonstrates regulations designed to protect railroad workers must be clear to avoid any ambiguity, ambiguity, and eliminate risks. He says between 1997 and 2017 55 roadway workers were killed in 52 accidents and the NTSB investigated eight accidents in 2020 involving railroad and transit worker fatalities.

[00:12:24] These sobering statistics are why improve rail worker safety is an item on the NTSB. Most wanted list of transportation safety improvements. The collision would not have occurred. Had the required regulations been applied to work trains and not exclude provisions that provide OnTrack protections to all roadway workers on or near the tracks.

[00:12:47] The intermodal train would either not have been permitted to enter the same signal block or not allowed to enter established working limits the NTSB set the NTSB issue. Two safety recommendations to the federal railroad administration. Based on these findings of the investigation, these safety recommendations address the use of restricted speed and protection of roadway workers who are engaged in maintenance of way tasks.

[00:13:15] The railroad accident report 21 slash oh one is available online and links that will be in the show notes. They say fast, true reaction and early communication with the us coast guard prevented any fatalities or serious injuries. When the fishing vessel re Rebecca Mary sank while underway last year, the NTSB said in Marine accident, brief 21 slash 12 released Tuesday.

[00:13:40] Around 4:00 AM on June 17th, 2020 after a bilge alarm sounded a deckhand noticed the port AFT corner of the fish Laden vessel was taking waves over the Gunwale or upper edge of the vessel side. Seawater was accumulating on the AFT deck and over the top of the hatch to the lesser at the AFT most under deck compartment.

[00:14:06] The hatch was equipped with a cover that could not be latched closed with the situation deteriorating. The crew quickly dawned their survival suits at 4:09 AM. The captain made a distress call to the coast guard on VHF channel 16 and activated the emergency position indicating radio begin or perp.

[00:14:29] While pumping seawater from the AF spaces. The captain also provided several radio updates at the same time, the crew monitored the seawater level on the working deck, which kept creeping up as the vessels stern sank deeper into the water. The captain stated that he was unable to access the Lazarus hatch, but believe the hatch cover was gone.

[00:14:53] Because the vessel could not be examined after sinking. It is unknown. If there were any hole failures or other areas of water entry prior to the time the deckhand noticed seawater coming in after 5:00 AM the vessel sinking by the stern, the crew tied the vessels life raft to the port side handrail.

[00:15:15] And through its canister overboard, the life draft inflated successfully, but almost immediately afterward the Rebecca Mary rolled over to port during the roll, the vessels rigging tore into the life graph instantly deflating it and forcing all crew members into the water in their survival suits. Once in the water, they locked arms and waited just minutes later at 5:07 AM.

[00:15:39] A coast guard. Helicopter arrived on scene. By 5:59 AM. All four crew members were at air station, Cape Cod, early communication with coast guard and preparing to abandoned ship by dining survival suits or personal flotation devices when experiencing significant flooding, fire, or other emergencies increases the likelihood of survival.

[00:16:01] The report said when deploying life rafts and other life saving appliances crews should attempt to launch and or inflate in areas clear of obstructions. And on May 27th, the national transportation safety board said in a report issued that the medical incapacitation of an Eagle express truck driver led to the fatal January 3rd, 2019.

[00:16:25] Multi-vehicle crash on  near Al Tewa, Florida. I’m sure I pronounced that horribly. The accident, brief states, truck drivers, incapacitation resulted in his failure to maintain his travel lane and led to the truck, crossing the highway center median and colliding with several vehicles in the opposite lanes of travel evidence from the roadway, dashboard, camera and witness interviews suggest the driver did not attempt evasive action as the truck veered across the median and into oncoming traffic.

[00:16:59] The crash resulted in seven fatalities and injuries to eight others. The crash involved, five vehicles, autopsy results identified ischemic heart disease as a contributing factor in the truck drivers cause of death. However, the truck driver had a number of medical conditions and use medication that could have also caused the incapacitation.

[00:17:23] During his most recent medical certification examination, the driver did not disclose all his medical conditions nor all the medications he was taking the failure to disclose his conditions to medical examiners led to his receipt of a medical certification valid for a maximum of two years. NTSB investigators noted that.

[00:17:44] Had the driver disclosed his relevant health information. It may have resulted in a shorter medical certification period, but it would not have predicted the incapacitation on that day of the crash. NTSB investigators determine the Eagle express truck, a 2016 Freightliner with a 2018 Vanguard.

[00:18:04] Semi-trailer had no apparent defects that would have led to the crash. And analysis of maintenance records and a search of the safety recall database and related records show no factors relevant to the events in the crash. The report is available online and links will be in the show notes. A new rule from the federal aviation administration will enable the sharing of pilot records among employers in an electronic database, maintained by the agency.

[00:18:35] The final rule for the pilot records, database requires air carriers and certain other operators to report pilots, employment, history, training, and qualifications to the database. The rule also requires air carriers and certain operators to review records contained in the database when constrained pilots for employment.

[00:18:55] The rule will update the current records reporting process to meet information sharing requirements in the airline safety and federal aviation administration extension act passed by Congress and 2010. Once the transition period is complete, the database will serve as the repository for pilot records from the FAA and records reported by current and former employers.

[00:19:21] The database will include the following information. FAA pilot’s certificate information, such as certificates and ratings, FAA summaries of unsatisfactory pilot applications for new certificates or ratings. FAA records of accidents, incidents, and enforcement actions records from employers on pilot training, qualification and proficiency.

[00:19:44] Pilot drug and alcohol records, employers, final disciplinary action records, pilot records concerning separation of employment and verification of pilot motor vehicle driving records. The final rule takes effect 60 days after it is published in the federal register, additional actions and timelines to support implementation of the rule include.

[00:20:09] Six months after the rule is published. Operators must begin reviewing FAA records electronically in the database instead of submitting a form requesting records. One year after the rule is published, operators will begin to report and review records to the database and operators will have three years and 90 days to transition and fully comply with the rule.

[00:20:32] The FAA will publish an advisory circular to accompany the final rule and we’ll offer additional resources to support industry adoption and the use of the database. They say the rule has been thoroughly debated and incorporates feedback from all aviation stakeholders. And the FAA announced that the government of Mexico does not meet international civil aviation organization.

[00:20:58] Staff safety standards based on a reassessment of Mexico, civil aviation authority. The FAA has downgraded Mexico’s rating to category two from category one. While the new rating allows Mexican air carriers to continue existing service to the United States. It prohibits any new service and routes. U S airlines will no longer be able to market and sell tickets with their names and designators codes on Mexican operated flights.

[00:21:27] The FAA will increase its scrutiny of Mexican airline flights in the United States. The FAA is fully committed to helping the Mexican aviation authority improve its safety oversight system to a level that meets I C a O standards to achieve this. The FAA is ready to provide expertise and resources and support of its ongoing efforts to resolve the issues identified in the international aviation safety assessment process.

[00:21:56] Both the a F a C and FAA share a commitment to civil aviation safety sustained progress can help a F a C regained category one during its reassessment of the agency. Federal day, Ava shown civil from October, 2022, February, 2021. The FAA identified several areas of noncompliance with minimum  safety standards.

[00:22:24] A category two rating means that the country’s laws or regulations lack the necessary requirements to oversee the country’s air carriers in accordance with the minimum international safety standards or the civil aviation authority is lacking in one or more areas, such as technical expertise, trained personnel, keeping inspection procedures, or resolution of safety concerns under the.

[00:22:49] I a S a program. The FAA assesses the civil aviation authorities of all countries with air carriers that have applied to fly to the United States, currently conduct operations in the United States, or participate in code sharing arrangements with the us partner airlines, the assessments determined whether international civil aviation authorities meet the minimum.

[00:23:14] I C a O safety standards, not FAA regulations. To obtain and maintain a category. One rating, a country must adhere to the safety standards of I C a O the United nations technical agency for aviation ICA establishes international standards and recommended practices for aircraft operations, maintenance.

[00:23:36] And you can find more information on the FAS website. And the Boeing company will pay at least 17 million in penalties and undertake multiple corrective actions with us production under a settlement agreement with the federal aviation administration, the FAA found the Chicago based manufacturer installed equipment on 759, Boeing seven 37 max and N G aircraft containing sensors that were not approved for that equipment.

[00:24:05] And submitted approximately 178, Boeing seven 37 max aircraft for airworthiness certification. When the aircraft potentially had non-conforming slat tracks installed, and improperly marked the slat tracks, FAA administrator, Steve Dickson said keeping the flying public safe is our primary responsibility.

[00:24:25] That is not negotiable. And the FAA will hold Boeing and the aviation industry accountable to keep our skies safe. Boeing will pay the 17 million penalty within 30 days after signing the agreement. If Boeing does not complete certain corrective actions within specified timeframes, the FAA will levy up to 10.1 million in additional penalties.

[00:24:48] The corrective actions include, but are not limited to strengthening procedures to ensure that it does not install on aircraft. Any parts that fail to conform to their approved design. Performing safety, risk management analysis to determine whether its supply chain oversight processes are appropriate and whether the company is ready to safely increase the Boeing seven 37 production, right?

[00:25:11] Revising its production procedures to enable the FAA to observe production rate readiness assessments, the data on which the company bases, the assessments and the results of the assessments. Taking steps to reduce the chance that it presents to the FAA aircraft, with non-conforming parts, for airworthiness certification or a certificate of export and enhancing processes to improve its oversight of parts suppliers.

[00:25:40] The FAA will continue its oversight of Boeing’s engineering and production activities, and it is actively implementing oversight provisions from the 2020 aircraft certification safety and accountability act. In its investigation report released on the 25th of May. The transportation safety board of Canada identified a recurring issue of approaches continued in low visibility environments as a contributing factor in the 2020 Buffalo airways limited runway excursion.

[00:26:10] The investigation found that the flight crew believed the landing was permitted giving the absence of an approach ban. And landed, even though the reported ground visibility was below the minimum aerodrome operating visibility on the 28th of April, 2020, a Buffalo airways lemonade Beechcraft king air.

[00:26:28] A 100 aircraft was conducting a charter flight under instrument flight rules from the Cambridge bay airport with two flight crew members and freight on board immediately after touchdown at kg grock. All right, I’m going to butcher these names. I’m sorry. Co kg of Rook airports, the aircraft veered to the right and departed the runway surface.

[00:26:53] The aircraft came to arrest after colliding with a snowbank on the north west side of the runway. The crew was uninjured and egress the aircraft via the main cabin door. There was no fire, but the aircraft sustained substantial damage. The investigation determined that during the later stages of the approach, a crosswind from the left end visual effects of blowing snow contributed to the aircraft being aligned with the right side of the runway, the aircraft touched down near the right edge of the runway.

[00:27:24] And when the right landing gear impacted the deeper snow along the runway edge, the aircraft veered to the right into part of the runway surface. Approaches to airports north of 60 degrees. North latitude are not restricted by ground visibility. And as a result, the flight crew continued the approach when the report of visibility was one core statute mile, which is lower than the published of advisory visibility of one and three core statute miles.

[00:27:51] For this approach, the flight crew believed that the lack of an approach ban permitted the landing. And landed at the airport, even though the reported ground visibility was below the minimum aerodrome operating visibility of one half statute mile. The rules that govern instrument approaches in Canada are too complex, confusing and ineffective at preventing pilots from conducting approaches that are not allowed or banned because they are below the minimum weather limits.

[00:28:20] In 2020, the TSB issued recommendation, a 20 dash oh one and a 20 dash oh two, calling on transport, Canada to review and simplify operating minima four approaches and landings at Canada aerodromes. And to introduce a mechanism to stop poaches and lendings that are actually banned. In a response to both recommendations, TC stated that it would be forming and leading an industry working group to draft a notice of post amendment to update approach ban regulations, as well as the supporting documentation and guidance.

[00:28:57] Until these recommendations are fully addressed. There remains a risk that flight crews will initiate or continue approaches in weather conditions that do not permit safe landing. Following the accident, Buffalo airways lemonade conducted a survey among its pilots. The survey collected data regarding knowledge, understanding and application of airdrome visibility restrictions.

[00:29:18] It revealed that not all pilots realized that in the absence of published reduced visibility, operations procedure in the Canada flight supplement. The minimum visibility for operating at an aerodrome is one half statue mile. A review of the applicable regulations was carried out with company pilots and was also added to the company’s initial and recurring flight training.

[00:29:42] Only 21st of May. The TSB released its investigation report on the 2018 grounding of the passenger vessel. Academic WAF or Lafaye, I don’t know. The transportation safety board of Canada determined, determined that there are unique risks associated with operating in the Canadian Arctic, and as such the board is issuing a recommendation for the development and implementation of mandatory mitigation measures in order to ensure the safety of passenger vessels and to protect the vulnerable Arctic environment.

[00:30:16] On the 24th of August, 2018, the passenger vessel with 102 passengers and 61 crew and expedition members onboard ran aground near the astronomical society islands 78 nautical miles north, Northwest of cook ruck. None of it, I, I don’t know how to pronounce these names. Multiple searches and rescue assets from both the Canadian armed forces and Canadian coast guard were tasked to assist the distressed vessel, the vessel self refloated with the flooding tide.

[00:30:52] Later in the day, the passengers were evacuated and transferred to another passenger vessel. The next day, the vessel sustained serious damage to its hall. To ballast water tanks and to fuel oil, bunker tanks were breached and took on water. Approximately 81 liters of the vessels fuel oil was released to the environment.

[00:31:13] No injuries were reported. The investigation determined that the vessel was sailing through narrows in a remote area of the Canadian Arctic, where none of the vessels crew had ever been, which was not surveyed to modern hydrographic standards. Since the navigation charts did not show any Shoals or other navigational hazards, the bridge team considered the neuro safe.

[00:31:35] And despite a note to Mariners, indicating that the information used to establish water depths was of a reconnaissance nature. They did not implement any additional precautions or add extra personnel to, to the watch consequently, with the officer. Of the watch multitasking and the helmsmen busy steering the vessel, the steady decrease of the under keel water depth went unnoticed for more than four minutes because the echo Sounders low depth alarms had been turned off.

[00:32:08] The investigation also found that the passenger safety operations did not meet the international convention for the safety of life at sea requirements. For example, safety briefings were carried out more than 12 hours following the vessels departure while they requirement’s state that newly embarked pastures must undergo safety briefings and musters before or immediately upon the vessel departure.

[00:32:34] Additionally, exhibition staff were informally tasked to coordinate passenger safety during the voyage and provided the safety briefings to passengers on behalf of the vessel’s crew. The Solas convention also requires that passenger vessels like this one have in place a decision support system to manage all foreseeable emergency situations that may occur on board.

[00:32:58] The investigation determined that the decision support system onboard the vessel did not include emergency procedures for the vessel touching bottom or running a ground. Since 1996, there have been three groundings of passenger vessels and one of a chartered yacht in the Canadian Arctic TSB investigations into three of these found that deficiencies in voyage planning or execution were significant contributing factors.

[00:33:26] His investigation noted that operating in the Canadian Arctic poses, unique risks as passenger vessels are often negotiating in areas that are not charted to modern standards in a harsh climate with limited local search and rescue resources. Given these risks, it is critical that operators of passenger vessels operating in the Canadian Arctic adopt additional mitigation strategies to address them.

[00:33:49] Transport Canada and fisheries and oceans, Canada combined have the regulatory mandate to implement various risk mitigation measures to reduce the likelihood and consequences of passenger vessels. Running a ground in Arctic waters, therefore until coastal waters surrounding the Canadian Arctic archipelago are adequately charted.

[00:34:11] And if alternate mitigation measures are not put in place, there is a persistent risk that vessels could make unforeseen contact with the sea bottom, putting passengers crew and the environment at risk. This is why the board is recommending that the department of transport in collaboration with the department of fisheries and oceans develops and implements mandatory risk mitigation measures for all passenger vessels operating in the Canadian Arctic coastal waters.

[00:34:37] And Australia’s ATS B says fatigue and mild hypoxia likely led to pilot incapacitation involving a Cessna two oh eight B near Brisbane airport on the afternoon of two, July, 2020, the pilot of a Cessna two oh eight B aircraft registered Victor hotel, Delta Quebec Papa was conducting a fairy flight from Cairns to Redcliffe Queensland.

[00:35:03] After encountering unforeseen icing conditions and poor visibility due to clouds. The pilot climbed from 10,000 feet to 11,000 feet. When the aircraft was about 53 kilometers west, Northwest of sunshine coast, airport air traffic control attempted to contact the pilot regarding the descent into red cliff.

[00:35:22] No response was received from the pilot at that time or for the next 40 minutes during the flight air traffic control with the assistance of pilots from nearby aircraft made further attempts to contact the pilot. When the aircraft was 111 kilometers south Southeast of the intended destination, the pilot woke and communications were reestablished.

[00:35:44] The pilot was instructed by air traffic control to land at gold coast airport. The pilot track to the gold coast and landed safely without further incident, the HTSP found that the pilot was likely experiencing a level of fatigue due to inadequate sleep the night before and leading up to the incident further operating at 11,000 feet with intermittent use of supplemental oxygen, likely resulted in pilot, experiencing mild hypoxia.

[00:36:11] This is likely exacerbated by the pilots, existing fatigue and contributed to the pilot falling asleep. The ESB safety watch highlights the broad safety concerns that come out of our investigation findings and from the occurrence and from the occurrence data reported by the industry. One of the priorities is fatigue, which is a physical and psychological state typically caused by prolonged wakefulness and or inadequate sleep.

[00:36:39] Most people generally underestimate their level of fatigue and tend to overestimate their abilities. The incident emphasizes the importance of pilots monitoring their own health and wellbeing to ensure that they are well rested and adequately nourished, especially when conducting single pilot operations further demonstrates that although mild hypoxia is not known to impair complex cognition.

[00:37:04] It has been found to increase fatigue and decreased vigor symptoms of hypoxia can begin very subtly at lower altitudes and can also begin to show below 10,000 feet for people who are smokers, unfit, or fighting off an illness. Further information about assessing your fitness to fly and hypoxia can be found at the HTSP website.

[00:37:27] The HTSP also says an unapproved track work authority practice caused a near hit with a rail worker by passenger train in new south Wales. On Saturday, May 9th, 2020 NSW train link, passenger service, two eight three Delta. Traveling from Newcastle to Sydney, encountered a rail worker on the. Up main track at approximately 130.5 kilometers.

[00:37:54] The worker saw and heard the approaching train and remove themselves from the track and out of the danger zone. The train stopped past the location where the worker was situated. And the driver spoke with the worker to understand what had happened. The driver learned that the worker was an outer hand signaler, otherwise known as an OHS for the track work authority, TWA.

[00:38:19] Work site at Dora Creek bridge at 127.1 kilometers. The OHS had been instructed by the protection officer PO for the work site to remove the railway tracks, signals or RTS is being used for protection of the TWA. The instruction was made in the knowledge that there was a train approaching, the OHS location, but no warning or other fake information was relayed to the worker.

[00:38:48] In relation to the proximity of the train, HTSP found an unapproved practice occurred during the application of the approved method of protection of a TWA. This practice involved, the person managing the safe, working the PO. Instructing workers to remove the RTS used to protect the work site while trains work closely approaching.

[00:39:13] This was for the purpose of improving train operations. This practice put the track worker involved at risk, and there was no defined process or method for protecting this worker. This practice was not part of the recognized methodology of using a TWA as established by the rail infrastructure manager, Sydney trains, Sydney trains acknowledged an unapproved practice occurred during the tub TWA, whereby workers were directed to remove the RTS while the train was closely approaching its location.

[00:39:46] Sydney trains have included this issue in their change request process for network rules. The amendment will reinforce the existing requirement in step 12, as it relates to the TW a using inner and outer hand signal LER protection in that both the inner and outer protection must be replaced immediately after the passage of each rail traffic movement.

[00:40:12] At TSB also says an incapacitating medical event likely caused a collision with Trane involving a BK one, one seven helicopter in new south Wales on the afternoon of 17, August, 2018, the pilot of a Kawasaki heavy industries BK one, one seven helicopter was conducting firebombing operations, approximately nine kilometers west of.

[00:40:39] Lula doula, new south Wales. The pilot was on the third flight of the day and was conducting repeated water bombing of a fire on plot road, Woodburn new south Wales on the fifth fire bombing circuit at this location, the pilot filled the slug Bambi bucket without incident from a nearby dam and departed towards the fire area.

[00:41:04] Shortly after the helicopter diverted off course. The bucket and long line became caught in trees and the helicopter collided with the train, the pilot was fatally injured and the helicopter was destroyed. The HTSP found that it was likely the pilots suffered a incapacitating medical event. As a result, the pilot unintentionally diverted off track leading to the bucket, becoming entangled in the trees and causing the helicopter to collide with terrain pilots.

[00:41:32] Post-mortem identified a. Focus of acute inflammatory change in the heart muscle, a condition known as, as lymphocytic myocarditis, this condition is capable of causing sudden impairment or complete incapacitation. Well, it is unlikely to have known they suffered from this condition. There are no risk factors for the development of this condition and it cannot be detected by medical screening.

[00:41:58] The pilots post-mortem also identify coronary heart disease, which is capable of causing sudden impairment. Any incapacitation. This condition was being effectively managed by medication. Despite the pilot suffering from these two heart-related conditions, there was insufficient evidence to determine if they contributed to the accident.

[00:42:18] The TSB also determined that the pilot was known to use an over-the-counter medication for the treatment of hayfever that although labeled as non-sedating was not approved for use while conducting flight operations. Finally, the pilot did not wear the upper torso restraint correctly. Although on this occasion, the accident was unsurvivable.

[00:42:38] The use of such shoulder harness restraints greatly reduce the likelihood of fatal head injuries. They say they also say undetected water contamination led to fuel exhaustion and forced landing of a Cessna four 41 in Western Australia on March 2nd, 2018. A Skipper’s aviation Cessna, four 41 conquest departed, a scheduled passenger service from Fitzroy crossing in broom, west or Western Australia with one pilot and nine passengers onboard during descent, the fuel level low annunciators illuminated.

[00:43:15] The pilot observed that both fuel quantity gauges indicated sufficient fuel remaining and continued flying towards broom. The right engine began, surging followed by a similar surging from the left engine, subsequently the right engine lost power and the pilot conducted an engine failure checklist. The pilot declared Mayday and advise air traffic control that as the left engine was still operating, the aircraft would be able to reach broom.

[00:43:40] However, the left engine also lost power and both engines were unable to be restarted. The pilot landed the aircraft safely on the nearby highway, there were no injuries and the aircraft was on damaged ATS, be found due to water contamination in fuel tanks. The aircraft fuel quantity gauges were significantly over reading on the day of the occurrence.

[00:44:01] And previous days the water contamination had existed for some time without being detected by multiple pilots. Feel quality testing. All of the pilot routinely compared indicated versus calculated fuel quantities and indicated versus flight plan fuel quantities. The pilot did not routinely conduct to other methods stated in the operators procedure for cross checking fuel quantity gauge indications.

[00:44:29] In addition, although the operator had specified multiple methods of crosschecking fuel quantity, gauge indications for its C four four one fleet. There were limitations in the design definition or application of these methods, the primary method. Indicated versus calculated fuel was self-referencing in nature and not able to detect gradual changes in the reliability of fuel quantity.

[00:44:54] Gauge indications. Pilots also did not record and were not required to record sufficient information on flight logs to enable trends or patterns in fuel quantity, gauge indications to be effectively identified. And pilots did not routinely crosscheck information from fuel quantity gauge indications with information from the independent fuel.

[00:45:14] Totalizer the fuel level, low annunciators likely eliminated approximately 30 minutes before fuel was exhausted in each tank. And when the aircraft was still within range of suitable, alternative airports, however, the pilot disregarded the enunciations and relied on the erroneous fuel quantity indicators, and continue to broom until the engines lost power.

[00:45:36] At which point, a forced landing on the highway was the only remaining option. The operator increased the frequency of fuel quantity, comparison checks to a known quantity to ensure continued quality measurement accuracy, specify Clare requirements for determining discrepancies. When using fuel totalizer figures implemented additional fuel management record keeping and increased management oversight of its broom operations.

[00:46:03] It also increased focus on fuel management procedures during training. That’s it for that one. And now we’ll move on to a story of a Learjet 31, a performing a role on descent. The Learjet 31 alpha corporate jet took off from London, Biggin hill airport unite in the UK airport of destination was Pharaoh Portugal.

[00:46:29] It was a positioning flight without passengers conducting an instrument or. It was a positioning flight without passengers conducted under instrument flight rules. The pilot in command occupied the left-hand seat and was pilot flying. The copilot in the right-hand seat was the pilot monitoring. Two employees of the company were seated in the cabin.

[00:46:51] After about one hour of flight time at 1130, the aircraft was in Portuguese airspace during descent, the pilot and command asked the copilot. If he agreed to. Fly a roll about the longitudal act longitudinal access of the aircraft. The co-pilot provided the BFU with a written statement that he did not agree to such a flight maneuver and had told the pilot in command such according to the copilot statement and the flight data recorder, the pilot and command had disengaged the autopilot at 1136.

[00:47:29] At about 13,200 feet pressure altitude and flew the aircraft manually at 1137 at 11,500 feet pressure altitude to steep turns with a bank angle of about 140 degrees. Each were flown left and right at 1138, the pilot conducted. The role about the longitudinal access of the airplane also at about 11,500 pressure altitude leveling off 10 seconds later, the flight maneuver was initiated at 301 knots indicated airspeed during, and the role airspeed decreased continuously leveling off.

[00:48:10] Occurred at 251 knots indicated during the, the initiation of the flight maneuver, a maximum load factor of 2.47 G occurred, which decreased continuously to one G during the flight. No one was injured at 1149 hours. Landing occurred at Pharaoh airport Portugal. In May, 2019, the operator charged another company with routine readout of the flight data recorder, data as part of the flight data, the monitoring program.

[00:48:44] After the read out the flight maneuver was identified duty, exceptionally high role angled data on June 4th, 19, the operator reported the occurrence to the BFU. So nobody who was on that flight, the two crew in the cabin or the copilot, nobody actually reported it. It was a flight data that caught that one.

[00:49:07] Now we’ll head back to the U S and see what OSHA has been up to first app. We have of OSHA sites to Michigan companies after demolition collapse, that killing power plant in Manchester, Ohio kills two workers. When the Kellen power generation stations building collapse unexpectedly on December 9th, 2020 it’s steel beams fell on and killed two workers employed to demolish the facility, a labor cutting steel and a truck driver preparing to move the scrap metal off site.

[00:49:37] OSHA investigated the multi-employer multi-employer project and cited two Michigan companies, general contractor, Alamo of Detroit and SCM engineering demolition, Inc of east China. OSHA cited both for multiple safety violations on the demolition project, including violations of the. General duty clause and failing to inspect the site regularly to detect potential hazards resulting from the demolition process, such as weakened or deteriorated floors, walls, and loosened material.

[00:50:11] OSHA has determined that the company’s allowed employees to continue working under hazardous conditions without adding shoring, bracing or other means to stay to the structure and failed to train them on identifying potential hazards. Some of the most dangerous construction projects are those that involved hushing buildings said area director, Kenneth Montgomery in Cincinnati.

[00:50:35] This tragedy could have been prevented if the employer protected their workers with proper planning, training, and appropriate personal protective equipment. By complying with OSHA standards, he said OSHA proposed penalties of $181,724 to Alamo. For one willful repeat serious and other than serious safety violations, SCM engineering faces penalties of 12,288 for three serious violations.

[00:51:06] And OSHA has announced a role proposal to clarify handrail and stair rail system requirements in general, distri walking, working surfaces. U S department of labor’s occupational safety and health administration is proposing updates to the handrail and stair rail system requirements. For general industry walking, working surfaces standard, OSHA published a final rule on walking, working surfaces and proposed personal protective equipment in November, 2016.

[00:51:37] That updated requirements for slip trip and fall hazard. The agency has received numerous questions asking when handrails are required and about what height requirements for handrails on stairs and stair rail systems. The proposed rule does not reopen for discussion. Any of the regulatory decisions made in 2016, rulemaking.

[00:51:57] It focuses solely on clarifying some of the requirements for handrails and stair rail systems finalized in 2016. And I’m providing flexibility in the transition to OSHA’s newer requirements. And that’s it for this week’s news. Remember, you can find full show notes with links@safetyinvestigations.net.

[00:52:16] You can follow our subscribe to this podcast on most podcasting apps. Thanks for listening and have a safe week.

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