News Brief 5/21/2021

Safety Investigations news brief for 5/21/2021

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17 May 2021 – TSB Deployment notice

US Department of Labor proposes $558K in fines for Texas bath, shower manufacturer for willful, repeat safety violations at Waco facility | Occupational Safety and Health Administration

OSHA finds three California contractors failed to conduct inspections, identify hazards in investigation of fatal incident at Agua Caliente Casino | Occupational Safety and Health Administration

Preliminary Report for Investigation of Fatal, Seacor Power Capsizing

Failure to Control Airplane Following Loss of Engine Thrust Caused Crash That Killed 10

Air transportation safety investigation report A20A0001

OSHA’s Proposed Rulemaking to Amend the Hazard Communication Standard | Occupational Safety and Health Administration 

30 IN-381N (76 CM -97 CM)


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21-05-21 News
This is your safety investigations news brief for May 21st, 2021. I’m your host Charles Current. And here are this week’s headlines, TSB deploys, a team of investigators to Les co Quebec. Following a helicopter accident. The NTSB is investigating the crash of a Cessna one 82 near Jasper township, Michigan, and the NTSB is also investigating an accident that killed a pan am railways worker in Newington, New Hampshire.
[00:00:29] Us department of labor proposes $558,000 in fines for Texas bath and shower manufacturer for willful repeated safety violations at a Waco facility and OSHA fines, three California contractors failed to conduct inspections and identify hazards in an investigation into a fatal incident at Agua Kelly, auntie casino.
[00:00:51] And the NTSB has issued a preliminary report for the investigation of the fatal C core power capsizing. The NTSB says failure to control airplane. Following loss of engine thrust caused crash that killed 10. The TSB released its investigation report on the January, 2020 runway overrun at Halifax Stanfield international airport.
[00:01:14] OSHA issues, a notice of informal hearing to discuss updates to its agency’s hazard communication standard.
[00:01:29] you can find full show notes with links, to all the stories Our first story this week, the. Transportation safety board of Canada, otherwise known as the TSB is deploying a team of investigators to the site of an accident involving an Arab helicopters, a S three 50 B two.
[00:01:50] Are you in Les S communes Quebec, and I apologize to all Canadians and French speakers for how badly I probably Bush, how badly I probably butchered that I can barely speak English, as you can tell from that last sentence anyway, uh, and for, uh, Future butcherings I will probably do later in this episode, the TSP will gather information and assess the occurrence.
[00:02:13] And the NTSB is investigating the May 17th, 2021 crash of a Cessna one 82 H near Jesper township, Michigan. The NTSB air safety investigator was expected to arrive on scene May 18th. The NTSB is also sending out three investigators to Newington New Hampshire to investigate the May 19th, 2021 accident that killed a pan am railways worker.
[00:02:40] During switching operation investigators were expected to arrive on scene May 20th. And in a press release, the U S department of labor says moving machine parts have the potential to cause serious or fatal injuries. When safety, precautions and procedures are ignored. And yet Waco, bath, and shower manufacturer.
[00:03:00] Once again, failed to provide its employees a safe and healthful workplace and inspection by the us department of labor’s occupational safety and health administration in November, 2020 found Clark products Inc. Failed to use required machine guards and cited the manufacturer for 19 violations. The violations include willful and repeated failures related to machine guarding and fall protection.
[00:03:26] Proposed penalties, total $558,821 in October, 2018. OSHA cited Clark products for failing tour to ensure the use of guards. OSHA area director, Timothy miner said the willful and repeated violations found during this inspection show. Clark products ignored required worker safety precautions. OSHA will cite employers who disregard their legal responses, ability to provide workers with safe workplace headquartered in Colleyville Clark products, Inc had approximately 110 employees at its Waco facility at the time of the inspection.
[00:04:05] And in another press release, OSHA said just a month after the Agua Caliente casino, cathedral city opened a metal gate near the casino’s loading dock collapsed, crushing a 41 year old construction worker under its 3000 pound weight. A us department of labor OSHA investigation that followed the December 7th, 2020 tragedy found the projects contractors.
[00:04:31] Penta building group, no limit steel and the Raymond group failed to conduct inspections to discover hazards, instruct employees on how to recognize work place dangers and install, caution signs to warn workers about potential hazards. The three contractors face $64,169 in combined penalties. OSHA area director, Derek en guard said required oversight and communication related to workplace safety and health could have prevented this tragic loss of life.
[00:05:04] This case is a painful reminder of why employees or why employers must make complying with workplace safety standards, a priority. The Penta building group is a general contractor with offices and operations in Las Vegas, Phoenix, Los Angeles, Palm Springs, and Reno. The Raymond group provides wall and ceiling construction services in Southern California.
[00:05:28] No limit steel is a contractor based in Los Angeles. The national transportation safety board published Tuesday, the preliminary report for its ongoing investigation of the fatal capsizing of the lifeboat C core power, April 13 to 2021 near port Fourchon, Louisiana. And I’m sure I butchered that name information in the report is polling Canary and subject to change as the investigation progresses and as such no conclusions about the cause of the accident should be drawn from the report.
[00:06:00] There were 19 people board, the U S flagged 175 foot long C core power. At the time of the accident, six people were rescued by the coast guard and good Samaritan vessels. Six people died in the accident and seven remained missing the C Corp power departed port for Chon at about 1:30 PM, April 13th bound for the oil and gas lease area.
[00:06:24] Main pass block one 38 in the Gulf of Mexico. A weather report emailed to the vessel at 7:02 AM. That day predicted afternoon winds at nine to 12 knots from the Southeast with three foot seas, NTSB investigators learned that about 3:30 PM as the C Corp power transited. The open waters of the Gulf, a squall passed over the lifeboat with visibility dropping and winds increasing significantly.
[00:06:52] The crew decided to lower the C Corp power’s legs. To the sea floor to hold the vessel in position until the storm passed the crew member at the helm attempted to turn the C Corp power into the wind. As the legs began to descend before the term was completed, the lifeboat healed to starboard and capsized and TSB investigators also learned several people were able to escape onto the exposed port side of the sea core power deck house.
[00:07:21] High winds and sees that had built to 10 to 12 feet, prevented rescuers from reaching. Those who remained on the lifeboat, some were washed into the water and six were eventually rescued one survivor suffering, a serious injury. NTSB investigators have interviewed survivors, other personnel who previously crude the C Corp power representatives for the owner and charter.
[00:07:45] Vessel inspectors and surveyors and search and rescue responders. When the C Corp power is salvaged, NTSB investigators intend to return to inspect the vessel and collect further evidence. The preliminary report is available online. A link will be provided in the show notes for this episode. And the failure of a pilot to control an airplane.
[00:08:07] Following the loss of thrust in one of two engines, just seconds after takeoff led to the fatal crash of a general aviation airplane in Texas, the NTSB said in a report published Tuesday, a Textron aviation bead as 300, also known as a King air three 50. Crashed into an aircraft hangar 17 seconds after lifting off a runway at Addison airport, Addison, Texas, June 30th, 2019.
[00:08:35] The accident killed both pilots and all eight passengers. The personal flight on the privately owned airplane was bound for St. Petersburg, Florida. Investigators analyzed flight track data broadcast by the airplane video from multiple cameras on and off the airport, as well as the known flight performance data and characteristic characteristics of the airplane to recreate the accident flight path and determine the airplane’s position speed altitude and roll angles.
[00:09:05] The NTSB said in its report that after the left engine lost almost all thrust several seconds after takeoff. The pilot responded to the emergency with left rudder input, the opposite action of what the emergency called four seconds later, the pilot applied right rudder. But by that point, the airplane was rolling inverted and there was insufficient altitude for recovery investigators, determined that had the pilot initially applied right rudder input.
[00:09:35] The airplane would have been controllable. The audio from cockpit voice recorder revealed the pilot did not call for any of the checklists that would typically be used before takeoff, nor did they discuss what they would do in case of loss of engine thrust on takeoff or any other emergency procedure.
[00:09:52] The NTSB said the pilot’s failure to follow checklists and adhere to the airplane manufacturers. Emergency procedures contributed to the accident. A detailed examination of the left engine and its control systems found no condition that would have prevented normal operation. The NTSB noted that there was a known risk of unintentional movement of the engine power lever.
[00:10:14] If its friction Lock was adjusted incorrectly, friction Lock settings are one of the items in the pre takeoff checklist that the pilot failed to use. Investigators were unable to determine if the friction lock settings played a role in the loss of engine thrust on the left engine, because for the loss of engine thrust could not be determined.
[00:10:36] The 22 page accident report is available online and a link will be provided in the show notes. The accident docket, which contains interviews, photos studies, and other factual material was open to the public on August 4th, 2020 and is available online and a link to that will be in the show notes as well.
[00:10:57] In its investigation report released today, the transportation safety board of Canada found that changing runways without recalculating the landing distance required based on the changes in wind and runway surface conditions led to a runway overrun in Halifax, Nova Scotia in 2020. On five, January, 2020, a West jet Boeing seven three seven dash eight.
[00:11:20] CT aircraft was conducting flight whiskey, Juliet alpha two four eight from Toronto, Lester, B Peterson, or Pearson international airport, Ontario. To Halifax Stanfield international airport in Nova Scotia with 172 passengers and six crew members on board. The flight crew had originally planned to conduct an approach for runway five, however, due to a lowering ceiling and reduced visibility, the crew requested a change to the runway one, four instrument landing system approach, which allows for landing with lower minimum ceilings and visibility requirements than the approach to runway five.
[00:12:02] The aircraft then touched down with a tailwind component on wet snow covered runway. The aircraft could not be stopped and it overran the end of runway one for coming to rest in snow with the nose wheel, approximately 91 meters beyond the runway. And there were no injuries and no damage to the aircraft.
[00:12:22] Investigation found while preparing for the runway change. The flight crew mentally assessed that the headwind for runway five would become a crosswind for runway one, four as a result. They did not recalculate the effects of the wind for the approach to runway one, four, but rather considered that the landing distance and target approach speed calculated for runway five were still appropriate.
[00:12:47] However the report had wind speed and direction changed as the flight progressed resulting in a tailwind component that exceeded the operator limitation, a lower required approach speed, and yeah, the landing distance that exceeded the runway length available. None of this was recognized by the flight crew.
[00:13:05] And as a result, they continued the approach to runway one for the unchanged target approach speed combined with the tailwind component, resulted in the aircraft, touching down at a faster ground speed, thus requiring a longer stopping distance. The wet snow contamination on the runway reduced braking effectiveness, which also contributed to an increase in landing distance.
[00:13:30] Runway overruns have been on the TSB watchlist since 2010. When a runway overrun occurs during landing, it is important that the aircraft have an adequate safety area beyond the end of the runway to reduce adverse consequences. In this occurrence, the aircraft stopped within the 150 meter runway end safety area, which meets current international standards.
[00:13:53] Following the occurrence WestJet highlighted to its pilot group. The importance of using the actual runway intended for landing. When making pre landing performance calculations, the company also revisited its emergency response checklist to include the requirement to pull the cockpit voice recorder and flight data recorder, circuit breakers.
[00:14:13] After an incident, it is now monitoring for landings that exceed the maximum tail one component in its flight data monitoring program. You can see the TSPs investigation page for more information. And a link will be in the show notes. The us department of labor’s occupational safety and health administration has issued a notice of informal hearing on the agency’s hazard communication system or HCS.
[00:14:38] The hearing will be September 21st, 2021 at 10:00 AM. Eastern daylight time, and it will be held virtually using WebEx if necessary. The hearing will continue from 9:30 AM until 5:00 PM Eastern daylight time on subsequent days, additional information on how to access. The informal hearing will be posted on OSHA’s proposed rulemaking to amend the hazard communication standards webpage.
[00:15:05] Individuals interested in participating in the hearing must submit a notice of intent to, which is the federal rulemaking portal submissions and request to appear must be received by June 18th, 2021. Read the federal register notice for additional details.
[00:15:30] The HCS first finalized in 1983 provides a standardized approach to workplace hazard communications associated with exposure to hazardous chemicals. The standard was updated in 2012 to align with revision three of the GHS to provide a common and coherent approach to classifying chemicals and communicating hazard information.
[00:15:53] OSHA expects. The HCS update will increase worker protections and reduce the incidents of chemical related occupational illnesses and injuries by further improving the information on the labels and safety data sheets for hazardous chemicals. Proposed modifications will also address issues since implementation of the 2012 standard and improve alignment with the, with other federal agencies and Canada links to those pages discussed will be in the show notes.
[00:16:24] And that’s it for this week’s news. Remember, you can find full show notes with You can follow or subscribe to this podcast on most podcasting apps. Thanks for listening and stay safe.


News Brief 5/14/2021

Safety Investigations news brief for 5/14/2021

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

NTSB investigating mid-air collision involving a Metroliner & a Cirrus near Denver, Colorado

AAIB investigating a light aircraft accident near Headcorn Airfield in Kent

damage to it’s main gear tires.

NTSB Investigative Update: Wednesday’s Mid-Air Collision Near Denver 

Centennial Mid-Air Collision! 5/12/2021

Watched Ballistic Parachute AND Mid-Air Collision during First Student Solo!


An ATR 72-600 returned to land at Taipei-Songshan Airport (TSA) after suffering serious 

Inspections yield 4 willful, 35 serious violations for New Jersey, Pennsylvania companies

NTSB Issues Preliminary Report for Fatal, Texas, Tesla Crash

TSB releases investigation report about a 2020 landing accident in Calgary, Alberta

A Safe System Approach to Traffic Safety Roundtable

NTSB: Sinking of Fishing Vessel Scandies Rose Subject of June 29 Board Meeting

NTSB to hold Most Wanted List Roundtable on A Safe System Approach to Traffic Safety



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21-05-14 News

This is your safety investigations news brief for May 14th, 2021. I’m your host Charles Current. And here are this week’s headlines. The AAB investigating a light aircraft accident near headquarters airfield in Kent NTSB investigating an accident involving a beach B 24 R that crashed near new Lenox, Illinois.

[00:00:21] An ATR 72 dash 600 returned to land at Taipei Seung Shan airport after suffering serious damage to its main gear, tires, inspections, yield for willful and thirty-five serious violations for New Jersey, Pennsylvania. Company’s NTSB investigative update on Wednesday’s mid-air collision your Denver and issues preliminary report for fatal Texas Tesla crash.

[00:00:47] The TSB releases investigation report about a 2020 landing accident in Calgary, Alberta. The NTSB announced the sinking of the fishing vessels. Candies Rose will be the subject of a June 29th board meeting. And the NTSB to hold a most one endless round table on a safe system approach to traffic safety.

[00:01:17] nine full show notes with links to stories We’ll start off with. The AAB have sent a team to investigate an accident involving a light aircraft that occurred near headquarter airfield in Kent, according to their Twitter account, the NTSB tweeted that they are investigating the May 13th, 2021 accident involving a beach B 24 R that crashed at the intersection of  and highway six, near Lenox, Illinois.

[00:01:47] The NTSB is not traveling to that scene and ATR. 72 dash 600 return to land at Taipei song Shan airport after suffering serious damage to its main gear tires, uni air flight Bravo seven Niner zero nine or one made an emergency landing due to ruptured main gear tires. The ATR 72 two dash 600 registration Bravo one seven zero one zero was departing runway one zero when both right main tires were damaged.

[00:02:21] The crew safely returned to song Shan. There were no injuries among the 74 people on board. And OSHA says that six contractors constructing luxury single family homes at the future site of Hawthorne estates in Medford. Put workers at risk for serious fatal injuries by failing to comply with federal requirements to prevent falls.

[00:02:47] The leading cause of death in the construction industry. After multiple onsite investigations, the us department of labor’s occupational safety and health administration cited the companies for exposing workers to falls and other dangerous safety hazards while erecting walls and sheathing roofs. OSHA initiated three of the inspections as part of its regional emphasis program on falls and construction.

[00:03:10] During the first in October 20th, 2020, the compliance officer observed workers exposed to falls and other hazards inspectors observed the same hazards during a second inspection. Two days later, prompting the third inspection on October 31st. After three inspections, OSHA proposed total penalties of $244,397 and cited the companies collectively for four willful and 35 serious violations, including exposing workers to falls greater than six feet and not providing personal protective equipment.

[00:03:43] The companies citations and proposed penalties are Claudio de Souza operating as lifetime contractor Corp in Philadelphia. Two willful and 14 serious violations, $107,279. Lazin ho Susa operating as lifetime contractor Corp. Also out of New Jersey, two willful and nine serious violations for a total of $87,381.

[00:04:14] W S J construction out of New Jersey, three serious four $16,383. Gustavo Quinto mill, no operating as lifetime contractor Corp as well out of New Jersey for serious for $12,874. L w J construction, LLC, out of New Jersey, three serious four, $12,288. And RMM contractor LLC also out of New Jersey, too serious for $8,192.

[00:04:51] OSHA area director, Paula Dickson Roderick in Marlton, New Jersey said a fall can permanently alter or end a worker’s life in a matter of seconds, contractors and subcontractors in the construction industry have a legal obligation to comply with the law and ensure their workers and their shifts safely.

[00:05:11] When employers fail to follow requirements, OSHA will hold them responsible to the highest extent of the law. OSHA encourages employers to use its stop falls, online resources, including detailed information on fall protection standards in English and Spanish. The site offers fact sheets, posters, and videos that illustrate various fall hazards and appropriate preventative measures.

[00:05:34] The NTSB released an investigative update. For Wednesdays mid-air collision near Denver. It reads the national transportation safety board investigators continue Thursday to gather information about Wednesday’s mid-air collision involving a Cirrus Sr two airplane and a swearing-in Metro liner airplane in near Centennial airport, Denver.

[00:05:56] No one was injured when the swearing, Jen Metro liner operated by key lime air and a Cirrus Sr dash Tutu rented from independence, aviation quieted. As the planes were landing at Centennial airport. The NTSB investigator in charge for this accident has interviewed both pilots and an NTSB air traffic control specialist has listened to recordings from air traffic control interviews of the controllers, working with the Cirrus and Metrolina pilots are planned.

[00:06:25] An NTSB investigator examined the wreck Cirrus Wednesday and we’ll can we’ll examine the Metro liner Thursday. The insurer of the Cirrus arranged for removal and transport of the plane to Centennial airport. And the Metro liner is at key lime air facility at Centennial airport. Both aircraft were operating under part 91 general aviation rules.

[00:06:47] The Cirrus was a local flight from Centennial. And the Metro liner was repositioning from Salida, Colorado, the NTSB investigation of the mid-air collision. Well, in general terms, look at the people involved in the accident, the airplanes involved in the accident and the environment in which the accident happened.

[00:07:07] There are currently four NTSB investigators working on this accident investigation. We are working to understand how and why these planes collided said, John Brennan, a senior air safety investigator from the NTSB central region office and the investigator in charge for the accident investigation. It is so fortunate that no one was injured in the collision.

[00:07:29] He said a preliminary report will publish in the next 14 days. And the investigation is expected to take between 12 and 18 months to complete. If you want more information on this incident, you can check out Juan Brown of the Blanca Lario YouTube channel. He has some excellent early coverage of this event.

[00:07:49] And VAs aviation on YouTube has a video with all the, the radio communications, uh, that led up to the accident and afterwards. So I will have links to both of those and all these other tweets and other information sources in the show notes as usual. Also the national transportation safety board issued Monday, a preliminary report for its ongoing investigation for the fatal April 17th, 2021 crash of the 2019 Tesla model S near spring, Texas information in the report is preliminary and subject to change as the investigation progresses and as such no conclusions about the cause of the crash should be drawn from the report.

[00:08:29] They say. The report States the model S P 100 D car was equipped with autopilot Tesla’s advanced driver assistance system. The system requires both traffic aware, cruise control and the auto-steer systems to be engaged NTSB tests of an exemplar car at the crash location showed that traffic aware cruise control could be engaged, but auto-steer was not available on that part of the road where the crash happened, which is hammock dunes place.

[00:08:59] According to the report. The crash trip began at the owner’s residence footage from the owner security cameras show the owner entering the driver’s seat and the passenger entering the front passenger seat. The video also shows the car slowly entering the roadway and then accelerating down the road away from the camera and out of sight.

[00:09:18] Based on examination of the accident, scene investigators have determined the car traveled about 550 feet. Before departing the road on a curve, driving over the curb, hitting a drainage culvert, a raised manhole and a tree. The post-crash fire destroyed the car’s onboard data storage device and damage the cars, restraint control module.

[00:09:43] The damaged module was recovered and taken to the NTSB recorder laboratory for evaluation. Restraint control modules can record data associated with vehicle speed, seatbelt status acceleration and airbag deployment. The steering wheel from the Tesla was shipped to the NTSB materials laboratory for analysis of the damage to the steering wheel investigators observed during the post-crash inspection.

[00:10:08] The 59 year old owner and 69 year old passenger died in the crash. The NTSB is investigation of the crash is ongoing and investigators continue to gather information, including data to analyze the crash dynamics. Post-mortem toxicology test results, seatbelt use occupant egress and the post-crash fire.

[00:10:28] Moving up to Canada. In its investigation report released today, the transportation safety board of Canada found a flap malfunction combined with the flight crews handling of the flips fail landing procedure led to a loss of aircraft pitch control and subsequent contact of the rear fuselage with the runway while landing in Calgary, Alberta.

[00:10:52] On 23rd of February, 2020, uh, Bombardi, a challenger six Oh five operated by the Canadian Pacific railway company. Departed Palm beach, international airport, Florida in the U S for Calgary international airport, Alberta with three crew members and 10 passengers on board. During the descent, the flight crew attempted to deploy the flaps and immediately received a flaps fail caution message.

[00:11:19] The flight crew proceeded to complete the flap failure procedure. From the quick reference handbook, the investigation found that after the nose we all touch the ground during the landing maximum reverse thrust was selected. However, insufficient pressure was applied to the control column to maintain nose gear on the runway.

[00:11:37] As a result, the nose pitched up and the rear fuselage contacted the runway. The aircraft’s stall protection system, then commanded a rapid nose down control input, leading to damage to the forward section of the aircraft. When the nose wheel contacted the runway, once the landing was completed, the aircraft continued to the intended parking area.

[00:11:56] There were no injuries to any of the aircraft occupants, although there was significant damage to the aircraft. The flat failure occurred when one of the flat flexible drive shafts failed moisture entered the flat flexible drive shaft casing, likely through the undetected puncture holes on the shaft drive casing to flap actuator interface, which led to the subsequent corrosion and failure of the inner drive shaft.

[00:12:23] As the aircraft’s actual annual utilization was approximately half of that expected by the manufacturer. The calendar time interval between maintenance inspections increased as a result, the corrosion that developed was not detected because the shaft had not yet reached 2,400 flight hour maintenance interval.

[00:12:43] The pilot monitoring did not read the cautions included on the flaps, fail checklist out loud to the pilot flying during the completion of the QRH procedure. As a result information critical to the safe operation of the aircraft was not brought to the pilots flying attention. It was also found that the challenger six Oh five flight simulator used for recurrent training did not accurately represent the zero flap handling characteristics of the aircraft when they thrust reversers are deployed, nor was it required for certification.

[00:13:16] As a result, the flight crew was inadequately prepared to prevent or recover from the nose pitch up that occurred when the thrust reversers were deployed. Following the occurrence, CP amended its procedures to address the differences between the caution and warning notes published in the aircraft flight manual.

[00:13:36] And QRH Bombardi eight issued a temporary revision to the QRH flat failed procedure. The TSB issued an air safety information letter to highlight the challenger six Oh five series flap system inspection interval, and a CLL 60 series cross fleet. Product improvement observation, you can visit the TSPs investigation page for more information and links will be in the show notes.

[00:14:05] The national transportation safety board announced Thursday, its intent to hold a virtual public board meeting June 29th to determine the probable cause for the 2019 sinking of the fishing vessel. Scandi is Rose. These candies Rose sank December 31st, 2019 2.5 miles South of South wick Island, Alaska.

[00:14:25] The vessel had a crew of seven, two are rescued and five others missing after the accident were never found during the meeting. The NTSB is five member board will vote on the findings probable cause and recommendations as well as any changes to the draft final report. In keeping with established a federal and local social distancing guidelines to prevent the spread of coronavirus.

[00:14:49] While also ensuring the NTSB is compliance with the government in the sunshine act. The board meeting for this event will be webcast to the public with board members and investigative staff meeting virtually there’ll be no physical gathering to facilitate the board meeting. It will take place. Tuesday, June 29th at 9:30 AM.

[00:15:10] Eastern time. Ailing to the webcast will be available shortly before the start of the That link will be in the show notes. It says NTSB chairman, Robert L some Walt will take questions from reporters during an immediate availability scheduled to start 30 minutes after the board meeting ends journalists wishing to participate must send an email to NTSB media

[00:15:42] A link with instructions will be emailed. A recording of the availability will be on the NTSB YouTube channel shortly after the session. In a new blog, post NTSB member, Tom Chapman discusses the need to adopt a safe system approach to eliminate traffic crash related deaths and injuries. A link to that blog post will be in the show notes.

[00:16:05] The NTSB also announced that is going to hold a most wireless round table on a safe system approach to traffic safety. They say reaching zero traffic deaths requires a shift from the traditional driver centric approach to the integrative shared responsibility, safe system approach. This is a proven effective strategy.

[00:16:25] First adopted in Sweden in the 1990s to reduce motor vehicle crash related deaths and serious injuries. In recent years, many U S cities have adopted vision zero policies that are rooted in the safe system approach. On May 20th, the national transportation safety board will present a round table, entitled a safe system approach to like safety and TSB member.

[00:16:50] Tom Chapman will serve as moderator member Chapman in an NTSB investigators will discuss investigations and studies related to vulnerable users. And why protect vulnerable road users through safe system approach is on the most wanted list. Mats achy. Berlin PhD, Swedish transportation administration will present on the safe system approach, including its history.

[00:17:17] Additionally, NTSB member, Jennifer Hamadie and other traffic safety experts will join the round table to discuss the elements of a safe system and ideas for improving road safety, through a proactive integrative, and shared responsibility approach at the national state and local levels. That round table will be again, May 20th, 2021, between 12 and 2:00 PM.

[00:17:42] Eastern standard time. The round table will be webcast only on the day of the event. You can access the webcast at a link, which I will provide in these show notes, which will be labeled NTSB live. Remember, you can find full show notes with You can follow horse, subscribe to this podcast on most podcast apps.

[00:18:07] Thanks again for listening and stay safe.

News Brief 5/07/2021

Safety Investigations news brief for 5/07/2021


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21-05-07 News

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[00:25:14] Bye.

Hydrogen Sulfide Release, Odessa, TX, Oct 26, 2019, CSB Board Meeting


The U.S. Chemical Safety Board (CSB) held a public board meeting on May 4, 2021 to adopt the final report on the 2019 hydrogen sulfide release at the Aghorn Operating waterflood station in Odessa, Texas.

The release fatally injured an Aghorn employee who was working at the facility that evening, as well as his spouse who attempted to locate him at the facility after he did not return home.

All audio is courtesy: U.S. Chemical Safety Board.  The audio was cleaned up and meeting breaks removed. 

If you want to see the visuals, you can download the presentation from the May 4th public board meeting at 

Or you can watch the YouTube video posted on the Safety Investigations Podcast channel.

The CSB’s final report will be released in the next few weeks. 

A press release with the findings is available at


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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.
H2S Release , Odessa, TX, Oct 26, 2019, CSB Board Meeting
Bryan Clark: [00:00:00] They see a speeds, chairman and CEO, Dr. Katherine limos will know again, today’s meeting.
[00:00:07] Katherine Lemos: [00:00:07] Thank you for joining us and welcome to this virtual meeting of the chemical safety and hazard identification board. I call this meeting to order I’m Katherine llamas, and I’m honored to serve as the chairman and the CSB and the CS CEO of the CSB.
[00:00:30] Today, we meet an open session as required by the government and the sunshine act, and the board will consider the chemical release of hydrogen sulfide at the ag corn operating waterflood station in Odessa, Texas on October 26, 2019, this toxic chemical release climbed two lives that of an ag Corp employee and a member of the public through their acute inhalation of the chemical.
[00:01:03] On behalf of all of us at the CSB, I offer our most sincere condolences to the families that lost their loved ones. In this event, please understand that the reason for our investigation of this tragedy and thus today’s meeting is so learning from this incident to prevent similar tragedies. In the future in response to the chemical release we discussed today, Odessa fire rescue was the first to arrive on scene a special thanks to those first responders, both paramedics and fully trained firefighters that possessed knowledge and expertise and the dangers of hydrogen sulfide.
[00:01:54] Fortunately, the chemical release did not claim any other lives nor was there impact to a nearby residential community. So today we will discuss the incident, the events leading up to the incident and the response and staff will present the board with pertinent facts and our analysis from the draft report followed by their proposed findings, probable cause statement and recommendations.
[00:02:26] Now in considering adoption of the report, the board will ask questions of staff to ensure it provides the best opportunity to enhance safety. That is our mission. As the CSP, we’ll discuss the dangers associated with hydrogen sulfide or H two S and how in certain geographic locations, the water funding process designed to increase production.
[00:02:58] Yields H two S as a byproduct now, due to the pervasive nature of H two S and the oil they’re in reservoirs and ADESA Texas, and many other location across the Permian basin workers and residents alike may be desensitized to the owner over 85% of the natural gas produced from the Permian basin contains a concentration of H two S that is immediately dangerous to life or health.
[00:03:36] So our review of this event is not just about the unfortunate loss of two lives. It is about the nearly 5,000 facilities in Texas alone. That produced H two S as a by-product of the water flying process that required our careful consideration, the sheer number of facilities that potentially expose workers to the risk of toxic levels of H two S by non-operational detection and alarm systems were other safety gaps, warrants our attention, especially when these workers are commissioned to work alone in their daily surveillance of these facilities.
[00:04:21] For this reason, we’ll talk about the detection of H two S and we’ll examine the methods, the methods employed by ag one to detect an alert for the presence of toxic levels. In broader fashion, we will discuss the importance of design maintenance test and operational procedures and safely operating this type of chemical facility during routine operations and in responding to off nominal conditions.
[00:04:54] In addition to detection and alert systems, critical elements for water flooding stations or facilities that involve H two S include the design of both the physical environment and operational procedures to ensure proper ventilation in the event of a release, as well as site security measures to protect the public.
[00:05:19] We will talk about the importance of safety management programs in addressing myriad risk at chemical facilities. And we’ll examine whether ag porn adopted a comprehensive and purposeful approach in protecting their workers. We will examine whether they provide their employees with their necessary equipment, information, procedures, training, and management.
[00:05:50] To ensure worker safety, the regulations in place by the occupational safety and health administration or OSHA aimed at protecting workers at chemical facilities will be a part of this conversation. Whether a company is mandated to comply with formal safety management systems, such as OSHA, as process safety management or the environmental protection agencies or EPA risk management program does not preclude the responsibility to adequately address risks and protecting employees and the public.
[00:06:31] On that note, we sincerely appreciate the support of our federal state and local partners, Odessa fire rescue, Ector County Sheriff’s department, the railroad commission of Texas OSHA and EPA all contributed to this investigation. At this time, I will turn the meeting over to our acting managing director, David looser.
[00:07:01] Thank you,
[00:07:04] David LaCerte: [00:07:04] chairman LMO stated I’m David will sir, the senior advisor and executive council, and I’m also the acting managing director of the CSB. Say, we’ll hear from Steven Kleist the CSB executive director of investigations and recommendations. We’ll introduce our presenter. Lauren grim, the investigator in charge of the ag or an investigation.
[00:07:25] I see, and technical staff will give an overview of the incident and reduce areas of investigative focused to include elements of factual analysis and a narrative fashion. After this presentation to the board, the board may then ask questions of the staff on the information in executive director.
[00:07:42] Clients will then deliver the findings of the investigation. The board may ask questions about the findings and may or may not participate in discussion for each finding prior to any motion for changes or any motion to accept the findings executive director Kleist will then present any probable cause statements from the investigation with similar rounds of questions or discussion as requested by the board followed by any potential motions for changes or any motions to accept the probable cause.
[00:08:09] Filing executive director Klyce will deliver any recommendations from the investigation, followed by another round of questions or discussion as desired by the board. The board will then make any motions for changes or emotions to adopt to the recommendations the chairman and the made to choose may then choose a closing statement and or join the meeting depending upon the flow of the meeting.
[00:08:30] We may pause for a brief break at some period. I have reviewed all public comments prior to today’s meeting, and I’m confident that today’s meeting and the subsequently released final report will satisfy those comments. Any additional questions may be sent to for consideration and follow-up.
[00:08:49] The United States chemical and hazard investigation board is currently operating with a single board member. Their so-called form of lawn is provided four and 40 CFR, 1600.5 a under the law, three board members constitute a CSB coral. However, provisions also state that if the number of board members in office are fewer than three, the quorum shall consist of the number of members in office.
[00:09:14] So they, that number is one, as we have a single board member for the duration of today’s board meeting, we will suspend parliamentary procedure and all votes from the board shall be considered to be made under unanimous consent. We welcome the opportunity for future board members. After they have been nominated by the president and confirmed by our Senate.
[00:09:31] I wanted to personally thank the entire investigative team today. I note their dedication to their jobs. I’m grateful to be a part of this great team so that we can advance on other investigations and recommendations and further in some of our missions. I’ll now hand it over to executive director of investigations and recommendations.
[00:09:46] Steve Clice Steven, thank you, Mr. L assert the office of investigations completed the investigation, the investigation of the accidental release of the hydrogen sulfide gas at the Agon operating waterflood station in Odessa, Texas that occurred in October 26th of 2019. The report includes a number of safety issues that were identified by staff during the investigation.
[00:10:11] Perhaps the most fundamental of these issue was with lack of an effective safety management program. Safety management program should be an essential element of every organization’s business plan. They safety management program provides for the systematic identification of hazards and the development of effective controls of the hazards present, or likely to be present with me today to present the draft report to the board for their consideration to adopt our supervisory chemical incident, investigator Lauren grim and director of recommendations.
[00:10:45] Charles Barbie, Ms. Grimm assumed the role of investigator in charge of this investigation earlier this year and will be presenting an overview of the incident. The safety issues identified and the key findings I wish to acknowledge. Will’s Hogan, the original investigator in charge for his outstanding work and professionalism while serving in this role.
[00:11:08] While Mr. Hogan is no longer with the agency, his contributions were the foundation of the, this incident investigation report. Ms. Grim, please proceed with your presentation. If you director class, I will first give an overview of the process of the akward facility. I, I Corrine’s foster, do you water flood station where the incident occurred, received, produced water, which is a by-product of oil extraction in the area from approximately 68 crude oil Wells in the Permian basin.
[00:11:44] The station is used to improve the extraction of oil from underground oil reservoirs ag corn operates over 600 producing oil and gas Wells in New Mexico and Texas. You can advance slides, please, right there shown in the figure on the right and this and this slide. Pumpjacks extract oil from oil reservoirs and transfer the oil to a tank battery through pipes at the tank battery.
[00:12:13] The oil is stored in large tanks where small amounts of water separate from the oil. This water called produced water typically contains other components, including hydrogen sulfide or H two S which is a toxic gas known to be present in oil and gas reservoirs in the area. After it’s separated from the oil other pipes transfer the produced water from several tank batteries to the foster de-water flood station.
[00:12:41] The waterflood station pumps the produced water back into the oil reservoir. On October 26th, 2019, an ag horn employee called pumper a responded to a pump oil level alarm at ag horns foster D water station in Odessa, Texas. The pump, which is called pump. Number one was located in a building called a pump house.
[00:13:06] In response to the alarm pumper, a worked to isolate the pump from the process. By closing the pumps, discharge valve had its suction valve pumper aid did not first perform lockout tagout to isolate pump number one from its electrical energy sources before performing work on the pump. At some point while pumper Ray was in the vicinity of the pump, the pump automatically turned on and water containing H two S released from the pump.
[00:13:33] The investigation team found post-incident that the pump had a broken plunger from which the water and the H two S released pumper a was fatally injured from his exposure to the released age. Two us subsequently the spouse of pumper, a gained access to the waterflood station and searched for pump Bray.
[00:13:55] During her search efforts, she also was exposed to the released age to us, and she also was fatally injured. The investigation team identified the following six safety issues and its investigation. It was not the non-use of pumper A’s personal H two S detector, the non-performance of lockout tagout confinements of H two S inside the pump house ag corns, lack of a safety management program, ag horns non-functioning IX, H two S detection and alarm system and ag horns deficient site security.
[00:14:33] I will now discuss each of these safety issues. Safety issue. One was the non-use of the personal injury to us detector ad warn supplied its employees with personal H two S gas detectors to be worn on their person. No personal H two S gas detector. However, was found on pumper a after the incident emergency responders found a personal H two S detector inside pumper A’s work truck.
[00:15:01] When they removed it from the vehicle, the device was admitting an audible alarm, meaning that the detector had been exposed to elevated levels of H two S while agg horn did train its employees in February of 2019 on H two S hazards ag horn did not have a formal policy in place requiring its employees to always wear H two S detectors at waterflood stations.
[00:15:27] The staff proposes a recommendation to add horn in this area or the board’s consideration safety issue. Two is the non-performance of lockout tagout. Post-incident. The incident scene was found with conditions that include the following pump. Number one was found running produced. Water was observed spilling out of pump.
[00:15:50] Number one, the power switch for pump number one within the automatic position, meaning that it was configured to be controlled by the PLC. The main power switch for pump. Number one was in the on position. The discharge valve handle for pump number one was in a position indicating approximately 95% closed.
[00:16:12] Uh, advanced next slide please. And the position indicator on the suction valve for pump number one was about 50% closed. The investigation determined the investigation team determined that pumper EY did not perform lockout tagout as required by OSHA regulation. 1910 0.1 47 called the control of hazardous energy lockout, tagout to de-energize pump number one from electrical sources before performing work on the pump pump for a closed pumped number one’s discharge valve, any partially closed pump.
[00:16:46] Number one, suction valve wild pump was still configured to be automatically operated by the PLC. The PLC is automatic activation of some number one, allowed water containing H two S to release from the pump while pumper a within the pumps vicinity at the time of the incident ag corn did not have any written lockout, tagout policies or procedures in interviews.
[00:17:11] That’s three ag, corn employees, including the vice president and two production, four men. One of whom had previous, previously been a pumper. They explained to the CSB investigation team that the ag born lockout tagout practice was commuted, communicated on the job only. Ag corn did not provide the CSB with sufficient records for the CSB investigators to determine to what extent pumper a was trained on the verbal lockout tagout practice.
[00:17:41] The staff proposes a recommendation for ag corn in this area for the board’s consideration safety issue. Three is confinement of age to us inside the pump house. The waterflood station pumps were installed inside the pump house and despite being housed in the pump house, these waterflood station pumps could be installed and operated outdoors in an unenclosed environment.
[00:18:07] And ag barn also operates another waterflood station where a building does not enclose the pumps. The pump house was ventilated by the two Bay doors on the East side of the pump house on the night of the incident and these doors were approximately 60% open. The pump house was also equipped with ventilation fans, but the CSB did not have sufficient evidence to determine if these fans were operational at the time of the incident.
[00:18:35] The open Bay doors did not adequately ventilate toxic H two S gas from the building during the incident because the failed pump was inside the inadequately ventilated pump house. The released H two S gas was confined within the building contributing to the high H two S levels to which pumper AE and his spouse were exposed.
[00:18:58] The staff proposes a recommendation to ag born in this area for the board’s consideration safety issue. Four is the lack of a safety management program. The CSB investigation team requested from ag horn, all written policies and procedures used by Akron operating at the time of the incident ag corn’s policies and procedures included.
[00:19:21] One is cell phone use policy to an alarm call-out procedure and three, a pamphlet on H two S hazards ag corn had no additional formal company safety policies or procedures. Comprehensive safety management practices include risk identification, assessment mitigation, and monitoring of design procedures, maintenance, and training.
[00:19:46] And they are an essential element of protecting workers and the public from toxic gases at chemical facilities, the lack of a formal company, safety policies and procedures likely contributed to the non-performance of lockout tagout and the non-use of pumper A’s personal H two S detector. The staff proposes a recommendation to ag born in this area for the boards consider issue safety issue five is the non-functioning H two S detection and alarm system.
[00:20:18] The ag barn, waterflood station was equipped with an H two S detection and alarm system, which ag horn stated to the CSB investigation team was designed to initiate an alarm. When the system detected H two S above the specified specific concentrates to detect the gas, the waterflood station used eight points detectors, which were installed around the perimeter of the tanks.
[00:20:42] Some buildings and two were installed inside the pump house. Any one or more of these detectors since the concentration of H two S gas above the specified level, the system was then designed to send it, send a signal to the control panel in the control room. The control panel would then activate two separate alarms, one with an alarm connected to the phone system, which would call the pumper on duty and let them know about the dangerous atmosphere at the facility and to a rotating red light at the top of the pump house to provide a visual cue, that there was a dangerous atmosphere at the facility.
[00:21:20] The alarm system did not incorporate an auditory, uh, physically at the facility, CSB investigators asked emergency rooms, sponsors, and ag corn personnel who responded to the incident if they heard or saw any alarms, such as an illuminated light on top of the pump house. None of the emergency responders or ag horn personnel told the CSB investigators that they saw the light illuminated during the emergency response.
[00:21:50] The CSB also tested the alarm system after the incident. And the testing found that none of the working detectors communicated with the alarms control panel, which is located in the control room. Some of the, some of the facilities detectors were set to a testing mode, which prevented them from sending an alarm signal and other sensors that were correctly set up were unable to send a signal to the control room.
[00:22:16] The CSB also tested whether the beacon light could be functioned, had the detection and alarm system been properly configured. And when a test signal from the control panel with sent to the beacon light on top of the building, it did eliminate the CSB requested from ag horn, all maintenance and calibration records for the H two S detection and alarm system and ag corn responded to the CSB stating that it did not locate any responsive documents at corn did not maintain or properly configure it’s fostered waterflood station facility, H two S detection and alarm system without the alarm panel receiving any signal signals from the detectors, neither the beacon light, nor the foam system alerted pumper a to the dangerous atmosphere.
[00:23:08] The staff proposes a recommendation to ag corn in this area for the board’s consideration and safety issue. Six was deficient site security site security at the facility consists of a gate at the entrance from the public road, a barbed wire fence around the perimeter and a chain link fence topped with barbed wire around the waterflood station immediately to the left of the gate.
[00:23:34] And, uh, advanced the slide please immediately to the left of the gate of the fist facility near the public road. There are signs that lists several warnings, including warnings about the potential for H two S gas to be present. Additional signs installed to the left of the gate of the interior chain link fence also worn the potential presence of H two S many of the aides to us warning signs were corroded.
[00:24:00] The signs likely were not non-corrosive. They were not reflective. They were not lit, and they were likely difficult to read under low light conditions. Eichorn told the CSB that they expect the waterflood station access Gates to be locked each day after employees complete their tasks. While employees are present at the facility, the Gates are typically left, open and unlocked on the night of the incident and both the gate and the chain link fence were left open since pumper a was working in the pump house.
[00:24:35] The unlocked Gates allowed comfort his spouse to drive up to the waterflood station and enter the pump house where she was exposed to toxic H two S gas, several industry standards, issue, guidance and requirements for site security at petroleum and petrochemical facilities. Two of which include ANSI API standards, seven 80 security risk assessment methodology for the petroleum and petrochemical industries and API RP seven 81 called facility security plan methodology for the oil and natural gas industries.
[00:25:10] The staff proposes a recommendation to add corn in this area for the board’s consideration and chairman. This now concludes the staff presentation on the incident. Everyone, the board is now available for questions or comments as you deem appropriate.
[00:25:32] Katherine Lemos: [00:25:32] Uh, thank you so much, Lauren, for, um, the educational and comprehensive, um, overview of the report. This is great. I’m now going to ask some questions, uh, just clarify, um, some issues. So in the report it mentions, um, something OSHA refers to as olfactory fatigue that can occur after exposure to high concentrations of H two S.
[00:26:04] Um, or over extended periods now, from your understanding, this is a common phenomenon, uh, a fatigue, not specific to H two S correct.
[00:26:17] David LaCerte: [00:26:17] So olfactory fatigue is that is a condition I’ll say that can happen with different kinds of gases that have an odor, um, that over time you may not be able to smell the particular chemical, the longer you’re exposed to it.
[00:26:35] Um, H two S is one chemical that where people can experience all factory fatigue. So even if they are in the presence of H two S they may not know it from the sense of smell, because they can’t smell it any longer. There are other chemicals that also, um, that condition can arise. Um, it’s not, it’s not specific to H two S but we know that it does happen with H two S
[00:27:01] Katherine Lemos: [00:27:01] so excellent.
[00:27:02] And, um, to put it in, in perhaps some layman’s terms, I, I have heard that. So for example, people living in Hershey, Pennsylvania report that they stopped smelling chocolate after several months. So visitors report smelling, smelling chocolate, For up to a distance of 40 miles, and this could be the same type of thing.
[00:27:29] Um, in the sense that, that you mentioned that when you arrived in Odessa, it was overwhelming to you. Um, but that may not have been, um, uh, detected by people who live permanently there. Correct?
[00:27:46] David LaCerte: [00:27:46] That’s correct. Um, well, I can’t comment on if people in the area can smell AIDS to us. I know when we were at the facility, we could, we got whiffs of age to us and we were able to smell it.
[00:28:00] Um, it has a very low odor threshold. So at low concentrations, if you’re not fatigued to the smell, you can detect it.
[00:28:09] Katherine Lemos: [00:28:09] Got it. So, um, and we’ll talk about this later, but when the, uh, response team arrived at the facility, they could even smell it at the entrance of the gate. And therefore, uh, this meant that there were actually really high levels of H two S present, correct?
[00:28:31] David LaCerte: [00:28:31] We can make the determination on concentration on the smell alone because of the low odor threshold. But we do know that emergency responders did smell H two S which has, um, a rotten egg voter to it when they arrived at the facility.
[00:28:50] Katherine Lemos: [00:28:50] Excellent. So for this reason, is that why OSHA warns that the sense of smell should not be relied upon as a detection method for H two S yes.
[00:29:03] Excellent. So as described in the report, um, with any pump failure, as a horn should have trained employees to be alert to the potential for a release two H two S can you tell me more about this,
[00:29:18] David LaCerte: [00:29:18] this facility, um, pumped produced water that came from, uh, oil and gas reservoirs at a high pressure. It was about 900 PSI G.
[00:29:31] Um, and we know that the water content that goes through this particular facility does have a high concentration of H two S in it. Um, so in the event of an equipment failure, the investigation team determined that it would be good practice for companies to train their employees that that could indicate the release of water continuing age to us, and to be on the alert of the potential for an age to rest age to us release
[00:30:02] Katherine Lemos: [00:30:02] understand.
[00:30:03] So because of the fact that these, this terrain in this area, this part of the Permian basin is likely to have H to us and the company was aware of it. They trained for it. Um, Any type of pump failure could result or pump release of fluid could involve then, uh, H two S as a component, right?
[00:30:28] David LaCerte: [00:30:28] Yes, that’s correct.
[00:30:30] Okay. C H two S is within the produced water.
[00:30:34] Katherine Lemos: [00:30:34] Okay. Thank you. Now, as describing the factual ag corn employed, two methods to detect and alert for toxic levels of H two S and I have questions about each of these one is the facility H two S detection and alarm system. And the other is the personal H two S detector that employees are issued to wear on their persons.
[00:31:00] So regarding the H two S facility detection and an alarm, how many sensors did the foster D facility? H two S a texted an alarm system include both inside and outside of the facility
[00:31:16] David LaCerte: [00:31:16] we installed, um, is two ads detection and alarm system incorporated eight separate detectors. There were six on the outside of the pump house within the waterflood station, and then there were two inside of the pump house itself.
[00:31:32] Katherine Lemos: [00:31:32] Okay. And at the time of the incident, how many of them were in a condition to transmit the detection of H two S to the control room, H two S detection and alarm control panel.
[00:31:46] David LaCerte: [00:31:46] What we know is that none of the detectors were actually able to send any kind of signal, alarm signal to the control panel. So in the event of an H two S relieves, the alarm system would not be able to function on alarm.
[00:32:04] Katherine Lemos: [00:32:04] Okay. And when you say it’s not able to function, um, to produce an alarm, you’re saying them both alarm or alert mediums associated with a system were not functional. The two that I’m going to go through those in a second, but neither of them were executed or operational because of the fact that the control panel never received the
[00:32:28] David LaCerte: [00:32:28] signals.
[00:32:29] Yeah, that’s correct. So the control panel and even ever released was not able to get any kind of alarm from the, from the signal communication from the detectors in the field. So therefore the control panel was not able to respond or trigger either the beacon light on top of the building or the phone call.
[00:32:50] Katherine Lemos: [00:32:50] Excellent. Okay. So let’s assume for a moment that the system was operational and that the control panel received, uh, signals from the sensors, um, that reached a threshold. If the system was operational, the control panel would have triggered a luminous illumination of a rotating red beacon light top of the facility, right?
[00:33:18] Yeah. Okay. So was this only visible from the outside of the building?
[00:33:24] David LaCerte: [00:33:24] Yes. The beacon light would have only been visible from the outside because it was on top of the pump house.
[00:33:30] Katherine Lemos: [00:33:30] Okay. So there would have been no opportunity for a pumper inside the pump house. Let’s just say, had the event occurred after their arrival, there would have been no opportunity for a pumper inside the pump house to see it.
[00:33:47] David LaCerte: [00:33:47] Yeah. That’s our understanding. Okay.
[00:33:51] Katherine Lemos: [00:33:51] And have the system and operational what the control panel will have also triggered a phone call and the copper on
[00:33:57] David LaCerte: [00:33:57] duty. Yeah. That’s also our understanding. It triggers both the beacon light and a phone call to the pumper.
[00:34:06] Katherine Lemos: [00:34:06] So under what conditions would we expect that this phone call could have occurred in the timeframe for pumper age to respond successfully?
[00:34:17] So what assumptions or challenges would be present if it occurred after arrival for them to respond successfully?
[00:34:33] David LaCerte: [00:34:33] We can’t know that, um, we. There wasn’t enough evidence for us to establish in our timeline, whether the pump failure itself, which was the shattering of the plunger happened before or after the pumper arrived at facility.
[00:34:50] Um, and the events of the primary water loss of containment happened after the pump up pumper was already in the pump house. What we don’t know is what the dose of age to us was to the pumper and his first couple of breaths and that, so that makes a difference in whether someone would actually be able to escape if they received the phone call, um, with very high doses, um, becoming unconscious from S release can be very quick if it was a lower dose, it’s possible that the pumper may have had enough time to escape, but we just, we don’t know that.
[00:35:34] Katherine Lemos: [00:35:34] Um, um, thank you. So can we, can we establish that things such as the cell reception, uh, in the facility or surrounding the facility in route the facility, The, whether or not the pumper has her phone because we have a phone, um, policy, not sure if the pumper would have had their phone with them. And as we understood from the, The, um, Alert that the pumper received from the system regarding the, uh, pump failure or pump anomaly.
[00:36:17] There was a five minute delay from the detection in the controller to the actual phone call. Um, so it’s possible that all these things could have played a role. And what I’m trying to get at as is the system wasn’t functional the day of the incident. And therefore we’ll never know if comper a might have received an alert, correct?
[00:36:44] David LaCerte: [00:36:44] We do know that he did not receive an alert of an H two S release from a phone notification or from the beacon light on top of the building because of the detection and alarm system was not operational.
[00:36:59] Katherine Lemos: [00:36:59] Thank you. That that’s helpful. So do you agree that even if operational this system was not effective in alerting employees, especially if they were inside the pump house, when an event occurred,
[00:37:16] David LaCerte: [00:37:16] The, the way for someone inside the pump has to be alerted of an age to have to release that they had their phone on them, on their person.
[00:37:26] Um, and they were the person configured in the system that would receive that phone call. Um, if they did not have their phone or if they were not one of the people configured to receive the phone call, they would not have received a notification of an HQs release.
[00:37:43] Katherine Lemos: [00:37:43] Um, and we don’t even know if there was a five minute delay, a five minute delay with, um, with a massive or a significant release of, of H two S that that could overcome them.
[00:37:56] Well, prior to the receipt of, of a, an alert, correct.
[00:38:01] David LaCerte: [00:38:01] Uh, with the delay of notification that, and the lethality of age two as that’s possible. Um, okay. That’s good. And again, the main issue here was that the detection system itself was not operational.
[00:38:17] Katherine Lemos: [00:38:17] Got it. Okay. So can you tell me more about what features would render this type of warring system more effective,
[00:38:27] David LaCerte: [00:38:27] uh, to make the system work back to would be to ensure that the detection and alarm system is operating as it’s designed to be operating and to do that, that requires a dedicated maintenance program and inspection program by the operating company to make sure they have systems in place to make sure that detection and alarm system is always functioning as it should be.
[00:38:51] This should be considered a safety critical component of the facility because it’s there to protect workers.
[00:39:00] Katherine Lemos: [00:39:00] Um, and there are, um, in the end, you know, in the factual, especially in the analysis, there’s guidance on the design of systems that, uh, are improvements to this particular one, absolutely. That this system was functional and working is a basic, what is the guidance on the design of such symptom, such systems that are available that would provide, um, alerts to those inside the pump house?
[00:39:35] Um, if, if it occurred at that point, at that moment, um, or to other non-employees,
[00:39:45] David LaCerte: [00:39:45] uh, for these kind of detection and alarm systems, there’s, there’s multiple modes that alarms can be communicated to people at the facility, both indoors and outdoors. One is the lights that they had installed. Um, there could also be lights installed the pump house to give the visual cue.
[00:40:04] And then the second is having an audible component and to, to help alert people up the facility up an alarm.
[00:40:11] Katherine Lemos: [00:40:11] Um, thank you. And I know you have recommendations in this area, as you mentioned in your presentation. So now I want to move on to the age, stress, personal detection devices. Um, to confirm at the time of the incident, despite the issuance of, of the personal H two S detectors and their training, did ag corn actually require that employees wear this personal H two S detector went off the waterflood station.
[00:40:45] David LaCerte: [00:40:45] What we know is that ag corn did not have a defined, written policy or procedure Quiring their employees to wear HQs detectors,
[00:40:56] Katherine Lemos: [00:40:56] right? Didn’t you learn through interviews that the only method of reinforcement was during formal conversations with employees to encourage its use.
[00:41:10] David LaCerte: [00:41:10] Uh, we also know that they did train their employees.
[00:41:13] They had one of their, um, when we asked for policies and procedures, one of the items they provided to us with was an H two S pamphlet on the hazards. Uh, and we also have training records that they did train the employees on H two S hazards. Uh, the gap we identified as they didn’t have a formal policy requiring wearing H two S detectors.
[00:41:37] And we were not provided information on the frequency with which they may have reinforced the requirement where each two us detectors with their employees.
[00:41:48] Katherine Lemos: [00:41:48] Yeah. Reinforcement seems to be a big issue because especially, uh, I mean, In any, um, accompany or the safety culture, it’s what the management attends to that the employees follow and, and seem to gravitate towards.
[00:42:14] So if there was only informal conversation with the employees to encourage its use, that doesn’t seem to be a mandate or a requirement,
[00:42:25] David LaCerte: [00:42:25] correct? Yeah, that’s correct. Um, mandates and requirements, um, would more so be documented in a written policy by the company.
[00:42:36] Katherine Lemos: [00:42:36] Got it. Which, which I didn’t have. Um, and finally, do you believe that the training on the, uh, personal H two S detectors and hos in general was consistent with the OSHA warnings, um, that we talked about earlier with regard to olfactory fatigue, do you, do you believe it was consistent with what we know, um, from, from guidance, from, um, OSHA and NIOSH,
[00:43:07] David LaCerte: [00:43:07] um, the, the training information we received, they did cover, um, levels at which a two H two S may or may not be detected by the sense of smell.
[00:43:18] So it appears from what we have, they did cover olfactory fatigue, um, It appears, they also discussed wearing H two S detectors in the training, the left, the wish, the latest one, I believe was February of 2019. Um, so it appears that the company did talk about H two S hazards. Really the gap came back to what is their policy requiring that employees were H two S detectors.
[00:43:48] And was there a system to ensure that employees were following that policy?
[00:43:53] Katherine Lemos: [00:43:53] Um, so I would venture to say that if a company doesn’t require it, and if it only in formal conversations to encourage it doesn’t sound like a whole hearty. Um, uh, it doesn’t sound like a sanction that we must do this. And this is like, for example, wearing hard hats, wearing safety glasses, you have to go in wearing your ACS detector.
[00:44:26] And I’ve been in facilities, uh, uh, over the past year where I was issued an eight, uh, personally should ask detector. And that wasn’t the main risk, um, at the facility. So when I hear about. Informal conversations to help encourage this. Doesn’t make me feel comfortable that the company was serious about the impact that personal HQs at H two S detectors could have,
[00:45:03] David LaCerte: [00:45:03] um, uh, policy, policy and procedures is the step in the right directions to ensure that employees are following actually to want to establish the policy. So employees are aware of it. And then there’s the component of having a program to ensure that employees are following that policy. Two parts that we see that both of them were lacking here.
[00:45:28] Katherine Lemos: [00:45:28] Excellent. I agree with you. So now I want to move on to the topic of ventilation. Um, remind me, what were the three potential sources of ventilation in the pump house?
[00:45:43] David LaCerte: [00:45:43] There were two Bay doors, kind of like large garage doors on the East side of the building. Um, there was, um, some cutouts for ventilation fans were installed on the bottom and up the West side of the pump house.
[00:45:59] And then there were just also some events within the pump house building itself and correct
[00:46:05] Katherine Lemos: [00:46:05] me if I’m wrong. But, um, my understanding through the investigation and the, and the draft report. You were able to confirm that the Bay doors were likely at least 50% open, if not more. And which was, which was established as common practice, you were unable to confirm whether the fans were operational and in use.
[00:46:29] And on third, there was no mention of whether you were able to confirm the, if the events were functional and in use. Correct.
[00:46:40] David LaCerte: [00:46:40] Uh, so the first responders who were there, we were able to get some video, what the facility looked like and they arrived. And the video does show that the Bay doors were about 60% open.
[00:46:56] Um, the ventilation fans themselves. Uh, we don’t have any data indicating whether they were operational at the time of the incident. And that, that was not something we were able to determine. The determinants part of the investigation is if they were actually on at the time of the incident and as to the events, um, they were just kind of natural openings within the building.
[00:47:23] Um, but what we, what we do know was that the concentration of H two S within the building would have been high enough to cause the fatal injuries.
[00:47:35] Katherine Lemos: [00:47:35] Um, okay. That helps to clarify. So. And I think you helped me lead into the next question, which is, do you have reason to believe that have the Bay doors been open, say 60%, but like between 50 and 75%, which is what was indicated as common practice and with the events and the fans operational and in use these three elements would or could have provided sufficient ventilation to mitigate the impact of this chemical release.
[00:48:14] So do we know had all of those been operational and we were able to quantify that, are we able to ascertain whether this was sufficient?
[00:48:27] David LaCerte: [00:48:27] No, we cannot ascertain had the fans been operational if they would have been sufficient based on documentation alone, because there was not an official ventilation study performed backward.
[00:48:42] It’s like air changes. If there was an H two S release, how effective with all those ventilation components be in ventilating, the building, um, that would require more robust modeling was may or may not give us really a true answer to what actually happened on the day of the incident. But going back, we just know at the time of the incident, the building was not sufficiently ventilated.
[00:49:07] Katherine Lemos: [00:49:07] Um, and that not actually asked his answers my ass question. Um, did I record and provide you with any assessment or analysis of the effectiveness of their ventilation? No. Okay. So would it be fair to say that there’s no method to quantify the contribution of the fans of events? No,
[00:49:29] David LaCerte: [00:49:29] not from documentation alone, that would require some level of modeling.
[00:49:34] Katherine Lemos: [00:49:34] And I appreciate that. Would it be fair therefore, to state that ag corn’s ventilation approach as implemented on the day of the incident was inadequate, regardless of whether we confirm the status of all three of those elements of ventilation?
[00:49:55] David LaCerte: [00:49:55] Yes. The building was not adequately ventilated to prevent a lethal concentration of H two S inside the building.
[00:50:05] Katherine Lemos: [00:50:05] Okay. So I, I will, uh, reserve some further comments for later. Um, as, uh, as in respect to, uh, findings. Now we’ll move on to, um, other parts of ventilation in terms of their procedures. Can we state affirmatively that H two S was a known risk for ed horns foster D water flood state.
[00:50:38] David LaCerte: [00:50:38] Yes, because of we know that there was a, they had a pamphlet on H two F hazards and they did train their employees on H two S hazards.
[00:50:49] All right.
[00:50:51] Katherine Lemos: [00:50:51] You also indicated that ad corn did not provide you with an assessment or indicate that they assess the adequacy or effectiveness of the means to ventilate the compounds.
[00:51:03] David LaCerte: [00:51:03] Correct? We did not receive any kind of ventilation study or design documents
[00:51:12] Katherine Lemos: [00:51:12] now. No. If the pumps are made specifically to handle H two S not, not uniquely, but can they handle S
[00:51:22] David LaCerte: [00:51:22] it’s our understanding?
[00:51:25] Yes. I’ll say we did not do in detailed design review of the pumps themselves because of the scope of the investigation. But in practice, I’m assuming the pumps are maintained to contain the process equipment. They can, they’re capable of pumping the water that contains.
[00:51:50] Katherine Lemos: [00:51:50] And what I understand from the manufacturer manuals, um, There are other ACS and other toxic chemicals could be processed by this type of pump. And there’s reason to a pump manufacturer manuals would not have pride in provided specific information to the release of each chemical. Would you agree with that?
[00:52:18] David LaCerte: [00:52:18] The design manuals themselves and determining if the pumps are capable of operating, um, what the process fluid that ad partner, any chemical facility use that that’s really falls on the company to make sure they’re looking at the design they’re selecting and looking at their process conditions and doing an analysis to see if the equipment is suitable for the job that, so there’s a determination of pumps suitability for the process to be the operator facility’s responsibility when designing the process.
[00:53:00] Katherine Lemos: [00:53:00] Um, that’s actually a great segue into my next question. If the manuals don’t provide that, which I wouldn’t anticipate, they would given the number of chemicals that could be processed by these pumps. How would companies such as ag horn or their predecessors since we know that they purchased it. Um, um, from previous companies, how would they have evaluated the design of their facility environment to mitigate the risk of a toxic release, uh,
[00:53:32] David LaCerte: [00:53:32] facilities can perform what’s called a process hazard analysis.
[00:53:38] So they’re looking at the hazards of their process and making sure their equipment can handle those hazards and components of the process. So it’s first kind of becoming fully aware of what’s called process safety information of what, what actually is being pumped through the pumps. What hazards are inherent to those, for example, corrosion, um, reaction with the material of construction of the pump, for example, and then selecting a pump that can handle the properties of that particular fluid.
[00:54:15] Katherine Lemos: [00:54:15] And, and that makes sense. So are there companies that specialize in conducting these types of assessments?
[00:54:24] David LaCerte: [00:54:24] Yes. Um, there’s companies out there who can do kind of consulting services and also the manufacturer a lot of times can provide information on, on that. Also
[00:54:38] Katherine Lemos: [00:54:38] your knowledge, is this a common practice for chemical companies in general?
[00:54:43] Not just waterflood stations, but. Are there are that companies that do assessments of the design of the year, their facility, um, not just for the pumps, but the federal elation to ensure that any mitigation of a potential release is addressed.
[00:55:07] David LaCerte: [00:55:07] I would venture to say that OSHA would say that to requirement for operating facilities, to assess all the hazards of their process and the events, the hazard that employees are exposed to the hazard to protect their employees from hazards.
[00:55:28] Katherine Lemos: [00:55:28] So the next question is would this type of risk be identified in the company, had a safety management program,
[00:55:36] David LaCerte: [00:55:36] a safety management program would be a significant step in the right direction. Um, and when a safety management program is, is kind of the collection of policies and procedures that a company would use to manage safety at its facility.
[00:55:59] Um, so ensuring that those procedures are in place that they’re accurate and that they’re being followed would help prevent this kind of incident from happening in the future. Um,
[00:56:12] Katherine Lemos: [00:56:12] so. What you’re saying is that safety management programs or best practices would have caught this. But you’re saying that companies of all sizes also have the responsibility under OSHA requirements and regulations to already assess this.
[00:56:32] David LaCerte: [00:56:32] So that I’ll say there’s, uh, there’s uh, that depends, um, answering to my question. Um, OSHA has different regulatory requirements depending on the chemicals and the quantities in facility. So chemical facilities that have threshold quantities of certain chemicals fall under the process safety management standard, um, companies that don’t fall under that threshold of quality requirements just are susceptible to OSHA’s other regulatory requirements that aren’t specific to the process safety management regulation.
[00:57:10] Um, but all of their requirements ultimately require employers to protect workers from hazards. Um, and so there are certain OSHA regulations that have specific requirements, for example, lockout tagout, and if standard on air contaminants, then there’s a general, general duty clause that requires employers to protect workers from hazards.
[00:57:40] Katherine Lemos: [00:57:40] Okay. So what you’re saying is that would fall under the general clause or protection, even if a company does not meet the requirements or the level of production or quantity of chemicals to meet the requirements of the, um, risk management program for EPA or the PSM for OSHA. Right. Right. Okay. Um, okay, so now we’ll move on to log out, log out, tag out.
[00:58:16] And, um, the first question I have, because you did, you did a great job of describing what this is, but can you describe for me in the audience today and the audience, right. What is lockout tag out of a pump mean in layman’s terms?
[00:58:36] David LaCerte: [00:58:36] Um, OSHA regulation on lockout tagout, and really the whole purpose is to protect workers who are working on equipment from hazards.
[00:58:46] Can that particular piece of equipment. And so what the regulation requires is the isolation of the energy from that piece of equipment. And so there’s many different forms of energy. So it’s up to the company and to identify what are the available sources of energy to isolate the equipment. But that could be.
[00:59:09] Um, electrical energy that could be hydraulic energy, um, chemical, thermal, kinetic, energy mechanical, um, anything potentially that could ultimately cause harm to the worker if they’re working on live equipment.
[00:59:31] Katherine Lemos: [00:59:31] Um, that helps explain. And, uh, some of my, you know, up questions. So you’re talking about all sources of energy being associated with a pump are disabled or disengaged.
[00:59:45] David LaCerte: [00:59:45] Correct.
[00:59:46] Katherine Lemos: [00:59:46] And that includes both in this case, electrical and hydraulic energy, correct? Yes. Okay. And when you say isolating, that’s, it’s really a term that’s anonymous and wisdom the report. I just want to clarify that.
[01:00:02] David LaCerte: [01:00:02] Yeah. It’s just preventing energy sources really from coming in contact with the worker, so, or preventing energy sources from activating the piece of equipment that the workers working on.
[01:00:15] Okay.
[01:00:17] Katherine Lemos: [01:00:17] So in the pump and you facture a manual, a daily lockout tag out of each pump is recommended to include both electric, electrical and hydraulic energy sources. So. Without assumption, what would be the benefit to executing lockout tag out procedures on a daily basis?
[01:00:44] David LaCerte: [01:00:44] So the lockout tagout should really be performed prior to workers performing work on equipment.
[01:00:51] And so, um, ensuring the electrical energy is turned off, uh, isolation, valves that allow process fluids to enter the equipment. Those are close, any residual energy and the equipment is removed. Um, that’s, that’s the intent of the standard. There’s not, it’s my understanding of time requirements. It’s really just any event workers are going to be working on equipment.
[01:01:23] Katherine Lemos: [01:01:23] So the daily lockout tagout was not something that you discovered to be, although recommended by the manufacturer. You, you, you did not discover that to be essential.
[01:01:38] David LaCerte: [01:01:38] I can say from our investigation and looking at the evidence that was not a requirement and we did not see, um, when such a requirements would, would be necessary.
[01:01:57] All right.
[01:01:57] Katherine Lemos: [01:01:57] Yeah. I mean, there could be preventative maintenance issues that could be discovered. Um, but, but in looking over the verbal procedures, um, you mentioned in a report that it was addressing the electrical energy source, what is the impact of not relieving the hydraulic pressure?
[01:02:21] David LaCerte: [01:02:21] A consequence?
[01:02:23] Well, consequences in this case was that the hydraulic pressure was able to cause water to come out of the pump when there was the pump failure, which was, um, that’s possible if it’s a really high pressure inside of the equipment and the hydraulic pressure is not relieved. Um, you know, this pump generally pumps output pressure of about 900 PSI G, which is pretty high pressure.
[01:02:51] So you want to remove anything that potentially inter employees and so high pressure conditions. You don’t want people working on that or potentially being exposed to that.
[01:03:05] Katherine Lemos: [01:03:05] And that’s right. And we saw that the fact that they even turned off the electrical elements, but then not o’clock the next morning we still have a lot of H two S present.
[01:03:16] Um, it’s related to the suction tank. The vice-president of acorn is involved. Um, In the factual, do the verbal procedures provided by ag horns, vice president, and two company foreman accomplish a complete lock out tag out process as described by the pump manufacturer. Sure.
[01:03:41] David LaCerte: [01:03:41] Um, we learned from ag horn, um, when its personnel arrived at the facility on the night of the incident that, uh, the electrical switches from in the, on position for this pump pump number one.
[01:03:57] So one of the first steps they took was turning off the electrical supply to pump number one, that would be a step you would do in a lockout tag out procedure. Um, and this particular incidents incident, since there was a release, they were also working to try to turn off the water supply to the pump. So one thing they did was they isolated the Wells that fed this particular water flood station by closing, by not having that water come to this waterflood station.
[01:04:30] Um, and then it, when water was still releasing, they, they identified there was another isolation valve they needed to close between the suction tank and the, uh, which prevented any water at all from getting to the pump and closing that would be able to fully stop the release.
[01:04:51] Katherine Lemos: [01:04:51] So I think what you’re talking about is what the pumper in that moment executed as well as what was executed over the next 12 plus hours.
[01:05:03] Right. Um, and the fact that they turned off other elements or, or isolated other elements, do the procedures that you list, the verbal procedures that you list, um, that were provided to you, do they address both the electrical and the hydraulic sources associated with the pump,
[01:05:31] David LaCerte: [01:05:31] The, um, verbal Chris feature.
[01:05:35] And then we have in the report, um, primarily talks about isolating left forces, which is turning off the main power switch. So the pump, as well as turning off, um, the PLC control panel and turning a switch that, um, puts the pump automatically aggravated by the PLC talk. So it was two offs and the, in the verbal practice, um, that was the extent of the verbal speed there.
[01:06:10] We were told in one of our interview, we were not, uh,
[01:06:14] Katherine Lemos: [01:06:14] anything beyond that. All right. So it included the electrical per your factual. It only addressed the electrical energy sources associated with a pump crack, not the hydraulic
[01:06:29] David LaCerte: [01:06:29] in the, in the interview. That’s what, that’s, what was told to us. Um, and again, it all goes back to not having the policy and procedure written down.
[01:06:41] Um, and the interview was possible just that portion was told to us because the eye, the electrical portion was found on. Um, but in training, if it goes beyond that, uh, we don’t have records specifically on lockout-tagout with training, or we don’t know specifically what was communicated to the gray.
[01:07:02] Katherine Lemos: [01:07:02] Got it.
[01:07:02] So we, we can state that these verbal procedures were incomplete. If what you listed in the factual was the complete list of lockout tagout process it, and it didn’t include hydraulic, even though we understand that the pumper tried, tried to address that in some form or fashion, the verbal procedures were incomplete.
[01:07:29] David LaCerte: [01:07:29] I, yeah, it all, it all comes back to the need to have a written thought out procedure. Cause then. And interviews, um, you know, were people tell us what they remember at the time were not there during the training. So, um, to the extent of what we have in the report, it does only cover the electrical portion
[01:07:53] Katherine Lemos: [01:07:53] of lockout tagout.
[01:07:54] All right. So add corn submitted post-incident to you, um, to the team, a, a lockout tagout procedures. Did they include both of these elements or did they include only the electrical element?
[01:08:16] David LaCerte: [01:08:16] Uh, post incident Eichorn did inform us that they did establish a new, uh, written lockout, tagout policy and procedure as to what the content of that procedure, um, and the full requirements I would have to, um, go back and review that the evidence, and I can provide that to you if you’d like.
[01:08:36] Katherine Lemos: [01:08:36] No problem. Um, so can you confirm for me that the vice-president of the bag worn into company format, I want to previous pumpers, you mentioned all indicated that the lockout tagout procedures not written anywhere. This is, this is a focus of this next question, uh, train that were not written anywhere, and they were trained
[01:09:03] David LaCerte: [01:09:03] on the job.
[01:09:04] Yeah, we so Acquin did not provide us with a written lockout, tagout policy and procedure that they had in place before the incident. So based on that, we know it wasn’t a written procedure. Um, there were some of the workers did communicate that it was on the job training, but yes.
[01:09:27] Katherine Lemos: [01:09:27] So do you believe that lockout tag out of a pump is considered to be a critical action for pumpers to be familiar with?
[01:09:36] David LaCerte: [01:09:36] Yes, because part of their job is to any events that the pump malfunction to do equipment isolation and preparation for any work that needs to be done on the pump potentially by a third party. So the pumpers do need to be aware, lockout, tagout procedures and requirements are
[01:09:59] Katherine Lemos: [01:09:59] potential consequences. And I don’t mean in every case, but are the potential consequences to the failure to lock out tag out severe and require immediate action
[01:10:13] David LaCerte: [01:10:13] and say, yes, the potential for the potential consequences for not following lockout, tagout are severe.
[01:10:24] Um,
[01:10:28] in this instance and in many other, um, Maintenance instances where any employees are in performing work on equipment. There are real hazards associated with equipment and which can cause fatal injuries. So performing lockout tag out is an essential component to protecting workers,
[01:10:51] Katherine Lemos: [01:10:51] essential component to protecting workers.
[01:10:53] I like how you say that, because that’s what I’m trying to get at from your experience as an investigator, across the range of operations in the chemical industry that you have become familiar with. And you’ve been with our agency fortunately for a long time, and we really appreciate your work here. So from your experiences across these industries, is it a normal practice for the company to have only verbal instructions for all walk, work
[01:11:23] David LaCerte: [01:11:23] procedures?
[01:11:25] Normal is a difficult question. Uh, we, we investigate a lot of types of facilities. Um, they’re all required to have a written policy. Uh, I’d say it’s more typical for us to see the existence of written policies, but sometimes lack of policies is also an issue that we find and was the instance in this particular incident
[01:11:55] Katherine Lemos: [01:11:55] and who requires them to have written policies and procedures.
[01:12:01] David LaCerte: [01:12:01] The requirements themselves come from OSHA and EPA. Okay. And this case, primarily OSHA, because this was not subject to the EPA risk management program.
[01:12:16] Katherine Lemos: [01:12:16] Got it. And, and I know you point out in the report that Eichorn was not compliant with, uh, um, with the OSHA regulations. So how about for critical items?
[01:12:29] How often do you see that critical safety items don’t have any written policies and procedures for their, for their employees?
[01:12:43] David LaCerte: [01:12:43] The, how often? The question is again difficult because we, we come to a facility after they’ve had a significant incident of sunsets of some type. Um, and sometimes it is for, from lack of procedures that we find causal.
[01:12:59] Sometimes we find it causal from ineffective procedures or procedures that may not have been followed. Um, it’s, it’s a component or a facet of the investigation that we always look at, but, but sometimes it happens where procedures are not in place. Is it
[01:13:17] Katherine Lemos: [01:13:17] rare that a company has absolutely no written procedures for critical safety items?
[01:13:26] David LaCerte: [01:13:26] It’s possible. We’ve seen it. We’ve seen it before.
[01:13:30] Katherine Lemos: [01:13:30] So if they had written the seizures, um, and if it was such a essential safety item, as you mentioned, I’ll use your terminology, essential safety item, wouldn’t you also expect there to be a checklist posted in the control room, close, you know, close to the controller that says, this is how one would isolate and conduct a lockout tag out of a pump.
[01:14:00] David LaCerte: [01:14:00] That could be a strategy that companies employ. Um, so the, the way a company decides to I’ll say force it’s written policies and procedures is really up to the company. That’s not necessarily something that’s pre defined by OSHA of actually how to enforce it. That that’s a company responsibility, but a checklist is a potential option there.
[01:14:29] So that
[01:14:29] Katherine Lemos: [01:14:29] would come into play in the risk assessment and the safety management practices, safety management program, best practices that you identified, the things that are most have the most potential to harm employees. And you would address those through mitigations, whether or not that assessment processes require.
[01:14:53] They need to do that to me. OSHA regulations to protect employees,
[01:14:57] David LaCerte: [01:14:57] correct? Yeah. It all, it all comes down to having the written policies and procedures and then ensuring employees are following the written policies and procedures.
[01:15:10] Katherine Lemos: [01:15:10] Okay. And, and training plays a role too. If you have written procedures and you don’t train and you don’t test for currency of how often they accomplish something, um, you can have written procedures, but do you agree that written procedures alone are insufficient?
[01:15:29] David LaCerte: [01:15:29] Yeah, it’s a whole, I mean, it’s a whole safety management program system, so procedures are one component. Um, and then there’s, you can’t just stop there. There’s a whole nother component that you need to make sure that procedures are kept up to date. You need to make sure people are aware of them through training, and then there needs to be audit programs are what the company will employ to just make sure that they’re also being followed.
[01:15:56] So it just takes a lot of attention by company leadership to make sure the safety management program parts are all working together.
[01:16:08] Katherine Lemos: [01:16:08] Um, I agree. Uh, so, so two more questions on this topic of lockout tagout, and then we’re going to take a short break. In the factual you state that you have notes provided by ag horn from September of 2019.
[01:16:25] And this was two months prior to the incident and indicates that pumper a had previously performed lockout tag out as described. And I’m assuming as described verbally by the ag horn VPN to company form, in which we have established, we’re likely incomplete do the records indicate which steps specifically that the pumper AA took
[01:16:55] David LaCerte: [01:16:55] the notes, make it appear that he did isolate the electrical energy.
[01:17:01] Um, and we’re just going off handwritten notes. We don’t have a real record of the event. It’s notes on a sheet, um, about isolating another piece of equipment. Um, but it does appear in that case that he did isolate electrical energy sources.
[01:17:19] Katherine Lemos: [01:17:19] Right. So, so, um, the next question is then a statement and based on your response, you were not really able to confirm his knowledge of these procedures and which sources of energy were shut down or isolate, correct?
[01:17:35] David LaCerte: [01:17:35] Yes. And in that case, it’s off of a few handwritten notes, but actually confirming what happened. We don’t have
[01:17:44] Lauren Grim: [01:17:44] data or information to actually confirm that, and we don’t have. Specific training records on lock out, tag out for pumper a to know to what level he was trained on lockout
[01:17:55] Katherine Lemos: [01:17:55] tag out. Excellent. Uh, and, and I agree because I actually read all of these documents myself and what, from what I understand, pumper a was trained, but we don’t know what they were trained to or what the qualifications were for meeting that certification of training, et cetera.
[01:18:13] Yes. Um, if lockout and tagout were, was not performed on a routine basis and especially if the procedure trained were only verbal, they may not have been the complete set of procedures as required by the manufacturer. Do we have any way of knowing whether the pumper or anyone else tasked to conduct lockout tag out of a pump was actually competent to do so?
[01:18:43] We, we are not
[01:18:45] Lauren Grim: [01:18:45] able to make that determination. It’s again, it comes back to the need for procedures and following, but whether the competency level of that, we don’t have information to make that
[01:18:56] Katherine Lemos: [01:18:56] determination understand. So if you don’t have procedures and you don’t have minimum requirements, then you can’t qualify.
[01:19:04] Correct. Okay. All right. Um, um, Mr. Looser, I believe this is his time for a break. Um, Can we have some, yeah,
[01:19:15] David LaCerte: [01:19:15] I think it’s a good point. I think a normal board process, we might rotate in a rolling quorum here, um, to give the board members a break since we don’t have that today. Uh, we’ll go ahead and take a quick five to 10 minute pause.
[01:19:26] Um, so Brian hosts, can you go ahead and, uh, uh, rotate back to the old screen,
[01:19:33] Katherine Lemos: [01:19:33] I would say 10 minutes so that we, everybody has pick a number so that everybody has an understanding
[01:19:39] David LaCerte: [01:19:39] time, 10 minutes, and I’ll give a 62nd warning when we’re about to come back, come back live. So thank you.
[01:19:46] Katherine Lemos: [01:19:46] Appreciate it.
[01:19:47] David LaCerte: [01:19:47] All right.
[01:19:48] And we’re back, uh, with the gentleman rejoining us, we have regained our forum and we are ready to proceed.
[01:19:54] Katherine Lemos: [01:19:54] Excellent. Thank you. So, sir. All right. So we have, um, two remaining sections to discuss, uh, based on the presentation Lauren that you have, um, provided the next topic is site security. Now I understand that ag horn had signs posted on the two Gates or offenses as entryways to the facility and they warn of hydrogen sulfide as a poisonous gas.
[01:20:27] My question is this, even if the science were not corroded and were visible from all angles legible and well-lit. Do you believe that the average public citizen is some with a chemical compound of H two S and aware of the potential dangerous associated with it
[01:20:52] Lauren Grim: [01:20:52] to the average person?
[01:20:54] Katherine Lemos: [01:20:54] Um,
[01:20:56] Lauren Grim: [01:20:56] potentially, no, it could be different in this particular area of Texas, though, where there, this is an oil and gas town, I’ll say a lot in the area.
[01:21:09] So the town itself might be more aware.
[01:21:14] Katherine Lemos: [01:21:14] Um, yes. And as you mentioned, there was a, a smell or the odor associated with age two as pervasive in the town, even with the most obvious signage for those not professionally trained, basically do not enter maybe even cross in school bunks, as we saw in some of the Gates.
[01:21:38] Do you believe this would detract a spouse or loved one of any type from trying to locate their family members? I can only
[01:21:50] Lauren Grim: [01:21:50] speak for myself and my experiences, but I would say that just a warning sign probably will not stop person from trying to
[01:22:02] Katherine Lemos: [01:22:02] find a family member. Excellent. Okay. So. Even though the signs were corroded and I could, I mean, you look at them in the report.
[01:22:12] There are pictures of, um, there is, uh, uh, a cross in a school bomb. There’s a hydrogen sulfide, there’s, uh, a high electrical component. I’m, I’m not sure as a layman, where do I go? And where do I not go? And how does that affect me? Right. Um, so you mentioned guidance, materials that API produced regarding site security, what to you are the most relevant elements recommended to this type of sensibility?
[01:22:47] Lauren Grim: [01:22:47] So this waterflood station,
[01:22:49] Katherine Lemos: [01:22:49] um,
[01:22:53] Lauren Grim: [01:22:53] I’d say not in the heart of the main town, it’s, it’s a little bit further out. Um, and it’s, it’s occupied maybe just a couple hours a day by a single person most days. Um, and so in this kind of facility, I’d say, what, what seems most frequent is just having a gate, a closed gate, potentially a locked gate.
[01:23:19] Katherine Lemos: [01:23:19] Um,
[01:23:21] Lauren Grim: [01:23:21] and that’s the extent of what I’m, I’ve seen primarily.
[01:23:25] Katherine Lemos: [01:23:25] Okay. But that’s The, the API guidance produces a range of options, correct?
[01:23:35] Lauren Grim: [01:23:35] There’s API guidance that applied to a wide variety of chemical frothy, refineries, and petrochemical facilities, um, going from a refinery to which, and it could also include this kind of facility of the waterflood station.
[01:23:52] Um, so they, they do have a range of guidance, uh, onsite security that the operator can consider when developing a security program.
[01:24:06] Katherine Lemos: [01:24:06] Great. So there are other options, but at the time of the incident, the Gates, not the signs, not, I’m not saying signs are not important, but the Gates were the best line of defense available at the time against the unplanned entry of non-employees that may not be familiar with the chemicals, correct?
[01:24:33] Lauren Grim: [01:24:33] I, yeah, I would agree with that. I closed gate will generally deter people from entering the facility.
[01:24:41] Katherine Lemos: [01:24:41] So to confirm, add horns on official policy was for employees. So leave the Gates open when visiting the facility, it doesn’t matter how many hours per day, but that was the unofficial policy for when employees were present.
[01:24:55] Correct.
[01:24:57] Lauren Grim: [01:24:57] Well, we were informed was then I’ll call it a practice. But practice was to close the Gates upon leaving there wasn’t specifically community communication to us that they require people close it while they’re there. It’s just there. They instructed their employees to close it when they left the facility.
[01:25:21] Well,
[01:25:21] David LaCerte: [01:25:21] we have a little time to heal, difficult to hear Brian. I think we’re back up and running. Gotcha. I know the chairman was booted off the stream there, so let her a regional way and we’ll
[01:25:31] Katherine Lemos: [01:25:31] get our cards. I was booted for sure. So, um, we had like the, the pinwheel, uh, the proverbial pinwheel going. So can, can everybody hear me and see me
[01:25:44] David LaCerte: [01:25:44] clear?
[01:25:45] Katherine Lemos: [01:25:45] Excellent. So, um, I’ll repeat my last question because I wasn’t sure if we covered it and what was her? So at the time the, the Gates were the best line of defense available from our knowledge of what ag horn had installed against an unplanned entry of non-employees. That, that doesn’t mean that there were not other, other options available, but at the time, but Agon hadn’t, um, implemented the best line of defense to prevent the spouse from entering the facility, um, full access.
[01:26:27] Would have been by closing the Gates, correct? Yes. Okay. And to confirm ag Warne’s unofficial policy was for employees. So leave the Gates open when visiting the facility, regardless of how often or how, what length of time that occurred, correct. Their practice was
[01:26:47] Lauren Grim: [01:26:47] that employees closed the Gates upon leaving.
[01:26:52] Uh, the, the practice did not specifically that we were communicated to not specifically talk about the practice when they’re there, but when they’re leaving there
[01:27:00] Katherine Lemos: [01:27:00] to close the gate, um, I’ve got it. But I believe I read in the factual report that it was common and maybe on an official policy, on an official and unwritten policy was to leave the Gates open when you entered, because you were there for a certain amount of time and they came out right.
[01:27:21] Lauren Grim: [01:27:21] It’s the pumpers could do that. And then, so our,
[01:27:25] Katherine Lemos: [01:27:25] uh, our
[01:27:27] Lauren Grim: [01:27:27] understanding from the incident that the Gates were likely open when the spouse arrived
[01:27:32] Katherine Lemos: [01:27:32] and you, you collected this information from also other ag horn employees who said that the common practice was to leave the Gates open. Uh,
[01:27:42] Lauren Grim: [01:27:42] it’s our understanding that pumpers didn’t leave the Gates open while they were facility.
[01:27:48] Katherine Lemos: [01:27:48] Okay. To your knowledge and experience. And now I’m broadening this to other chemical facilities. Is it this type of accessibility, common at other types of facilities with toxic chemicals present or the potential to release them?
[01:28:08] Lauren Grim: [01:28:08] I’d say it depends on what kind of facility you’re at. Um, big, major chemical facilities and refineries have very advanced site security.
[01:28:20] Uh, these kind of facilities, these oil and gas facilities that might be more in a remote area that may or may not be occupied very often. We’ll often have less security from what we’ve seen. It might be offense or just even signs. Um, and then that’s, I’ll say typical
[01:28:43] Katherine Lemos: [01:28:43] from what we’ve seen, that they do not have the fences closed.
[01:28:49] So,
[01:28:49] Lauren Grim: [01:28:49] um, if there’s a fence there,
[01:28:54] Katherine Lemos: [01:28:54] um,
[01:28:56] Lauren Grim: [01:28:56] they can be closed. Uh, some certain facilities that could age to have a two S may not even have a fence in some cases, but this facility did. Um, and that was the main protection to prevent, uh, and grass from members of the public.
[01:29:17] Katherine Lemos: [01:29:17] So I’ll just state that. Um, and we’re going to get to this again, but there are almost 5,000 of these H two S producing or yielding waterflood stations, which we know come from more or less 60 something.
[01:29:40] Um, um, oil drilling stations, which come to the water facility. There’s a, uh, a lot of opportunity, um, for potentially the public to have on, upon a gate that’s open. And it concerns me, concerns me personally, that ag horn was aware of the dangers. They had an interest in protecting the public, and one would think that they would have considered the risks and mitigations.
[01:30:16] And this speaks to a safety management system or best practices. In my view, this is a major oversight on, on the part of the company and all other companies that have the potential to release toxic chemicals to the degree that occurred in this event. So let’s move on to safety management and, and talk about safety management programs and practices.
[01:30:46] So we’ve already established that our ad horn had no procedures for a number of things. And I’ll just list a couple because we’ve talked about them wearing the personal H two S detector testing and maintenance of the facility, H two S detection and alarm system. It was not functioning of a pump lockout, tagout process, ventilation of the pump house, and site security.
[01:31:15] Can you please say it again? And I know you mentioned this early in your presentation and it’s in the report. What written procedures ag horn did have, um, prior to the incident,
[01:31:32] Lauren Grim: [01:31:32] corn had a cell phone use policy. Let me pull this up. So I quote the correct ones. They had a cell phone use policy. They had an alarm call-out procedure.
[01:31:41] So that’s really what happens. Um, if there is an alarm, how does the phone notification system work? Um, and then, uh, they also had a pamphlet on H two S hazards.
[01:31:55] Katherine Lemos: [01:31:55] And for this type of operation, what type of safety or operational procedures would you expect to see? One of the statements in the report is there were no.
[01:32:07] Safety or operational procedures. Um, other than what you just mentioned, what other, what other procedures, what other safety or operational would you expect to see and just name a few
[01:32:23] Lauren Grim: [01:32:23] in this case, um, having a lockout and tagout procedure, uh, that specifies when employees need to lock out tag out equipment and how to do so that one needs to be in place,
[01:32:35] Katherine Lemos: [01:32:35] um, crispy, Verizon,
[01:32:39] Lauren Grim: [01:32:39] or requirements, at least on per PPE requirements for when operators are at these kinds of facilities,
[01:32:47] Katherine Lemos: [01:32:47] um,
[01:32:50] Lauren Grim: [01:32:50] operating procedures on how to operate the equipment at the facility.
[01:32:55] Katherine Lemos: [01:32:55] Yeah. Uh, those are examples. So would these type of procedures depend on whether the company was actually required to submit to formal safety management programs through OSHA or EPA?
[01:33:12] Lauren Grim: [01:33:12] The, so the requirement for a safety management program itself from OSHA more so comes under the process safety management regulation, which add corn was not a susceptible to, they didn’t have the threshold, quantity of chemicals.
[01:33:33] Um, There are other voluntary standards out there on establishing safety management programs and there’s guidance out there, which would be The, it wouldn’t be the requirement, but it would be a best practice for facilities. Like, so
[01:33:49] Katherine Lemos: [01:33:49] what I’m trying to get at is the, not the safety management program, but the safety or operational procedures that you just mentioned on lock out, tag out, site security, you name it are those dependent on whether or not a company is beholden to OSHA EPA for a safety management program.
[01:34:10] Lauren Grim: [01:34:10] No, cause OSHA has separate standalone regulations on lockout, tagout and air contaminants, which are the ones we specifically talk about in the report. And those apply to
[01:34:25] Katherine Lemos: [01:34:25] great that’s exactly. That’s exactly right. They would have been the Holden and required to comply with those regulations as you spell out in a report and they not. Um, and that has nothing to do with safety management systems or practices. Although we could agree that those are encompassed in a risk assessment, safety management system.
[01:34:51] And can you repeat for me what you said during your presentation regarding what a safety management program entails? Uh, there are
[01:35:02] Lauren Grim: [01:35:02] a lot of components, um, On the certain on the, I’ll say on this level, it’s first establishing for the, I guess, going back to understanding the hazards of your facility, that’s part one, um, and then establishing procedures.
[01:35:19] Some of those are to manage the hazards of your facility, and then there needs to be programs in place to ensure those procedures are kept up to date and that employees are trained on the procedures and that employees are following procedures. There’s other, other components too, but that’s a summary of what a safety management.
[01:35:40] Katherine Lemos: [01:35:40] You said you did, you did a great job earlier in presenting it. I was just trying to get to repeat that, but, but, but another component is also ensuring that the mitigations they’ve put in place to, to, uh, for the identified and prioritized risks would actually be, um, monitored because what if you put a mitigation in place that was not effective, right?
[01:36:03] It’s a dynamic and living system. Um, and would you agree that this type of system makes good business sense? Uh,
[01:36:15] Lauren Grim: [01:36:15] having a robust and effective process safety management program with our system in place can help reduce the likelihood of these kinds of incidents, um, and protect employers and, and protect members of the public.
[01:36:30] So. Or my business sense. So you have less likelihood of having a major incident and all the significant costs that entails. So yes, from that perspective, um, there is a business case for having a strong safety management program.
[01:36:47] Katherine Lemos: [01:36:47] Thank you. And even if it’s not required because you don’t meet the minimum threshold for complying with OSHA or EPA safety management systems, have you come across other small companies that employee safety management systems and best practices?
[01:37:09] Lauren Grim: [01:37:09] Oh, the question was, have we come across other companies that employ say to management systems and best practices?
[01:37:17] Katherine Lemos: [01:37:17] Yes. And I, and I’ll just sort of help out here because I I’m very familiar with recommendations. We make to small companies to employee safety management systems, even though they’re not required, um, by EPA and OSHA per the minimum threshold.
[01:37:37] So I guess the question is for you to confirm you’ve come across other small companies that either have safety, that’d be either employee safety management systems and the best practices and in what we just discussed or we’ve required it of them. Correct.
[01:37:56] Lauren Grim: [01:37:56] Uh, I know there are small companies out there who do have safety management.
[01:38:01] Systems in place. My personal experience is colored by the CSB and our investigations. And a lot of times the facilities, even small companies have gaps in their safety management programs or a lack of one altogether from what we see. Um, but we don’t, we don’t investigate. I mean, we don’t go to every facility.
[01:38:24] So there are companies out there who do have strong systems in place,
[01:38:30] Katherine Lemos: [01:38:30] but we do believe that had ag horn had a safety management program. And I’m not going to say, I say safety management program. And I believe that’s in the word, but this reason if they had a safety management program to include best practices of this, which includes risk assessment, prioritization, mitigation, implementation, and monitoring, we believe this is beneficial for all companies.
[01:39:00] Um, even if it’s not mandated by the regulator, correct?
[01:39:07] Lauren Grim: [01:39:07] Yes.
[01:39:07] Katherine Lemos: [01:39:07] Correct. Okay. Do you agree that the benefit of written procedures is consistent action across all employees and confirmation of priorities from the management.
[01:39:22] Lauren Grim: [01:39:22] Well, I’m not. So that would be the result of a strong safety management program is you’d have defined procedures.
[01:39:30] People would be making sure management really would be making sure the first few they’re just procedures are being followed. And so you would have consistent action from your workers, which would lead to a safer
[01:39:41] Katherine Lemos: [01:39:41] outcome. Um, thank you. And final question in this, in this, um, uh, section of our, our event today, um, who was ag horns safety officer, uh, I’ll ask all these three questions together.
[01:40:01] When was the last time that they inspected the facility and what did this involve? I
[01:40:07] Lauren Grim: [01:40:07] can’t say that I can answer that from information I collected. Um, we don’t have the name, the name of an official safety officer or what a role might’ve been.
[01:40:24] Katherine Lemos: [01:40:24] So the company did not identify a safety officer across a number of facilities. If I just do the quick math based on the number of, uh, drilling operations or drill drilling sites, we could have maybe up to nine waterflood stations guessing because, cause I don’t know. Um, and so from your understanding, you, you weren’t provided with a name of a safety officer.
[01:40:52] That would have been looking at these types of issues, even if they didn’t have a formal safety program, but the safety officer would be required to ensure compliance of the company to a minimum OSHA guidelines, correct.
[01:41:11] Lauren Grim: [01:41:11] The structure of ag corn. And if they had a person in the safety officer role, um, I’d say we don’t have sufficient evidence that we’ve gathered to really opine on the adequacy of it.
[01:41:27] So, um, we can look further at that if needed.
[01:41:32] Katherine Lemos: [01:41:32] Uh, no, I am just shy. We don’t know if they have one and if one was not offered the not that tells me enough. Right. Uh, typically in investigations where you would interact with a safety officer, if they had one, if they didn’t have one month, one, one assumption could be that.
[01:41:53] Um, that’s why you didn’t receive a name. Um, so at this time I am done with my questioning on the factual analysis section and I believe it is the time for, uh, director Kleist at David, correct me here to read the findings.
[01:42:18] David LaCerte: [01:42:18] Correct. Um, uh, executive director. Kleist would you go ahead and, um, and give the board, uh, your presentation on the findings?
[01:42:27] Yes. Thank you. Mr. Lewis cert, the staff developed a total of 33 findings in connection with the investigation of this incident. Weather was not a significant factor in the outcome of this incident, due to the limitations of the available evidence. The CSB was unable to determine whether the pump failure and loss of containment of the produced water occurred before pumper a arrived at the facility or occurred when the pump energized while pumper a was closing valves to isolate the pump due to the limitations of available evidence.
[01:43:01] The CSB was unable to confirm whether the pump house exhaust fans were operational at the time of the incident. Since the waterflood station equip equipment contained deadly hydrogen sulfide gas ag horn should have trained its employees, which should have led to pumper. A being aware that an equipment malfunction could indicate eight, eight, 800 self, I guess, release pumper a was not wearing his personal hydrogen sulfide detection device upon entering the facility.
[01:43:32] And there was no evidence that Agon management required the use of these devices, regardless of when the pump failed. Pumper had a pumper, a been wearing his personal hydrogen sulfide detection device. He could have been alerted of the hydrogen sulfide gas, danger, and potentially been able to escape prior to succumbing to the toxic guests, all ag horn facilities, where the potential exists to expose workers or non-employees to hydrogen sulfide gas concentrations at or above 10 parts per million would benefit from mandatory use of personal hydrogen sulfide detection devices as an integral part of every employee or visitor personnel protective equipment kit.
[01:44:16] Prior to entering the facility at going to not comply with OSHA regulation 29 CFR 1910 0.147. The control of hazardous energy commonly referred to as lockout tagout procedures to ensure the equipment was isolated from energy sources prior to performing work on it. Ag horns lack of a formalized comprehensive lockout tagout program contributed to pumper A’s failure to de-energize pump one before working on it had pumper, a lockout and tagout pump.
[01:44:49] Number one, before performing work on it, the significant hydrogen sulfide gas release and fatal outcome of the incident may not have occurred. All that facilities should have a formalized and comprehensive lockout tagout program to include policies, procedures, and training. To protect workers from energized equipment hazards, such as exposure to hydrogen sulfide gas ag Warren’s pump system could operate outdoors.
[01:45:19] And at the time of the incident confinement and inadequate ventilation allowed hydrogen sulfide gas to accumulate to deadly levels inside the pump house ag corn did not have sufficient fixtures or facilities to ventilate the pump house. And there was no evidence of ag horns assessment of the facility design to ensure proper ventilation, all facilities where the potential exists to expose workers.
[01:45:46] So hydrogen sulfide gas concentrations at, or above 10 parts per million would benefit from a comprehensive analysis of the facility design vis-a-vis ventilation and mitigation systems to ensure the workers are not exposed to toxic gas levels. Ag horn did not adhere to the OSHA regulatory requirement, 29 CFR 1910 100 air contaminants to implement administrative or engineering controls to minimize or eliminate the risks to employees being exposed to air contaminants that going did not employ sound safety management principles and addressing the risks associated with hydrogen sulfide, I guess, at the foster D waterflood station.
[01:46:34] Ag horn, lacked operational tech, training, testing, and maintenance procedures and records. Comprehensive safety management practices include risk identification, assessment mitigation, and monitoring of design procedures, maintenance, and training, and are essential elements of blocking, uh, protecting workers.
[01:46:56] And non-employees from toxic gases at chemical plants at all facilities where the potential exists to expose workers or not, or hydrogen sulfide gas concentrations at or above 10 parts per million should be governed by a safety management program. That includes a focus on protecting workers and non-employees from toxic hydrogen sulfide guess improve communication of the hazards that contributed to the incident as well as the regulatory requirements to control those hazards could help prevent future similar incidents Backhorn did not maintain or properly configure its foster D waterflood station hydrogen sulfide detection and alarm system without the alarm panel receiving any signals from the detectors, neither the beacon light, nor the phone system alerted pumper age, who dangerous atmosphere.
[01:47:52] Had ed horn properly maintained and configured the hydrogen sulfide gas detection and alarm system. And if water produced and hydrogen sulfide released to his arrival prior to his arrival, pumper a would have been notified of the presence of toxic levels of hydrogen sulfide gas in and around the pump house at all locations where the potential exists to expose workers to hydrogen sulfide gas concentrations at, or above 10 parts per million, the hydrogen sulfide gas detection and alarm system should be properly maintained and configured and companies should have a program and process that dresses, installation, calibration, inspection, maintenance, training, and routine operations ag har acorns, hydrogen sulfide gas detection and field alarm system was not designed with multiple layers of alerts leading to the opportunity for a single point.
[01:48:52] Failure have the chemical release occurred after pumper a arrived on scene. The one alerting device remaining would only have been the evidence from outside the pump house, regardless of when water produced. And hydrogen sulfide gas was released. Had there been multiple layers of alerts and the hydrogen sulfide gas detection and alarm system design at the facility, such as a thorough, uh, such as thorough, both through the both visual and audible alerts, both internal and external to the pump house pumper a would have been warned of pending danger.
[01:49:33] Even if the field hydrogen sulfide alert system had been tested and operational is designed, it was highly unlikely to have deterred the spouse entering the facility, or provided her with warning of the release of the hazardous chemicals that might threaten her life, where those of her children, audible alarms provide additional warning of toxic guests, hazards all facilities where the potential exists to expose workers or non-employees within the perimeter of the facility to hydrogen sulfide gas detect gas concentrations at or above 10.5 parts per million would benefit from hydrogen sulfide detection and alarm system designs that employ multiple levels, levels of alerts, unique to hydrogen sulfide gas, such as with the use of both audible and visual mediums so that workers and not employees, and all locations would be alerted to a significant release
[01:50:33] pumper, a spouse likely. Did not see the hydrogen sulfide gas warning signs because they were corroded and she arrived during the night conditions. If she did see the hydrogen sulfide warning signs, she may not have known that she could have been in danger ag horn site security did not meet industry guidance and standards to include the ANSI API standard seven 80 security risk assessment methodology for petroleum and petrochemical industries.
[01:51:05] And the APR recommended practice seven 81 facility security plan methodology for oil and natural gas industries had ag horn designed the facility. According to these guidelines, the Gates would have been secured preventing pumper, a spouse from entering the facility, all facilities where the potential exists to expose workers or non-employees to hydrogen sulfide gas concentrations at or above 10 parts per million would benefit from formal written site-specific security programs that require employees to Lock access Gates upon entering and departing the facility.
[01:51:43] Chairman limos. This concludes staff’s findings developed in connection with this investigation and staff has prepared to answer questions. Thank you, Steve. And, uh, the floor is open for the board to ask any questions for any discussion you may desire.
[01:51:58] Katherine Lemos: [01:51:58] Uh, thank you so much. Um, executive director, Mr.
[01:52:03] Kleist. Um, one thing I’d like to bring up, which is, is I do not believe a change in the finding depending on the position of the staff. So, um, director of clients, I’m going to address this to you, please feel free too. Um, how have Lauren contributed as well across the draft report as in the executive summary and the factual, as well as the analysis?
[01:52:38] Um, there, there seems to be an inconsistency as to when the pump release least, um, the hazardous amount of hydrogen sulfide. So, uh, in, in various portions, I, men was just quote this here. At some point while pumper a was in the vicinity of the pump, the pump automatically turned on and water containing hydrogen sulfide, a toxic gas released from the pump.
[01:53:13] We also have the finding, which I thought was, uh, uh, the main message, but it seems inconsistent due to the limitations of the available evidence. The CSB was unable to determine whether the pump failure. And a loss of containment of the produced water. One occurred before pumper a arrived at the facility or two occurred when the pump energized while pumper EY was closing valves to isolate the pump.
[01:53:51] And the reason this is important is because in numerous statements, it says pumper a did not execute lockout tagout successfully. And therefore there was a release of hazardous chemicals when we have this exclusionary statement. So can you please help me to better understand the staff’s positioning here regarding when am I happen?
[01:54:16] Uh, when, when the release, the significant release might’ve happened, are these two statements potentially accurate meaning could there have been a pump failure that occurred prior to the pumpers arrival as well as a secondary release or continued release while the pumper was at the, in the vicinity? So I’m trying to, I’m just, I’m trying to clarify that for myself, please.
[01:54:46] Help me.
[01:54:47] David LaCerte: [01:54:47] Thank you for the question chairman. The. Situation that the staff was faced with is the absence of a significant, a significant level of data to be able to make that determination with the highest degree of specificity and certainty. The process control data was virtually non-existent. There was no video surveillance data available that we could, uh, examine to determine at one point, uh, the major release took place.
[01:55:23] And when it affected the pumper, uh, that was engaged in the procedure. What we do know is that there was a high concentration of hydrogen sulfide gas upon the arrival of the emergency response personnel, uh, the employee spouse, uh, succumb to the high levels of that concentration. So whether there was a residual amount, uh, upon his arrival that may have been undetected based on the olfactory fatigue issue that we discussed earlier, or it, it was when the major release took place while the pump was energized.
[01:55:56] Again, getting back to the need, to have a inappropriate lockout tagout procedure that would enable the. Pumped to be both electrically isolated, along with the hydraulic isolation. Again, we noted the positioning of the switches of the valves to, to do that. Uh, we don’t have that level of information to know exactly what had happened, but we do know that there was the release that at some point during the time the individual was there again, uh, it addresses the overarching, uh, findings of the staff was that having a quality safety management program in place that addresses these risks, starting with the company’s assessment of what the risks are, the appropriate mitigation strategies, the appropriate policies in place, along with the safety assurance, essentially all of the core elements of a safety management program are in place.
[01:56:48] Katherine Lemos: [01:56:48] Um, much appreciated. I understand the limitations to the information we had at the time. And, and, uh, from that time till now, um, my concern is that the way it’s written in the report, which the audience says does not have access to today would indicate that it was the pumpers failure to perform the lockout tag out, to de energize it that caused the automatic activation.
[01:57:23] And therefore the release while they were in the vicinity. And if our finding is correct, we don’t have to correct a finding if you actually believe what the finding States, which is number two, due to the limitation of the available evidence, the CSB wasn’t able to determine whether the pump failure and loss of containment of the produce water occurred before pumper a arrived at the facility or occurred when the pump energized while pumper a was closing valves to isolate the pump.
[01:57:59] Now the automatic nature of the system could have caused both, but one indicates that it was, it occurred only one when the pumper was there, which I find inconsistent with the fact that it could have occurred prior. And if the finding is accurate, what I am requesting of staff is to simply make consistent verbiage that would, um, clarify that it wasn’t just in the vicinity and, and make it consistent with the findings that you’ve presented to me.
[01:58:39] Um, I can explain, I can
[01:58:42] Lauren Grim: [01:58:42] explain that brings ology and the appearance of inconsistency. Um, but the executive summary says at some point while the pumper was in the vicinity of the pump, the pump turned on and was operating. The reason we know that is because we know the pump was operating at the time the emergency responders arrived at the scene.
[01:59:09] And we also know the location of where a Bray was found as to whether pump Ray was alert at the time when the pump turned on. We’re not specifying and report, but we know that it did turn on while he was, well, we don’t know is when the actual failure occurred. It could have happened before we got there.
[01:59:35] It could have operated then too, before you’re out there, it could have failed while he was at the facility. Um, but if that needs to be clarified, can be clarified, but that was the reasoning behind the language in the report. But, um, any feedback on that, and we’ll very willing
[01:59:55] Katherine Lemos: [01:59:55] to take a look at. So, so I actually think in the findings, you, you accurately describe exactly what you just mentioned, that we don’t know it’s possible that the automaticity and the automatic function of the pump occurred.
[02:00:16] Prior to the arrival. Um, and as you mentioned in the finding, I believe we need some consistency to clarify that it wasn’t only when as, as it’s not just the executive summary, it’s in the factuals and the analysis it’s populated throughout the report, I would simply want consistency between the facts to ensure that we are not insinuating, that it was, we believe it was only the relief is only when the pumper was in the vicinity.
[02:00:53] Um, and it could have been prior, and we can’t determine that the level of chemical release, right. But if you, if you were to make, if staff was a minimal to ensuring the consistency between the uncertainty of when this occurred with the finding that I have no issue with the finding,
[02:01:19] David LaCerte: [02:01:19] uh, chairman, uh, if it pleases the board, we can go through the report to identify areas that, uh, fit that description that you just presented to us and, uh, make the change so that it is consistent throughout the report.
[02:01:36] And it matches the language in the, uh, essential message being conveyed in finding number two.
[02:01:44] Katherine Lemos: [02:01:44] Thank you so much director Kleist. Um, I have one more on this topic, and again, it’s about information that leads up to an, a stated in safety issues and numerous, uh, parts of the report. And the reason this is important to me is because people are gonna, you know, have takeaway messages and it’s, it’s important.
[02:02:08] They understand what were the critical items in our discussion earlier. And in the findings we established at the ventilation was not adequate, right? The ventilation as implemented, despite the fact that we don’t know, uh, whether the fans were operational and to what contribution they could provide, as well as the events.
[02:02:39] We do know that, that there are two fatalities, which I, I take very seriously. Um, and regardless of whatever system or approach was in place at the time, it was not adequate. So I asked questions earlier about, you know, Add horns, a ventilation approach implemented on the day of the incident, some of the language supporting that similar to similar to the previous discussion insinuates.
[02:03:20] This it’s just that this the Bay doors were not sufficient. We don’t know that other things would have been sufficient or not, because we don’t, all we know is whatever they did was not sufficient on that day. And I would request a staff if they are open and acceptable to this, to ensure that the verbiage in the, you know, the factual only now this to include the executive summary accommodates, what we actually put in the findings and the probable cause and the recommendations.
[02:03:59] David LaCerte: [02:03:59] Again, we’ll go through the report sections that apply to, uh, finding 12, uh, to ensure that the report language, uh, is consistent with that use in finding number 12. The concept here is that the adequacy issue is, was there a sufficient, uh, air flow through the facility that would keep the level to that below 10 parts per million and a very high capacity, uh, ventilation system may actually be able to provide that, uh, environment within the facility.
[02:04:37] In this particular case, we know that it did not because of the outcome of the two casualties. So, uh, we believe we were, uh, accurate in the way that we described it. However, we will go through the report to ensure that the language used is consistent with the findings.
[02:04:53] Katherine Lemos: [02:04:53] I appreciate that because I believe the finding is on target some of the data and it may be just to, you know, I believe the finding is accurate.
[02:05:04] I just want to make sure that the facts that support the findings are, are consistent. And if you’re amenable to that, I’ve identified, uh, the sections. I’m sure you can find them as well. If you’re amenable to that, then that’s, that’s wonderful. Those are some of the minor revisions and the entire report that we would, uh, vote on today, um, would that I am done with my questions regarding the findings.
[02:05:32] We can now move to the probable cause.
[02:05:35] David LaCerte: [02:05:35] Well, I think we need to properly, you can get a vote on that.
[02:05:43] I think from what I’m hearing, it sounds like, um, that with unanimous consent, you’re approving the pen, you’re approving, um, the findings pending revisions. Correct.
[02:05:54] Katherine Lemos: [02:05:54] So actually not, I am with unanimous consent. I’m approving these findings as presented the pending revisions would be in the entire report in some of the supporting information.
[02:06:08] That’s okay with you works right. Your, your, my process, you know, Jamie right here. So, so I believe the findings are accurate. I really strongly believe in the accuracy of them. It’s some of the supporting information that we just make need to make sure there’s no confusion for those people who are going to be reading and digesting this report in the future.
[02:06:34] So done, done with findings. Um, let’s move on to a statement.
[02:06:42] David LaCerte: [02:06:42] See if you want to present the probable cause statements. Yes. Thank you. Step proposes the following probable cause in connection with this incident investigation, the CSB determined that the probable cause of this incident was ag horns failure to enforce operator use of personal hydrogen sulfide gas detectors went in the vicinity of equipment.
[02:07:05] Or facilities with the potential to release hydrogen sulfide and ag horns failure to develop, train on an enforced lockout tagout procedures that led to pumper a performing work on a pump while it was still energized, contributing to the incident was the ag horns facility, physical and operational design, which not allow for adequate ventilation of the toxic hydrogen sulfide gas inside the pump house and ed horns, deficient safety management program likely also contributing to the incident was ag horns failure to maintain and properly configure the site.
[02:07:43] Hydrogen sulfide gas detection and alarm system contributing to the severity of the incident was ag warns, poor site security that allow pumper a spouse to gain access to the facility.
[02:07:58] Katherine Lemos: [02:07:58] Uh, thank you, director. Kleist um, I’m not sure if I’m here yet again. Okay. There we go. Um, just a few questions to clarify, because I think the probable cause statement is on target. Um, the H two S detectors were the first line of defense given the system, um, design at Eichorn at the time. Just a few questions to help clarify for myself on the audience.
[02:08:35] Um, in terms of a likely contributing to the incident was ag corn’s failure in maintaining and probably configuring that site, uh, hydrogen sulfide detection and alarm system. So can you tell me why this is only, uh, contributing to, to the event, The,
[02:09:02] David LaCerte: [02:09:02] given that the employees presence within the building?
[02:09:06] Uh, one of the elements of the, uh, of the risk assessment program and their mitigation strategy should have been a use of personal, uh, hydrogen sulfide gas detection systems. So if the person was, uh, close more closely, uh, in close proximity of the source emanating, the hydrogen sulfide gas detector, hydrogen sulfide, the personal alarm would have worked, uh, allowing the person to re remove themselves again, based on, uh, what was, uh, put forth earlier in that if the system was isolated, you would have had a limited amount of hydrogen sulfide gas.
[02:09:43] It could have been, uh, released into the air, uh, because you’ve not only electrically isolated the pump, but you also physically isolated the pump from its inlet and outlet sources. So again, a confined amount of, of gas, uh, but if it was configured properly, uh, the, the likely terminology here, uh, would be that.
[02:10:04] He could have provided, uh, the spouse with the, uh, awareness that with the beacon on something was wrong. And if it took place before, if the leak hydro self, I guess, release took place before the persons entering the facility, even if it was a very small amount, uh, the alarm would have been activated.
[02:10:26] Katherine Lemos: [02:10:26] Um, so I appreciate that.
[02:10:28] Um, if the book, but what you’re saying is if the pumper were already inside, they would not have had this visual alert to attend to. And as, uh, through our discourse with Lauren, we understand that there are many complications. So whether or not the pumper would receive a timely, um, uh, phone call that would allow them to respond in time.
[02:11:01] If we have a five minute delay from the register to the phone call that’s, uh, that’s uh, that can be significant.
[02:11:09] David LaCerte: [02:11:09] Yes. Yes. The awareness and detection concept is, uh, perhaps is the best way to describe what took place here. The, The w. Devices that would have provided the, uh, individuals, whether it be the pumper or the spouse or any other individual on site was visual or located outside facility.
[02:11:32] So it would have provided no, uh, meaningful information to the pumper once they’re inside the building. And if it were properly maintained and it was properly configured, it would have contained multiple layers of notification and audible alarm. It would have also contained the visual alarm so that the person would have been able to be aware that there was a presence of hydrogen sulfide gas above the 10 parts per million.
[02:11:57] And if Lauren has anything to add, uh, please, uh, supplement if you, if you have any additional information to share,
[02:12:08] Katherine Lemos: [02:12:08] uh, thank you both. So I would pause it that a person who is not familiar with hydrogen sulfide, maybe if their spouse had mentioned it to them, et cetera, unless the spouse had mentioned specifically that a rotating beacon light means danger versus we’re operating versus, uh, all, all good to go.
[02:12:39] How would, how would that be contributory? Um, and you’ve mentioned here that it’s a likely. Contributing to the incident and really we’re referring to the pumper, but do you believe that this actually could have deterred the spouse if she had looked? If it was obvious if it was operating, if she had seen the woman, uh, illuminated light on top of the building?
[02:13:11] David LaCerte: [02:13:11] Hmm. Uh, for the, for the spouse contribution to this incident, if there were illuminated signs, uh, again, going back to the concept of a properly developed system with all of the elements included in the design and functionality of the detection system. And, uh, not only would the rotating beacon on roof, uh, been an indication, but also, uh, a illuminated sign that would be activated that would, uh, have a message, uh, such as do not enter, uh, emergency condition, uh, that still may not stop a person who going through, but it provides additional awareness as an element of that notification of a condition that is hazardous, uh, once, once they enter that facility.
[02:13:59] Katherine Lemos: [02:13:59] Um, understood. So, so the reason that that, that isn’t a likely is because we don’t know that the spouse would have known, and we don’t know if the pumper would have seen that prior. So it’s likely, yes.
[02:14:14] David LaCerte: [02:14:14] We don’t know the action of the, what the spouse would have been.
[02:14:17] Katherine Lemos: [02:14:17] Exactly. Okay. So, um, Mr. Russert with unanimous consent, I approve this probable costing then as presented
[02:14:34] David LaCerte: [02:14:34] director, would you move on to the recommendation section? Yes. Thank you. Uh, Stanford is proposing nine recommendations for the board to consider for adoption in connection with the investigation report, the first areas of recommendations are to Agora and operating. Um, recommendation are one for all waterflood stations where the potential exists to expose workers or non-employees to heightened sulfide concentrations at or above 10 parts per million mandate the use of personal hydrogen sulfide detection devices as an integral part of every employee or personal visitors, personal protective equipment PPE kit prior to entering the facility.
[02:15:19] The acidity of the facility ensure detector use is in accordance with manufacturer specifications. Number two, for all Agon facilities, develop a site specific formalized and comprehensive lockout tagout program to include policies, procedures, and training, to protect workers from energized equipment hazards, such as exposure to hydrogen sulfide.
[02:15:46] Ensure the program meets the requirements outlined in 29, CFR part 1910 0.147 and includes energy control procedures, training, and periodic inspections are three for all waterflood stations where the potential exists to expose workers to hydrogen sulfide concentrations that are above 10 parts per million commission, an independent and comprehensive analysis of each facility, design vis-a-vis ventilation and mitigation systems.
[02:16:17] To ensure that in the event of an accidental release workers are protected from exposure to toxic guests levels. Number four, for all waterflood stations, where the potential exists to expose workers or non-employees to hydrogen sulfide gas concentrations at or above 10 parts per million develop and demonstrate the use of a safety management program.
[02:16:43] That includes a focus on protecting workers and non-employees from hydrogen sulfide. The program should include risk identification, assessment, mitigation, and monitor of design procedures, maintenance, and training related to hydrogen sulfide. The program must be in compliance with 29 CFR 1910 100 air contaminants and 29 CFR 1910 0.147.
[02:17:12] The control of hazardous energy lock out tag out. Number five waterflood stations where the potential exists to expose workers to hydrogen sulfide concentrations, 10 parts per million, ensure that ensure the hydrogen sulfide detection and alarm systems are properly maintained and configured and developed site-specific detection and alarm programs and associated procedures based on manufacturer specifications, Current codes, standards, industry, good practice that guidance, the program must address installation, calibration, inspection, maintenance, training, and routine operations.
[02:17:59] Number six, for all water flush stations where the potentially exists to expose workers or not employees within the perimeter of the facility to hydrogen sulfide concentrations at or above 10 parts Vermilion ensure that the hydrogen sulfide detection and alarm system employ multiple layers of alerts, unique to hydrogen, such as with the use of both audible and visual mediums, so that workers and non-employees within the perimeter of the facility would be alerted to a significant the system design must meet manufacturer specifications, Current codes, standards, and industry good industry guidance.
[02:18:44] And our seven four all waterflood stations where the potential exists to expose non-employees to concentration, to hydrogen sulfide concentrations at, or above 10 parts per million develop and implement a formal written and site-specific security plan to prevent unknown unplanned entrance of those non employed by ag horn, starting with the requirement for employees to Lock access Gates upon entering and departing the facility.
[02:19:13] Stanford’s proposing one recommendation to the occupational safety and health administration. Our eight issue with safety information product such as a safety bulletin or safety alert that addresses the requirements for the poor protecting workers from hazardous air contaminants and from hazardous energy.
[02:19:32] One recommendation to the railroad commission of Texas are nine develop and send a notice to operators, to oil, oil, and gas operators that fall under the jurisdiction of the railroad commission of Texas that describes the safety issues described in this report, including non-use of personal hydrogen sulfide detectors non-performance of lockout tagout, confinement of hydrogen sulfide inside pump, house, lack of a safety management program.
[02:20:02] Non-functioning hydrogen sulfide detection and alarm system deficient site security. Chairman limos that concludes staff’s proposal for recommendations in connection with this investigation.
[02:20:16] Katherine Lemos: [02:20:16] Thank you, director. Kleist. Um, I do have a question, a few questions, uh, regarding the recommendations. We, we definitely, um, build up support for a lot of the recommendations that are addressed to uh Eichorn.
[02:20:36] And so my questions are going to focus in the section on the recommendations that we make to OSHA and the railroad commission. Um, my first question is, does OSHA have an existing safety enforcement program or regulations that apply to the safety lapses app ag horn facility?
[02:20:59] David LaCerte: [02:20:59] The, for the elements that are covered by OSHA regulations, there isn’t an enforcement program in communication with the OSHA team.
[02:21:12] They do have a certain constraints with regard to resources. And there’s also the issue from a, a more tactical level that when they do inspections, there’s a requirement for them to perform. These is unannounced inspections and given the mode of operation. Associated with these waterflood stations. It’s often difficult to find in an unannounced fashion.
[02:21:37] Someone that is actually performing work at these locations where they can actually successfully execute a compliance, uh, inspection operation. So, uh, again, it is included in their program. However, uh, from a practical standpoint, uh, implementation is a challenge for OSHA.
[02:21:56] Katherine Lemos: [02:21:56] Um, and I guess that my next question, uh, director clients, do they do these OSHA inspections and entail programmed or unprogrammed efforts?
[02:22:13] David LaCerte: [02:22:13] Uh, there is a targeted enforcement program that OSHA has and, uh, asked direct Barbie if he would like to provide more information on their targeted enforcement program. Hi, yes, executive director Kleist, um, terminal illness. They, um, they have a national emphasis programs and they have a regional emphasis programs depending upon way where they’re finding, um, areas of non-compliance or, or rank things at higher risk.
[02:22:46] And, and, and that’s sort of how they, they set these programs up.
[02:22:53] Katherine Lemos: [02:22:53] Okay. So, um, I’m trying to, I’m trying to understand the takeaway applied to this particular issue.
[02:23:05] How does your description of programmed and unprogrammed apply to this topic that we’ve been discussing today and the risks?
[02:23:17] David LaCerte: [02:23:17] Well, in this particular case, they have a regional emphasis program that is looking into, um, the oil and gas, um, components. Now, as far as whether they get all the way down downstream into this particular component with the waterflood facilities and that kind of thing, there is some question on that.
[02:23:39] Um, however, at the end of the day, OSHA is responsible for the safety of workers in the workplace, and we have identified, um, safety issues. And so just by jurisdictional requirement,
[02:23:57] Katherine Lemos: [02:23:57] they have oversight. Excellent. Thank you. So a question, can the ocher regional emphasis program be used to expand their oversight of waterflood stations that might be is yes or no, or an in-between.
[02:24:16] David LaCerte: [02:24:16] It, it can be expanded. Uh, that, that is absolutely true. However, with, with expansion comes consequences too. Um, the, the agency that does that, um, question being is how many of these facilities are there and, and how many additional resources would they need to actually go out and check for these kinds of things.
[02:24:39] And those are
[02:24:39] the
[02:24:40] Katherine Lemos: [02:24:40] kinds of pieces of information that only OSHA would have correct. Only OSHA would have. And we’re not at, it’s not our responsibility to do their risk assessment or their, their prioritization for them. Um, they’re the ones that determine whether or not this makes sense from a risk perspective, correct?
[02:25:06] Yes. Ma’am. That is correct. All right. So we asked them for a safety bulletin. My, my opinion, this is like the lowest bar we would potentially ask them for. I could ask them for, we could ask them for much more. Um, why is it important that OSHA take a stand in prioritizing, um, the category, which is a broader scope, right?
[02:25:39] Of hazardous air contaminants from hazardous energy. Why is it important for us to, for them to establish that that is their priority?
[02:25:52] David LaCerte: [02:25:52] Well, they, they actually have regulation, is that specifically address them. These are their regulations and they are The, the regulator and enforcement body for them. So, uh, the strongest message comes from that particular group.
[02:26:08] Obviously what we do, we, we investigate the worst of the worst and we could put that information out. However, OSHA is the expert, like I said, the regulator, the enforcer. So it has a lot
[02:26:22] Katherine Lemos: [02:26:22] more behind it. If it comes from that, I completely agree with you, uh, director Barbie, I believe that OSHA coming out with a statement of a parade authority of this type of potential risk.
[02:26:37] And I said, vocations is the starting point. Um, because then we go down to the railroad commission, right. And if the federal OSHA does not prioritize it, then it’s going to be very challenging for the local, um, or state entities to do so. Um, so speaking to the railroad commission of texts, uh, Texas. Um, why is it that we make that so much more specific than we do the OSHA recommendation for a safety bulletin?
[02:27:15] David LaCerte: [02:27:15] Well, in this particular case, they are talking to, um, that and most of these groups are in, in Texas or, or relatively close to that. And so they oversee their jurisdiction is vast. And so because of that and all the things that we identified, which go beyond, um, the, the very specific requirements of OSHA, they have the ability to reach out and touch all of these, um,
[02:27:44] Katherine Lemos: [02:27:44] entities
[02:27:45] David LaCerte: [02:27:45] much
[02:27:46] Katherine Lemos: [02:27:46] easier.
[02:27:47] Do they need the blessing of OSHA?
[02:27:51] David LaCerte: [02:27:51] Oh, they absolutely do
[02:27:52] Katherine Lemos: [02:27:52] not. They’re a state agency, but could they benefit from the bossing of Roshe?
[02:27:58] David LaCerte: [02:27:58] Well, and with regard to worker safety, everybody can,
[02:28:01] Katherine Lemos: [02:28:01] so I would say yes. Okay. Thank you. Um, so does the railroad commission of Texas have the ability to implement regulatory oversight over process safety programs at water flooding stations in Texas?
[02:28:24] David LaCerte: [02:28:24] Um, yes, they do. Um, we, uh, we have issued recommendations to them in the past to, to do these kinds of things. And so, um, from a historical standpoint yes. And they are a state agency. So state regulations are well within
[02:28:37] Katherine Lemos: [02:28:37] their purview. Okay. And final question here, recommendations appear to focus on increased awareness and process safety notices.
[02:28:49] If ag corn had implemented their toxic gas detection and alarm systems and implemented their perimeters, sorry, perimeter security systems effectively, could this have avoided this tragic outcome,
[02:29:11] David LaCerte: [02:29:11] uh, based on the gaps that we’ve identified within the investigation? Um, we would say that it is a likely yes.
[02:29:20] Katherine Lemos: [02:29:20] So, um, Mr. Will assert I am ready to vote on these recommendations. I believe there are solid and sound. I appreciate staff’s dedication to making sure that they are. Um, and I would say with unanimous consent, I approve these recommendations as present.
[02:29:47] David LaCerte: [02:29:47] Fantastic. Uh, one of the things, uh, specifically Chuck and Steven for their.
[02:29:52] Portion of this presentation. Um, I know, um, we can probably expect the final report to be really shortly and we can probably expect the animation to follow that for, uh, those questions that we’ve received on that note. Uh, and, um, uh, chairman Ramos, the floor is yours for any closing arguments that you would like to get?
[02:30:14] Katherine Lemos: [02:30:14] Uh, yes. So I believe, um, at this point there is a vote of the report as a whole, um, that is required. So we voted on the, the initial elements. Um, there are a few changes in the non, uh, I wouldn’t say non-substantive, um, but there are, when you do, we do need a vote to accept the report as a whole before, before the closing statements?
[02:30:46] David LaCerte: [02:30:46] Yeah. Yes. Um, I believe it would be proper to accept, uh, with unanimous consent, the report as a whole pending the revisions as discussed.
[02:30:57] Katherine Lemos: [02:30:57] Uh, great. So with that, with unanimous consent, I approve this report, um, with the, The minor pending revisions that we’ve discussed in public domain today, um, as discussed and I would anticipate within several weeks we would have this report, uh, posted on the website and its final form.
[02:31:21] Okay. All right. In closing. Um, first I want to thank staff for completing this investigation and their diligent preparation for this board meeting their professionalism and industry knowledge brings attention to important safety issues for the community. Meeting our mission at the CSV requires the full support of all staff, not just the investigation and recommendation teams, which we heard from today.
[02:31:52] And I appreciate the efforts of each employee at our agency, for the dedication they bring to making every day a productive step towards raising the safety bar across a very diverse chemical industry. And even the most basic of protections for workers in this incident were not reinforced by ag horn, training and management attention to safety issues, such as wearing a personal H two S detector is the best and first line of defense in preventing this type of facility fatality for workers and public alike worker safety must be prioritized by especially those companies with employees working in remote locations.
[02:32:50] I know this is something we talked with OSHA about the recommendations that we issued today, go a long way to set the example for how companies of all sizes should prioritize the safety of their workers and what they need to do to demonstrate that. So meeting the minimum, Mark is essential going beyond this is a commitment to your employees.
[02:33:19] Safety management programs are a comprehensive approach to risks at any chemical facility. And we encourage all operators to embrace these principles and best practices as whether this is mandated by any regulatory oversight authority. If our recommendation to OSHA is implemented, this would send a very strong message to the chemical industry of their priority to protect workers from the risks of chemical releases, such as those experienced in the sense that the statement would not be limited to hydrogen sulfide, but would encompass workers across the facility, uh, domains in the chemical industry.
[02:34:10] If our recommendation to the railroad commission is implemented, this would make significant strides to educating the chemical industry involved in extracting natural gas and address the majority of waterflood stations that involve H two S. Now, many of these companies are small and this recommendation will go a long way to help educate those companies that may not be on the leading edge of safety at this time.
[02:34:46] Now, as I mentioned in the opening of this meeting, the impact of our investigation to the ag corner event is not just about unfortunate and circumstance that occurred to two lives and their families and extended families, albeit tragic. This is a call to action for all companies, large and small to step up to the plate, to prioritize the safety of your workers and your community.
[02:35:19] With this, we stand adjourned.

News Brief 4/30/21


Safety Investigations news brief for 4/30/2021


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

This is a safety investigations news brief for April 30th, 2021. I'm your host Charles Current. And here are this week's headlines. The NTSB announced that it is investigating six new crashes. This week. They have released preliminary reports for the fatal April 13, 2021 crash of a Cessna, a one eight eight near pine view, Georgia.

And the fatal January 1st, 2021 crash involving a Dodge SUV and a Ford F150 near Evansville, California. And they also released the final reports for the contact between the Atlantic Huron and the West center pier at PSU locks and the collision between the offshore supply vessel Cheramie Bo truck number 22 and ATB Maria Moran, Texas.

OSHA announced this week that a Jackson, Alabama company faces $121,000 in penalties for workplace safety failures. Also a Naperville warehouse failed to quarantine employees and implement safety measures and a water technology company faces $234,000 in penalties. And the chemical safety board chairman welcomes the start of the nomination process for three new CSB board members.

the NTSB announced it is investigating the April 23rd crash of a Robinson R 44 helicopter and Towanda, Pennsylvania. The NTSB is not traveling to the scene at this time. They also announced they are investigating the crash of a Swearer engine, S a two, two six dash T and Winslow Arizona on April 23rd, investigators are traveling to that scene.

They are also investigating the April 25th crash of an Aero pro C Z a two 40 in Richmond, Indiana. They are not traveling to that scene at this time. And DSP is also investigating the crash of a Piper, PA 46, three 10 P near Danville, Arkansas on Friday, April 23rd, the wreckage was found Saturday, April 24th.

And investigator is traveling to that scene and they are investigating the April 28th, 2021 crash of a bell four to nine helicopter, New York Eden North Carolina and NTSB investigator was expected to arrive on scene Thursday, April 29th. Also investigating the crash of the April 28th crash of a beach C 23 airplane near Middlesborough Florida.

And the NTSB investigator is already on scene there. It says. And the NTSB issued Thursday, the preliminary port for its ongoing investigation of the fatal January 1st, 2021 crash involving a Dodge SUV and a Ford F-150 near Evansville, California. At about 8:00 PM Pacific standard time on Friday, January 1st, 2021, a 2013 Dodge Journey sport utility vehicle occupied by 28 year old driver was traveling South on state, route 33 in Fresno, near Evansville, California.

The driver had just departed a new year's day gathering and traveled about 1.2 miles from the party location. When the SUV approached a 2007 Ford F150, extended cab pickup, traveling North in the opposite lane of travel. The lanes were separated by a broken the yellow center line. And the highway had a posted speed limit of 55 miles per hour.

The pickup truck was occupied by a 34 year old driver and seven passengers ranging in age from six to 15 years old. The driver and child age passengers were returning from a trip to Pismo beach, California. About one mile North of the King County line, the SUV departed the roadway to the right, traveling over the West asphalt shoulder, and then onto the addition, dirt and gravel shoulder.

As the drivers steered left to ran into the roadway, the SUV yard clock counter-clockwise and crossed into the northbound lane colliding with the front and left side of the oncoming pickup. After impact both vehicles rotated counter-clockwise. The SUV came to rest facing in a northeasterly direction and it's damaged front end over the highway center line.

The pickup truck caught fire and came to rest in a dirt and grass area, East of the roadway facing in a westerly direction. As a result of the crash, the driver of the SUV and all eight occupants in the pickup were fatally injured. The NTSB is examining seatbelt use by occupants in both vehicles to determine if the injuries could have been mitigated in this severe head-on crash.

Because of the collision and fire damage to onboard event, data recorders, investigators were unable to retrieve operational data from either vehicle. The NTSB is reviewing the physical evidence and three-dimensional laser scan data of the crash scene and damaged vehicles to evaluate the dynamics of the crash event.

The SUV driver was unlicensed. His post-mortem toxicology test revealed a blood alcohol concentration level more than double California's per se legal limit of 0.08. Both drivers test results showed evidence of marijuana used. The NTSB is awaiting results of further toxicology tests for both drivers.

And we'll evaluate the potential of alcohol and drug impairment in this crash, medical and human performance evaluations will also examine whether drivers for fatigue, distraction, or medical conditions were factors in the crash. The NTSB continues to gather information on actions of both drivers, vehicle conditions, event, data recorder, crash, worthiness, highway condition, and maintenance and issues related to occupant protection.

All aspects of the crash remain under investigation as the NTSB determines the probable cause with the intent of issuing safety recommendations to prevent similar crashes. The NTSB is working alongside California highway patrol, which is conducting a separate parallel investigation. Also the NTSB issued Wednesday, the preliminary report for its ongoing investigation of the fatal April 13th, 2021 crash of assessment, a one eight eight near pine view, Georgia on April 30th, 2021 about Oh 900 Eastern daylight time, a Cessna, a one eight eight B.

November four, nine or one to Quebec was substantially damaged. When it was involved in an accident near pine view, Georgia, the pilot was fatally injured. The airplane was operated as a title 14 code of federal regulations. Part one 37 aerial application flight. The airplane was based a private strip in Unidilla Georgia.

According to the operator, the airplane did party. Unidilla uh, about Oh seven 15 with about two hours, 30 minutes of fuel onboard. The pilot was spraying for mosquitoes and had two more residences to complete before returning to Unidilla. The wreckage was located inverted about eight miles Southeast of the airstrip in a field near power lines.

The power lines were about 50 feet above ground level and damage to the power lines and landing gear were consistent with both main landing gear, contacting the power lines in a West to East direction, both main landing gear, separated during impact with the power lines. Additionally, the propeller and lower engine cowling also exhibited damage consistent with contact with power lines.

The power lines were approximately 1.2, five inches thick consisting of a steel core with Aluna wires twisted around the core. A sat Lock Bantam GPS was recovered and retained for data. Download. Anti SPL also released the final report for the contact between the Atlantic Huron and West center pier at PSU locks.

They determined that the probable cause of the contact was not following the manufacturer's requirement to use thread locking fluid during installation of the feedback ring locking pin set, screw on the vehicles, controllable pitch propeller system, which led to the failure of the controllable pitch propellers oil distribution box.

The national transportation safety board also released its report for the collision between the offshore supply vessel Cheramie Bo truck number 22 and ATB Maria Moran, Texas, and determined that the probable cause was the offshore supply vessel mates turn across the path of the ATB. During a meeting situation, contributing to the accent was lack of early communication from both vessels.

OSHA announced that a global spice importer exposed workers to amputation struck by and crushed by hazards at a Jackson facility. Their announcement says when employers disregard safety measures and failed to properly supervise employees, the risk of serious injury or illness increase. This is exactly the scenario that OSHA inspectors discovered during an investigation at ice bias, LLC, a global spice importer processor and supplier based in Jackson, Alabama.

Oh, sure. I've found workers exposed to amputation struck by crushed by and electrical hazards. The company faces $121,511 in penalties. OSHA determine the employer allowed workers to clean mixing machines without using a lockout device that prevents the machines from starting unexpectedly during service and maintenance.

Ice spice also failed to implement energy control procedures, train workers on lockout tagout practices. The employer also exposed workers to electrical hazards by allowing multiple boxes and outlets that were uncovered or lacked face plates and used a fan with an exposed splice in the cord. This employer put their employees at serious risk needlessly by failing to provide training and implement.

Well known protections said OSHA area, director, Jose Gonzales in mobile, Alabama. These protections are not optional. They are every worker's right. He said, I spice LLC faces $121,000 in penalties as a result of the findings. In other news, OSHA cited, Midwest warehouse. And distribution system Inc. After one employee dies 22 second by Corona virus.

They say, if you days after employees add Midwest warehouse and distribution system, Inc gathered in its Naperville facility break room for a luncheon, some workers experienced symptoms consistent with coronavirus exposure. Employees began reporting to the company that they had tested positive for coronavirus on October 27th, 2020.

A U S department of labor, occupational safety and health administration investigation alleges that the company failed to take immediate steps to identify inform isolate and quarantine all potentially exposed employees by November 9th, 2020, 23 employees tested positive for coronavirus, including one worker who died from complications on November 4th, 2020.

OSHA's inspection found the company failed to follow its own internally developed controls for potential coronavirus exposure, or take immediate steps to contain the outbreak on November 4th, 2020 following discussions with DuPage County health department, the facility closed the agency has proposed a penalty of 12,288 for one serious violation of OSHA's general duty clause.
Discaimer: This transcript is auto generated and is not manually checked for errors.  It more than likely contains very significant errors.

This case is a tragic reminder of the importance of fully implementing coronavirus protection measures that include wearing face coverings, physically distancing and quarantine workers who exhibit symptoms to protect other workers from coronavirus exposure said OSHA director, Jake Scott in Naperville, Illinois.

Based in Woodridge, Midwest warehouse and distribution system is a full service logistics company, servicing grocery liquor and beverage electronics automotive and other industries. The company operates 15 warehouses nationwide. OSHA also cited a Milwaukee area water technology facility. After a worker was injured by falling into a water test pit, their announcement reads a worker for Xylem, Inc.

A water technology company in. Pewaukee suffered an injury when a guard rail loosen and he fell and struck his head on a support beam. As he lowered himself into a nearly 30 foot deep water test pit, the us department of labor's occupational safety and health administration received a report of the injury on October 29th, 2020 its inspectors later determined that the company exposed employees to walking, working surface hazards.

Failed to provide employees with fall protection before they entered a 100 by 24 foot water testing, pet, and failed to follow a specific permit required confined space safety procedures prior to entering the water test pits, OSHA proposed penalties of $234,054 for one willful and eight serious safety violations.

This worker's injury could have been prevented if appropriate fall protection was provided, said OSHA area director, Christine Zortman in Milwaukee. OSHA has regulations for protecting workers who enter confined spaces, including having rescue equipment available and attendants ready to ensure their coworkers safety and to call for rescue services.

If necessary. She's at. Based in rye Brook, New York, Xylem is an international company that tests troubleshoots and repairs, large industrial water treatment pumps used by power plants and municipalities. The company employs more than 1600 workers nationwide and 57 at the  facility, the chairman and CEO of the chemical safety board.

Dr. Catherine  welcomes the start of a nomination process for three new CSB board members. She says. This additional support from such technically strong and professionally proficient candidates will strengthen our advocacy and outreach efforts to make chemical facilities safer for workers, communities, and the environment board members play an important role in reviewing and voting on investigative reports and safety studies, as well as advocating for the CSBs recommendations at the federal state and local levels to ensure the necessary steps are taken to minimize the potential for another tragic accident.

And I look forward to working with them, to strengthen our agency. She said, and that's it for this week. And thanks for tuning in for this week. Safety investigation news brief.

News Brief 4/23/21


Safety Investigations news brief for 4/23/2021

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Mid-Air Collision, Ketchikan, AK, May 13, 2019, NTSB Board Meeting


The National Transportation Safety Board announced its intent to hold a public board meeting April 20, 2021, 9:30 a.m. Eastern time, to determine the probable cause of a fatal midair collision involving two air tour operators in Alaska.On May 13, 2019, a float-equipped de Havilland DHC-2 Beaver and a float-equipped de Havilland DHC-3 Turbine Otter collided in flight about eight miles northeast of Ketchikan, Alaska. The DHC-2 pilot and four passengers suffered fatal injuries; the DHC-3 pilot suffered minor injuries, nine passengers were seriously injured, and one passenger suffered fatal injuries.The NTSB’s five-member board will vote on the findings, probable cause and recommendations as well as any changes to the draft final report.In keeping with established federal and local social distancing guidelines to prevent the spread of the coronavirus, while also ensuring the NTSB’s compliance with the Government in the Sunshine Act, the board meeting for this event will be webcast to the public, with the board members and investigative staff meeting virtually. There will be no physical gathering to facilitate the board meeting.All audio is courtesy: National Transportation Safety Board.  The audio was cleaned up the best I could manage and meeting breaks removed.If you want to see the visuals, you can go to Additional investigation-related images can be found at or watch the YouTube video posted on the NTSBgov channel.An abstract of the final report, which includes the findings, probable cause, and all safety recommendations, is available at The full final report will be published in the next few weeks.The docket for the investigation is available at

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Mid-Air Collision, Ketchikan, AK, May 13, 2019, NTSB Post-Board Meeting Media Availability


NTSB Chairman Sumwalt and Aaron Sauer, Acting Deputy Regional Director, Central Region, conduct Q&A with journalists following completion of the April 20, 2021, board meeting for the NTSB’s investigation of the fatal, May 13, 2019, mid-air collision near Ketchikan, Alaska.All audio is courtesy: National Transportation Safety Board.  The audio was cleaned up and meeting breaks removed.If you want to see the visuals, you can watch the YouTube video posted on the NTSBgov channel.For more information visit

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News Brief 4/16/21


Safety Investigations news brief for 4/16/2021

CSB Deploying to Fatal Incident at Paint Plant – General News – News

CSB Deploying to Fatal Incident at Paint Plant – General News – News

Erratic Steering Led to 2019 Sabine Pass Collision

Pilot’s Actions, Maintenance Issues, Ineffective Safety Management System and Oversight, all Contributed to Fatal Crash of Historic B-17 Airplane

MEDIA ADVISORY: Fatal Midair Collision Subject of April 20 Board Meeting

  • Link to webcast
  • The virtual media availability with Chairman Sumwalt will be conducted using Microsoft Teams Live Event. Journalists who RSVP to will receive an email with the link and information about how the availability will be conducted

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NTSB Most Wanted 2021-2022 Board Meeting April 6, 2021


The National Transportation Safety Board announced its intent to hold a public board meeting April 6, 9:30 a.m. Eastern time, to finalize its 2021 – 2022 Most Wanted List of Transportation Safety Improvements.  The NTSB’s Most Wanted List of Transportation Safety Improvements is a communication strategy through which the agency identifies its top safety improvements that when made will prevent accidents, reduce the number and severity of injuries, and save lives.  In keeping with established federal and local social distancing guidelines to prevent the spread of the coronavirus, while also ensuring the NTSB’s compliance with the Government in the Sunshine Act, the board meeting for the Most Wanted List will be webcast to the public, with the board members and NTSB staff meeting virtually. There will be no physical gathering to facilitate the board meeting.All audio is courtesy: National Transportation Safety Board.  The audio was cleaned up and breaks removed.If you want to see the visuals, you can watch the YouTube video posted on the NTSBgov channel.You can find the 2021-2022 NTSB Most wanted list on their website here

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