Safety Investigations News 6/18/2021 – Safety Investigations Podcast
Safety Investigations news for 6/18/2021
For full show notes with links and to subscribe to this audio podcast go to http://safetyinvestigations.net
NTSB
https://www.ntsb.gov/investigations/AccidentReports/Pages/RRD21FR010-preliminary-report.aspx
AAIB
https://www.gov.uk/aaib-reports/aaib-investigation-to-sikorsky-s-92a-g-lawx
ATSB
http://www.atsb.gov.au/publications/investigation_reports/2021/aair/ao-2021-023/
http://www.atsb.gov.au/publications/investigation_reports/2021/rair/ro-2021-006/
http://www.atsb.gov.au/publications/investigation_reports/2021/aair/ao-2021-016/
http://www.atsb.gov.au/publications/investigation_reports/2018/aair/ao-2018-026/
CSB
https://www.csb.gov/chemtool-rockton-il-explosion-and-fire-/
OSHA
https://www.osha.gov/news/newsreleases/region1/06152021
https://www.osha.gov/news/newsreleases/region2/06162021
https://www.osha.gov/news/newsreleases/region6/06152021-1
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Transcription
Disclaimer: This transcript is auto generated and is not manually checked for errors. It more than likely contains very significant errors.
SIP News 21-06-18
This is your safety investigations news for June 18th, 2021. I’m your host Charles Grant in this week’s episode, the NTSB announced it is investigating five new crashes and they issued the preliminary report for the ongoing investigation of the May 29th, 2021 fatal crash of a Cessna 1 72 S near Ogden, Utah.
[00:00:19] The aunties be issued the preliminary report for its ongoing investigation of the mate. 1922. Accident that killed Pan-Am railways worker during a switching operation near Newington New Hampshire. The AA be released its report on a Sikorski S 92. A controlled flight towards terrain at TSB also is investigating a separation issue involving Augusta Westland.
[00:00:45] AWU 1, 3, 9, and a Piper PA 44 dash 180 near Mangalore airport Victoria on six, June, 2020. The HTSP is also investigating a safe work breach near crystal Brook, south Australia on 10, June, 2021. And they released their preliminary report on the loss of control and collision with terrain involving assess.
[00:01:08] Now our 1 72 K near Sutton new south Wales on 13, April, 2021. They also released their report on the loss of control and collision with water involving a Eurocopter
[00:01:24] Uh, near Hardy reef, Whitsundays Queensland on 21, March, 2018. The U S CSB is monitoring an explosion and fire event at the chem tool plant in rock Rockton, Illinois. That occurred on June 14, 22. I won the us department of labor sites, Rhode Island, medical practice owner for exposing employees to coronavirus in new province, west Greenland.
[00:01:51] OSHA sites, Bronx contractor. After 21 year old labor erecting scaffolding suffers a deadly fall at Brooklyn to building. And a federal inspection finds San Marcos tortilla manufacturer repeatedly exposing workers to amputation dangers
[00:02:16] U S national transportation safety board announced it is investigating five new crashes this week, a June 13th crash of a Piper, PA 32 dash two 16 year Madisonville, Texas. The June 16th crash of a Landcare evolution in lone tree, Colorado, June 15, the crash of an experimental vans RV six near Doylestown, Pennsylvania, the June 15th crash of a air tractor.
[00:02:44] near Paragould, Arkansas, and the June 15th crash of a Cirrus Sr 20 near Truckee, Calvin. And the end has be issued a preliminary report for its ongoing investigation of the May 29th, 2021 fatal crash of a Cessna 1 72 S near I’ve been Utah on May 29th, 2021 about 1,000 hours. Mountain daylight time, a Cessna 1 72 S airplane, November one seven to seven.
[00:03:14] Tango was destroyed when it was involved in an accident near Ogden. The flight instructor and student pilot were fatally injured. The airplane was operated as a title 14 code of federal regulations, part 91 instructional flight, according to the airplane operator ATP flight school. This was an introductory training flight designed to assess the student’s skill level from preliminary automatic dependent surveillance broadcast eight ESB data showed the instructor and student pilot departed the flight schools, local base at.
[00:03:49] Hickory airport Ogden, Utah, about oh 9 41 and immediately turned to an easterly heading the AASB data. Ceased five nautical miles east of the departure airport at oh 9 46 and was subsequently picked up by radar nine out of 10 miles east. Ogden at oh 9 49, the airport flew south of pine view reservoir and then turned Northwest while maintaining an altitude of about 2000 feet AGL at oh 9 55.
[00:04:22] The airplane turned to the Northeast into a canyon where it began to climb over rising train in the next 60 seconds. The airplane descended to about 1000 feet AGL. Or about 7,550 feet MSL below the Ridge lines on either side of its flight path. The flight track ceased at oh 9 56 and 40 seconds. The airplane was located in mountain is trained at an elevation of about 8,000 feet.
[00:04:49] MSL. All major sections of the airplane were accounted for at the accident site. The debris field was small and comprised of mostly windshield fag. The first point of impact was marked by a tree located 30 feet west of the main wreckage, which came to rest on a northerly heading and was consumed by post impact fire.
[00:05:09] The wreckage was retained for further examination and they also issued the preliminary report for their ongoing investigation of a May 19th, 2021 accident that killed a Pan-Am railways worker during a switching operation near Newington, New Hampshire. And that report reads. A Pan-Am railways conductor of train Pan-Am local was fatally injured while dropping off and picking up rail cars in the sub comm industrial track ne in Newington, New Hampshire, the train consisted of two locomotives and two loaded rail cars.
[00:05:48] The train crew consists of one engineer with 34 years of experience, one conductor with 42 years of experience. The train crew was tasked with picking up three empty rail cars and setting out two loaded rail cars. The sub comm industrial track is approximately 200 feet long with an east to west descending grade.
[00:06:10] Immediately. Before the accident, the train crew moved the two loaded rail. East into the industrial track and successfully coupled them to the first rail car in the track. Preliminary information indicates that two of the three rail cars to be picked up were not properly coupled together after five previous attempts to couple them, the conductor was pinched between the two coupling mechanisms during the sixth attempt to couple of the rail cars.
[00:06:37] The conductor was transported to the hospital by ambulance, where he died from his injury. National transportation safety board, investigative team examined the accident location collected and gathered preliminary information, conducted interviews, inspected equipment, and completed the accident.
[00:06:53] Reenactment. While on scene, the anti-ice investigation into this accident is ongoing. Future investigative activity will focus on causal factors and railroad worker safety and industrial facility. Parties to the investigation include the federal railroad administration. Pan-Am railways, brotherhood of locomotive engineers, and train men, and the international association of sheet metal, air rail and transportation workers.
[00:07:20] The UK is air accident. Investigation branch released their report on a Sikorsky controlled flight towards terrain and Warburg star. It says. On approach to a private landing site in conditions of reduced visibility shortly before night, the pilots of a Sikorsky golf, Lima, alpha whiskey x-ray became uncertain of their position.
[00:07:45] And the helicopter descended to within 20 feet of rising train, close to a house during the subsequent emergency climate lo indicated airspeed engine torque increased to 131%. And the pitch attitude of the helicopter was unstable. The helicopter made another approach to the landing site and landed without damage or injury to the occupants.
[00:08:07] The investigation identified the following factors, standard operating procedures for altitude alert, setting, stabilized approach criteria and crew communication were either absent or not effective, a strong desire as a customer facing director, not to inconvenience the client, which was. Potentially intention with his obligation as the coach to ensure a safe flight uncertainty about the rules of air when landing and attitudes, behavioral traps, and biases likely to have contributed to the occurrence.
[00:08:44] The circumstances of the serious incident indicate the need for greater awareness of hazards, of operating in degraded visual conditions and highlight the potential safety benefits of point and space approaches. Atlantis. The AIB made eight safety recommendations in these areas. It recommended that the civil aviation authority published guidance on the meaning and intention of the phase of flight alleviations in UK S E R a were detailed as, except for takeoff and landing to better enable pilots to plan and act on minimum height requirements for safe operation.
[00:09:23] It recommended that star speed limited specify in its operations manual stabilized approach criteria for visual approaches, including at off airdrome landing sites. It recommended that the civil aviation authority encourage the development and deployment of point in space operations at landing site.
[00:09:45] And it recommended that the civil aviation authority revise its guidance on helicopter flight in degraded visual conditions to include further information on managing the associated risks. It recommended that star speed limited. Describe in its operations manual for the Sikorsky S 92 helicopter. The criteria for setting barometric altitude alert values at each stage of flight.
[00:10:11] It recommended that star speed. Specify in its operation manual, a formal process for crew members to monitor escalate concerns. And if necessary take control during a flight, it is recommended that the civil aviation authority ensure that operators show clear evidence within their system for operational control as required by UK Oro dot G E n.one one oh.
[00:10:39] Of how the tasking process separates the customer from the flight crew. And finally it recommended that the civil aviation authority assess the safety benefits and feasibility of helicopter flight data monitoring programs for onshore helicopter operators, conducting commercial operations, or non-commercial complex operations and publish.
[00:11:00] It’s fine. The operator informed the AAB that it has conducted a training day, focusing on the occurrence, gained approval from the client to install cloud base and visibility monitoring equipment at the landing site transferred the role of safety manager from the commander to the compliance manager and has begun the process of delegating responsibilities for the SMS, from the accountable manager to the compliance manager.
[00:11:32] Added the following note to the front page of the GL three procedure on the EFB note, the GL three is not an aid for poor or marginal visual conditions to be used as visual approach aid in VMC only and included inadvertent IMC at low level and low IAA. As an additional training requirement to be delivered during simulator training issued a flying staff instruction, updating the OEM part, a section to address operations in marginal weather conditions.
[00:12:11] The FSI covered the following areas. Definition of marginal conditions by day and night departure at night in VMC air speeds to be flown indicated airspeeds to be. Assessments of cloud base at off airfield landing sites, light levels, and time of year planning and briefing of approaches and departure routes.
[00:12:37] Use of the GL three, the requirement for an alternate plan, operational control and supervision of the go no-go go decision in marginal conditions, operational control and supervision of management, post holders. The operator stated that it intends to revise the OEM parts, a B, and D to include NSLP on deviation calls in multi pilot operations and explore the feasibility to install cloud-base and visibility equipment.
[00:13:10] At other landing sites, the Australia and transportation safety bureau is investigating a separation issue involving two aircraft, a a Maura been aviation services, PA 44 1. And a Babcock mission critical services. AWU 1 39 above Mangalore airport in Victoria on six, June, 2021 at 1556. The AWU 1 39 was flying southbound toward Mangalore at 3,100.
[00:13:42] At 1556, the AWU 1 39 was flying southbound toward Mangalore at 3,100 feet above mean sea level. At the same time, the PA 44 was conducting a practice instrument approach to Mangalore the PA 44 commenced, a missed approach from below 3000 feet in a northerly direction towards Mangalore and the pilot broadcast at the aircraft would climb to 3,900.
[00:14:07] Shortly after the PA 44 began climbing the pilot of the AWL, 1 39 received a traffic collision and avoidance alert, a TKs alert and maneuvered the aircraft to increase separation between the two aircraft. Both flights continued without further incident. The evidence collection phase of the investigation will include reviewing recorded communications, air, traffic control, surveillance, data, and weather information, and interviews with the flight crew.
[00:14:36] The final report will be released at the conclusion of the investigation. And the TSB is also investigating a safe work breach near crystal Brook, south Australia on 10, June, 2021. The protection officer obtained an authority to undertake ultrasonic testing between crystal Brook and Konami. However, the road rail vehicles on tract between Rocky Creek and crystal Brook, about three kilometers prior to where the authority was to.
[00:15:05] As part of the investigation, the TSB will obtain a report interview the protection officer and involved crew and gather additional information. The report will be published at the conclusion of the investigation. The TSB issued its preliminary report on the loss of control and collision with Trane involving a Cessna R 1 72 K near Sutton, new south Wales on 13th, April, 2021.
[00:15:33] It says on 13, April, 2021 at about 1324 Eastern standard time. The pilot of a Cessna, our 1 72 K aircraft registered Victor hotel, Delta Lima, alpha departed Canberra airport, Australia, capital territory with an observer on board to conduct power line survey, work to the north of Sutton new south Wales at 1622 Delta Lima alpha.
[00:16:01] Tele D’Andrea lane and proceeded with survey work, concentrating on power lines, servicing properties to the east of the lane. Following the completion of two orbits at 1624, the pilot initiated a right turn and track to the Northeast witnesses in the area, described the aircraft flying lobe of the trees before commencing a left banking turn followed by a steep descent and collision with.
[00:16:27] The witness reports indicated that the loss of control and entry into the S a span preceded the ground impact the pilot and the observer were fatally injured analysis of recorded Garmin GPS and Oz runways flight data identified that the last garment GPS data point at 1624 and 48 seconds show the height of the aircraft to be about 164 feet above ground.
[00:16:53] And about 115 meters from the wreckage, the final Oz runways data point at 1624 and 50 seconds was about 80 meters from the accident site. The wreckage was located in an open field about 30 meters east of Telegu Andrea Lane, and about 10 kilometers to the west of . There was little spread of wreckage and few parts liberated in the accident, sequence, larger items, including the propeller and the right under care’s leg were found next to the fuselage items from the luggage locker were located within five meters of the initial impact point.
[00:17:34] The most distant item from the main wreckage was the aircraft battery, which was found near the edge of Telegu Andrea. Examination of the records show that the aircraft impacted the ground in a near vertical nose down attitude that the Lima alpha was a single engine Cessna, 1 72 K aircraft. It was manufactured in the United States in 1977 with serial number Romeo, 1 7 2 2 8 0 Niner and was first registered in Australia in 1978.
[00:18:06] To date the HTSP has examined the wreckage collected items for further examination, interviewed witnesses, retrieved flight related, electronic data, collected weather data from the bureau of meteorology and interviewed the operator. The investigation is continuing and will include further examination and analysis of the aircraft fight path, including analysis of recorded flight data, pilot qualifications, experience, and medical history, pilot flight, and duty period.
[00:18:34] Aircraft weight and balance aircraft maintenance records, flight survey, operational procedures should a critical safety issue be identified during the course of the investigation. The HTSP will immediately notify relevant parties so that appropriate and timely safety action can be taken. Final report will be released at the conclusion of the investigate.
[00:18:55] It is B acknowledges the assistance of the new south Wales police force in supporting the TSPs onsite investigation team through the evidence collection phase and operation, and the HTSP released its report on the loss of control and collision with water involving a Eurocopter ISI one 20 B here, Hardy reef with Sunday’s Queensland on 21, March, 2018.
[00:19:20] They say on 21, March, 2018. Eurocopter helicopter registered Victor hotel, whiskey, India, India, and operated by wit Sunday air services, departed Hamilton island, airport Queensland on a charter flight to Hardy reef onboard where the pilot and four passengers, the pilot conducted the approach to the pontoon landing site at Hardy reef into the wing.
[00:19:48] During the approach, the pilots slowed the helicopter to allow birds to disperse. The pilot was then planning to yall. The helicopter left into the intended landing position. And there was about 20 knots crosswind from the right of the intended position. When the helicopter was yawing left into position, just over the pontoon, the pilot noticed a message eliminate on the helicopters vehicle engine malfunctioned.
[00:20:15] And elected to conduct a go around during the go round. After the helicopter climb to about 30 to 40 feet, there was a sudden and rapid Yar to the left in response to the unanticipated rapid yacht. The pilot lowered the collective, but was unable to recover the situation. In the limited time available after the unsuccessful action to recover the rapid left jaw, the pilot did not deploy the helicopters, floats and conduct a controlled ditching.
[00:20:43] The helicopter collided with the water in a near level attitude with forward momentum and front right corner. Almost immediately, the helicopter rolled to the right and started rapidly filling with water, the pilot, and two of the three rear seat passengers evacuated from the helicopter with minor injuries.
[00:21:03] Although impact forces were survivable. The other two passengers were unconscious following the impact and did not survive the accident. The helicopter sank and associated with unfavorable weather conditions. In the days, following the accident, subsequent searches were unable to locate and recover the elephant.
[00:21:20] Although, none of the possible VEMD messages required immediate action by the pilot, the pilot considered a go round to be the best option. Given the circumstances at the time during the go round, the helicopter continued yawing slowly to the left and the pilot very likely did not apply sufficient right pedal input to correct the developing Yar and conducted the go round into the.
[00:21:46] The helicopter then continued yawing left towards a downwind position until I sudden and rapid yaw to the left occurred in response to the rapid yaw. It is very likely that the pilot did not immediately apply full and sustained right pedal input the operator complied with the regulatory requirement for training and experience of pilots on new helicopter.
[00:22:10] However, the HTSP found the operator had limited processes in place to ensure that pilots with minimal flight time and experience on a new and technically different helicopter type, had the opportunity to effectively consolidate their skills on the type required for conducting the operators, normal operations, two pontoons.
[00:22:31] In this case, the pilot of the accident flight had 11 hours experience in command of the helicopter. And had conducted 16.1 hours in another and technically different helicopter type during the period of acquiring their experience associated with this limited consolidation on the , it is likely the pilot was experiencing a high workload during the final approach and a very high workload during the subsequent goal.
[00:23:02] In addition to limited consolidation of skills on the type, the HTSP found that the safety margin associated with landing the helicopter on the pontoon at Hardy reef was reduced due to a combination of factors. Each of which individually was within relevant requirements or limits. These factors included the helicopter being close to the minimum, all up weight, the helicopter’s engine power output being close to the lowest allowable.
[00:23:29] The need to use high power to make a slow approach in order to disperse birds from the pontoon and the routine approach and landing position on the pontoon requiring the pallet to turn left into a right crosswind. Anyhow, copter with a clockwise rotating main rotors. The HTSP also identified that the passengers were not provided with sufficient instructions on how to operate the emergency exits and the passenger seated next to the rear left sliding door emergency exit was unable to locate the exit operating handle during the emergency.
[00:24:05] And as a result, the evacuation of passengers was delayed until another passenger was able to open the exit. The nature of the handle’s design was such that its purpose was not readily apparent. And the plaque card providing instructions for operating the sliding door did not specify all the actions required to successfully open the door.
[00:24:26] The investigation also identified safety factors associated with the operators. Use of passenger volunteered weights for weight and balance calculations. The operator system for identifying and briefing passengers with reduced mobility, bird hazard management at the pontoons and passenger control at the pontoon.
[00:24:46] What has been done as result in July, 2019, the helicopter manufacturer released a safety information. Notice about unanticipated left yard in helicopters with a clockwise rotating main motor system. The notice provided detailed advice regarding the circumstances were unanticipated y’all can occur and the importance of applying full opposite.
[00:25:08] Right? Rudder pedal. If it occurred. The notice also stated that for helicopters with a clockwise rotating main motor system, to prefer your maneuvers to the right, as much as possible, especially in performance limited conditions. Following the accident, the operator implemented several additional processes for pilots transferring to new helicopter types and for operations on at pontoon.
[00:25:36] This included pilots conducting only into wind operations at pontoons until they had completed 20 hours on type the operator also introduced a safety management system, revised processes for obtaining accurate passenger weights and introduced training for pilots in how to avoid birds and how to inspect blades.
[00:25:57] Following a bird. In addition, the operator revised their pre-flight safety briefing, video and passenger briefing cards to include all types of seatbelts and instructions on how to operate all emergency exits and address other matters. The civil aviation safety authority revised its passengers, safety briefing guidance, which now contains information specific to helicopter operator.
[00:26:23] The civil aviation safety regulation part 1 33 manual of standards applicable to helicopter operators also requires that passengers seated in an emergency exit row are briefed about what to do when an exit is required to be used. In addition, all passengers must be verbally briefed on the location of exits and brace.
[00:26:46] The U S chemical safety and hazard investigation board is monitoring an explosion and fire event at the chem tool plant in Rockton, Illinois. That occurred on June 14th, 2021 at 7:15 AM. Central time. All 70 workers in the facility were evacuated without injury. One firefighter suffered a minor injury and was transported to a local hospital for evaluation.
[00:27:12] The facility manufacturers petroleum based lubricant. The CSB will continue to monitor the incident and tentatively plans to deploy a team to the area early next week, to expand dialogue with federal and state partners to include EPA personnel, regional OSHA personnel, and fire emergency management personnel.
[00:27:33] At this point, assessments appear to indicate that the incident is a fire event and not a chemical process safety event. Interviews with employees may provide more clarity to the events leading up to this incident and the potentially severe impact to the community and environment warrant concern. The air quality at ground level continues to be in the acceptable range.
[00:27:58] The incident commander reported yesterday that the plan was to allow the volatiles to burn off since the facility is adjacent to the rock river. And there was a significant concern surrounding release of firefighting water and suppression foam into the waterway. This initial poach has been reassessed and the plan is now to berm and boom, the access to the river and extinguish the remaining blaze.
[00:28:19] This may add an environmental impact element into the incident. Dynamic. Additional updates will be released as available. The U S department of labor’s occupational safety and health administration has cited the owner operator of, for Rhode Island medical facilities for failing to protect workers from exposure to coronavirus and implement proper safety measures.
[00:28:41] After six employees tested positive for the corner fires in the fall of 20. OSHA investigators found that the owner of north Providence urgent care, Inc. North Providence primary care associates, Inc. Center of new England urgent care, Inc. And center of new England primary care Inc willfully exposed employees to coronavirus the agency determined the owner, continued to interact with workers and did not fully implement safeguards after he exhibited symptoms of the coronavirus and later tested.
[00:29:13] The owner and his company, his face, a proposed fine of $136,532 for failing to implement engineering controls, such as portable, high efficiency, particulate air fan filtration systems and barriers between adjacent desks, failure to implement administrative controls, such as cleaning and disinfecting and symptom screening for all employees and failure to manage.
[00:29:42] Contact tracing or quarantine periods after employee exposure to the Corona virus exposed patients. OSHA also cited a Bronx contractor after 21 year old labor erecting scaffolding suffered a deadly fall at a Brooklyn building. They say falls are the leading cause of fatalities in construction. A fact, sadly illustrated by the death of a 21 year old laborer who fell nearly 50 feet as he installed a supported tubular welding frame scaffold during construction of a seven story, Brooklyn.
[00:30:18] And OSHA investigation of the November 13th, 2020 incident determined, ever scaffolding Inc of the Bronx failed to ensure the labor’s fall arrest harness was attached as required. OSHA provost $300,370 in penalties for two willful and two serious safety violations. The agency found the company failed to evaluate the feasibility.
[00:30:45] Of using fall protection and failed to use feasible fall protection during the erection of a support scaffold, they did not properly train employees on fall hazards associated with scaffold work. They failed to inspect fall arrest systems before use, and they did not determine if the Anchorage for employees personal fall arrest systems could support at least 5,000 pounds.
[00:31:10] The company has contested OSHA’s findings to the independent occupational safety and health review commission, and a federal inspection finds a San Marcos tortilla manufacturer, repeatedly exposed workers to amputation dangers, previous inspections by the us department of labor’s occupational safety and health administration have given the operators of the family owned tortilla factory, south of Austin.
[00:31:34] Every opportunity to resolve its safety issue. Yet OSHA has found the accompany still exposing workers to the risks of amputation and other serious injuries. Worker complaints of dangerous amputation hazards led OSHA to again, investigate conditions at El Milagro of Texas, Inc. And the agencies inspectors chairman that the company, once again, failed to follow hazardous energy control procedures to prevent sudden machine start-up or movement during maintenance and service.
[00:32:05] As a result, inspect your sighted Elm Allegro for three repeat violations related to energy control and for serious violations for failing to follow lockout, tagout procedures, OSHA RSL side of the company for a repeat violation for failing to fit test workers, using respirators and a serious violation for not performing medical evaluations for respirators.
[00:32:30] The agency has proposed $218,839 in fines. OSHA sided the company for the same violations in 2015 and 2018. And that’s it for this week’s news. Remember, you can find full show notes with links@safetyinvestigations.net. You can follow or subscribe to this podcast on most podcasting apps. Thanks for listening and have a safe week.
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