Safety Investigations News 6/25/21 – Safety Investigations Podcast
Safety Investigations news for 6/25/2021
For full show notes with links and to subscribe to this audio podcast go to http://safetyinvestigations.net
NTSB
https://www.ntsb.gov/investigations/Pages/HWY21MH009.aspx
https://www.ntsb.gov/investigations/AccidentReports/Pages/MAB2113.aspx
https://www.ntsb.gov/investigations/AccidentReports/Pages/MAB2114.aspx
TSB
https://www.bst-tsb.gc.ca/eng/enquetes-investigations/rail/2020/r20h0082/r20h0082.html
http://www.tsb.gc.ca/eng/rapports-reports/marine/2020/m20p0320/m20p0320.html
AAIB
ATSB
http://www.atsb.gov.au/publications/investigation_reports/2021/aair/as-2021-015/
http://www.atsb.gov.au/publications/investigation_reports/2021/aair/ao-2021-024/
http://www.atsb.gov.au/publications/investigation_reports/2021/rair/ro-2021-007/
http://www.atsb.gov.au/publications/investigation_reports/2018/aair/ao-2018-056/
http://www.atsb.gov.au/publications/investigation_reports/2019/aair/ao-2019-050/
SIAA
CSB
https://www.csb.gov/update-on-chemtool-activities-/
OSHA
https://www.osha.gov/news/newsreleases/region4/06222021
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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.
Safety Investigation News 21-06-25
This is your safety investigation news for June 25th, 2021. I’m your host Charles Current in this week’s episode, the U S NTSB is investigating seven new aircraft and one new fatal multi-vehicle highway crash. The NTSB also issued the preliminary reports for its ongoing investigation of the fatal June six, crash of a diamond da 40 NG in Darlington India.
[00:00:23] And for its ongoing investigation of the fatal June 13th, crash of a Piper, PA 32 to 60 in Madisonville, Texas, they say inadequate navigational assessment leads to contact with the Peter P cob Memorial bridge and severe weather led to barge breakaway and damage to the I 10 bridge Canada’s TSP is investigating the June 7th crash of a bell two 14 St.
[00:00:48] Near Nipigon Ontario. The TSB also launched a safety issue investigation into a higher rate of railway crossing accidents during the winter and Canada. And it released its investigation report on the Lafarge Eagle grounding on one November, 2020 in British Columbia. And the UK is AIB is investigating a nose gear collapsed at London Heathrow airport.
[00:01:12] The Australian transportation safety bureau is conducting a safety study into aerial firefighting in Australia. And it’s investigating the collision between a light engine and a coal train at Westwood Queensland on 18th of June and the crash of a Piper, PA 32, 300 aircraft in or near Morbin airport, Victoria on 22, June eight.
[00:01:38] DSB released reports on the depressurization and crew incapacitation of a Boeing 7 37, 3 76 SF in a new south Wales. And loss of control and collision with water involving a bell. EWH one H also in new south Wales, the Romanian, civil aviation safety investigation and analysis authority released its report on a serious incident at Bucharest on rake Honda international airport.
[00:02:06] CSB provides an update on chem tool activities and the U S department of labor sites to Koa plastic recycler for violating safety standards. After worker sustains fatal injuries from it.
[00:02:28] you can follow or subscribe to this podcast. On most podcast apps, you can find full show notes with links to the stories discussed@safetyinvestigations.net. This week, the U S national transportation safety board is investigating the June 17th crash of an air tractor, 84 0 2 B airplane. Kingston. Kinston North Carolina, the June 18th crash, but Piper, PA 28, 1 40 near rush valley, Utah, the June 18th crash of assess.
[00:02:59] Now one 50 L near for Nan DIA beach county, Florida. The June 18th, 2021 crash of a Cirrus Sr 20 near Conway, Arkansas, the June 20th crash of a Kitfox series C. Near likely California, the June 20 crash of a Piper, PA 22, 1 35 near white city, Oregon, the June 21st crash of a Cirrus Sr 22 near Mercer, Tennessee in the NTSB in coordination with the Alabama highway patrol is sending 10 investigators to conduct a safety investigation of a fatal June 19th.
[00:03:38] Multi-vehicle crash on in Butler county, Alabama. The NTSB investigation will focus on vehicle technologies such as forward collision warning systems, CMV or commercial motor vehicle. I think fuel tank integrity, motor carrier operations and occupant survivability. On June 6th, 2021, about 10 20 Eastern daylight time, a diamond aircraft, D a 40 N G airplane, November 8, 5, 3.
[00:04:10] Lima was destroyed when it was involved in an accident near Darlington Indiana. The pilot and flight instructor were fatally injured. The airplane was operated as a title 14 code of federal regulations. Part 1 41 instructional. A review of automatic dependent surveillance broadcast, or a DSB data revealed the airplane departed from the Indianapolis international airport and flew Northwest at an altitude of about 4,000 feet.
[00:04:39] Mean sea level. At the time of the accident, the flight was not in contact with air traffic control, a witness located in a house nearby, heard the airplanes engine and impact. Another witness heard the airplane and looked up the airplane was in a nose down, left spin before it disappeared behind a tree line.
[00:05:00] He added that. It sounded like the propeller was at a high RPM before impact ground scars and wreckage were consistent with the airplanes impact with terrain in a slight right wing, low nose down attitude. The main wreckage was near its initial impact point on a heading of about 37 degrees. The wreckage was highly fragmented with scattered debris that extended for about 75 yards, a preliminary review of the garments G 1000 flight data also revealed the airplane departure and northwesterly track.
[00:05:36] The flight data revealed several turns, engine power, and altitude changes consistent with the airplane maneuver. The data also revealed the airplane was about 4,000 feet MSL. When engine power was reduced as the air speed decrease, the airplanes pitch attitude increased the airplanes pitch, then decreased to a nose down attitude, and the airplane made a right spiral.
[00:06:00] Turn consistent with a stall and spin entry on June 30th, 2021 at 2355 central daylight. A Piper, PA 32 to 60 airplane, November 3, 2, 5 8 whiskey was involved in an accident near Madisonville, Texas. The airplane sustained substantial damage. A private pilot was fatally injured and five passengers received serious injuries.
[00:06:27] The airplane was operated by the pilot under title 14 code of federal regulations, part 91 as a personal flight. The airplane impacted trees that were about 50 feet in height. About 680 feet south of the approach. End of runway three six at Madison bill municipal, airport Madisonville, Texas. The airplane was located about 550 feet south of the approach.
[00:06:52] End of the runway post accident examination of the airplane revealed that the propeller displayed S shaped, bending consistent with engine power, the trees along the wreckage path exhibited slash marsh, consistent with the propellers. Wing flaps were fully extended. Flight control. Continuity was confirmed.
[00:07:14] There were no mechanical anomalies that would have precluded normal airplane. Operation NTSB says inadequate navigational assessment leads to contact with Peter P cob Memorial bridge on August 19th, 2020. The towing vessel, all glory pushing the loaded barge Cole northbound on the intercoastal. Struck the protective fendering for the Peter P Cod Memorial bridge resulting in $646,000 in damages.
[00:07:45] There were no injuries. According to the United States coast pilot, there is a strong cross current at the Peter P Cub Memorial bridge. As the tow approached the bridge, the relief captain slowed the vessel, which reduced the maneuverability of the toe while the current pushed it outside. Towing vessel regulations require the officer of a navigational watch to conduct a navigational assessment, using all resources available to gather information on conditions that could impact the safety of navigation.
[00:08:18] Had the relief, captain Ben aware of the intercoastal waterway chart, cautionary note, and information contained in the United States. He would have been better prepared to address the risk of strong currents often seen near the Peter P Cub Memorial bridge. The report said the coast pilot and navigational charts are valuable sources to Mariners that contain amplifying information on local conditions, such as tides and currents, channel characteristics and bridge description.
[00:08:52] It is important to check the coast, pilot and charts when developing voyage plans to improve knowledge of the area and prepare for a safe passage. The NTSB also says severe rainfall and flooding from tropical storm. Imelda led to barges breaking away from their moorings and striking the interstate 10 bridge in Channelview, Texas.
[00:09:13] On September 19th, 2019 11 barges broke free from a San Jacinto river barge fleeting area north of the bridge in Channelview during tropical storm Imelda, the fifth wettest tropical cyclone on record in the continental United States, six barges struck pier columns, supporting the bridge resulting in more than 5.4, $6 million in damages.
[00:09:40] There were no issues. During the storm, San Jacinto river fleet, tow boats and crews worked to control the breakaway barges and return them to one of the tiers. A designated areas for grouping barges is what that is. The vessels could not hold the barges in the rising floodwaters and the barges subsequently struck the bridge fendering system and pilot.
[00:10:05] As a result, the westbound bridge was closed for four months and the eastbound bridge did not return to normal capacity until five months after the accident, the NTSB determined that the San Jacinto river fleet should have implemented its severe weather plan and take an earlier action to secure the barges and in the fleeting area and TSP found Sheryl K Marine operator.
[00:10:30] Of the fleet did not follow their own safety management system policies related to severe weather and swift flood water plans. Canada’s TSB has deployed a team of investigators near Nippon, Ontario to gather information, following a crash involving a bell two 14 S T helicopter that occurred on Monday, June.
[00:10:52] A transportation safety board of Canada is launching a safety issue investigation into factors, leading to an increase in the rate of railway crossing accidents. During winter months and Canada, they say every year, approximately 23 people are killed and another 28 seriously injured at railway crossings in Canada in 2019 29% of the crossing accidents resulted in fatalities or serious injuries, making them one of the deadliest types of rail access.
[00:11:19] The TSP has identified a seasonal pattern in level crossing accidents involving motor vehicles where during the winter months, the average rate of accents increases by about 61%. The goal of the safety issue investigation is to compare the factors contributing to level crossing accidents that happen in non vacation, winter months, January, February, with those contributing to accidents that take place.
[00:11:49] Non vacation, non winter months may, June and September a secondary objective is to learn more about other factors contributing to accents at level crossings, whether the factors be human, environmental crossing, or roadway related drivers and eye witnesses to recent accents at level crossings will be interviewed by TSP investigators.
[00:12:12] So that firsthand accounts can be document. Those accounts as well as data from other sources will be compiled and compared statistically to identify and better understand the underlying causal factors to these occurrences results of the SII will be published in a final TSB investigation. A safety issue, investigation or SII also known as a class, one investigation and analyzes a series of occurrences with common characteristics that have formed a pattern over a period of time as AIS, which may include recommendations are generally completed within two years.
[00:12:54] For more information, you can see the TSB policy on occurrence classification. The TSB has released its investigation report into the grounding of the barge Lafarge Eagle while under tow of the tug Mona Mona LOA in the Fraser river, British Columbia on November 1st, 2020, the report highlights failures in risk management and communications.
[00:13:19] It reads vessel operators must be cognizant of the hazards involved in their operations and proactively manage them to reduce risks. To as low as reasonably practicable implementing effective risk management processes provides vessel operators with the means to identify hazards, assess risks, and establish ways to mitigate them a documented and systematic approach also helps ensure that individuals at all levels of the operation, including the master, have the knowledge, tools, and information necessary to make effective decisions in any operating.
[00:13:57] When the Mona LOA departed the Lefarge terminal with the barge in tow, there were several conditions present that were not viewed as hazards by the crew. The departure was in darkness. The channel in which the loaded barge was to be turned was narrow. The current was at a maximum EDD. Additionally, the Mount Allah single screw configuration increased the difficulty of the plan.
[00:14:25] As did the light fuel load and its forward distribution. Consequently, the tug was lighter AFT than usual resulting in the propeller, providing less thrust than the crew were accustomed to furthermore schedule changes resulting from loading issues had led to the engagement of an assist tug that had never assisted at this location or for this company.
[00:14:48] Finally, a training master was assigned to the Mount LOA. Even though the departure maneuver was challenging and had the potential for significant consequences in the event, it did not go as planned. Although salmon bay barge line Inc had voluntarily implemented a safety management system. The SMS did not contain any formal risk management processes and had not been audited by an external authority, no written guidance was provided to the master on assessing risks, such as.
[00:15:22] Current limitations for executing various towing, maneuvers, tug characteristics, and configuration and cyst tug requirements. The company relied solely on the experience and judgment of individual masters to make decisions about such factors without any formal risk management processes. The master did not have the benefit of a systematic approach to help with the identification of hazards and mitigate risk.
[00:15:48] TSB investigations have previously identified the absence of formal risk management processes by towing operators as causal or contributor contributary to an occurrence or as a risk factor. Effective communication is key to the success of maneuvers that involve the coordination of multiple vessels.
[00:16:09] During towing operations. The lead tug is often out of sight of the assistance. And therefore maintaining oral communications is essential, effective communication includes among other things. The use of pre towing safety briefings and the clear transfer of instructions between the lead tug, the vessel being towed or assisted and any assist tugs.
[00:16:31] The absence of effective communication is a factor that the TSP has frequently identified as causing or contributing to access. In this occurrence after the pre towing safety meeting, the training master on the Mount of LOA was assigned the controls and the responsibility for communicating, communicating with the CMP, the assist tug during the departure, when the amount of LOA came under the influence of the current and began to deviate from the intended track, there was no communication between the two.
[00:17:05] During the four minutes from the time, the amount of load master took control from the training master until the barge is grounding. It was unclear who was responsible for communicating with the assist tug noise from the vent stack near the AFT conning station also make communications between the master and the training master more difficult.
[00:17:26] The assistant did not query the Mauna LOA when it became evident that the maneuver was not going according to plan. Which meant that the master of the Mount of LOA was not prompted about how the assist tug could help control the barge or stop its forward momentum. The full report can be falling honed at the link in the show notes, the UK air accident investigation brand says they have sent a team to London Heathrow airport to begin an investigation into the incident involving an aircraft that suffered a nose landing gear collapse, while being loaded with cars.
[00:18:02] The Australian air transportation safety bureau is conducting a safety study into aerial firefighting in Australia. They say an a TSP statistical report into aerial firefighting occurrences between July, 2000 and March, 2020. Found an increase in occurrences per year. Over recent years, the report also found an increase in average size of aircraft and complexity of operations.
[00:18:27] Within the data was the 20, 19 to 2020 bushfire season, which the national aerial firefighting center advised demanded activity of around four times the usual rate. Additionally, the CSI R O has projected an increase in land use putting people into conflict with Bush fires and increased, dangerous bushfire weather over the coming year.
[00:18:51] The at TSB, consider this an appropriate time to conduct a more detailed examination of aerial firefighting activities to identify any systematic safety issues and other learning opportunities that could enhance the safety of future operations. As part of the investigation, investigators will conduct a detailed review of recent occurrences to identify common characteristics, obtain aircraft activity, data, to evaluate the rate of occurrences over recent years.
[00:19:20] Meet stakeholder organizations to understand their processes and challenges. Consider previous reviews of aerial firefighting activity and survey a sample of operational personnel involved in aerial firefighting activities. A final report will be published at the conclusion of the investigation.
[00:19:38] Should any safety critical information be disclosed at any time during the investigation, the TSB will immediately notify operators and regulators so appropriate and timely action can be. And the HTSP announced it is investigating the collision with terrain of a Piper, PA 32, 300 aircraft, Victor hotel, Charlie whiskey, kilo near moribund airport Victoria on 22, June at 1205.
[00:20:04] The aircraft had been conducting circuit operations at moribund airport and collided with train approximately one kilometer north of the airport at Heatherton. Emergency services attended the accident site shortly afterwards and rescued the pilot. The sole occupant from the wreckage, the pilot had been seriously injured and was transported to the hospital.
[00:20:25] The aircraft was destroyed by the impact. The evidence collection phase of the investigation will include examination of the accident site and wreckage by eight investigators and the collection of other relevant evidence, including recorded data and communications, air traffic control surveillance.
[00:20:43] Weather information, witness reports, aircraft operator procedures, and maintenance records, and interviewing the pilot. A final report will be released at the conclusion of the investigation. The TSB is also investigating the collision between a light engine and a coal train at Westwood Queensland on 18, June, 2021.
[00:21:05] They say a light engine, a diesel locomotive with no other rolling stock attack. They say the light engine, which they define as a diesel locomotive with no other rolling stock attached was being used by Queensland rail for driver tuition. There was a tutor driver and two other drivers on board. And the light engine was being operated westbound with the long end leading that is in the reverse direction of normal operation.
[00:21:33] The Caltrain was operated by Aurizon and was stationary at the Westwood. 45.05 kilometers from Rockhampton at about 1126 Eastern standard time. The light engine struck the stationary Coltrane, the light engine and five wagons of the Coltrane were significantly damaged of the light engines. Three occupants, one sustained minor injuries.
[00:22:00] One was seriously injured and one was fatally injured. The two drivers of the coal train were uninjured. The ATSB deployed three investigators to the site to examine the site and wreckage. As part of the investigation, the TSP will also interview the drivers and train controller, analyze recorded data from the light engines, data logger and other sources participate in more detailed examination of the light engine and gather additional information.
[00:22:27] And a report will be published at the conclusion of the investigate. The TSB has released their report on the depressurization and crew incapacitation of a Boeing 7 37, 3 76 SF in new south Wales on 15, August, 2018. And it reads on the evening of 15, August, 2018, a Boeing 7 37, 3 76. Special freighter registered Victor hotel.
[00:22:55] X-ray Mike Oscar operated by express freighters. Australia was transporting freight from Brisbane airport Queensland to Melbourne airport in Victoria when the master caution and right-wing body overheat and unseat are illuminated, the non-normal checklist was actioned, followed by further troubleshooting in consultation with maintenance personnel.
[00:23:19] This resulted in a reduction of cabin. The crew dawned oxygen masks and the aircraft was entered into an emergency descent. During the initial part of the descent, the captain was temporarily incapacitated by a reaction to the increased supply of breathing oxygen from the mask a made a was declared by the first officer and the aircraft was diverted to Canberra airport, Australia capital territory.
[00:23:46] During the diversion, the first officer also experienced incapacitation. The aircraft landed at Canberra airport under the control of the captain with no further issues. The HTSP found that faults in the right wing body overheat detection system likely led to intermittent flickering of the master caution, light and elimination of the right wing body overheat, an unsafe.
[00:24:12] The operating flight crew conducted the appropriate non normal checklist. However, the overheat indication could not be rectified due to the fault in the wing body overheat detection system and additional fault with an isolation valve in the aircraft pressurization system prevented isolation of the right wing body pressure duct.
[00:24:36] This led the crew to conduct further troubleshooting during which the cabin air supply was reduced. In conjunction with a higher than normal Kevin leak rate that reduced air flow also lessen the cabin pressure. The flight crew responded to the cabin pressure reduction by donning their oxygen masks and descending the aircraft.
[00:24:56] During the descent, the captain selected emergency flow on the oxygen mask resulting in an ingestion of gaseous oxygen causing temporary incapacitation. After the flight was diverted to Canberra. The first officer experienced symptoms consistent with hyperventilation leading the captain to declare the first officer incapacitated, post occurrence medical testing and assessment were carried out on the flight crew with no effects from the flight identified.
[00:25:25] During post flight inspections, Quantis engineers identified a range of serviceability issues with the aircraft fuselage cabin drain valves, peace lodge Dorsey. And the auxiliary power unit ducked bellows seal that affected the capacity for aircraft to hold Kevin pressure. The operator advised the, at TSB that following the occurrence amendments were incorporated into the approved scheduled maintenance program to incorporate a functional check of the cabin drain valves, specifically verify the integrity of the auxiliary power unit duct bellows C.
[00:26:03] Introduce an enhanced aircraft cabin pressurization system. Check the operator implemented an inspection regime to ensure timely detection and rectification of faults compromising the operation of the wing body overheat detection system. And the operator also advised that flight troubleshooting outside the non-normal checklist procedures and flight crew operations manual is now prohibit.
[00:26:28] The HSB says this occurrence is a reminder to flight crews of the hazards of dealing with system malfunctions that are not resolved using the approved non-normal checklist procedures in such circumstances associated system effects need to be taken into account when electing to conduct further troubleshooting outside of the non-normal procedures, even with the assistance of external maintenance specialist.
[00:26:54] Configuration changes to an aircraft system may induce other effects due to underlying unserviceable components that may not be immediately apparent. The NTSB also reminds flight crews to be cognizant that non-normal situations can lead to misapplication of emergency equipment in the moment that is actually needed in this case, the selection of the emergency flow setting.
[00:27:20] Fixed oxygen system resulted in a temporary incapacitation of the captain. Finally, a sequence of non-normal events in conjunction with the use of emergency equipment can add pressure and workload to the flight crew. So it would seem unlikely to occur. These pressures may result in hyperventilation, increasing the potential for incapacitation during a critical phase of.
[00:27:44] And the TSB also released their report of the loss of control and collision with water involving a bell EWH in new south Wales on six, September, 2019. They say on six, September, 2019 at 1430 Eastern standard time. The pilot of a bell helicopter company, U H one H helicopter registered Victor hotel, uniform, Victor, Charlie departed, Archerfield airport Queens.
[00:28:12] On a private flight with four passengers, four banks, town, new south Wales. Following a refueling stop at Coffs Harbor new south Wales. The pilot made contact with Williamstown air traffic control while Northeast of Broughton island and requested clearance to track south via the visual flight rules, coastal route the initial radio calls between the pilot and Williamtown ATC.
[00:28:41] Occurred about six minutes prior to the published time of last light, the radio calls indicated that the helicopter was being affected by turbulence. And as a result, the pilot was having difficulty maintaining a constant altitude in response to controller issue the clearance for the aircraft to operate between two thousand four hundred and three thousand five hundred feet once passed and a bay.
[00:29:04] And about 11 minutes past published last night. Uniform Victor. Charlie was observed on Williamtown ATC radar to make a left turn to the south, depart the coastal route and head off shore on a direct track to bank town, airport. The turn likely resulted in the pilot losing visual cues and encountering dark Knight conditions.
[00:29:30] The helicopter continued to track off shore to the Southwest for about 90 seconds, maintaining between about two thousand five hundred and three thousand two hundred feet before commencing a rapid descending left spiral. Turn it disappeared from Williamtown radar coverage. About 12 minutes after published last light attempts by the controller to contact the pilot were unsuccessful and authorities were subsequently advised of a missing helicopter.
[00:29:58] On 25, September, 2019 wreckage from the destroyed helicopter was located in about 30 meters of water, five kilometers Southwest of Anna bay. Two of the five persons onboard the helicopter were confirmed to have received fail injuries. The bodies of the pilot and two passengers were not found, but they are presumed to have similarly not survived the area.
[00:30:20] The NTSB found that the pilot continued to fly after last light, without the appropriate training and qualifications, and then into dark night conditions that provided no visual clues that significantly reduced the pilot’s ability to maintain control of the helicopter, which was not equipped for night flight.
[00:30:38] Once visual references were lost, the pilot likely became spatially disoriented and lost control of the helicopter resulting in a collision with one. Further the pilot did not disclose ongoing medical treatments for significant health issues to the civil aviation safety authority that prevented specialist consideration and management of the ongoing flight safety risk, the medical conditions and prescribed medications posed the NTSB, says various ATS be research and investigation.
[00:31:09] Investigation reports refer to the dangers of flying after last light without appropriate qualifications. And. NTSB report avoidable accidents. Number seven, highlights. The risks of visual flight at night. Risks include reduced visual cues, increased likelihood of perceptual illusions and spatial disorientation.
[00:31:33] A VFR flight in dark conditions should only be conducted by a pilot with instrument flying proficiency. As there is a significant risk of losing control. If attempting to fly visually in such conditions. If Dave VFR rated pilots find themselves in a situation where last light is likely to occur before the plan destination has reached a diversion or precautionary landing is probably the safest option.
[00:31:58] Air traffic control assistance with available landing options is also available. This accident also highlights the importance of aviation medical certificate, certificate holders, reporting, relevant conditions and medications to their designated aviation medical exam. A full understanding by the civil aviation safety authorities, aviation medical specialists of a pilots, medical conditions, and use of medications enables management of the risk for both the individual and flight safety.
[00:32:29] Overall, the Romanian civil aviation safety investigation and analysis authority released its report on a serious incident at Bucharest Henri Quanda international area. On October 13th, 2016, the aircraft type ATR 72 dash 2 1 2, a registered Yankee Romeo alpha tango, India carrying 38 passengers and four crew members was scheduled to perform the commercial flight on the route from Bucharest, Henri, Conda international airport to yes, airport after passengers boarding, taxing and aircraft lineup on runway.
[00:33:11] Zero eight left for takeoff. The aircraft started the takeoff roll, but after a short time, the crew rejected the takeoff due to strong vibrations in the nose gear area. After a boarded take-off the aircraft vacated the runway at the end on taxiway Oscar continued taxing on taxiways, Papa, and Charlie, and returned to the apron on the same parking spot, a thorough check of runway zero eight.
[00:33:40] Was performed. And there was found metallic elements and glass, which were identified as elements of the lateral runway edge lights. It was found that some runway edge lights on the south side of zero eight left runway were missing. The findings of the report are after performing the procedures for aircraft cleaning insecurity.
[00:34:03] The flight deck crew did not resume the check-ins. From the item of preliminary cockpit preparation, according to the flight crew operating manual, which states all steps have to be performed before the first flight of the day or following crew change or maintenance action. After the taxi clearance was received, the flight crew did not apply the sterile cockpit concept as stated in the operations man.
[00:34:29] According to declarations the pilot and command, which performed the taxi did not wear the spectacles requested by her medical license limitations. When entering the zero eight left runway, the aircraft initially follow the central yellow line of the whisky taxi way. But after the entrance on the runway, it turned to the left, leaving the yellow line, then turned to the right and did align on the right-hand runway.
[00:34:58] The aircraft initiated the takeoff, but after 700 meters at a speed of 82 knots indicated the crew rejected takeoff. The reason for that being vibrations at the nose wheel, after the rejected takeoff, the aircraft vacated the runway on taxiway Oscar then continued with taxi on Papa and Charlie until the parking position.
[00:35:22] The airport personnel performed a runway check entering the runway via Viktor taxiway. Then towards the displaced runway zero eight left threshold along the north side and turning before the aircraft aligned for takeoff turning on and following on the south part of the runway until the intersection with Victor taxi.
[00:35:43] Where from the run was on the taxiway center line, vacating the runway at its end on Oscar taxiway. During this control, nothing abnormal was found during the time interview of 2129 through 2133 from zero eight left runway three more. Commercial flights took off and the runway edge light system issued three defect alone.
[00:36:10] The airport personnel requested a technical check of the aircraft in its parked position. Following these check, the closing down of zero left and two six, right runway was requested during a thorough control of zero eight left runway elements of runway edge light system have been found, metallic elements and glass, which have been identified as debris of runway edge light system.
[00:36:33] It was identified that six runway edge light. We’re completely missing from their positions numbers 3, 4, 5, 6, 14, and 16. All of them on the south edge of zero eight left, they list the causes as lack of crew concentration during this flight phase, distraction of cruise attention during this fight phase and the aircraft did not follow the yellow line, marking the center line of the whiskey taxiway until the intersection with the runway center.
[00:37:05] The U S chemical safety and hazard investigation board, but are known as the CSB deployed two of its senior leadership members to chem tool, Inc. In Rockton, Illinois, where they met with Kim tool, regional and site leadership, the onsite federal and local emergency responders, the environmental protection agency and the occupational safety and health agents.
[00:37:28] On June 14th, the CSB began tracking, documenting and coordinating this incident with federal counterparts. They CSB determined. The first opportunity for the agency to engage on scene would follow the fire and environmental emergency response efforts. Those emergency efforts continue as several hotspots are still burning incident commander.
[00:37:50] Brockton fire chief Kirk Wilson said these fires are being extinguished, but could continue to burn for another 24 to 48 hours. CSB is grateful. No one was seriously injured inside or outside the fence line. The concern about the environmental release was also quickly mitigated by the emergency responders.
[00:38:09] The site remains closed to investigators, correct. Tracking monitoring, investigating the causes of, and preventing accidental chemical releases remains the top priority for the CSB. And we would like to congratulate all the first responders who worked to save lives and protect the environment. They say that’s all the information we have currently on that.
[00:38:30] And that is actually a couple of days, the U S department of labor sites to COA plastic recycler for violating safety standards. After worker sustains fatal injuries from. They say with the holiday fast approaching a 56 year old worker at a Tacoma plastic processing facility could never have known. He would spend Christmas day in the hospital and die from a head injury after falling more than six feet from an elevated place.
[00:38:58] And inspection of the December 21st, 2020 incident by the us department of labor, occupational safety and health administration found that while scrap masters in CAD installed some fault protection on the platform, it failed to meet federal safety standards. OSHA cited the company for failing to equip stairs and platforms with guard rails to prevent falls.
[00:39:20] In addition, Oser determined the employer failed to Mount and mark fire extinguishers, exposing workers to fire hazards. The employer also did not implement a training program for the use of fire extinguishers. They failed to repair powered industrial trucks and ensure workers wore seatbelts when operating a fork.
[00:39:40] Failed to provide a training program on powered industrial trucks that consists of formal and practical training, as well as evaluation of the employee’s performance in the workplace. They failed to develop and utilize specific procedures for employees, performing service and maintenance activities on machines, exposing them to amputation hazards, and they failed to prevent workers from being exposed to occupational noise levels above the allowed time.
[00:40:06] Wait. In all OSHA cited, scrap masters with eight serious and five repeat violations and proposed $164,308 in penalties. Scrap masters, Inc. Recycles plastic, automobile gas tanks, and has a sister office in Manchester. Michigan OSHA has inspected the company five times in the past five years with four of the inspections occurring at the Tacoma facility.
[00:40:34] Of those four inspections, three resulted in citations being issued. And that’s it for this week’s news. Remember, you can find full show notes with links@safetyinvestigations.net. You can follow our subscribe to this podcast on most podcast apps. Thanks for listening and have a safe week.
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