Safety Investigations News 6/4/2021


Safety Investigations news for 6/4/2021

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Investigation: AO-2021-021 – Flight below the minimum safe altitude involving Beechcraft Baron 95-B55, VH-CBG, 5 km north of Parafield Airport, South Australia, on 13 May 2021

Investigation: AO-2021-022 – Tail rotor blade strike involving Leonardo Helicopters AW139, VH-TJK, 19 km north east of Sydney Airport, New South Wales, 30 May 2021



Dutch Safety Board 


Fort Myers behavioral healthcare center agrees to revamp its workplace violence prevention program after OSHA investigation of five incidents | Occupational Safety and Health Administration

Lack of hazardous energy control safeguards, unexpected steam release led to two workers’ deaths at Department of Veterans Affairs’ West Haven campus | Occupational Safety and Health AdministrationTranscript

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Disclaimer: This transcript is auto generated and is not manually checked for errors. It more than likely contains very significant errors.

21-06-04 News

This is your safety investigations news brief for June 4th, 2021. I’m your host Charles currant. And here are this week’s headlines. The U S national transportation safety board announced it was investigating five new crashes this week. It also issued a preliminary report for its investigation of the fatal May 18th, 2021 crash of an air tractor, Inc 85.

[00:00:22] in Clayton, Louisiana. And it issued three new safety recommendations with its final report on the fatal September 20th, 2019 rollover bus crash near Bryce canyon, city, Utah, the Australian transport safety bureau. ATS announced it as investigating one new crash and two serious incidents this week, the national bureau of air accidents, investigation of Ukraine, the NBA AI.

[00:00:51] Or at least the preliminary report of its investigation into a Cessna C five 10, which struck runway sidelights on March 3rd, 2021, and the Dutch safety board warns of hazards of returning aircraft to service after COVID-19 storage and us OSHA says Fort Myers behavioral healthcare center agrees to revamp its workplace violence prevention program after OSHA investigation of five incidents.

[00:01:16] And they also say lack of hazardous energy controls and safeguards, unexpected steam release led to workers deaths at department of veterans affairs in west Haven campus

[00:01:37] links to all stories is discussed, can be found in the show notes, which will be If you choose to look them up. So this week the U S NTSB announced it is investigating several new accidents. The May 28th crash of a Lank air evolution airplane in McDermott, Ohio. The crash of assess.

[00:02:01] Now one 72 S in Eden, Utah on May 29th. He May 29th crash. Also have a P Z L dash one oh four airplane in Houston, Texas. And the crash of assessment citation five oh one airplane in some Mirena, Tennessee on May 30th and the June 1st crash of a beach, a two, three airplane in pinnacle, North Carolina. They also issued the preliminary report for their investigation on an air tractor, Inc.

[00:02:30] 85 oh two eight airplane in Clayton, Louisiana. They say on May 18th, 2021, about 1325 central daylight time and air tractor airplane, November eight, eight, seven, Lima alpha was substantially damaged when it was involved in a accident near Clayton, Louisiana, the pilot was fatally injured. The airplane was operated as a title 14 code of federal regulations, part one 37 aerial application flight.

[00:02:56] The operator stated that the pilot had completed several flights already and was in the process of spraying product on a field. When the accident happened, witnesses stated that the airplane had just completed a spray pass and was in the process of turning around. During the turn, the airplane pitched up, rolled to left into a steep bank so that the wings were almost upside down.

[00:03:18] One witness stated that it looked like the pilot didn’t pull out of a barrel roll. They say the airplane fell out of the sky and impacted the ground inverted on a Southeast heading a post accident. Examination revealed ground impact marks from the outline of the wings, which indicated the airplane impacted the ground in a flat and wings level, inverted attitude.

[00:03:40] The wing fuel tanks were found breach and a significant amount of fuel was noted in the dirt. Under the airplane. The cockpit was crushed into the ground and partially buried. The propeller blades were twisted and bent, and also partially buried on the ground. The flaps were found near full extension. A sat lock GPS was removed from the airplane and sent to the NTSB vehicle recorders lab for examination and data.

[00:04:05] Download. And this week they issued three safety recommendations with their final report on the investigation of a fatal September 20th, 2019 rollover bus crash near Bryce canyon city, Utah in its safety recommendations. The NTSB asked the national highway traffic safety administration to require lane departure prevention systems on all new commercial motor vehicles with a gross vehicle weight rating above 10,000 pounds.

[00:04:34] They also recommended that they require all new buses, other than school buses with a gross vehicle, weight rating above 10,000 pounds to meet a roof strength standard to provide that provides maximum survival space for all seating positions. And they also suggest that they require all new buses other than school buses with a gross vehicle, weight rating above 10,000 pounds to meet a window glazing standard that prevents occupant ejection.

[00:05:01] And I guess our children in school buses don’t matter anyway, in the report, the NTSB also reiterated five previously issued safety recommendations, including two concerning stability control systems for commercial vehicles and classified five others as closed. Unacceptable action superseded. The crash happened bend when a medium sized bus was traveling east on Utah street.

[00:05:26] Route 10 operated by a 60 year old driver and carrying 30 passengers during a trip from Los Angeles to salt lake city. At a recorded speed of 64 miles per hour in a posted 65 mile per hour zone. The buses, right wheels departed the right edge of the roadway. The driver steered left and the bus went into the westbound lane.

[00:05:47] The driver then steered sharply to the right, causing the bus to become unstable. The bus then rolled 90 degrees onto his left side, sliding for about 85 feet until its roof struck the guardrail. Rolled over the guard rail and came to a rest on its wheels. Straddling the damaged guardrail. He crashed killed four passengers, 17 others suffered serious injuries.

[00:06:09] Nine more suffered, minor injuries. And a total of 13 of the 30 passengers were ejected from the bus. The driver was not injured. The NTSB determined the probable cause of the crash was the drivers of failure for undetermined reasons to maintain the bus within its travel lane. And his subsequent steering overcorrections, which caused the bus to become unstable and rollover factors that contributed to the severity of the crash, include the bus roofs, deformation and collapse, which created ejection portals and compressed passenger survival space.

[00:06:42] The national highway traffic safety administration is failure to develop an issue standards for bus routes, strength and window glaze to enhance the protection of bus passengers. The lack of passenger lap shoulder belts on the bus contributed to the objections and severity of injuries, NTSB investigators, determined driver experience licensing, alcohol or drug use fatigue, distraction, and or medical issues were not factors in the crash nor was the mechanical operation of the bus.

[00:07:12] Similarly highway design markings, signage, and friction, characteristics of the highway were not considered as factors in the crash. Motor carrier operations and state or federal oversight of the motor carrier, American shin Jai Singh, Gaia. I’m not sure how that’s pronounced. We’re also ruled out as factors in the crash.

[00:07:34] Highway accident report is available online link in the show notes. The docket will also be linked in the show notes. The Australian transport safety bureau or a TSB is investigating a collision with training accident involving a Robinson  helicopter, 70 kilometers west Northwest of Hey new south Wales on 26 May, 2021.

[00:07:56] During aerial agricultural operations, the helicopter collided with terrain, the helicopter sustained substantial damage. And the pilot, the sole occupant was fatally injured. They’re also investigating a flight below minimum safe altitude involving a Beechcraft Baron 95 dash B 55. On 13th, May, 2021 while conducting a visual approach at night under instrument flight rules to runway 21.

[00:08:23] Right at perifield airport. The aircraft was maneuvered outside the circling area while below the minimum safe altitude, the pilot lost visual contact with the runway and after regaining visual contact maneuvered the aircraft to rejoin the circuit for runway two, one, right. And also investigating a tail rotor blade strike involving Leonardo helicopters, a w one 39 in the vicinity of Shelley beach, about 19 kilometers, Northeast of Sydney airport, new south Wales on 30 may, 2021, they say while conducting single pilot EMS flight, the aircraft was flown into a confined area and unimproved landing site with the aid of goggles.

[00:09:10] During the later stages of the approach, the aircraft drifted towards train the crew, aborted the approach and elected to conduct a precautionary landing about one kilometer away inspection of the aircraft, vertical fin and tail rotor blades revealed aircraft had contacted tree foliage while maneuvering in the confined area.

[00:09:30] The next story is from the national bureau of air accidents. Investigation of Ukraine also known as the NBA AI, they released their preliminary report of investigation into a serious incident, which took place with a Cessna C five 10 on March 3rd, 2021. The circumstances in their report say on three, three, 2021, the Cessna C5 Tam was performing a night flight in visual meter out logical conditions from.

[00:09:59] Uniform kilo, kilo kilo two uniform kilo, Oscar Oscar at 1802 UTC. The crew requested permission from the taxi controller to start taxing taxing of the aircraft from the L eight stand to the start point of taxiway. TW two was performed along the apron. Following the follow me vehicle, then the crew taxi long T W2.

[00:10:26] Ahead of the Cessna C five 10 N a N seven four aircraft of the aviation of the national guard of Ukraine was taxiing for takeoff at 1808. The crew of the C5 10 got in touch with the airport traffic control tower and reported. They had reached the holding position near runway two six. The controller issued a clearance to the crew to occupy runway two, six, and instructed to await further commands.

[00:10:55] According to the video recording from a surveillance camera located opposite the junction of TW two with runway two six at 1810. The Cessna crossed runway two six passed over. Sidelight number 45 and stopped along the left side lights of runway two, six and 1812. The S the controller gave the Cessna permission to take off according to the landing gear tracks of the aircraft.

[00:11:21] The aircraft passed through the sidelights number 44 43 42, and then move to the left of the line of lights and took off on a heading of two, five, nine. As a result of the collision and incursion lights, number 44 and 42 were destroyed. The aircraft was not damaged. The Dutch safety board is currently investigating two serious incidents involving airliners that had not been used for some time due to the pandemic.

[00:11:50] Immediately after takeoff, both planes encountered problems with speed and altitude indications. These ongoing investigations already give the Dutch safety board a reason to issue warning regarding the risks with recommissioning of commercial aircraft. It says so on October 3rd, 2020, a Boeing seven 37 dash 800 returned to Amsterdam.

[00:12:17] I don’t know how to pronounce these names. Uh, airport following an airspeed anomaly on April 24th, 2021, a Boeing seven 37 dash 700 diverted to Amsterdam. The same airport. When the flight crew noticed a discrepancy in the altitude and airspeed data after takeoff from Rotterdam airport, when the aircraft are temporarily out of service, the systems that measure air pressure is covered.

[00:12:42] The this prevents the pipes from becoming clogged by insects. For example, the cover must be removed again before using the aircraft. After a long period of storage pipes that are the same system are normally loosened and cleaned, the pipes should then be reconnected. The air pressure system provides essential information for two important flight instruments, a spinoff or air speed indicator and altimeter.

[00:13:07] In one of these incidents, a productive cover was not removed in the other incident. Some pipes were not correctly connected in both cases. This led to pilots being presented with incorrect altitude and speed information. I apologize if this reads a little strange, because this is translated from Dutch in both incidents, the Dutch safety board is investigating.

[00:13:29] The weather conditions were such that the crew could use visual references outside of the aircraft. As a result, they succeeded in controlling the speed and attitude of the aircraft. With the warning. The Dutch safety board wants to alert airlines to the safety risks that can arise. When aircraft are put back into service, after a period on the ground, the expectation is that this will happen frequently in the coming months due to the relaxation of the COVID-19 measures.

[00:13:58] The U S department of labor, occupational safety and health administration has reached a settlement with Fort Myers, behavioral health care and residential treatment facility to prevent future employee injuries after a series of violent incidents in the spring and fall of 2020. Solace care Inc has accepted and OSHA finding that it exposed behavior health technicians to attacks on five occasions in 2020, when workers were spit on kicked in the ribs and suffered sprains cuts fractures, and a concussion OSHA issued the center a serious citation for failing to adequately protect workers from patient on staff violence and the other than serious citation for failing to report a worker hospitalizations within 24 hours.

[00:14:45] Solace care agreed to pay $6,747 for these citations. As part of the settlement, the company will hire qualified consultant to improve its workplace violence prevention program. Develop a way to alert workers to violent patients and triggers that may lead to violence. Revise its safety protocols, increased staffing, provide worker training and improve communication about safety.

[00:15:09] And two workers at a Bridgeport veteran’s healthcare facility suffered fatal injuries caused by hot steam after a metal fixture on the main steam line blew off, the workers had just finished making repairs to the steam pipe within the us department of veterans affairs, Connecticut healthcare system, west Haven campus in November of 2020.

[00:15:31] U S department of labor, OSHA inspection determined that the VA Connecticut failed to protect employees from struck by and burn hazards. And the agency identified numerous deficiencies in the facilities, lockout tagout program. One of the workers was an employee of the VA, Connecticut, and the other was an employee of Mulvaney and mechanical, Inc.

[00:15:54] A Danbury based contractor. OSHA also found the VA Connecticut program failed to properly shut down to avoid additional or increased hazards to employees relieve or renders safe, all potentially hazardous residual energy, such as condensate, water, maintain adequate procedures for isolating each steam main branch supply in campus buildings conduct a periodic inspection of all lockout tagout procedures to correct any deviations or inadequacies.

[00:16:26] Provide adequate training to supervise your employees, retrain employees when there was a change in their job assignments or a change in machines, equipment, or processes that presented a new hazard, notify infected employees of the application and removal of lockout, tagout devices inform Mulvaney mechanical of VA Connecticut’s lockout, tagout procedures.

[00:16:50] And ensure each authorized employee affects a personal lockout or tagout device to a group lockout device before working on the machine or equipment. OSHA issued nine notices of unsafe and unhealthy working conditions to the VA, Connecticut for one willful three, repeat in five serious violations under executive order.

[00:17:12] One two, one nine, six federal agencies must comply with the same safety and health standards. As private sector employers covered under the OSHA act. The federal agency equivalent to a private sector. Citation is a notice of unsafe and unhealthy working conditions. OSHA cannot propose monetary penalties against another federal agency for failure to comply with OSHA standards.

[00:17:37] If the U S department of veterans affairs, we’re a private sector employer. The total penalty would amount to $621,218. OSHA sided Mulvaney mechanical, Inc for four serious violations with $38,228 in proposed penalties for failing to develop and document and use lockout tagout procedures for the control of potentially hazardous energy.

[00:18:03] Adequately train employees on the methods necessary to isolate and control energy inform VA, Connecticut of Mulvaney mechanicals, a lockout tagout procedures, and ensure that each authorized employee affects a personal lockout or tagout device to the group lockout device. And that’s it for this week’s news.

[00:18:22] Remember, you can find full show notes with You can follow or subscribe to this podcast on most podcasting apps. And thank you for listening.


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