TransAir Flight 810 Crash, Honolulu, HI, July 2, 2021, NTSB Recovery Operation Media Briefing

Summary

NTSB Senior Air Safety Investigator Lorenda Ward briefs media in Honolulu, HI, October 9, 2021,  prior to the start of the TransAir B-737 cargo jet underwater recovery operation.

All audio is courtesy: National Transportation Safety Board.  The audio was cleaned up the best I could..

If you want to see the visuals, you can watch the YouTube video https://youtu.be/NPZ2-sPri5U posted on the NTSBgov channel.

Transcript

— Send in a voice message: https://anchor.fm/safety-investigations/message Support this podcast: https://anchor.fm/safety-investigations/support

Transcription

CSB Quarterly Board Meeting, July 29, 2021

Summary

Subscribe to this audio podcast at http://safetyinvestigations.net/ 

Recording of the CSB’s July 29, 2021, public meeting. The Board reviewed the CSB’s progress in meeting its mission and highlighted safety products newly released through investigations and safety recommendations.

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 watch the YouTube video CSB July 29, 2021, Quarterly Board Meeting posted on the CSB Public Events channel 

Transcript

— Send in a voice message: https://anchor.fm/safety-investigations/message Support this podcast: https://anchor.fm/safety-investigations/support

Transcription

Disclaimer: This transcript is auto generated and is not manually checked for errors. It more than likely contains very significant errors.
SIP CSB Quarterly Board Meeting, July 29, 2021
Good morning, you have joined the us chemical safety and hazard investigation boards, or the CSBs public meeting. We will now begin this meeting with Dr. Katherine limos, the chairperson and CEO of the city. Welcome, and thank you to everyone that has joined our quarterly public meeting. These meetings are a great opportunity to provide an update on CSB activities and progress.
[00:00:27] Since our previous meeting in April, this is our first virtual public meeting that we did have a successful virtual board meeting in may to close out the ag horn investigation. I look forward to continuing in this medium and also look forward to this time when we can safely meet in person. It’s important for us to personalize incredible staff behind the voices.
[00:00:55] Some of what you’ll hear. Allow me to first summarize the mission activities of the CSP. We are an independent non-regulatory federal agency with a mandate to investigate accidental chemical releases at fixed facilities, with significant impact to the safety of onsite workers, members of the community and our environment, the investigations examine and evaluate a wide range of aspects to include equipment and system design regulations, industry standards, and guidance, training operations, and procedures and human and organizational factors.
[00:01:43] And with these facts, we conduct analysis to determine the probable cause and contributing factors of the event so that we can better understand not just what happened. But why we issue safety recommendations for the purpose of preventing the likelihood and consequence of similar incidents in the future.
[00:02:08] So today I’m joined virtually by Bruce Walker, our senior advisor, David lesser, our executive council, senior advisor, and acting managing director, Stephen Kleist, our executive director of investigations and recommendations and talk Barbie, our director of recommendations. Now executive director clients is calling in from Laport, Texas, supporting our deployment team.
[00:02:38] And we thank him for his dedication to our mission and to our public meetings. Now allow me to walk through today’s agenda. After my opening, we will hear from acting managing director will assert who will provide some administrative updates on the agency, as well as our anticipated schedule of product delivery over the coming several months.
[00:03:03] I know this is important to everybody. Executive director Kleist will introduce a new safety product being released today, which I’m very enthusiastic about. And then director Barbie will highlight a sample of key recommendations. We have recently closed as with previous meetings. I will have questions to highlight the impact of the safety action and why I supported the staff’s recommendation for there, for my vote.
[00:03:40] So an opening, I have several topics to cover. I’d like to start by reviewing the purpose of today’s public meeting, which is to provide stakeholders and the general public with the insight and transparency into the business of the CSB in meeting our mission. These quarterly public meetings have not traditionally involved board member deliberation and voting recent administrative actions and open investigations are already listed on our website.
[00:04:14] So we have chosen to review substantive business items and updates with a greater focus on our mission performance in our movement towards greater transparency. We are holding public board meetings for the close of investigations. So you have insight to staff investigation, process, the facts and analysis and findings and recommendations.
[00:04:42] And further the board’s deliberation is public and occurs in real time. Poor our requests. Some of you have submitted comments to public@csb.gov and consistent with previous meetings. We will address some of those comments during today’s meeting. If you have comments during the meeting, please continue to send them to the same email address.
[00:05:12] On that note, we receive a significant number of comments and input throughout the year. It would be impossible to address all of these topics in a public meeting. And in most cases, we’ve responded by scheduling virtual meetings with the individual stakeholder or groups that race adjustments concerns.
[00:05:34] And in many cases, requests for further support of the CSPs mission. How can we help. We will continue with this practice as a productive medium for dialogue on the range of really quite complex issues. I want you to know that I am listening. We, as the leadership team are listening, we appreciate your comments and input and trust that you will continue to provide it for the good of the CSB and the safety of our nation.
[00:06:13] I’ll now address the topic of recommendations. Many of you are already aware of the significant progress and improvement we have made in fiscal year 2021 and advancing recommendations from previous investigations or safety studies. In fact, much of our effort over the past quarter has been dedicated to key recommendations that remain.
[00:06:39] Their resolution is just as important as the investigation itself, without stakeholder support in adopting and implementing these recommendations, the process would be left incomplete and any effective and driving needed safety changes for the Cape chemical community. And for this reason, we have been highlighting recommendation status changes over the past year in our public meetings, many recommendations require a significant amount of work and investment on the part of CSB staff, the recipients and the stakeholder community.
[00:07:22] And we appreciate all of your efforts due date and fiscal year 2021. We have issued nine new recommendations. And advanced 47 recommendations of which 28 have been closed with successful outcomes. This is an increase up from fiscal year 2020, which yielded no new recommendations, 15 advanced of which four were closed with successful outcomes.
[00:08:00] These advancements occurred late in fiscal year, 2020 during my tenure. So I want you to know how diligently we’re working on our mission performance. All recommendations, status changes are voted on the board and a critical role for board members is to advocate for our top Prayerview recommendations, likely to yield the most impact in safety chain.
[00:08:31] So before I turn the meeting over to acting managing director was cert, I’d like to point out a video we’ve posted on the CSB website Tuesday. It’s a message for me as the CSPs, chairperson and CEO, that outlines our priorities to meet the mission of our agency, commitment and advances in enhanced transparency and our commitment to remain independent and objective throughout the investigative process.
[00:09:05] These priorities and commitments have remained consistent for the past year and have been communicated in every possible medium. With that. I would like to turn the meeting over to acting managing director of assert Vistaril assert. Please proceed.
[00:09:28] As the chairman of stated, my name is David and I serve as senior advisor and executive council. And I’m also continuing to fill in as acting managing director. I’d like to first start off with staffing, we recognize the importance of a career acting managing director for which we plan to begin the recruiting process shortly after completing our current wave of filling for investigator positions, we have received a large number of applications for this round of investigative hiring.
[00:09:56] We hope to narrow the field shortly after bring and bring a number of investigators on board from this applicant pool. We do plan on another applicant pool after another round of hiring at a more junior grade. Although the CSB has attempted to maintain a team of generalists who can respond to any incident, the agency is making further efforts to diversify experience and background during the subject matter expert review.
[00:10:26] This is an effort undertaken with feedback from stakeholders before a more diverse skillset among investigative teams or the increasingly complex missions before the agency and approach, which has been very successful at the CSB. In previous years, additionally, we will be posting and hiring a significant number of support positions in the fields of procurement, human resources, legal and other key areas, which we will address following our highest priority of hiring.
[00:10:57] That is the mission staff vacancies, admission staff includes both investigators and recommendation specialists working together as a team to affect safety chain. Of course, we also have several prospective board members, which may maybe onboarding in the coming months. We are grateful for the attention from president Biden and recognizing our need for additional board members.
[00:11:21] And we are also thankful to the United States Senate in fulfilling their duties throughout the confirmation process. This morning, in the meantime, the CSB continues to meet our mission of driving chemical safety change. The challenges of continuing to move forward in the face of COVID-19 pandemic were noted by the inspector general.
[00:11:40] In last year’s management challenges report, we are pleased to highlight that the CSB has deployed staff who seven incidents in the previous calendar year, a sharp rise after making four deployments in each of 2018 and 2019. Additionally, the CSB has deployed to another three incidents in the current calendar year, and there’s a sharp contrast to some of our federal colleagues.
[00:12:04] For example, for one regulator inspection figures in fiscal year 2020 dropped 34% from a relatively steady average over the prior five years. The lean and agile nature of our agency has enabled us to be better equipped to navigate through the challenges of this all investigative staff and many support and management positions are now fully remote recruitment of the bulk of our workforce.
[00:12:33] May now be done on a nationwide basis with strengthens our applicant pools as geographic diversity, and allows us to better reach our goals and equity and inclusion. The design of our pandemic workforce is still in progress. As we consult with the recently issued and still evolving guidance from OPM, we are mindful of our priority on safety.
[00:12:57] We also seek advantage, seek to take advantage of the options and this new worldwide environment become even more efficient and effective in meeting our mission. The credit in our success stories in the face of this pandemic launched efforts over the investigative staff and support personnel work behind the scenes to keep them in the.
[00:13:16] I commend the staff at this as this is hard work in tough environments and away from their families. Thank you. There’s also plenty of room for improvement. Our agency. We need to do a better job of timely finalizing investigative files and accompanying recommendations. A primary driver of this has been turnover of investigator position and the learning curve of a new investigator inheriting an older file.
[00:13:43] I’m happy to report that all files have an assigned investigator in charge and that we are diligently working toward closing all activities. Moving on to our anticipated schedule of product delivery. Two board meetings to close investigations in the August and September timeframe. The 2019 trial tragic explosion and fire at AB specialty Silicon in Illinois playing the lives of forwards and seriously injured.
[00:14:10] The fatal fire in 2020 at the evergreen packing mill packaging mill and Canton, North Carolina tragically resulted in the deaths of two contractors. Additional information on these incidents can be found@csb.gov. And we look forward to bringing the investigations before the board for a full public board meeting or public board meeting in may was the first CSB meeting and several years to present investigations for vote for the board in an open and transparent public meeting.
[00:14:40] As the chairman mentioned, this new level of transparency can be expected moving forward as we can now close investigations in full view of the public. One topic we’ve been asked about frequently is how we intend to use and share the incident data we’ve received directly. We have the national response center.
[00:14:58] This initiative is a constant work in progress, but we are continuously analyzing. How did that, um, will inform our deployments are critical drivers. Safety product options and advocacy priorities to address the many events that meet our reporting criteria. We are revisiting a range of products to maximize our assignment of resources, as well as the safety outcomes from those events and all or nothing approach for investigation and deeper review leaves, a gap for more analysis and a wider broadcast of lessons learned and incidents, which did not meet both criteria, adopting an approach to include additional products such as what is seen at the NTSB.
[00:15:39] An incident brief model would provide an opportunity for additional influence and gains to our mission without impacting our full deployments and investigative reports as voted on at our open board meetings, I’m working diligently with executive director Kleist on how to best capture the right level of information, prioritize our efforts.
[00:16:00] Oh, to phase in and resource these new activities, which will yield additional safety, understanding safety products and safety recommendations. As I have mentioned, the CSB has launched deployments for full investigations at a rate of 150 of the historical average over calendar years, 2020 and 2021. Even in the face of the pandemic, the CSB anticipates continuing this aggressive approach to accomplishing our mission.
[00:16:29] In the meantime, our top priority is to complete our backlog of open investigations while attending to new investigations. I’d like to make a note regarding an operational update in the external company review of pre-decision investigation products in the past, the agency would provide a copy of the draft investigative report to key stakeholders to include the company involved and the accident as well as the EPA and OSHA for their review and comment prior to presentation of the.
[00:17:00] Policy moving forward will be a default position to only provide the factual portion of the report to these external stakeholders. Prior to board review, there will be situations which warrant a more detailed review by the owner operator or other stakeholders, especially if there is a specialized information use of technology or resources, which will enhance the understanding of the investigative team.
[00:17:27] In fact, we currently already seek input from independent subject matter experts in a variety of fields and disciplines. In some reports. This position is a change from CSB operations in recent years, but it better reinforces the independence of our investigative team from the stakeholders in which we engage.
[00:17:47] This approach also allows the agency, the flexibility to incorporate valuable information from them on a case by case basis, as mentioned by the chairman. We encourage all stakeholders to include citizens, corporations, and associations. You submit your full input throughout the investigative process, based on your knowledge and perspectives.
[00:18:09] As you can see, we have a considerable amount of movement here at the agency. And with our mission, we know this impact stakeholders across government industry, the workforce, and with a number of non-governmental organizations, many organizations have reached out and I’m very happy that we share common goals and the agency looks forward to continuing our dialogue and how to achieve our mutually beneficial outcomes.
[00:18:34] As always, we look forward to providing the public with these updates and comments are welcome@publicatcsb.gov, which we will attempt to address each public meeting. I can also be reached personally at David at csb.gov. If anyone would like to discuss a particular. I think the chairman for the opportunity to serve.
[00:18:56] And I think all of our CSB staff, again, for the hard work and dedication or agency and mission thank you. As, um, acting administrator acting managing director of David listserv mentioned, we’re looking to close two investigations over the coming two months, executive director Kleist and his team have been diligently working to refine the internal review process, which will allow us to close and investigations at a more efficient pace moving forward.
[00:19:32] I sincerely appreciate these critical efforts. Thank you, director. Kleist I’ll now hand the meeting over to executive director of investigations and recommendations, Mr. Kleist. Thank you, chairman linens. Thank you, Mr. . The recommendations team has been working aggressively to review and assess responses from recommendation recipients.
[00:19:58] I would like to take this opportunity to thank the recommendations after their hard work, to advance safety in the chemical and petrochemical industry. Today, we are going to highlight five recommendations. Status changes recently adopted by the board director. Bobby will present this information to you.
[00:20:15] Dr. Barbie, please proceed. Thank you very much. Executive dreads collide. As previously stated we will be highlighting the five recommendations that were issued from the CSP of safety or a hazard study and three CSB investigations. They are from the oil sites safety hazard study. We will highlight the EPA is implementation of our work.
[00:20:37] From the Arkema plant, a chemical plant fire investigation, we will highlight Arkema incorporated implementation of our three from the prior test, fatal gas, well explosion and fire investigation. We will highlight the American petroleum institutes or API implementation of our six as well as pays on systems, corporations implementation of our 16.
[00:21:00] And lastly, from the California refinery fire investigation, we will highlight the state of California implementation of our 21. So without further hesitation, let’s begin with the oil site safety hazard study sometimes referred to as the teens in tanks study for an incident summary on October 31st, 2009, two teenagers they’d 16 and 18 were fatally injured when a petroleum storage tank.
[00:21:29] In a Royal oral field in Carnes, Mississippi, six months later, a group of young adults and teenagers were exploring a similar tank site. And Weleetka Oklahoma when an explosion and fire fatally injured one individual two weeks later, a 25 year old man and a 24 year old woman were on top of an oil tank in rural new London, Texas.
[00:21:55] When the tank exploded finally entering the woman and seriously injuring the man in April, 2010, the CSB initiated a hazard study into the cause of these tragic things. All three incidents involve rural unmanned oil and gas stored sites and lacked fencing and signs warning of the hazards, which might’ve otherwise deterred members of the public from using them as places to gather the CSB identified 26 similar incidents between 1983 and 2010, which resulted in a total of 44 fatalities and twenty-five injuries.
[00:22:31] As a part of this hazard study, all of the victims were 25 years of age or less as a part of a hazard study. The CSB also reviewed a number of environmental statutes, relevant to oil and gas production, including the clean air act, the clean water act, the comprehensive environmental response, compensation and liability act.
[00:22:51] The resource conservation and recovery act and the toxic substances control act four provisions related to protection of human health. The CSB found that many of these statutes contained various exemptions, applicable oil and gas Wells. But that’s a general duty clause and reduced in 1990 by the clean air act amendments applies to extremely hazardous substances has a high rate of carbon stored at these oil exploration and production facilities.
[00:23:21] Meet the definition of extremely hazardous substances based on his flammable properties. The CSB concluded that they would be subject to the clean air act general duty clause, which holds owners and operators responsible for preventing chemical accidents involving these substances. Consequently, the board voted to issue a recommendation to the EPA, to publicist safety alert directly to owners and operators of exploration and production facilities with flammable storage tanks, advising them of the general duty clause responsibilities for accident prevention under the clean air act.
[00:23:54] So the number of recommendations. That were issued during this hazard study, we’re six and only three of those, including this one, um, remain open. And number of recommendations that were issued to the EPA was one. And so this is going to close them out. So the highlighted recommendation here is recommendation number 2 0 1 1 2011 dash H X X dash one dash one.
[00:24:20] And it reads, published the safety alert, directed to owners and operators of exploration and production facilities with flammable storage, gas storage tanks, advising them of the general duty clause responsibilities for accident prevention under the clean air act at a minimum, the safety alert should a Warren that storage tanks that unmanned facilities may be subject to tampering or introduction of ignition sources by members of the public, which could result in the tank explosion or other accidental release to the environment.
[00:24:54] Recommend the use of inherently safer storage tank design features to reduce the likelihood of explosions, including restriction on the use of open vans for flammable heart hydrocarbon, flame arresters pressure vacuum event valves, floating roofs, vapor recovery systems, or an equivalent alternative C describe sufficient security measures to prevent non-employees access to flannel the storage tanks, including sets, measures as full fence surrounding the tank with locked gate hatch locks on tank man ways and barrier securely attached to the tank, external ladders or stairways, and the recommend that hazard signs or placards be placed on or near tanks to identify the fire and explosion hazards, using words and symbols recognizable by the general.
[00:25:48] Okay, so now here’s what the EPA did. The closest recommendation in March of 2021. The CSB received notification from the EPA that his office of land and emergency management had published a new safety alert, entitled public safety at oil and gas upstream facilities, which is EPA 5 4 0 B 2 0 0 0 1, dated March of 2021 in response to the CSP recommendation.
[00:26:18] And it also made it available on his website. The EPA also advise the CSB that this new safety alert was being sent to state and territorial emergency response commission and to the Indian tribal governing bodies. The safety alert was very detailed and addressed all aspects of the recommendation. As a result on July 28th, 2021, the board voted to change the status to close acceptable action.
[00:26:50] I know, I know there are follow-up questions. I’m trying to follow the script here. Um,
[00:26:59] sorry. Um, so Chuck, I have a few questions for you, director Barbie, since the publication of CSPs 2011 hazard study, which I think was really important and critical. Have there been additional incidents affecting the public that have occurred at oil and gas storage sites?
[00:27:31] Unfortunately, yes. The CSB is aware of at least 10 incidents that have occurred at oil and gas storage sites. Since the publication of our hazard setting, the most recent occurred in April of this year. And we as Deanna, that resulted in one fatality, which was a 14 year old, who was trespassing when the tank exploded.
[00:27:51] The other nine incidents are described in appendix B of the EPA safety alert. Three occurred in Texas two in both Oak, uh, an Ohio and Oklahoma one each in New York and Pennsylvania that have resulted either in fatalities or serious injuries, community evacuations, or releases of hazardous material, new residence.
[00:28:17] So thank you, Dr. Uh, director of Barbie question next. And that was, uh, it was great information. Why is the publication. Of this recent safety alert by the EPA, so significant that we chose to highlight it them. Okay. Well, prior to the issuance of the EPA safety alert, voluntary guidance, most notably published by the American petroleum Institute has been the primary method used to communicate the hazards and safeguards needed to protect the public from the hazards posed by these sites.
[00:28:53] The EPA is safety alert, reminder oil and gas facility owners, and operators of their existing obligations under the general duty clause of the clean air act to identify hazard design and maintain safe facilities and minimize consequences of offsite releases. Okay. Um, the next recommendation comes from the Arkema incident, chemical plant fire investigation, and here’s the incident.
[00:29:21] On August 24th, 2017, hurricane Harvey, a category four camp hurricane made landfall in the Southeast Texas extensively caused by heavy rain fall from the hurricane, exceeded the equipment design elevations and caused the Arkema Houston it’s implant to lose power, backup, power, and critical organic peroxide refrigeration systems.
[00:29:46] Consequently are going to use standby refrigerated trailers to keep the organic peroxide products. Cool on August 31st, 2017 organic peroxide products stored inside the refrigerated trailer decompose causing the peroxide and the trailer to burn. When people sought medical attention from the exposure of fumes rated by the decomposing products.
[00:30:10] When the vapor traveled across the public highway, adjacent to the bus. Emergency response officials initially decided to keep it just highway open because this road served as an important route for hurricane recovery efforts. During the next several days, a second fire and a controlled burn conducted by a unified command consumed eight more trailers, holding Archimedes remaining organic peroxide products that required low temperature storage over the course of the free fires.
[00:30:39] The three fires, an excess of 350,000 pounds of organic peroxide combusted as a result, more than 200 relative is living within a 1.5 mile radius of the facility who had evacuated the area could not return home for. As a part of this investigation, the CSB examined our corporate policies pertaining to the evaluation of process safety, risks, risks due to extreme weather events and determined that while the existing corporate policy address flooding, it did not address other extreme weather events that are coming facilities, may experience consequences.
[00:31:16] Consequently, the board issued a recommendation to Arkema to ensure that critical safeguards are available and function as intended during extreme weather events. Now, the number of recommendations issued in this investigation were five and only three of those, which include this one, um, remained open a number of recommendations issued to our committee, Inc was to, and this was their, their final remaining open recommendation.
[00:31:45] And the highlighted recommendation is CFE recommendation. Number 2017 dash eight dash oh. Dash PX dash R three, which reads established corporate requirements for his facility is that manufacturer organic peroxide or that processes, which involve more than the threshold, quantity of highly hazardous chemicals to ensure that critical safeguards such as backup power functions as an tended during extreme weather events, including hurricanes or floods.
[00:32:23] And here’s what the recommend, uh, dation recipient did the closest recommendation between October, 2020 and January, 2021. Arkema supplied the CSB with copies of the natural disaster preparedness assessment and their natural hazards, assessment procedures, and other tools that are developed for plant sites to ensure that critical safeguards function as intended during extreme weather prevent, uh, events.
[00:32:49] In addition, Arkema supplied examples for the CSB review of individual plant site gap analyses and corrective action plans among the 22 plants that conducted these assessments, the procedures and supplemental documentation provided by Arkema meet the intent of the safety objectives as envisioned by the board.
[00:33:10] And therefore, as a result on July 28th, 2021, the board voted to change the status to closed acceptable. Thank you, director Barbie. So I have a few questions. So always to know me well enough. Um, how did Arkema conduct its natural hazard assessment? Um, argument evaluated his current facilities conditions against a variety of natural hazards, such as maximum potential height, wind loads, and seismic activity.
[00:33:41] Using a checklist to ensure consistency across all 22 facilities. Natural hazard potentials for all facilities were then scored and ranked then appropriate mitigation measures were developed and tracked to completion. Wait, I was needing my, uh, voice because we have some construction going on there. Um, but I’ll unmute.
[00:34:06] Let’s see here. Am I in reading? Um, were any special techniques used for these assessments, besides the checklist for a lower scoring facilities, publicly available data from the federal emergency management agency or FEMA and the national oceanographic and atmospheric administration or NOAA were utilized for higher scoring facilities, advanced modeling tools and techniques were used such as 3d drone flyovers for detailed evaluation measurements and or other commercial third party tools and software.
[00:34:48] So the next two recommendations come from the prior trust, fatal gas, well explosion and fire investigation, which, uh, you know, I’ve said previously, this is, this is my favorite investigation for dates. I love talking about it. So the, um, the incident summary is. On January 22nd, 2018, a blowout and rig fire occurred at prior trust 0 7 1 8 gas.
[00:35:10] Well number H R 180 9, located in Pittsburg county, Oklahoma. The fire resulted in the fatalities of five workers who were inside the drillers cabin on the rig floor. They died from a thermal burn injuries and smoke and foot inhalation. The blowout occurred approximately three and a half hours after removing drill pipe or tripping out of the well, the cause of the blowout in the rig fire was the failure of both the primary barrier.
[00:35:39] The hydrostatic pressure produced by drilling mud and the secondary barrier humid detection of influx and ax and activation of the blowout preventer, which were both intended to be in place to prevent a blowout as a part of this investigation. And specific to the two recommendations we are addressing today.
[00:35:59] The CSB determined that the lack of a well construction interface document or WCID between the drilling contractor and lease operator likely contributed to the lack of hazard analysis and management of change by both companies. When there were signs that the operations were veering from the original plan, however, the American petroleum Institute bullets in 97, well construction interface document guidelines applies solely to the offshore drilling industry had API bullets in 97, also applied to onshore operations.
[00:36:35] It could have potentially prevented this. Additionally, the CSB determined that pays on systems corporation supplied the electronic drilling data system for the prior trust drilling rig, but no alarm data was included as a part of the data package supply to the driller. This data could, could provide valuable insight into alarm performance, providing the basis for improving alarm management for drilling contractors.
[00:37:05] Now, from this investigation, there were 19 recommendations that were issued 13 of which including the two we’re talking about today, remain open. The number of recommendations issued to API where five of which this is the first of the recommendations that is to be implemented. And that recommendation number is 2018 dash one dash I dash.
[00:37:30] Okay. Dash R six, which reads. Update API bullets in 97. Well construction interface, document guidelines to specify that it applies to both onshore and offshore drilling operations. And here’s what API did in January of 2021 API communicated to CSB that rather than update bullets and 97 to apply to onshore drilling operations in December, 2020 API published recommended practice 97 L onshore.
[00:38:03] Well construction interface document to address WCID issues for onshore drilling operations, due to the differences between offshore and onshore operations and the response API outlined, how recommended practice 97 now addresses the provisions contained in the CSB recommendation. The CSB purchased and reviewed a copy of the December, 2020 edition of API recommended practice 97 out to evaluate that information.
[00:38:33] Although API did not extend the scope of 90 and 97 to include onshore drilling operations as envisioned by the CSB recommendation API met the intent of the recommendation by issuing a new recommended practice 97. Now that applies to WC IDs to onshore drilling as a result on July 28th, 2021, the board voted to change the status to closed acceptable alternative actions.
[00:39:05] Well, in, in past, uh, in anticipation of chairman limo’s questions, um, I’m going to answer what I would think would be a good question. Um, so you may ask, why did API, why did API issue recommended practice rather than just extending offshore documents to apply to the onshore drilling operations? Um, that would be because API and they, and they, they explained this when they responded to us, uh, they thought it was more appropriate to develop a separate document, given the, the significant difference between onshore and offshore operation.
[00:39:49] And I mean, when you start looking at that includes terminology, environment, conditions, and, and all kinds of things like that.
[00:40:04] I had not intended to not engage in that discussion director, Bobby, that I really appreciate it because my next question is why does API issue or new with emendation practice rather than just extending its off shore? Thank you for taking up the slack for this technical challenge, um, to apply it to onshore drilling operations.
[00:40:28] Oh, and it was, as I said, they’re just so radically different. They, they involve different groups, different terminology and environmental conditions. So, um, it just seemed that that was a better way to address the recommendation. I, and I appreciate that direct your poppy. So I thank you for taking the technical so cure.
[00:40:49] Can you provide additional details on what is to be addressed in the new onshore well construction interface? Document. Yes, ma’am the well construction interface document serves as a bridging document between lease operators and drilling contractors safety and a banner environmental management systems to address five provisions, one, it outlines responsibilities for lease operators and drilling contractor personnel.
[00:41:23] Two. It acknowledges that management of change and risk assessment processes should be used during well construction activities. And to address personnel, organizational changes to ensure personnel skill level is sufficient for the applicable position three, it provides a means for the drilling contractor to be involved when operational changes or conditions are identified that could require a well activity risk assessing.
[00:41:53] An example of that is a change from overbalanced to under balanced drilling or change. That affects a well barrier for it provides a method to align all parties regarding drilling health, safety, and environmental standards and applicable regulatory requirements. And five, it provides a method of communicating stop, work authority,
[00:42:19] and you know what, uh, director Bobby, I want to appreciate the fact that your background is, um, well suited to this topic. Um, having come from, you know, working with Bessie at Bessie, you understand what the regulator challenges are, the regular, they you’re responsive, sorry. Responsibilities are. And I, I appreciate that.
[00:42:47] Um, okay. Continue on. Thanks chairman. Um, the second, um, recommendation that we’re going to highlight from the prior trust investigation, um, was issued to pays on system corporation. And the number of recommendations that we issued to them was to, and this was the remaining open recommendation and it’s a CSP recommendation number is 20 18 1 dash R dash I dash.
[00:43:19] Okay. which reads design the pays on electronic drilling data systems. So that alarm information, including alarm set points, alarm activation, log, alarm horn status, which is on or off and alarm status on or off is provided to customers. And here’s what pays on did to close it in March of 2021, based on informed the CSB that they released the software enhancement to their electronic drilling recorder or EDR software, uh, last April that addressed all elements of the CSB recommendation.
[00:43:56] And they provided the CSB with a copy of the software release notes, which explain the changes that were made. Um, and based on our review, the changes that were made by a pilot pays on to its EDR software meets the intent of the recommendation. And as a result on July 28th, 2021, the board voted to change the status to closed exceptable action.
[00:44:21] I’ve got gardening people outside. So, you know, it’s, it’s just the fact of, uh,
[00:44:30] the fact of working tele-working. Um, so we are now on. Highlighting Chevron refinery or so the questions from the chairman regarding the software changing and pacing, why is it acceptable closure of this recommendation? Significant, there are two primary reasons that the acceptable closure of this recommendation is significant.
[00:45:01] First pays on systems. Corporation is one of two companies providing driven software to the onshore oil and gas industry. So this recommendation has a far reaching impact within this industry. Second second, now that this recommendation will be accepted, we closed Patterson UTI, which is one of the other recommendation recipients can use the updated software to provide information needed, to assist them in closing out their remaining open recommendation.
[00:45:32] So you said, so. Got it. That makes sense. And what specific enhancements at Payson Payson systems corporation make to their software to satisfy the CSP recommendations? Ah, well, the upgraded software now has a new event history feature that stores and displays a list of past events that can be used to determine the alarm systems state.
[00:46:03] And it can be used to reconstruct past events as well as to audit the system use. Okay. So finally, the last recommendation we are highlighting, so arguably the most significant specific deposit that we driving process safety change comes from the Chevron refinery fire investigation. And here’s the incident summary on August six.
[00:46:27] 2012, the Chevron refinery in Richmond, California experienced a catastrophic site failure in a crude unit causing the release of flammable hydrogen prosper or hydrocarbon processed fluid was partially vaporized into a large cloud. 19 Chevron employees engulfed by the vapor cloud escaped narrowly avoiding serious injury.
[00:46:52] The ignition and subsequent continued burning of the hydrocarbon process. Fluid resulted in a large plume of unknown particular vapor, approximately 15,000 people from the surrounding area sought medical treatment in the weeks. Following the end. If California is division of occupational safety and health administers, the California occupational safety and health program and enforces California’s process safety management standard established under title eight, section 5, 1 8 9 of the California code of regulations, U S chemical safety and hazard investigation board examine the effectiveness of the Cal OSHA program.
[00:47:35] The CSPs investigation concluded the following. The California PSM regulation did not effectively establish goals to prevent accidents or reduce risks. Only two of the 14 elements, process, hazard analysis and mechanical integrity of the PSM standard contains some goal setting. CalOSHA did not receive sufficient funding to employ a well-staffed multidisciplinary team capable of conducting thorough inspections of PSM covered facilities in California and Cal OSHA did not effectively collect or promote industry use of major accident performance indicators to drive industry, to reduce risks, to as low as reasonably practicable for eight alarm.
[00:48:24] So the number of recommendations that came out of this investigation were 37 11 of which remain open a number of recommendations issued to the governor and legislature in the state of California were nine and only three of those remain open. And that included this one, the CSB recommendation number is 2012 three I C a R 21.
[00:48:52] Which reads, and it’s a level one based on the findings in this report, enhance and restructure California’s process, safety management, or PS regulations for petroleum refineries by including the following goal-setting attributes. Hey require a comprehensive process hazard analysis or PHA written by the county company.
[00:49:18] That includes I, or one systematic analysis and documentation of all major hazards and safeguards using the hierarchy of controls to identify hazards and significantly reduce risks to a goal of as low as reasonably practical or similar to. Documentation of the recognized methodologies, rationale and conclusions used to claim that inherently safer systems have been implemented to as low as reasonably practical or similar.
[00:49:53] And that additional safeguards intended to control remaining hazards will be effective. Three documented damage mechanism has a review conducted by a diverse team of qualified personnel. This review shall be an integral part of the process hazard analysis cycle and shall be conducted on all covered processes, piping circuits, and.
[00:50:18] The damage mechanism, hazard review shall identify potential process, damage mechanisms and consequences of failure and challenges. Sure. Effective safeguards are in place to prevent or control hazards presented by those damage mechanisms require the analysis and incorporation of applicable industry, best practices and inherently safer design to the greatest extent, feasible into this review and for documented use of inherently safer systems analysis and the hierarchy of controls to the greatest extent, feasible and establishing safeguards for identified process.
[00:51:00] The goal shall be to drive the risk of major accidents to as low as reasonably practicable or similar include requirements for inherently safer systems analysis, to be automatically triggered for all management of change and process hazard analysis reviews, as well as prior to the construction of new processes, process, unit rebuilds, significant process repairs, and in the development of corrective actions from incident investigation recommendations B require a thorough review of the comprehensive process hazard analysis by technically competent regulatory personnel C require preventative audits and preventative inspections by the regulator to ensure the effective implementation of the comprehensive process hazard analysis.
[00:51:52] The require that all safety codes, standards, employer, internal procedures, and recognize, and generally accepted good engineering practices or rag again, using the implementation of the regulations contain adequate minimum requirements E require mechanisms for the regulator, the refinery and workers, and the representatives to play an equally and essential role in the direction of preventing major incidents require an expanded role for workers and management of process safety by establishing the rights and responsibilities of workers and the representative.
[00:52:31] On a health and safety related matters and the election of safety representatives and the establishment of safety committees with equal representation between management and labor to serve health and safety related functions. The elected representatives should have a legally recognized role that goes beyond consultation and activities, such as the development of the comprehensive process hazard analysis, implementation of corrective actions generated from hierarchy control analysis, management of change, incident investigation audits, and the identification prevention and control of all process hazards.
[00:53:10] The regulation should provide workers and their representatives with the authority to stop work that is perceived to be unsafe until the employer resolves the matter or the renovator intervene. Workforce participation practices should be documented by the refinery to the regulator. Require reporting of information to the public, to the greatest extent feasible.
[00:53:34] So it, as a summary of the comprehensive process, hazard analysis would, should include a list of inherently safer systems, implemented safeguards and implemented for remaining hazards standards utilized to reduce risks, to as low as reasonably practical or similar and process safety indicators that demonstrate the effectiveness of the safeguards and management system.
[00:54:00] G implement an approach or system that demonstrates when new or improved industry standards and practices are needed and initiate programs and other activities such as an advisory committee or forum to prompt the timely development and implementation of set standards and practices, and H ensure that it means of sustained funding as established to support an independent well-funded well-staffed technically competent regulators.
[00:54:32] Then here’s what the state of California did. The closer California’s newly adopted process safety management regulation for petroleum refineries. Under section 500 809 became effective on October 1st, 2017. The new regulation applies only to petroleum refinery. Within California. And it has the goal of reducing a risk of major incidents and eliminating or minimizing process safety hazards to its employees may be exposed according to the press release from California department of industrial relations or DIR the elements outlined in the regulation require the refinery employers to one conduct, damage mechanism reviews for processes that result in equipment or material degradation to conduct a hierarchy of hazard controls analysis to encourage refinery management, to implement the most effective safety measures when considering competing demands and costs when correcting hazards three, implementing human factors program, which requires analyses of human factors, such as staffing levels, training and competency, fatigue, and other effects of ship work and the human machine interface.
[00:55:49] For develop, implement and maintain written procedures for the men and management of organizational change to ensure that plant safety remains consistent during personnel changes five, utilize root cause analysis when investigating any incident that results in or could have reasonably resulted in a major incident, six perform and document a process hazard analysis of the effectiveness of safeguards that apply to processes and identify, evaluate, and control hazards associated with each process.
[00:56:26] And lastly, understand the attitudes, beliefs, perceptions, and values that employees share in relation to safety and evaluate responses to reports and hazards by implementing and maintaining an effective, effective process safety culture assessment program. The new regulation is intend to make California petroleum refineries safer for both workers and surrounding communities.
[00:56:52] And although California has newly adopted DSM regulations for petroleum refinery is not accomplish everything requested by the recommendation is the much more robust regulation that goes a long way toward improving process safety management. At these refineries, California CSM regulation introduces several new management system elements previous to the identified by the CSB as being necessary for improved refinery safety, including the use of hierarchy of hazard controls, performing damage mechanism reviews, and conducting safeguard protection analysis.
[00:57:30] The parts of the recommendation or the, excuse me, the parts of the regulation that were determined to be missing are further addressed in this parish. The recommendation requires proactively providing PHA information to the regulator and requires that the information to be reviewed by the regular, that the information would be reviewed by the regulator.
[00:57:51] So the regulation does not include this requirement. It does require a triennial compliance audit from the employer, as well as provides the authority for the regulator to receive that PHA information upon request. The regulations does not specifically require audits and inspections to be conducted by the regulator, but the regulator already has that authority to implement these programs on their own.
[00:58:17] Should they desire to do so? The regulation does not require the public reporting of PSM related information. However, The public already does have the ability to access this information. And lastly, the requirement to implement an approach that determines when new or improved industry standards and practices are needed and initiate programs and other activities to prompt the timely development of implementation is neither practical, enormous, measurable, any new standard or practice initiated and implemented is assumed to be based upon a need.
[00:58:54] And therefore can meet this requirement. Typically the need is based on some negative consequence and the timeliness requirement is relative to the parameters that already exist that allow for the development and implementation of set standards and practices though. Not specifically address in this regulation, the requirement all as written already generally exists in practice.
[00:59:18] So in summation, Of the totality of the requirements of the recommendation that are not addressed by the California’s PSM recommendation. It appears that there are alternatives that currently exist that allow that the objectives to be generally met California’s new PSM regulation, adopted many improvements, and it making refinery safer for workers and citizens, though, a more robust process safety management approach aimed at identifying hazards, implementing inherently safer solutions and reducing risks to the greatest extent feasible.
[00:59:58] So as a result of all of that information, um, on July 28th, 2021, the board voted to change the status to close, acceptable alternative actions
[01:00:15] as a big one.
[01:00:20] Um, I have just a few questions for you. Um, can you please provide some insights of the process of the state of California went through, uh, to create the PSM regulation for refineries? Yes ma’am. Um, as you can imagine, the state of California implied or employed a very thorough and rigorous rulemaking process to arrive upon the final adopted DSM regulation for refinery, they created a task force to conduct a significant amount of information gathering as well as interviews to better understand all the issues that needed to be addressed with the new rule.
[01:01:01] The state of California, occupational safety and health standards board issued a notice of proposed rulemaking in July, 2016, which provided the public, including the CSB, the opportunity. Public comments on the proposed rule. In September, 2016, they held a public hearing to consider revisions to the proposal.
[01:01:23] They held another public hearing in spring of 2017. And then finally in October of 2017, the new rule was adopted. Thank you, director Barbie. And I know we’re going a little bit long, but I, I, this is important information. Are you aware of any other states who may be looking to adopt this type of rule, um, for, for finery fees?
[01:01:50] Uh, I’m really glad you asked that question from the CSB is to thorough refinery fail explosion and fire investigation. Uh, the CSB in 2014 issued similar recommendations. To the governor and legislator, legislature of the state of Washington, as a result, they’ve been working diligently on drafting, a similar rule for their refinery.
[01:02:14] Over the last two years, the state of Washington has held a number of listening sessions and stakeholder meetings to discuss the specifics of the California rule and the desired topics to be covered in a new PS room rule or PSM rule for the state of Washington. The CSB is very hopeful that the state of Washington will be issuing a proposed rulemaking for comment sometime this year.
[01:02:40] So unless you have additional questions, I thank you for the opportunity to highlight these extremely impactful safety recommendations and pass it back to you. I thank you so much, director Barbie. I think we should move to something that I’m very excited about. Um, which director, uh, executive director Kleist will introduce, which is a new safety product that relates to our ag one, uh, closed investigation last month.
[01:03:13] Oh, we wait for Steve to pull up his screen. Uh, just wanna re rate, uh, the chairman’s earlier comments. Um, uh, I want to thank the, the investor, the recommendation staff. I think it’s incredibly important that the, the, uh, the general public is aware that the recommendations and the clearance of the rest of those recommendations is every bit as important as the investigation itself.
[01:03:35] Um, so with that, I think Steve, so Steve, take it away. Yes. Thank you. Uh, Mr. and thank you chairman for your very insightful comment about the staff’s work. We very much appreciate the recognition. This is the CSB we’ll be releasing today. The safety video that was produced to supplement the ag horn investigation report that was previously adopted by the board.
[01:04:01] Before we show the animation in the video, I will begin with an overview of the incident on October 26th, 2019 and ag horn employee pumper hae responded to the pump oil level alarm at ag horns foster D waterflood station in Odessa, Texas. The pump was located in a building whole they pump house in response to the alarm pumper, a work to isolate the pump from the process by closing the pumps, discharge and suction valve.
[01:04:31] Number eight did not first perform lockout tagout to isolate number one from the energy source before performing work on the pump while closing the pumps, discharge and suction vows war produced water containing hydrogen sulfide released from the pump. The CSB found post-incident that the pump had a broken plunger from which the water and hydrogen sulfide released bumper a was fatally injured from his exposure to the release of my consultant.
[01:05:05] Subsequently the spouse of pumper, a gained access to the waterflood station and search for pumper a during her search efforts, she was also exposed to the V released hydrogen sulfide and was fatally injured. The investigation team identified seven safety issues and its investigation of the issue.
[01:05:27] Non-use of pumper A’s personal hydrogen sulfide detector, nonperformance of lockout-tagout confinement of hydrogen sulfide in the pump house ag horns, lack of a safety management program, safety management oversight, ag horns, non-functioning hydrogen sulfide detection and alarm system. And according to deficient site security, we will now show the animation.
[01:05:54] That is part of video. Again, that will be released today.
[01:06:07] The acorn waterflood station is used as part of a process to extract oil from underground reservoirs in west Texas oil extraction starts at an oil well where pump jacks are used to lift oil from underground reservoirs. Reservoirs in west Texas also contain hydrogen sulfide, a toxic gas, which comes to the surface with the oil that is extracted.
[01:06:32] The oil comes out of the ground with some water in it to remove the water. The mixture is fed to a tank battery. As the oil and water mixture sits in the tanks. The water separates from the oil. The oil is then transported for further processing. The water is pumped through pipelines to the waterflood station.
[01:06:54] It is now called produced water because it can contain residual oil and other contaminants such as toxic hydrogen sulfide gas at the waterflood station, the produced water flows into a large storage tank called a suction tank. The water then enters a building called the pump house. Their pumps are used to pressurize the produced water and inject it back into the oil field through injection Wells.
[01:07:23] The injected water increases, reservoir pressure and displaces, the oil, allowing a larger quantity of oil to be extracted at the time of the incident. There were two pumps in the pump house. The pump house also contains a control room from which employees run the station. Typically the station is not continuously occupied.
[01:07:43] Instead. An ag horn employee called a pumper visits twice per day to record meter readings and inspect equipment. If there is an equipment problem and a pumper is not at the station and alarm system triggers an automated phone call to the pumper. It is then the pumpers responsibility to acknowledge the alarm and go to the station to determine what is causing it.
[01:08:07] The station was also equipped with a hydrogen sulfide detection and alarm system that would trigger a separate automated phone call to the pumper on duty. If it detected dangerous levels of the toxic gas, the system would also, aluminate a rotating red beacon light on top of the pump house, but the CSB found that this critical detection and alert system was not functional on the night of the incident.
[01:08:32] At 6:38 PM. On October 26th, the waterfloods stations controlled system activated an oil level alarm on a pump. Five minutes later, the phone system called an egg horn pumper alerting him of a pump malfunction of some kind. The pumper drove to the waterflood station. The hydrogen sulfide beacon light was not illuminated when the pumper arrived at the waterflood station or at any time for the rest of the night.
[01:09:00] The pumper parked near the waterflood station, leaving his personal hydrogen sulfide monitor inside his truck. The pumper went into the control room where the control system indicated the alarm was for pump. Number one, the pumper prepared for work on pump. Number one, the pump, which could automatically start when enough water was available to pump to the injection.
[01:09:23] Wells was still connected to its power source. The pumper did not. De-energize the pump. The pumper then walked to the pumps. He closed pump number one, discharge valve, and partially closed the pumps intake valve. While the pumper was near the pump, he was overcome and fatally injured by toxic hydrogen sulfide gas.
[01:09:46] After the incident, the CSB, I found that a plunger on the pump had shattered, which had allowed water containing hydrogen sulfide to escape from the pump into the pump house where the pumper was working. Due to limitations of available evidence. The CSB was unable to determine whether the pump failure and water release occurred before the pumper arrived at the facility, or if the pump automatically turned on while the pumper was closing bounds.
[01:10:13] After several hours, when the pumper did not return home, his spouse drove with their two children to the station to check on him. She entered the waterflood station facility and searched for him. She soon found him on the floor in the pump house. She then was also overcome and fatally injured by the toxic hydrogen sulfide gas.
[01:10:35] A short time later, emergency responders approached the pump house. They detected a very strong smell of hydrogen sulfide. This required them to set up the command post outside the front gate of the facility. And where’s, self-contained breathing apparatus. They found the pumper and his wife deceased inside the pump house and water spilling from pump.
[01:10:59] Number one, the responders rescued the two children who were inside the spouse’s car, working with ag horn employees. They were able to stop the water release the following morning.
[01:11:18] Thank you, Mr. Kleist. Uh, I’d like to spotlight the staff, uh, in who assisted in developing this, this short form video in long form can be found on all CSB outlets, specifically Hilary Cohen, John Sharma Longhorn and supervisory investigator of the ag court investigation. Lauren grim, uh, Dr. Lamaze, this concludes the public meeting and I invite you to issue any closure of your March remarks, which you may have, like Dr.
[01:11:47] Lewis might have a mic issue currently. Okay, there we go. Okay. Are we good now? All right. I want to thank everyone for their attendance of its public meeting and for your attention and support. I also want to thank my senior advisors and our dedicated agency staff for their contributions. All of them share a strong interest in preventing chemical accidents like this one in the future.
[01:12:26] And once again, the, we must remain true to our mission in conducting an issuing independent and objective. And now LASUS and recommendations is important to consider the expertise, knowledge, and priorities of our stakeholder community. Please look out for our upcoming announcements. In the very near term, uh, board meetings to close out the investigations that were mentioned in today’s meeting and our next quarterly public meeting with this, the meeting is adjourned.

Hydrogen Sulfide Release, Odessa, TX, Oct 26, 2019, CSB Production

Summary

The U.S. Chemical Safety Board (CSB) released a video explaining their findings on the October 26, 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.  If you want to see the visuals, you can watch the CSB video on the USCSB YouTube channelTranscript

Send in a voice message: https://anchor.fm/safety-investigations/message Support this podcast: https://anchor.fm/safety-investigations/support

Transcription

Disclaimer: This transcript is auto generated and is not manually checked for errors. It more than likely contains very significant errors.
Hydrogen Sulfide Release, Odessa, TX, Oct 26, 2019 – CSB
October 26th, 2019, the ag horn operating Inc waterfloods station near Odessa, Texas one ag horn employee succumb to toxic hydrogen sulfide gas that had escaped through a damaged. His spouse was also fatally injured by the hydrogen sulfide gas while searching for a mat. The facility after he didn’t return home, hydrogen sulfide is prevalent throughout oil and gas formations in the United States and many oil and gas production.
[00:00:43] And processing facilities, hydrocarbons from the Permian basin in particular, are known to contain high concentrations of hydrogen sulfide that are immediately dangerous to life. Our health, our review, this event is about the unfortunate loss of lives. But the lessons from this incident affect the multitude of other oil and gas facilities throughout the country that handle toxic hydrogen sulfide.
[00:01:15] This incident was both tragic and unnecessary. We urge companies operating oil and gas facilities, to understand the findings from this investigation and implement appropriate safeguards in training. We need to work together to ensure that our workers and community members return home safely eat. And every day
[00:01:50] YAG horn waterflood station is used as part of a process to extract oil from underground reservoirs in west Texas oil extraction starts at an oil. Where pump jacks are used to lift oil from underground reservoirs reservoirs in west Texas also contain hydrogen sulfide, a toxic gas, which comes to the surface with the oil that is extracted.
[00:02:15] The oil comes out of the ground with some water in it. To remove the water. The mixture is fed to a tank battery as the oil and water mixture sits in the tanks. The water separates from the oil, the oil is then transported for further processing. The water is pumped through pipelines to the waterflood station.
[00:02:36] It is now called produced water because it can contain residual oil and other contaminants such as toxic hydrogen, sulfide gas. At the waterflood station, the produced water flows into a large storage tank called a suction tank. The water then enters a building called the pump house. Their pumps are used to pressurize the produced water and inject it back into the oil field.
[00:03:03] Through injection Wells, the injected water increases, reservoir pressure and displaces, the oil, allowing a larger quantity of oil to be excited. At the time of the incident, there were two pumps in the pump house. The pump house also contains a control room from which employees run the station. Typically the station is not continuously occupied instead.
[00:03:27] An acorn employee called a pumper visits twice per day to record meter reads. And inspect equipment. If there is an equipment problem and a pumper is not at the station and alarm system triggers an automated phone call to the pumper, it is then the pumpers responsibility to acknowledge the alarm and go to the station to determine what is cost.
[00:03:49] The station was also equipped with a hydrogen sulfide detection and alarm system that would trigger a separate automated phone call to the pumper on duty. If it detected dangerous levels of the toxic gas, the system would also, aluminate a rotating red beacon light on top of the pump house, but the CSB found that this critical detection and alert system was not functional on the night of the incident.
[00:04:15] At 6:38 PM. On October 26th, the waterfloods stations controlled system activated an oil level alarm on a pump. Five minutes later, the phone system called an egg horn pumper alerting him of a pump malfunction of some kind, the pumper to the waterflood station. The hydrogen sulfide beacon light was not illuminated when the pumper arrived at the waterflood station or at any time for the rest of the night.
[00:04:42] The pumper parked near the waterflood station, leaving his personal hydrogen sulfide monitor inside his truck. The pumper went into the control room where the control system indicated the alarm was for pump number one, the pumper prepared for work on pump number one, the pump, which could automatically start when enough water was available to pump to the injection.
[00:05:06] Wells was still connected to its power source. The pumper did not. De-energize the pump, the pumper then walked to the pump. He closed pump number one’s discharge valve, and partially closed the pumps intake valve. While the pumper was near the pump. He was overcome and fatally injured by toxic hydrogen sulfide gas.
[00:05:28] After the incident, the CSB, I found that a plunger on the pump had shattered, which had allowed water containing hydrogen sulfide to escape from the. Into the pump house where the pumper was working due to limitations of available evidence. The CSB was unable to determine whether the pump failure and water release occurred before the pumper arrived at the facility, or if the pump automatically turned on while the pumper was closing.
[00:05:56] After several hours when the pumper did not return home, his spouse, there are two children to the station to check on him. She entered the waterflood station facility for him. She soon found him on the floor in the pump house. She then was also overcome and fatally injured by the toxic hydrogen sulfide gas.
[00:06:18] A short time later, emergency responders approached the pump house. They detected a very strong smell of hydrogen sulfide. This required them to set up the command post outside the front gate of the facility. And where’s, self-contained breathing apparatus. They found the pumper and his wife deceased inside the pump house.
[00:06:40] And water’s spilling from pump. Number one, the responders rescued the two children who were inside the spouse’s car, working with ag horn employees. They were able to stop the water release the following morning. During our investigation, we identified six major safety issues at the facade. One of the six safety issues identified was that the pumper was not equipped with his company issued personal hydrogen sulfide detection device inside the pump house.
[00:07:11] On the night of the incident, when the pumper’s personal hydrogen sulfide detector was located in his work truck, it was found to be in an alarm state, meaning it had detected dangerous levels of hydrogen sulfide. The potential for a hydrogen sulfide release was a known hazard at the waterflood station as indicated by the posted signage and a safety pamphlet provided to all employees.
[00:07:36] However, there was no evidence that ag horn management required use of personal hydrogen sulfide detectors or adequately craned employees. That equipment malfunctions could indeed. Uh, toxic hydrogen sulfide release. We should ensure workers always use the required safety equipment, such as personal detectors when entering a potentially hazardous area, regular training and posting signs will help remind employees to use their safety equipment every time.
[00:08:05] The second safety issue. CSB investigators discovered is that at the time of the incident, ag horn did not have any written lockout, tagout policies or procedures, but relied on verbal procedures without formalized training. On the night of the incident, the pumper did not properly perform lockout tag out to de-energize the pump before performing work.
[00:08:28] Instead, he started to close the pumps valves while the pump was still configured to be automatically operated by the control system. As a result, the control system automatically turned the pump on and water containing hydrogen sulfide was able to escape from the pump when the discharge valve was.
[00:08:49] Companies must have written lockout, tagout policies and procedures that instruct to isolate all possible sources of energy before employees perform work on equipment. Companies also need to routinely train employees on the lockout tagout procedures. Safety issue identified by the CSB was that the ventilation inside the pump house was inadequate leading to fatal concentrations of hydrogen sulfide gas within the.
[00:09:18] The CSB found that the pump house could be ventilated by two bay doors, exhaust fans and natural events on each of the four outside walls due to the limitations of available evidence. The CSB was unable to confirm whether the exhaust fans were operational at the time of the incident. The two bay doors were approximately 60% open, but this was not enough to adequately ventilate the baby.
[00:09:44] And the CSPs investigation could not find any evidence that ag horn assessed the pump house to ensure it could be properly ventilated despite the petition. For a hydrogen sulfide release to occur inside companies should evaluate any buildings that contain equipment handling toxic gases and determine if the building is necessary.
[00:10:05] If it is companies should ensure the building is equipped with a functioning, toxic gas detection and alarm system, and a ventilation system designed for the release of toxic gas. If the building is not necessary for the operation, a safety assessment should be conducted to determine if removal of the building or relocation of the equipment can prevent confinement of any toxic gas releases.
[00:10:30] The fourth safety issue noted by the CSB was the lack of a robust safety management program at EG. Comprehensive safety management practices include risk identification, assessment, mitigation, and monitoring of design procedures, maintenance. Safety management practices are an essential element of protecting workers.
[00:10:53] And non-employees from toxic gases at chemical plants at ag horn. There were no operational training, testing and maintenance procedures or records other than items, such as a cell phone use policy and a pamphlet on the hazards of hydrogen sulfide. These items were not sufficient to prepare employees for potential encounters with hazards in it.
[00:11:18] I work at facilities that handle toxic gases companies must develop and implement a robust safety management program to protect workers. And non-employees from exposure to toxic gas. The CSB identified a fifth safety issue at acorn, which was a non-functioning hydrogen sulfide detection and alarm system.
[00:11:41] Some of the facilities detectors were set to a testing mode, which prevented them from sending an alarm. And other sensors that were correctly set up were unable to send a signal to the control room. As a result, the pumper was not warn of the toxic hydrogen sulfide, either through a telephone alert or illumination of the red pump house beacon light at facilities that handle toxic gases gas detection and alarm systems must be adequately designed, maintained, and tested alarms should clearly alert to the hazard through visual and audible indication.
[00:12:16] Visual indications should be discernible. During any time of day signs alerting the facility handles toxic gas should be posted in clear view legible at day and night and should be well-maintained. And finally the sixth safety issue discovered by the CSB at acorn was deficient site security per egg horns, informal policy.
[00:12:40] When an ag horn employee is working at the facility, the access gates are normally left unlocked on the night of the incident. This practice allowed the pumpers spouse to drive directly to the waterflood station and enter the pump house where she was also fatally injured. Effective site security must be in place to prevent non-employee.
[00:13:03] From accessing hazardous areas. As a result of its investigation, the CSB made the following recommendations to ag horn operating Inc for safety improvements at all water stations where the potential for exposure to dangerous levels of toxic hydrogen sulfide gas exists. These include mandate the use of personal hydrogen sulfide detection devices.
[00:13:28] Develop a site-specific formalized and comprehensive lockout tagout program for each facility commission, an independent and comprehensive analysis of each facility to examine ventilation and mitigation systems develop and demonstrate the use of a safety management program. That includes a focus on protecting workers and non-employees from hydrogen sulfide.
[00:13:54] 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 the 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 acorn.
[00:14:29] The CSB also recommended that OSHA issue, a safety information. That addresses the requirements for protecting workers from hazardous air contaminants and from hazardous energy. And the agency made a recommendation to the railroad commission of Texas to develop and send a notice to all oil and gas operators that fall under his jurisdiction that describes the safety issues outlined in the CSPs.
[00:14:57] Ag corn safety deficiencies identified by the CSB through this investigation can be corrected. OSHA implementation of CSPs recommendation would send a strong message to the chemical industry of their priority to protect workers from the risks of chemical releases. This recommendation would not be limited to hydrogen sulfide, but would encompass workers across chemical facility to make.
[00:15:27] The implementation of CSPs recommendation to the railroad commission of Texas would make significant strides to educating the chemical industry and address the majority of waterflood stations that involve hydrogen sulfide. Many of these companies are small and involve employees that work alone. And in many cases in remote locations, This recommendation would also go a long way to help educate those companies that may not be on the leading edge of safety.
[00:16:05] This tragic accident did not need to happen. 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. For more information about the CSBs ag horn investigation, please.

Sinking of Scandies Rose, Sutwik Island, AK, Dec, 31, 2019 – NTSB Board Meeting

Summary

NTSB Meeting: Jun 29, 2021, Sinking of Scandies Rose

The National Transportation Safety Board held a virtual public board meeting June 29 to determine the probable cause for the 2019 sinking of the fishing vessel Scandies Rose.

The Scandies Rose sank Dec. 31, 2019, 2.5 miles south of Sutwik Island, Alaska. The vessel had a crew of seven; two were rescued and five others missing after the accident were never found.

During the meeting the NTSB’s five-member board voted 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 was webcast to the public, with the board members and investigative staff meeting virtually.

Visit https://www.ntsb.gov/news/press-releases/Pages/MR20210629.aspx for more.

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 https://youtu.be/3ADYkxW_QSM posted on the NTSBgov channel.

The docket for the investigation is available at https://data.ntsb.gov/Docket?ProjectID=100752

Transcript — Send in a voice message: https://anchor.fm/safety-investigations/message Support this podcast: https://anchor.fm/safety-investigations/support

Transcription

Disclaimer: This transcript is auto generated and is not manually checked for errors. It more than likely contains very significant errors.
Sinking of Scandies Rose, Sutwik Island, AK, Dec, 31, 2019, NTSB Board Meeting
Thank you for joining and welcome to this virtual board meeting of the national transportation and safety board. I’m Robert Walt, and I’m honored to serve as the chairman of the NTSB and joining us today are my colleagues on the board as chairman Bruce Landsberg, and we’re Jennifer Hamadie number, Michael Graham and member Tom Chapman.
[00:00:22] Today, we made an open session as required by the government in the sunshine act to consider the capsizing and sinking of the commercial vessel commercial fishing vessel. Scandi is rose near island, Alaska on December the 31st, 2019 of the seven crew members of board to escape the vessel and were rescued by the coast guard.
[00:00:46] But tragically tragically, the five remaining crew members and including the vessels captain were never found on behalf of all of us at the NTSB. I’d like to offer our sincerest condolences to the family, family, and friends of all of those who were lost in this tragic accident. Our purpose in this investigation is to learn from it, to prevent it from happening again.
[00:01:13] So others don’t have to go through what you’re going through year after year. One of the deadliest ways to make a living in the U S is to be a commercial fish. More than 800 people have lost their lives aboard fishing vessels in the past two decades. And the safety of commercial fishing vessels is on our current list.
[00:01:37] Most wanted list of transportation, safety improvements alongside safety of passenger vessels, but unlike passenger vessels, however, fishing vessels such as the Scandi is rose carry only their crew who are assumed to know the risk. There are many seasoned Mariners who take on those risks to make their living as fishermen, but as tragedies like this one, there’s our teams system there.
[00:02:09] But as tragedies like this one we will discuss today, remind us that this deadly occupation does not have to be so deadly. And that the risks that fishermen except should only be mitigated commercial fishing vessels. Like the Scandi is rose encounter, rough weather routinely and commercial fishing is a year round business off the coast of Alaska.
[00:02:33] And the winter icing is an all too common hazard. In fact, the Scandi is rose carried onboard tools to break up ice that accumulated on its Jack and structures. This is not an unusual arrangement in the waters off of Alaska and the wetter. The question is not whether icing as POS. The question is how much icing can be tolerated while still maintaining a margin of safety around the vessel’s stability.
[00:02:59] Today, we will discuss what icing conditions prevail during what part of the voyage. And we’ll discuss what, if anything, the captain and the crew could have done differently to avoid the tragic outcome and tragically and critically we will discuss whether they had or could have had the information needed to make the right calls specifically how icing might affect vessel stability in various loading conditions.
[00:03:27] Now, each board member has done a study, the draft report, and each of us have met individually with the investigative staff, but today’s board meeting is the first time that we, as a deliberative body will have gathered to discuss the report today, the staff will lay out the pertinent facts and analysis found in the draft report and they will present the draft findings.
[00:03:48] So probable cause and recommendations to the board. And then we own the board will question the staff to ensure the report as we adopted today, truly provides the best opportunity to enhance it. The public docket for this investigation conduct contains more than 4,500 pages of additional relevant material.
[00:04:10] And it’s available on our website, ntsb.gov. The final report will also be available on our website in just a few weeks. Once any amendments voted upon today are incorporated in the report and the report is finalized at this time. I’d like for each of my colleagues on the board to introduce themselves as chairman Landsberg.
[00:04:32] Good morning chairman. Uh, I’m looking forward to, uh, our deliberation. So thank you for the offer. Thank you very much. Remember Hamadie good morning, Mr. Chairman and to my colleagues and thank you very much to the staff. Look forward to the discussion. Great. Thank you. Good morning. Number. How many member Graham?
[00:04:56] Good morning, Mr. Chairman, vice chairman, uh, fellow board members and investigative stack staff. I look forward to our deliberations today, right? I good to see you and member chap. Good morning, chairman, looking forward to the discussion today and congratulations to our team for an outstanding event. Thank you very much.
[00:05:18] I’ll. Now I asked the deputy managing director of, for investigations, Brian Curtis, to introduce the investigative staff and those who will be participating in this morning’s board meeting. Good morning, Mr. Curt. Good morning. And thank you, chairman some wall. I’d like to also thank everyone who helped make this virtual board meeting happened today.
[00:05:39] My only advice administrative announcement this morning is a reminder for the meeting participants to silence all electronic devices at this time. I’ll now introduce the staff for today’s meeting unless otherwise indicated staff is from the office. Okay. Marine safety Morgan. Chirael the director for the office of Marine safety, Bart Barnum investigator in charge.
[00:06:01] Paul Suffern meteorology group chairman from the office of aviation safety, Julie piano report writer, Scott Rainey safety record commendations from the office of safety recommendations and communications. Casey Blaine, deputy general counsel for the NTSB, Dolly and hatchet director for the office of safety recommendations and communications Barbara check deputy director for the office of research and engineering, Dana Schultz director for the office of aviation safety, Liam LaRue, chief of investigations, Rob Jones, deputy chief of investigations and Eric Stolsenberg chief of product development.
[00:06:45] Patients will begin with an investigation overview by the investigator insurance, Bart Barnum, Mr. Barnum.
[00:06:57] Thank you. Good morning, chairman Stonewall, vice chairman, Landsberg and board members. I’ll be providing an overview of the events that took place on December 31st and January 1st, 2019. I would like to acknowledge the staff noted here for their support during the investigation and the report development.
[00:07:19] I would like to also acknowledge the staff noted here, who produced this virtual board meeting. The coast guard parties to this investigation are listed here and we would like to thank them for their assistance on scene and throughout the investigation. The coast guard was the lead federal agency in this investigation.
[00:07:42] Following the accident, the coast guard convened a Marine board of investigation and TSP investigators coordinated with coast guard investigators to avoid duplicating efforts from February 22nd to March 5th, 2021, the coast guard conducted a formal hearing into the accident during the hearing coast guard and NTSB investigators, question 43 individuals, including surviving crew members, company management, coast guard, personnel, and commercial fishing industry stakeholders.
[00:08:20] The Scandi is rose was a steel fishing vessel built in 1978 and registered in Dutch Harbor, Alaska, the vessel fished in the Bering sea for king crag, Propelio crab and Pacific Cod. In the summer months, the vessel would store and transport the catch for the salmon fishery vessels in the Bering sea and Gulf of Alaska.
[00:08:45] The scan, these rows was subject to the regulations set forth in 46 code of federal regulations, part 28, which included equipment stability and other safety requirements. The vessel was required to participate in the coast guards, commercial fishing vessel dock side safety examination program, which primarily focused on saving equipment on board.
[00:09:11] The vessel, the vessel was owned by the scandals rose fishing company based in Bremerton, Washington, and was the company sole vessel. The captain of the vessel had 45 years of fishing experience with about 40 years as captain on various fishing vessels in the Gulf of Alaska and bearing seed as captain of the vessel, you made determinations on when and where to fish, the vessel layout consisted of the foam below the main deck, starting at the bow was a ballast.
[00:09:47] Followed by an anchor chain locker and then dry store room, next staff, or three crab tanks, flexible holds use to store the catch outboard and below of the crab tanks and not pictured here where the vessels fuel oil storage tanks. After these tanks for the vessels engine room, machinery space and steering gear room housing, the vessels, propulsion equipment, and other machinery associated with the operation of the vessel.
[00:10:20] Mid ships on the main deck was the fishing deck where the crew would stack the vessels crab pots while not being fished. Collectively the pots on deck were referred to as a pot stack. Further AFT was the deck house consisting of three levels. Two days before the accident, the captain and crew prepared the vessel for departure from Kodiak, Alaska to participate in the Bering sea pop Cod fishery, which was scheduled to open on January 1st.
[00:10:54] The crew worked late into the night loading and securing 195 combination pots on the vessel. The next day, the crew prepared the vessel for sea. They chained the pot stack secured hatches and tested builds level sensors. The captain who was the vessels certified safety drill instructor conducted drills with the crew, including discussions about the locations of life rafts, the vessels emergency position, indicating radio beacon, and how to make it Mayday.
[00:11:29] Call one crew member. Don demonstrated how to Dawn an emerging suit on December 30th at 8 35 in the evening. This Gainey’s rose departed Kodiak five hours prior the national weather service issued a Marine forecast that included a Gale warning and a heavy freezing spray warning for the vessels proposed route.
[00:11:55] The vessels plan route was Northwest through the Cooper Knopf straight than Southwest through the Shelikof Strait towards false pass on route to the Bering sea on Tuesday, December 31st at about two o’clock in the morning. This game, these rows exited Cooper Knopf straight and entered the Shelikof between the south side of the Alaskan peninsula and the west coast, the west coast of Kodiak island.
[00:12:24] The vessel steadied on a southwesterly course that followed the Kodiak coastline. The captain passed the watch to one of his crew members in the part of the bridge on December 31st from two o’clock to eight o’clock in the morning. The crew of the scanners rose rotated through our long bridge watches.
[00:12:43] At the end of each, watch the ongoing crew member completed a round of the engine room to ensure that vessel’s engines and auxiliary equipment were in good working order. The vessel had begun to encounter freezing spray and accumulate ice Deccan. One who stood watch from six o’clock to seven o’clock in the morning, told the NTSB that he had observed one inch of ice filling the mesh of the Ford starboard pots and accumulating on the exterior railings of the vessel that came to on watch from seven o’clock to eight o’clock in the morning, all the NTSB that the weather had picked up from the night before the wind and waves were acting on the starboard bow of the vessel.
[00:13:31] Both crew members noted that the amount of accumulated accumulated ice on the vessel at that time was not enough to warrant manual removal at eight o’clock in the morning when deck had to pass the bridge, watch the captain, the vessel had an even keel later that morning at 1118, the captain call the fishing vessel, Emma Tuli, which had departed Kodiak ahead of the scanners rose on route to Dutch Harbor.
[00:14:02] Before the two captains ended their 12 minute phone conversation, the captain of the scabies road. Said that his said that it was very cold. His vessel was experiencing light icing and the sea conditions report about two o’clock in the afternoon. After finishing his six hour bridge, watch the captain passed the watch to his crew for the next six hours.
[00:14:27] The crew rotated through their watches. The vessels heading remain steady on a southwesterly course. According to deckhand to the wind and weather started coming up a lot more and progressively got worse all day. You also told the NTSB that the vessel was bucking into the seas, making a lot of spray and the spray was making ice about seven 15 in the evening.
[00:14:54] The crew member on watch Deccan to called the captain to wake him for his watch. Shortly after the captain arrived on the bridge, the, to discuss the worsening weather, the accumulation of ice on the vessels, superstructure and crackpots, and the development of an approximately two degree starboard list.
[00:15:16] It considered reducing the vessel speed and altering course to limit the freezing spray causing icing on the vessel. And the crew member asked the captain, if he should wake the crew to break ice off the pots, ultimately the captain decided to maintain course and speed and not wake the entire crew.
[00:15:37] That can to told the NTSB that the captain said the weather was too rough to have the crew out on deck chopping ice, and that they would wait until the vessel was in protected waters after being relieved by the captain. And before leaving the bridge Deccan too took note of the accumulated ice on the vessels pot stack through the bridge window.
[00:16:01] He said that all pots were glazed over with ice, the starboard side pots, or more heavily coated with what he estimated to be about two inches of ice inside webbing of the starboard Potts was also coated with ice starting about eight o’clock that evening. The captain is scanned. These rows made a series of phone calls first to a friend who said that the captain had told her that his vessel was icing and had a list.
[00:16:33] She added that at the time of the call. The captain did not sound alarm at 8:37 PM. The skinnies rose was about five and a half miles due east of Ireland. Still maintaining a southwesterly course. The captain call a fellow captain on the commercial fishing vessel, Pacific sounder, according to the Pacific sounder captain, the captain of the scanners rose said that his vessel was icing really bad.
[00:17:04] And he was concerned about a 20 degree starboard list that had developed before ending their conversation. The skinnies rose captain also noted that the winds were blowing 60 to 70 knots from the west. The temperature was 12 degrees Fahrenheit, and it was too rough to send a crew out on deck to break ice.
[00:17:27] He was trying to seek shelter Southwest of island at 9:45 PM. Vessel position data shows that the Scandi, these rose was about two and a half miles south of salt lake island. The vessel had turned 50 degrees to starboard and held a northwesterly course in the direction of sunblock islands. Southern bay, shortly after the vessel had turned towards Southwick, the Pacific sounder captain called the scanners rose back.
[00:17:59] He said that the captains tone had changed from the previous conversation. You said that the captain of the scanners rose said that I don’t know how this is going to go. And that his vessels list had gotten a lot worse. The captain of the Pacific sounder said that he had never heard the level of stress in the voice of the scanner’s rose captain before just after the heading change to starboard, the two crew members who survived the accident report.
[00:18:31] That they were jolted from their beds by a sudden sustained vessel list to starboard the entire crew of the scam. These rows made it to the bridge and attempted to Dawn immersion suits. While the vessel listed, the two survivors managed to climb out the port side door and finish donning their immersion suits while leaning against the vessel superstructure, the captain was able to broadcast a Mayday call with the vessels position.
[00:19:01] And at 9:55 PM, the coast guard received the message. The two survivors attempted to help other crew out of the port bridge door, but were not successful. Ultimately, a wave swept them off the side of the vessel and into the water while floating in the water. They observed the scanners rose sink and did not see anyone else get off the vessel that can one and two found themselves separated in heavy winds and seas.
[00:19:35] Before deck came, one saw the light from an inflatable life raft that had automatically deployed from the scanners rose. As she sank, he was able to swim to the covered raft and climb a board. Once inside. He began yelling for his fellow crew member after several minutes, hearing his fellow crew member yelling deckhand too.
[00:19:59] Swam to the raft and climbed aboard. After receiving the Mayday call from the scanners rose the coast guard repeatedly made unsuccessful attempts to establish communications with the vessel. They also initiated search and rescue operations, launching a rescue helicopter from air station Kodiak. It took the crew of the rescue helicopter, roughly two and a half hours to complete the approximate 170 mile trip and arrive on scene.
[00:20:30] And what the flight commander testified to be the most challenging flight of his career. Upon arrival at the captain’s Mayday coordinates, the rescue helicopter crew began to search for the vessel and any survivors upon locating the life raft. They sent a rescue swimmer down to investigate and discovered that it was empty.
[00:20:52] They located the other life raft with the two crew members of board shortly after on January 1st, shortly after two o’clock in the morning poisoning operations of the two crew members again on board, the helicopter, the two survivors informed the coast guard. They had not seen any other crew members get off the vessel before it saying, after recovering the two crew members and rescue swimmer from the water, the rescue helicopter returned to base.
[00:21:24] After arriving the two crew met surviving crew members were transported to a waiting ambulance and driven to a local hospital for hypothermia treatment. The coast guard continued to search for the remaining crew of the scan. These rows throughout the day in total, the coast guard used three helicopters to see one 30 airplanes and in high endurance cutter the search of roughly 1400 square mile area near sunblock island shortly after 8:00 PM, 20 hours after receiving the Mayday call and after 16 hours of searching for any additional survivors on the scan, these rose, the coast guard, suspended search and rescue operations.
[00:22:10] Following the sinking of the scan, these rows, the owners of the vessel hired a Marine salver and a hydrographic survey company to find the vessel and document the wreck. The scan, these rows was located in about 160 feet of water, about 1100 feet from the Mayday position. The remote operated vehicle conducted video surveys of the scan, these rows and the debris field.
[00:22:39] Several of the vessels, external doors appeared to have been damaged by the impact of the sea floor. The remote operated vehicle was unable to video the starboard side of the vessel. Because of the vessels orientation on the sea floor footage of the vessels, bottom port side and stern did not show any whole breaches, an empty emergency position indicating radio beacon bracket was located, but ultimately the beacon was not found safety issues that were identified in the capsizing and sinking of the scan.
[00:23:16] These rows were the effect of extreme icing conditions, lack of accurate weather data for the accident area, the vessels inaccurate stability instructions and the need to update regulatory guidelines on calculating and communicating icing for stability. Instructions. Staff believes that the following were excluded factors in the accident.
[00:23:46] The captain’s pre-departure decision-making operational pressures, fatigue, drug, and alcohol use the vessels propulsion and steering systems and the vessels halt integrity. This concludes my presentation, the meteorology group chairman from the office of aviation safety. Mr. Paul Suffern will now discuss whether it related to finance.
[00:24:15] Good morning, chairman Sumwalt and members of the board. I will now discuss weather related issues associated with the sinking of the commercial fishing vessels. Candies froze Mariners interviewed throughout the course of this investigation, highlighted the weather conditions west to Kodiak island, near salt lake island and picnic bay as particularly hazardous, including some of the harshest weather conditions.
[00:24:38] The Mariners had experienced many said that the worst icing that ever seen was near Setlik island as the colder wind from Northwest flows across the area. This graphic highlights the locations of the weather observations nearest the accident site with weather observation sites located around a hundred miles away and greater south of the Alaska peninsula weather conditions reported at the observation sites highlighted in this graphic at the accident time match the Gale force conditions forecast.
[00:25:10] However, around the accident time, the accident captain reported measured winds of 60 to 70 knots with a helicopter rescue cue reporting, 30 foot seas near Setlik island with both wind and sea conditions, worse than 4k. The national weather service uses weather data from stations along the Alaska peninsula for forecasting and Mariners use the data to make real-time decisions.
[00:25:35] But as illustrated with the winds reported compared to the winds experienced by the scan, these rows data from these weather observation stations do not fully match the conditions in the city. Look, island and technique bay region observations sites that are more spread out and remote areas like Alaska can result in data that do not accurately represent the entire area and can lead to any accurate and less precise forecast and weather modeling.
[00:26:02] Therefore, Philly’s that due to the limited surface observation resources near settler island and the chicken sick bay region along the fishing vessel route from Kodiak to Dutch Harbor, the national weather service cannot accurately forecast the more extreme, localized wind and sea conditions for the area which can lead to vessels and conditions that are worse than expected.
[00:26:25] Staff has proposed a recommendation to address this issue. Currently as the weather conditions warrant the national weather service issues, either a freezing spray advisory or heavy freezing spray warning to alert Mariners to the potential for sea spray icing conditions with a heavy freezing spray warning issued.
[00:26:45] When I see accumulation rates exceed two centimeters per year, In contrast to the text information, the Nash, the weather service ocean prediction center, experimental icing forecast graphic website provides more categories and details on sea spray, icing levels above two centimeters per hour, giving Mariners in the barracks Gulf of Alaska and around seven island.
[00:27:10] More precise information on the higher rates of sea spray, icing accumulates. They may encounter none of the captains of the fishing vessels in the area interviewed at the Marine board of investigation. Public hearing were aware of the national weather service ocean prediction center, freezing spray website, and agree that the graphical freezing spray information would be a useful resource when operating in areas where freezing spray was prevalent.
[00:27:37] Currently the national weather service ocean prediction center freezing spray website remains experimental and therefore would not operate as robustly as an operational and national weather service website, nor is the national weather service ocean prediction center, freezing spray website advertise as an available resource for marijuana use.
[00:27:57] Therefore staff believes that the national weather service ocean prediction center site could provide Mariners with more detailed graphical information, not currently available elsewhere, which would help them make decisions based on more accurate weather information. Staff has proposed a recommendation to address this issue.
[00:28:17] This concludes my presentation. The investigator in charge, Bart Barnum will now discuss operational matters. Thank you. My second presentation this morning, we’ll discuss other elements of this accident. These elements include the following, the effects of extreme icing on vessels, stability, inaccurate stability instructions, and their consequences.
[00:28:43] The limitations of regulatory guidelines when calculating the effects of icing regulatory, stability, oversight, and training, and the lack of requirements for personal locator, beacons based on the ice accretion rate obtained from the NTSB weather model, the skinnies rose experienced progressively worse asymmetric icing during the voyage throughout the day on the 31st, the vessel moved through bands of light, moderate, and heavy icing based on the localized weather conditions reported by the captain and crew.
[00:29:22] The scan, these rows would have experienced ice accumulation greater than 1.6 inches per hour, which is categorized as extreme over the final two hours of the voyage. Therefore staff believes based on the voyage timeline and the estimated ice accumulation over that period. The scan, these rows likely accumulated between six and 15 inches of ice on surfaces exposed to wind and dicing during the accident voyage casing, the extreme, extreme icing conditions over the final two hours of the voyage.
[00:30:04] The captain determined that it was too dangerous to put his crew out on deck and remove the accumulated ice. Instead, the opted to seek shelter in the Lee of set with island, which was along his intended route, an area he was familiar with. And shortly after he assumed the watched the closest point of land, therefore staff believes that although the captain’s decision to proceed to salt lake island was reasonable, but at the time he was close enough to turn into the li the icing conditions have accelerated and reduce the vessel stability.
[00:30:43] The scanners rose was carrying a full stack of pots that reached about 20 feet above the main deck. The healing force to starboard created by the accumulation of ice that was forming ASAP asymmetrically on the starboard side of the pot stack focal boards and portions of the house was being counteracted by the wind and seas.
[00:31:09] Once the vessel altered course to starboard toward the Leigh of salt, what time. The wind and seas were no longer supporting the vessel shortly after the course change the vessels list to starboard increased and the vent and the vessel. Eventually capsized staff believes that they added weight from ice, accumulating asymmetrically on the vessel and the stack crackpots on deck raised the scan, these roses center of gravity, reducing its stability and contributing to the capsizing.
[00:31:46] The scan, these rows had stability instructions per coast guard regulations that had been completed by a qualified individual prior to departure the captain and crew loaded the vessel with 195 combination pots, which was below the 208 limit set on their stability instructions. They secured the pots and all other deck gear against shifting and ensured all doors and hatches were closed requirements specified in the stability instructions.
[00:32:21] In addition, the vessels fuel and crab tank levels were estimated to be in compliance with the stability instructions. Following the sinking, the coast guards Marine safety center conducted a forensic technical stability analysis of the scanners road. Which evaluated the stability instructions for the vessel.
[00:32:45] They noted differences when comparing tank capacities, mathematical errors omissions, as well as that. The 2019 stability assessment apparently neglected down flooding a key criteria when calculating vessel stability. Therefore staff believes that although the crew voted the scan, these rows per the stability instructions on board, the stability instructions were inaccurate.
[00:33:14] Therefore the vessel did not meet regulatory stability criteria and was more susceptible to capsizing because the festival did not meet regulatory criteria. The captain had little room for error in icing conditions that the vessel encountered on his voyage, the captain relied on and loaded his vessel in accordance with the stability instructions.
[00:33:43] Therefore staff believes because the stability instructions were inaccurate. The captain was unaware that his vessel did not meet the margin of safety intended to be provided by the stability instructions. The regulations governing stability for vessels that operate in waters, where there is a potential for icing, such as the scan, these rows factor in a minimum set amount of added weight.
[00:34:09] For accumulated ice and specify that ice accumulation should be applied symmetrically to exposed surfaces. The regulations do not specify specifically provide guidance on how to apply ice accumulation on crab pots, Naval architects from the coast guard and private industry agreed that per the regulations, they calculate the added weight of ice on a stack of crackpots by applying ice uniformally, to continue to the continuous, horizontal and vertical surfaces of the pot stack, like a shoe box of ice of the regulatory thickness placed over the stack.
[00:34:55] However, because crab pots are made of tubular frames in mesh. They do not act as continuous, horizontal or vertical surfaces and will accumulate ice not only on the vertical and horizontal frames, but on a bow on all external and internal mesh or webbing of the crab pots. Additionally, Mariners reported at freezing spray often results in ice asymmetrically, accumulating on the vessel and its pot stack.
[00:35:30] Therefore staff leaves that current regulatory guidelines on calculating the effects of icing on fishing vessels. Do not take into account how ice actually accumulates on and in crackpots and crowd pot stacks staff has proposed two recommendations to address this issue. Captains of commercial fishing vessels testified that they frequently consulted their vessels, stability instructions when operating, but when they are asked, if prior to the sinking of the Scandi is rose aware of the amount of accumulated ice, the regulations prescribed to be factored into their stability history directions, none new one.
[00:36:18] I learned that the regulations allotted for uniform icing of 1.3 inches on horizontal surfaces and 0.6, five of an inch on vertical surfaces. And only on the external surfaces of their pots, they’re all surprised on how little it was many even acknowledge that they would typically carry more ice than will then what was allotted for in regulations on the scanners rose the crew noted one inch of accumulated ice as early as six, the clock, the morning of the accident, but the captain likely not knowing the ice thickness used in his stability report did not voice concern when he relieved the watch at eight PacLock, nor later in the day, when the ice continued to build.
[00:37:08] And ultimately determined to delay sheltering or taking other mitigative actions. Therefore staff believes that a vessel captains are aware of the amount of icing that has factored into their stability instructions. They would be better prepared to make critical vessel safety decisions. When operating in areas of potential icing staff has proposed two recommendations in this area to address the issue.
[00:37:40] The regulations do not require that owners, masters or crew of commercial fishing vessels received formal stability training, and neither the majority owner, the captain nor the crew of the scanners rose had taken formal stability training Mirenas must rely on experience and what they have learned independently coast guard guidance indicates that operators should be provided training on stability schools and training facilities offer coast guard approved stability courses, specific to fishing vessels.
[00:38:20] The effects of icing being one of the topics covered several captains would voluntarily taken stability courses said that they took great value from them and suggested that they should be made mandatory for all captains. Therefore staff believes that the formal stability training would provide fishing vessel crews with a better understanding of the principles and regulatory basis of stability, including the effects of icing and staff proposes a reiteration of a currently open recommendation to address this issue as part of the post casualty investigation, investigations of both the fishing vessel destination, a similar vessel that sank and the Bering sea in 2007 and the scanners rose the coast guard Marine safety center conducted stability assessments and vessel stability instruction to review both vessels stability instructions had been created by qualified individuals, but were not subject to technical oversight or a view from a classification society or the coast guard.
[00:39:36] Ultimately the Marine safety center concluded that the stability instructions for both the destination and the scan, these rows fail to meet regulatory stability criteria. Therefore staff believes that an oversight program to review and audit stability instructions produced for uninspected commercial fishing vessels.
[00:40:03] Like the scanners road. That are not required to carry a load line certificate would identify and reduce potential errors in stability instructions, which in turn may reduce the chance that vessels are sample. That vessels are sailing without the intended margin of safety provided by applicable stability criteria.
[00:40:27] Staff has proposed a recommendation to address this issue. Personal locator beacons can provide search and rescue operations with an accurate, continuously updated location of every person carrying one. In the case of the scan, these rows, the failure of the emergency position indicating radio beacon to provide a position after crew members were forced to abandon the vessel into the water without means of communicating with search and rescue personnel and the inadvertent miscommunication of the correct search area from the on-scene rescue access staff believes that personal locator beacons would aid in search and rescue operations by providing continuously updated and correct coordinates of crew members, location and staff proposes a reiteration of a currently open recommendation to address this issue.
[00:41:33] Mr chairman, this completes staff’s presentations and we are prepared to answer any questions. Thank you very much for those, uh, very good presentations and, uh, most importantly, thank you for an excellent investigation. We’ll now turn to the board member questions and we’ll begin with vice chairman latch.
[00:41:54] Thank you. Uh, Mr. Chairman. Um, so I have a question for, uh, our meteorologist here. Um, is the, um, would you consider that the weather forecasting was accurate and the conditions that the Scandi rose encountered? Uh, the based on the forecast information and the information observed by the, uh, vessel captain, the wind and wave, uh, conditions were, uh, worse than that forecasts, how accurate are the, uh, are the freezing spray forecasts in this particular case?
[00:42:35] The forecast for was for heavy freezing spray, or greater than two centimeters per hour accumulation and staff believes that’s what the vessel was encountering, uh, on their Southwest word trip. So for a period of of time, um, could we perhaps bring up slide number 34? Um, I think that might clarify this a little.
[00:43:01] And while we’re working on that, if I remember correctly, it said, uh, that the vessel was, uh, uh, had about seven hours of moderate icing from about 10 o’clock until about 1700. And so that refers to the rate of accumulation. Do they have any way of measuring the cumulative effect? So if you stay in moderate long enough, you’re continuing to accumulate.
[00:43:31] And as, uh, uh, Mr. Barnum’s presentation has shown, uh, the stability instructions don’t account for anything, uh, anywhere near what the reality is. So do they account at all for if you’re in a moderate icing for a period of time, that it’s going to be the equivalent of a, uh, heavy icing, uh, for a shorter period.
[00:43:57] Is there any computation for that? Um, as far as computation and what’s available in the stability instructions, I’ll have to pass that off to, uh, investigator in charge, Mr. BARR Barnum. Yes. So the, um, as far as the forecast goes, not to my knowledge that there is a, uh, calculation, uh, that can be, um, used by the.
[00:44:22] Marriner to calculate the total icing that they will experience in that period that they’re going through that a band of IC. Um, I think it should be noted that icing will affect vessels differently depending on size, um, multitude of different factors, air temperature, uh, uh, ocean temperature, vessel heading.
[00:44:46] Um, so, um, for just to have a basic or a, uh, generic equation for adding up icy mint for a certain time period, I don’t think there is one available now. Um, it, it, yeah, it, I think this makes it pretty clear though, that we don’t at this juncture have a really full understanding of, of how this works. And as I said, we’re looking at the rate of accumulation versus the cumulative effect, uh, Mr.
[00:45:15] Suffering, um, does NWS have any way of very, um, uh, verifying their forecast? And I realized that we’re, we don’t have a lot of information up in that part of the world, but, uh, do Mariners submit the equivalent of pilot reports, um, when they’re, when they’re up there that actually get, not just talking to each other, but can get into the forecast offices.
[00:45:39] So currently the national weather service has a, uh, a program called the voluntary observing ship program or Voss. And, uh, there are certain ships, uh, that do provide observations, uh, based on that system, choose the national weather service forecast office. Uh, for example, the us coast guard cutter that came to the search area.
[00:46:03] It was one of the, uh, Voss ships. Um, so that is one of the programs that’s available for Mariners to submit observations. Well, it would seem to me that it it’s, it’s tough when you’re doing forecasting and looking at models. If you don’t have a way of verifying, whether it worked the way you thought it was going to, and to be able to, to modify them, um, it, it’s tough to, to get better forecast.
[00:46:28] So, uh, um, anyway, thank you very much. Thank you, Mr. Chairman, and I’ll wait for the next round.
[00:46:40] Sorry about that. I had some delays with one of my, uh, was the mic. Thanks very much, uh, to the staff and, uh, um, just a few questions on, uh, personal locator beacons, but first I’m wondering, uh, if you can describe the conditions, uh, that the two surviving crew members encountered. I know that they had remained on board for, uh, they stated as long as they could, uh, uh, yelling into the bridge for their fellow crew members to exit a wave, swept them off the side, they had their immersion suits on.
[00:47:25] But if you could talk about some of the conditions, uh, I, I believe for them that period of time that they were facing in the water. Yes. Ma’am um, conditions reported by both the surviving crew members. And then also the, um, arriving helicopter flight crew were about 30 foot waves, um, which was, you know, considerable wave Heights for that area.
[00:47:54] Uh, and then also, you know, um, four to six degree water, temperature Celsius, and, um, and then also there was, um, significant, um, wind velocity. Between 60 and 70 knots. And, um, how far, uh, how, how long was it until they were able to locate, uh, the rat, one of the rafts, the one they eventually boarded? Um, yes, ma’am the, um, the survivors indicated that, um, that came to before he was able to locate the first raft users in the water between 10 and 20 minutes, I believe.
[00:48:38] And, uh, their immersions suits are tested for how many degrees in I and water and for how long, um, regulate. Yes, ma’am the regulations require that, uh, vessels such as scanners, rows, carry immersion suits that are designed to keep the, the, where, um, their core body temperature from dropping two degrees, both that’s two degrees Celsius over a six hour period, um, in tutory water.
[00:49:15] So those that they had on board would have been rated for that two degrees in calm water. Yes ma’am. And this was definitely not calm water. Uh, and so the HELOC, they, they were rescued about four hours later, correct. From one, they were swept off the vessel. Okay. And can you talk about how difficult it is for search and rescue operations in these, in such a remote area?
[00:49:51] Yes, ma’am. So areas like Alaska, where it’s a large, um, area of potential large area, they need to cover, uh, it’s extremely difficult to try to strategically place assets, um, where they can be most effective where the fishing fleets are in this particular instance. Um, air station Kodiak is a major, um, base there where they launch assets out of with the weather conditions that were forecasted.
[00:50:21] Um, they have limitations on what type of aircraft can leave air station Kodiak. So strategically they move their C1, 30 airplanes to anchors Alaska. So they would be able to be, they would be able to take off and assist in any search and rescue that was needed because they would be grounded in that type of weather while in Kodiak.
[00:50:41] Um, so obviously to answer your question, ma’am, uh, weather in this area is a huge factor as well. Um, it can, can affect their communications significantly and also their ability to search. And there was heavy icing in that area. Yes. Ma’am. Um, have you guys seen, was experienced obviously on board, the scan, these rows, um, but also the flight crew of the rescue helicopter that arrived on scene, um, while they deployed their rescue swimmer, once they retrieved him from the water, uh, he was, he had to be diced because the isolate accumulated on his body and has space gear.
[00:51:22] Well, I, I have to say I have a lot of respect for, um, uh, the coast guard. I, uh, I had spent some time in April, 2019, uh, in Kodiak at air station Kodiak and in Anchorage, uh, for a number of days with the coast guard. And, um, they do a tremendous job. Uh, that’s very difficult and, um, uh, thank them for their work.
[00:51:52] I will have additional questions about this in the next round. Thanks so much.
[00:52:01] Thank you, Mr. Chairman. Uh, four, I began, uh, with question, I would just want to, um, add to what the chairman said a few minutes ago in his opening statement. That knowledge, why the NTSB has revitalized its focus on commercial fishing safety with its inclusion on the 20 21, 20 22 most wanted list in this capsizing coming to a public board.
[00:52:25] Commercial fishing is one of the most dangerous occupations in the United States. Every year, more than 40 lives are lost the center for disease control estimates, a fatality rate, 35 times that of all us workers for an industry that supports more than 700,000 jobs and contributes more than $50 billion to the economy.
[00:52:50] These workers deserve better. We must do more to protect those who have been risking their lives to feed all of us. Have a few questions for our meteorologist Mr. Suffern, the, uh, national weather service has two main categories of alerts for freezing spray, heavy freezing, spray warning, and freezing spray advisory.
[00:53:12] Mr Sufran, can you explain the difference between the two? So you’re, you’re a crack. There are two, uh, different levels. Um, the first being a freezing spray advisory where, um, freezing spray accumulation is predicted to be between zero and two centimeters per hour, and then heavy freezing spray warning is for two centimeters an hour and above ICQ.
[00:53:38] Right? So based on their weather conditions during the last two hours of the accident voyage, what was the estimated ice accumulation? So based on the observed conditions provided, uh, uh, relayed by the accident captain, uh, to his fellow captain, the 60 to 70 knots would equate to extreme freezing spray conditions, which would be four centimeters per hour and above.
[00:54:04] And the weather service doesn’t have a, a advisory for that or a warning for that. Is that correct? The heavy freezing spray advisory being two centimeters and above would include four centimeters and above it doesn’t have an extreme one. So can you please discuss why the estimated icing rate and the final two hours of the Boyage would be described as extreme icing based on the model that they use?
[00:54:29] The open-ended. So currently the national weather service for forecasting freezing spray uses, uh, scientific equations and guidelines, uh, produced by Overland, uh, in the late eighties and early nineties. And that basically takes into account, uh, air temperature, uh, water, temperature, um, wind speed, and, um, the freezing point of, uh, salt water.
[00:54:57] And, uh, through some math can calculate and estimate, um, light, moderate, heavy, and extreme, uh, freezing spray for those calculations. Great. So currently, how can a Mariner know whether he or she will encounter heavy freezing, spray, or extreme threes? When the national weather service issues, a, a heavy freezing spray warning that would include both heavy freezing, spray and extreme, uh, freezing spray conditions.
[00:55:28] In addition, the national weather service has an experimental ocean prediction center, uh, graphical website, which provides, uh, a lot more categories for freezing spray conditions above two centimeters per hour. Okay, so the, uh, the ocean prediction centers, uh, experimental icing website attempts to fix this problem and provide localized, freezing spray information.
[00:55:53] I take it, it provides a graphical representation of, uh, the, the freezing spray categories that could be experienced by Mariners throughout, uh, the Bering sea, uh, Gulf of Alaska. And, um, and that portion of, uh, of the United, it’s my understanding that this website’s not, uh, available to the Mariners at this time.
[00:56:16] And do we have a proposal in, uh, the, uh, draft recommend or do we have a draft recommendation to the national war weather service to make an operation? So currently the website is experimental and has been. So since 2014, what that pertains to is that while the website is available, um, anyone can, can get on the URL and click on that particular website and view the information, um, being experimental.
[00:56:50] If the website were to go down for some reason, uh, it would, um, take, uh, someone noticing or, or additional it resources to bring it back up while making that website operational, which staff has, has recommended to this report would provide a much more robust website as well as potentially, uh, leading to more, um, opportunities for individuals, including Mariners to, to view the information on the website and make it more accessible to Mariners.
[00:57:20] Okay. Thank you, Mr. . I see my time is up. Thank you, Mr. Chairman. Thank you. You’re welcome. And member Chapman. Thank you, Mr. Chairman, the circumstances of this accident are those tragic and they’re frightened. I joined and expressing condolences to the surviving crew and those who lost loved ones in this accident, the draft report notes, and my colleagues have highlighted that the NTSP is current most wanted list appropriately includes the issue area, improved passenger and fishing vessel safety fishing consistently tops the list, the most deadly occupations, and this accident underscores the reasons for our focus on commercial fishing and the context of the most wanted list.
[00:58:09] All of us, the NTSB Sharon interest in doing what we can to help improve that safety record. The scam. These rows was required to have stability instructions completed by what the relevant coast guard regulations refer to as a qualified individual. The term qualified individual is defined within the regulations.
[00:58:32] I understand those who fall into this category are most often practicing Naval architects. What qualifications must an individual meet or possess in order to practice as a Naval architect? And are those qualifications regulated on the state level or the federal level? Yes, sir. The regulations will define qual or due to find qualified individual.
[00:58:58] Like you said, uh, as someone that, uh, has formal training and experience, uh, completing. Naval architectural calculations in this particular accident, the Naval architect who completed the stability instructions was a licensed professional engineer in the state of Alaska. Okay. So those are state level qualifications that have to be met and there’s no, there’s, there’s no specific requirement at the federal level.
[00:59:29] Is that correct? That is correct. Other than what’s defining regulation, right. Okay. Okay. Have the draft report highlights that there was no requirement for the scan, these rows, stability and stability instructions to be reviewed. And we’ll discuss a recommendation, which I support by the way, which will be a offering to the coast guard that it developed an oversight program to review the stability instructions of commercial fishing festivals in the category of the scan, these rows under the existing regulatory structure, what would trigger a review of stability instructions for a larger commission?
[01:00:07] Uh, I’m sorry, for a larger commercial fishing Bestival vessel. I’m sorry. I understand that those larger vessels are subject to review. What would trigger that review? Well serve. I believe the class of vessel you’re referring to is potentially a, a fishing vessel, a modern one that maybe is required to carry a load line certificate.
[01:00:29] Um, load lines. Ficket load line is not only a physical mark on the vessel that denotes safe loading, but it also is a classification that, uh, structured around the structural design, construction and maintenance of the vessel, the additional oversight. So vessel of that class required to clear a little vine certificate.
[01:00:51] Um, there’s the building instructions are going to be reviewed by classification society. Most often the American bureau shipping shipping, um, that, that, that oversight is, is, is then done again, uh, the, by the coast guard who oversees the abs in a random, randomly audited, uh, method where they will periodically check, uh, spilling instructions for those vessels.
[01:01:18] Okay. Thank you. Okay. That’s helpful. So for larger, larger vessels is the process for developing those stability instructions, essentially the same. That is our stability instructions developed by a so-called qualified individual. And I understand that that they’re subject to further review, but the process for developing those instructions is essentially the same.
[01:01:41] Is that correct? That is correct. Thank you, Mr. Chairman, I may have some additional questions on this.
[01:01:50] Remember, Chapman, thank you very much.
[01:01:56] Numbers Chapman. I remember Graham, uh, some of the figures from NIOSH, which is a part of the centers for disease control. NIOSH is the national Institute for occupational safety and health. And the figures provided by their expert. One of their experts in the fishing industry, uh, Samantha Case, uh, pointed out that commercial fishing for, for the year 2019, which this, this tragedy, the occurred in 2019 with just just two hours to go before the new year.
[01:02:29] But commercial Vish, commercial fishing in 2019, wasn’t just one of the most deadly occupations in America. It was the most deadly occupation in America. Surpassing what is typically number one, and that is logging, uh, this boy in the rate of fatalities, the rate per 100,000 workers in the industry, uh, commercial fishing, uh, it fatality rate of 140 500 per 100,000 full-time employees compare that to.
[01:03:08] The average of all workers, which is 3.5 fatalities per 100,000. So it is, uh, uh, there’s a lot of need for improvement in this area. The NTSB charity, uh, hosted a two-day three-day forum on commercial fishing vessel safety in 2010, uh, and more needs to be done in this area. And that’s why it’s on the most wanted.
[01:03:32] Plus, um, as I did say during the most wanted list board meeting, uh, sir, Walter Scott said nearly 200 years ago, it’s not fish that you’re buying it’s men’s lives. And, uh, and I think that those figures that I just mentioned highlights, uh, that we are really, um, buying men’s lives when we go out and buy fish, because it is such a deadly industry.
[01:04:02] It is truly the deadliest catch. Um, so I do want to thank staff for a good investigator. Um, I think that, um, um, the coast guard Marine board, uh, did not complete, uh, did not get their, uh, Marine board, uh, completed until March of this year. So the accident happened on the last day of 2000, 19 six weeks later, we entered into a pandemic actually that was two months and 11 days later, we entered, entered into a pandemic that we are still officially an and then the coast guard did their Marine board.
[01:04:43] So we weren’t able to actually get a lot done on this until the Marine board completed. And so I want to point out that even though the accident was a year and a half ago, the bulk of staff’s investigative work, um, had to be done in the last three months. So thank you for your good work. A question for you, Mr.
[01:05:04] Barnum. And that is, is that was the captain’s decision to set sail under those conditions and the conditions of national weather service, Gale warning, and a heavy freezing spray advisory was the captain’s decision to set sail under those forecast conditions. Was that a reasonable decision?
[01:05:30] Yes, sir. The, uh, staff believes that it was, um, foul weather in that part of the world is commonplace. Um, it’s, uh, something they encounter almost on a daily basis. Um, What is no normal occurrence, normal, um, procedure when encountering, foul, whether it’s to seek shelter, there’s a variety of places along the, along the plant route there that the vessel could have potentially sought shelter.
[01:05:58] The captain was also, um, comfortable with his vessel. Uh, he loaded the vessel in accordance with his instill, uh, new stability instructions that he had on board. Uh, he’d been sailing that vessel for, um, a little over eight years as captain and Ben in similar situations, uh, with pots on deck and it come out.
[01:06:18] Um, unscaved um, in addition also there was other vessels leaving at the same time. He wasn’t the only one leaving. So ultimately staff believe that his decision to leave, uh, was acceptable. Right. I think that’s a very important finding right there that you’re proposing. So I just wanted to establish that.
[01:06:37] So, um, we’ll now proceed to the next round of questions, uh, chairman Landsberg. Uh, thank you, Mr. Chairman. I’d like to follow up on that line of questioning. Um, so if I understood you correctly, Mr. Barnum, you’re saying that the fishing crews typically launch, uh, in, in forecast conditions like this, is, is that a fair assumption?
[01:07:03] Yes, sir. It is. Um, okay. And if the conditions become worse than forecast, um, there were, there are safe zones that they can go to. Is that correct, sir, as, as described by, uh, fishermen that have frequent those areas, um, in interviews, they indicated that yes, there is various locations where a vessel of that size can seek shelter.
[01:07:31] Were there any safe zones along the route prior to, uh, set with island? So, um, and this, this seems to things got rather rapidly worse, uh, along the way. Um, what would the, would there have been another place where the captain could have diverted to a prior to trying to reach that way? I mean, you said that he was familiar with that, but I’m just wondering if there were other places in, are they marked on the chart or is this sort of, um, uh, just known by the locals that this is where you go?
[01:08:09] Uh, yes, sir. There was, uh, from what we are told, uh, places along the Southern side of the Alaskan peninsula between, uh, the west coast, Kodiak and Celadon, where he could have a soft shelter. Um, so had he even an hour or two prior. You could have sought shelter. Uh, am I correct in understanding that if the captain of the vessel had, um, reason where he, where he thought that they would need to seek shelter at that moment?
[01:08:46] Um, potentially there was some locations he could have sought shelter prior to stop what guests. And it seems like, uh, and it became very clear to me as we looked at this, that the wind was simultaneously helping while, uh, creating the ice on the starboard side, it was also helping to prop up the vessel.
[01:09:11] Do I understand that correctly? Yes, sir. That’s what staff believes as the vessel continued along its Southwest or the course, uh, the prevailing wind and waves were acting on the starboard side of the vessel, as you say, essentially propping up the vessel. So when he made the turn, obviously he lost the stabilizing effect of the wind and now the weight becomes predominant.
[01:09:40] Am I understanding that correctly? Yes, sir. That is correct. Okay. And so ultimately what we get to is that the, um, um, stability instructions don’t really take much of that into account. Am. Am I correct in understanding that? Or is that incorrect? Yes, sir. Partially. I mean, the stability instructions, the stability criteria, which there they are created from are designed to provide an adequate level of safety for vessels that are operated prudently.
[01:10:20] It does this through, um, including a safety margin that safety margin that’s calculated into them, um, takes into account certain aspects such as wind and roll water on deck in this case, I seem, um, so there is some level of safety margin built into them, but to the degree that the skinnies rose encountered it wouldn’t have been nearly that, that much.
[01:10:47] So the margins under these conditions are not sufficient. Well, sorry, I leave, um, you know, first that as we’ve recommended this report, this draft report that, uh, a study needs to be completed so we can, so the fine is this best study can be analyzed and then incorporated into regulations in the future.
[01:11:11] We needed to know how exactly these eyespots ice and how they will affect the vessel stability once that’s done. I think we can more accurately see if the regulations are inadequate. Understand. Thank you. Uh, thank you, Mr. Chairman. Uh, appreciate the opportunity.
[01:11:35] Thanks very much. Uh, okay, so we have a 30 foot. See, I just want to pick up from where I left off. We have 30 foot seas, 56 to 60, uh, a mile per hour wind gusts. And, um, can you tell me how far they drifted from the vessel where the vessels tank, the two surviving crew members? Uh, yes, ma’am. I, I know that information is contained on some of the information on the doc docket, but off the top of my head, I don’t know exactly how far they tripped him.
[01:12:10] That’s okay. I mean, but we do know that they were on, uh, the, the raft for four hours until they were rescued. So it must’ve been some, some distance at, at some point and the helicopter or at least the coast guard had some difficulty locating them because at some point the lights went off on the raft pretty early.
[01:12:34] They had found, I think, an hour in their emergency kit and there was a flashlight and I believe they waved down the helicopter with the flashlight. Correct. That is correct. Ma’am so, uh, when you have a situation like this, what could have helped, uh, locate the surviving crew members more quickly? Uh, yes.
[01:13:02] Ma’am. So obviously staff believes that, you know, the search ref rescue was obviously effective and that the rescue, these two survivors, um, there was, um, some question in that because the perp did not broadcast a receivable signal. And as mentioned earlier, there was some confusion with, uh, communication coordinates passed.
[01:13:26] An error staff believes that personal locator, beacons, if worn and if, uh, obtained or if had by the crew of the vessel would help a search and rescue operations more accurately pinpoint their location. And so the difference between an , which would have said, which would have, uh, uh, indicated the location of the vessel, uh, had it activated, uh, the difference there is personal locator, beacons, if provided to the crew would have been with each individual, correct.
[01:14:03] Uh, yes. Ma’am that the crew is trained to, um, if they need to abandon the vessel or if there’s a disaster like that, to take the paper with them. So, or it’s designed to flow free. So the port might necessarily not be with the, with the vessel. Okay. Yes, you correct. The POV’s are designed to be worn on the criminal.
[01:14:23] Great. And so have we, and maybe this might be where Mr. Rainey comes up and talks about previous recommendations on personal locator beacon, that beacons that we’ve issued. Certainly remember how many we issued a M 1745 out, um, out of the El farro accident, uh, recommending that personnel employed on bustles and coastal great lakes and oceans service, uh, be provided with personal locator beacon.
[01:14:54] Status of that is currently open, unacceptable a response. The coast guard responded in 2018 that, uh, they felt that at the time the technology did not provide the requisite location accuracy for the purpose. Uh, they are continuing to look into the technologies, working with, uh, ISO and in our TCM, we, we disagreed with that and thereby classified it open.
[01:15:23] And what did we, why did we disagree? We felt that, um, the, the accuracy on the PLB is, was sufficient to provide a useful tool for searching. It’s very hard to find a person in the water. Um, and, and as you point out in the, in these, um, you know, sea states and weather conditions that the, um, the satellite capability, the PLB, plus some local home homing capabilities that we felt that it would be a useful tool.
[01:15:51] So we, we didn’t agree with the coast guard position at the time, but we do know that they are looking into the technology. And then in Alfaro, three days after the sinking search crews spotted the remains of a crew member in an emergent immersion suit, it is unknown when the crew member perish, but if their immersion suit had a working personal locator, be again attached to it with a, could they have been located sooner.
[01:16:19] And we found in an, another investigate or at least in another investigation, uh, personal locator beacons may have aided search efforts in Trinity too in 2011. And that investigation, the crew had to abandon ship and the master was not able to grab the perv. The 10 crew members abandoned the vessel and were not found for three days and only six survived.
[01:16:42] If the lifesaving equipment had included a personal locator beacon, could the, uh, search team team maybe have, uh, found the crews sooner than three days? I think that’s certainly possible. We would. That was the lift boat accident. Yes. This is a recommendation included in our most wanted list, uh, of transportation safety, safety improvements.
[01:17:09] Thanks very much. Sorry. Thank you. And now thank you, Mr. Chairman. I was just looking here at the, uh, stability instructions and instructions to the master. And, uh, I’m amazed that nowhere on it, does it discuss how much ice can accumulate on the deck and on the pot stacks? I that’s just amazing as a, as a master, I would think that kind of information would be most important to you for the safety of the vessel.
[01:17:39] And I definitely support the proposed recommendation of including the icing amounts use to calculate the stability criteria. Um, I have some questions on the stability instructions. What is a load line certificate? Uh, yes, sir. So as I mentioned earlier, uh, load line of the vessel, it is a higher degree of oversight of the vessel and name in regards to its construction and its maintenance, uh, large, newer fishing vessels built after, um, July, 2013, uh, are required to have a load line certificate, basically ensuring that they meet those higher standards and they’re built to, uh, to, uh, uh, not only the standards, but also are, um, inspected periodically.
[01:18:30] They’re hauled out of the water periodically that they’re hollows. Okay. So if, if the Scandi is rose was built after, what is it? July of 2013, uh, this size, it would have required a load line certificate, correct. Okay. Would a load line certificate D is in your opinion, would have helped the Scandi is rose captain better understand his stability requirements and its limitations?
[01:18:59] I don’t necessarily think, I don’t necessarily think that it would be accurate. I do believe that his stability instructions would have, have had more oversight and therefore would have been, uh, potentially been accurate. And, um, and he wouldn’t have left court as he did here with inaccurate ones. Okay.
[01:19:19] Thank you for that. Um, I’m going to switch to a stability training. I know back in 2010, the NTSB held a fishing vessel safety forum and discuss the issue of training fishing vessel crews on vessel stability. Um, about a year later in 2011, it, um, that led to the NTSB issuing safety recommendation am 11 dash 24, addressing fishing vessels stability training to the coast guard.
[01:19:47] And I’ll read it here, require all owners, masters, and chief engineers of commercial fishing industry vessels to receive training and demonstrate competency in vessel stability, watertight integrity, subdivision, and the use of vessel stability, infer mega information, regardless of plans for implementing the other training provisions of the 2010 coast guard authorization act.
[01:20:10] Uh, what is the status of this recommendation? Sir, please mammogram. The status is currently open, unacceptable. And as you mentioned, we, we have, uh, associated that with our current, most wanted list. Um, the coast guards last response was in, um, October of 2016, uh, letting us know that, uh, they are working with their federal advisory committee to develop a curriculum.
[01:20:40] Okay. So this, this recommendation has been out for 10 years and we haven’t heard anything in almost five years from an advisory committee. Yes. Okay. And, uh, and we’ve lost, or at least we’ve been investigated to a commercial major convention, commercial fishing vessel accidents since then. That’s correct?
[01:21:02] Yes, sir. Okay. Thank you for that. I’d like to see the coast guard act on this a little quicker, and I, I see we’re going to highlight that in our reiteration recommendation. So I thank you for that. And, uh, I yield back the rest of my time, Mr. Chairman. Thank you very much.
[01:21:25] Thank you, Mr. Chairman, a couple of questions about weather resources. Uh, obviously extreme weather conditions were a factor and I gather the accident site is known to be prone to difficult weather, including certainly. Yet the investigation revealed that the surface and the buoy station, I’m sorry, the surface and buoy stations nearest to the accident site where 95 and 125 miles away.
[01:21:51] Respectively, is it realistic to expect accurate Marine weather forecasting with such limited and widely dispersed surface observations based on the weather conditions that were experienced and the, um, the, the wind funneling through the terrain, uh, phenomenon typically, uh, discussed as Willy was in that area.
[01:22:15] Um, you’d have to have the surface observation resources to be able to be knowledgeable that, and, and, and the locations the observations are right now, they do not reflect, uh, the Willard walk conditions and the, and the conditions at the time of the accident while they were certainly on the extreme end.
[01:22:35] Not really unusual for that area. Is that correct? Um, based on the Mariner feedback, um, at a Marine board of investigation, they all described the weather conditions at the worst weather conditions that they experience were in the salt, WIC and Technica bay area. Do we know whether Noah or the national weather service have previously sought funding or whether they otherwise plan to increase surface, observation and resources in the area?
[01:23:06] Uh, as currently. And do we have a sense of what an optimal array or do you have an opinion about what an optimal array of observation resources might look like in that area? The observational resources to be able to capture the more extreme wind conditions, uh, especially on the higher end cases, such as this accident or other cases where you get a wind conditions that are, uh, basically hurricane force winds, uh, having the observation of resources to be able to not only let forecasters know those conditions are happening, but also, uh, highlight that to the mayor and our community would be a value.
[01:23:48] In addition, it would go into the weather computer model data, which would further make forecast, uh, conditions, more accurate, certainly need observation sites that are closer or more, more frequent than 95 and 125 miles away. It seems to me, um, there are few regions in the world where, uh, that are more dependent, uh, as you know, on Marine and aviation transportation than Alaska.
[01:24:20] In terms of Marine, it seems clear that weather observation resources are inadequate in the area. Encompassing the accident site. Are there similar gaps in resources necessary for aviation forecasts? Um, that particular, uh, line was not, um, um, discuss through this investigation. Oh, okay. I understand. Um, certainly I would, I would encourage Noah and, and NWS to take a look at that as well.
[01:24:50] It does appear that we’ve got some gaps here and that’s, uh, it’s, it’s an important area in terms of Marine and aviation. And, uh, it’s an area, obviously that’s subject to, uh, very difficult weather conditions. Mr. Chairman. I’m going to hold the remainder of my questions for the next round. Thank you. Thank you, member Chapman.
[01:25:10] I know that we’ve mentioned bits and pieces of the search and rescue effort. Um, but I think it’s worth noting a little bit more of it. Um, the coast guard is, uh, is an agency that some of us don’t think too much about until we see them rescuing people, plucking people off of roofs of homes during hurricanes and, uh, and extraordinary rescue efforts like this one.
[01:25:36] Um, the pilot, one of the pilots of the helicopter, uh, said it was the most challenging flight of his career to turbulence was so severe that it took both pilots, uh, to help keep the helicopter straight and level. There were severe turbulence. There was down drafts as a member Hamadie already pointed out.
[01:25:56] There were 30 foot seas. Helicopter was low on fuels. So they had to, uh, turn off the APU, uh, which turned off the heater inside the, uh, the helicopter once they were taking the, uh, the surviving two crew members back, uh, this was an incredible rescue. I think a lot of people don’t realize how remote parts of, uh, uh, Alaska can be.
[01:26:22] Can, can you, uh, elaborate, uh, Mr. Barnum, just a little bit more about the search and rescue efforts, those extraordinary efforts. Yes, yes, sir. I believe you put it extremely well there. Um, the, uh, when the coast guard was notified, uh, the search and rescue operation was gonna take place. They, uh, began to, uh, get preparations ready, um, because of the severe weather, uh, additional flight planning was required.
[01:26:52] Um, they needed to make sure that flying out there, they would be able to get back or get to another suitable location where they could take fuel and transport, any survivors. Um, but after doing that, they also had to, uh, throw in additional fuel on bullet the helicopter. Um, they traditionally don’t carry a full tank of fuel, uh, on board.
[01:27:12] So they, they had to fill, fill up on fuel. They also, after the helicopter left, they launched a C one 30 aircraft from Anchorage, Alaska that was acted as a overflight and was able to. Transfer communications from the helicopter, because it was low in flying at such low altitudes. Uh, any voice communication from the helicopter, wasn’t able to make it back to the base.
[01:27:37] So the, the overflight would, uh, would act as a communications platform. Yeah. Thank you very much. I want to switch now to stability because I think that’s certainly a central area of this, of this tragedy during the U S coast guard testing, uh, of where they sprayed, um, water, cold water on, uh, on grandpa during a test.
[01:28:06] Think they sprayed water on grandpa for like 72 hours. Uh, how much did the weight increase of that one pot? Yes, sir. I’m referring to the, uh, uh, preliminary kind of experiment on the polar star where they sprayed a crab pot with a freshwater for three-day period. The, um, the weight wasn’t accurately able to be determined because the load cell that they were using, uh, was maxed out and maxed out at 3000 pounds.
[01:28:38] Um, the gaining weight of the crab pot was roughly 1000 pounds. Yeah. So, so it, it more than tripled the. The regulatory requirements for stability calculations. Assume I think it’s a, I think it’s 1.3 inches of surface hard surface ice on the horror, horizontal surfaces and about points to six, five of an inch on the vertical set, um, surfaces.
[01:29:04] How realistic are those assumptions, sir, from what we experienced talking to captains and people familiar Naval architecture industry, uh, that deal with these types of vessels, aren’t often those, uh, assumptions. Weren’t very realistic. Yeah. And, uh, and in fact how much I did our investigative staff, uh, estimate was on the grandpa of Scandi is rose sure.
[01:29:38] Staff estimated to be between six and 15 inches of height between six and 15 inches. Um, yeah, so certainly I have more questions. We’re going to take a break before we take a break. I would like to encourage all participants to turn off their cameras and their microphones. And we’ll take a 10 minute break.
[01:30:00] We will reconvene at 1115, which is really about nine minutes from now. We are in recess.
[01:30:15] Okay. We’re back in session. And we will resume with questions from the board members as chairman Landsberg, Bruce, you may be muted. So I am, uh, if I could ask that we bring up a slide 39, please, but try to think we’ll, um, kind of illustrate all of the things that, uh, um, probably need to be covered here.
[01:30:41] And, and now I look at it, what, and I give all of my colleagues, uh, uh, accolades for, um, covering all of these points rather well, but you know, this illustrates, uh, this was, uh, a vessel that almost. Got into the same problem that the scan use roasted. Um, I think what we’ve seen is that even though we routinely operate in these environments, uh, we have rather badly underestimated, uh, the weather conditions, uh, that, and some of the requirements that we should have, um, we see that the national weather service doesn’t have the ability to accurately forecast or, or to model.
[01:31:26] And there are, uh, relatively easy fixes for that. What’s more observation points. We’ve seen that the stability instructions and regulations are not, uh, sufficient nor realistic. Uh, the chairman has pointed that out as have some of my other colleagues. Um, we’ve seen that, uh, personal locator beacons really are essential because a crew members can easily under these conditions be separated from the vessels.
[01:31:56] Uh and, uh, they, they do work rather well. I carry one, uh, when I, um, uh, sail or fly, I think, uh, the industry, uh, has operated under these environments and this sort of. Tribal wisdom, I guess that, um, you know, it’s going to be bad out there and y’all be careful. And after years of training, um, or I should say experience, not training, but experience, you kind of learn how to, how to deal with this.
[01:32:27] And in almost every case, we’ve overestimated our abilities to cope with some of the extreme conditions. And so I think if, uh, when we get to the recommendations, I’m really looking forward to hearing, uh, hearing that, because I think that can go a long way to stopping this from being the most deadly catch.
[01:32:48] So with that, Mr. Chairman, I have no further questions and thank you.
[01:32:58] Thank you. Uh, Mr. Barnum, can you, uh, talk about how much a personal locator beacon is roughly. Yes, ma’am, um, we’ve found that roughly $300 will buy a GPS equipped personal located. Okay, great. Uh, and I, I have a couple of questions. Well, at least one question that I always like to ask, uh, our director of safety recommendations and communications, Ms.
[01:33:28] Hatchet, um, about, uh, what happens after a board meeting with our recommendations. Once we adopt recommendations from my standpoint for board members and for the board in general, this is the first step in the process for, uh, bringing about change. So can you talk about, um, Ms. Hatchet, uh, what happens after the board meeting with our recommendations, certainly member hominy, uh, thank you for the question.
[01:34:01] Um, NTSB recommendations can prevent future accidents and save lives only if they’re acted upon. Otherwise. They’re just words on a piece of paper. So after the board meeting concludes our work continues and my office, the office of safety recommendations or SRC, as we like to call ourselves, we track and evaluate the responses to every NTSB recommendations that we issue to recipients.
[01:34:28] And we work with the board and the staff. To make sure that we keep the pressure on to close these recommendations, because it’s important for all the reasons that we’ve talked about here today. Um, we record the responses to the recommendations we issue. We track them. Um, of course we talked to Congress, um, we we’ll be speaking to them about the issues, um, and our recommendations, um, today.
[01:34:51] And we evaluate each response that we receive from our recipients to determine they’re not, you’re actually acting upon our recommendations. Um, as part of that, um, we manage the agency’s most wanted list. And I just want to pause there for a moment to explain why it’s important for us to elevate these issues.
[01:35:13] Um, as demonstrated by the scan, these rooms, this is an accident contract. Imagine that could have been prevented, proven fishing vessel safety is included on the most wines, that list to bring a tea attention to the safety issue. We most want action on, um, to amplify these issues and underscore our safety recommendations.
[01:35:33] I do want to point out that we are working with the office of Marine safety, who is planning for an October round table to make sure that our issues, our recommendations remain on the forefront and we keep pushing for the closure of those. So these are some of the things that the safety officer’s safety recommendation does to work with all of you to ensure that we cleat these issues on the forefront, uh, included in the dialogue of, uh, what we need to see happen so that we could prevent these accidents from occurring in the future.
[01:36:08] And I th I think, you know, I really appreciated what you said about the most wanted list, because if every once in awhile, I hear, why do you have a most wanted list? Uh, w you know, why bother with a list? And I think, you know, when, when we issue recommendations over and over again, to prevent tragedies, either to prevent the tragedy itself or prevent the loss of life, and I’m thinking, you know, personal locator, beacons right now, where we’ve issued recommendations in the past after Alfaro, um, we don’t have other, I mean, we do have dialogue ongoing with the coast guard, but this is one.
[01:36:50] Really great tool, the most wanted list. Keep that issue in the forefront to, to draw attention to the fact that we have issued this recommendation, these recommendations previously, and we need action to save lives. And this is a tool that allows that to happen, which is why we have a most wanted list. So I really appreciate, uh, you talking about that and I appreciate all the work of your staff and of course, uh, uh, our offices, our modal offices as well.
[01:37:23] So thanks very much. And that concludes my questions.
[01:37:28] Thank you. And, uh, uh, so we’ll now go to Michael Graham number grant. Uh, thank you, Mr. Chairman. I actually have no further questions member traveling. Thank you, Mr. Chairman, and I’ll be quick, uh, a quick clarifying question for Mr. Barnum. This is with respect to load lines certificates, and the requirement that, uh, the vehicle, um, uh, have one issued, uh, is that determined?
[01:37:59] Is that requirement determined by the size of the vessel, the date of manufacture, or is that a function of, of those of those considerations? Yes. Thank you, sir. For that clarification. Yes. It’s the function of the size vessel needs to be 79 feet or more, and the date of construction. Okay. All right. Thank you.
[01:38:18] Um, and a couple of questions, uh, uh, about personal locator, beacons, um, where as, as has been mentioned, we’re going to re reiterate a recommendation to the coast guard today, calling for our requirement that all, uh, personnel on certain commercial vessels be provided with a personal locator beacon. These appear to be relatively unintrusive devices.
[01:38:43] Um, I understand that they’re off the shelf. You mentioned previously the, the, the cost seemed they’re not inexpensive, but they’re relatively affordable. Is there any resistance on the part of crew to wearing PLTs?
[01:39:02] I believe that whenever there’s a new technology out like this, there’s, there’s both sides of the coin. Um, I think traditionally, when crews are required to wear this working on deck, they might see some issues with, with, uh, hitting, uh, as they’re loading, uh, some line that the crab pot or they’re doing some other function on deck, but ultimately from what we’ve heard from industry is that they’ve embraced them.
[01:39:28] And many people voluntarily have. So maybe a little bit of work to be done here in terms of educating, uh, the community of folks that are working on board these vessels, but, uh, generally easy to obtain affordable, relatively unobtrusive, and certainly the benefit, um, uh, outweighs, uh, any, any potential inconvenience in terms of wearing them.
[01:39:55] Uh, and a question I think this one really is, is for Mr. Chirael. Um, and this’ll be my last question, Mr. Chairman. Uh, my understanding is while we’re focusing today, of course, on the specifics of this tragedy, I understand that our office of Marine safety intends to develop a safety recommendation report, addressing broader issues associated with fishing vessel safety.
[01:40:19] Are you able to share additional details regarding the scope and objectives of that work? Uh, yes. Thank you. You remember Chapman? Uh, the officer Marine safety will be developing a safety recommendation report drawing from previous accidents. We’ve investigated, including the scan, these rows, the destination, and perhaps a half a dozen briefs we’ve done, uh, since 2012 each year.
[01:40:45] Uh, so there’s several dozen accents we’re looking at. Other report will include an analysis of accident. Data, many incidents that are investigated by the coast guard are below the threshold for the NTSB to investigate. So we’ll look at all fishing vessel incidents, not just, uh, majoring accidents, majoring, uh, casualties.
[01:41:06] So we’ll summarize the previous accident briefs. We’ll find a look for safety gaps and proposed safety recommendations to, uh, perhaps close some of those gaps and improve safety. Thank you very much forward to that. Congratulations to you and all of your team for an outstanding job on this investigation.
[01:41:26] Thank you, Mr. Chairman. That’s my last question and we’re Chapman. Thank you very much. That’s good. Barnum did, uh, did the 2019 stability assessment accurately model all of the decks on board, the closure on boards as candies rose, one sort of one point, uh, that was neglected on this, uh, 2019 spilling instructions was the worthy down flooding points of the vessel.
[01:41:54] Yeah. And did it properly model they poop deck and the fascial area of the boat. Based off the MSCs technical forensic analysis of the stability instructions. No, sir. It did not accurately model those two structures. Thank you. What are the, you mentioned mathematical errors in your opening presentation.
[01:42:16] What other error, errors or missions, uh, did, uh, did staff note in the 2019 stability assessment? So as previously met, previously mentioned, uh, the instruction neglected down flooding, which is a major criteria under Carmi vessel’s stability. Um, other more specific mathematical error errors. I can’t readily cite here, but are mentioned in the MSC report.
[01:42:45] Yeah. Thanks. Here’s the here’s the ironic thing is that after the destination, uh, Marine casualty, uh, the owners of Scandia rose, uh, decided to update their stability instructions and what they got was probably not what they paid for. Um, you know, they were trying to do the right things and, uh, there were errors and omissions in that report.
[01:43:14] And I think that’s a major point of this entire report. Um, Mr. Stolzenberg, you are a Naval architect. Uh, what does it take to be an, a Naval architect chairman. Typically it involves a, a four year program at a university, many folks go on to get a master’s some get doctorates. Um, and if you so choose, and a state has a professional licensing program, you can get a professional engineer’s license in the field as well in certain selected states, Washington state being thank you very much.
[01:43:51] It’s not just something that you can mail off for or apply for. And the internet is a very extensive, uh, qualification process. So, uh, um, and so anyway, we do know that there were errors and emissions in this one. And, uh, and as a result of that, the captain of this vessel was candies. Rose was not afforded the proper assessments that he needed to, uh, make determinations about the Seaworthiness of this vessel.
[01:44:21] Um, now overall, so we talked about the Arizona and emissions of the individual Marine, um, Marine architect, or I’m sorry, Naval architect, but let’s talk about the regulatory aspects of it. And I guess Mr. Barnum, this would be directed towards you. Um, do the current requirements for stability instructions, consider icing accumulation on pot stacks and the interior webbing.
[01:44:53] Yes, sir. Mr. Chairman, the current regulations do not allow account for icing on the interior webbing, but there is an allotment for the exterior surfaces of the pot stack, but it is assumed to be symmetrical icing and we’re learning. And we know that icing does not occur symmetrically. Is that correct?
[01:45:17] That is correct, sir. And so how can the, uh, regulatory requirements be changed to reflect, uh, icing, uh, cemetery and, uh, and for, um, icing and the interior, the webbing of the pots. How can that be changed, sir? As we mentioned in the draft report, we feel that a study needs to be conducted to accurately determine, uh, exactly how these pots ice and how they can be treated and referenced in regulation.
[01:45:48] Yeah. And that’s certainly a recommendation that staff will be proffering and that we will be voting on shortly. Thank you. And finally, one, one last question is, uh, should, so the way that pots are they, uh, the way that the icing is modeled currently is like you said, it’s a shoe box. Um, and so. And we’ve learned that it gets into interior webbing.
[01:46:15] So that messes up the modeling on the shoe box. Should pots be tart to allow for more symmetrical icing? Um, would that, would that, uh, do anything at all? Uh, Mr. Mr. Chairman, none. I know NTSB has had, uh, opinions on this in the past and in certain circumstances, um, individuals in the industry have indicated that harps will help prevent ice from accumulating inside the pots back.
[01:46:43] Um, obviously the ice still accumulates on the tarp on the outside. Um, but the majority of commercial fishing vessel captains that we spoke to on this topic indicated that often the tarp is a more a hindrance than it is, is good in their opinion. Uh, there’s dangers associated with removing the tarp when it’s time to fish on the tarps are traditionally ripped and ruined after they’re done.
[01:47:07] It’s a one-time use. So, um, ultimately there, isn’t an easy solution here, and there’s not a general consensus either on the use of tarps. Right. Thank you. And I guess, I guess ultimately what becomes of that would be what comes out of the study that we are recommending in any event. So, all right. Um, do any of my colleagues have any additional questions or comments before we move to the findings?
[01:47:34] Us seeing none at this time, uh, Mr. Curtis. If you would please read the proposed findings. Yes, sir. As a result of this investigation, staff proposes 13 findings, number one, none of the following were safety issues. The accident of voyage one, the captain’s pre-departure decision-making to operational pressures, three fatigue for drug and alcohol use by the vessels, propulsion and steering systems or six, the vessels hall integrity.
[01:48:16] Number two, based on the voyage timeline and the estimated ice accumulation over that period. The scan, these rows likely accumulated between six and 15 inches of ice on surfaces exposed to wind and icing during the accident voyage number three, although the captain’s decision to proceed to set WIC island was reasonable.
[01:48:38] By the time he was close enough to turn into the li the icing conditions had accelerated and reduced the vessels stability. And before the added weight from ice accumulating asymmetric asymmetrically on the vessel and the stacked crab pots on deck raised the scandium rose center of gravity, reduced stability and contributing to the capsule sizing number five, although the crew loaded the scanned, these rows per the stability instructions on board.
[01:49:11] The stability instructions were inaccurate. Therefore the vessel did not meet regulatory stability criteria and it was more susceptible to capsizing number six because the stability instructions were inaccurate. The captain was unaware that his decile did not meet the margin of safety intended to be provided by the stability regulation.
[01:49:34] Number seven, current regulatory guidelines on calculating the effects of icing on a fishing vessel. Stability do not take into account how ice actually accumulates on and in crab pots and crab pot stacks. Number eight, if vessel captains are aware of the amount of icing that is factored into their stability instructions, they would be better prepared to make critical vessel safety decisions.
[01:50:00] When operating in areas of potential icing number nine, formal stability training would provide fishing vessel crews with a better understanding of the principles and regulatory basis of stability, including the effect of icing number 10 and oversight program to review and audit stability instructions produced for uninspected commercial fishing vessels.
[01:50:25] Like the scan, these rows that are not required to carry a load bind certificate could identify and reduce potential errors in stability instructions. Which in turn may reduce the chance that vessels are sailing without the intended margin of safety provided by applicable stability criteria. Number 11, due to the limited surface observation resources near network island and the Chittick bay region along the fishing vessel route from Kodiak to Dutch Harbor, the national weather service cannot accurately forecast the most extreme localized wind and sea conditions.
[01:51:02] One of the area which can lead to vessels encountering conditions that are worse than expected. Number 12, the national weather service ocean prediction center site could provide Mariners with more detailed, graphical icing information, not currently available elsewhere, which would help them make decisions based on more accurate weather information.
[01:51:25] And number 13, personal locator beacons would aid in search and rescue operations by providing continuously updated and correct coordinates of crew members location, sir, Mr. Curtis, thank you very much for reading those recommendations at this time. We’ll have each of our board members, uh, we’ll do a roll call to make sure that all board members are ready to deliberate vice chairman Landsberg.
[01:51:52] I’m ready to deliberate. Uh, Mr. Chairman. Thank you. Thank you. Uh, look forward to the discussion. Thank you. Remember Graham. I am ready to deliberate Mr. Chairman. Thank you very much. And remember Chapman ready to go, Mr. Chairman, thank you very much. Um, so, uh, do we have a motion to adopt the findings as proposed?
[01:52:21] Okay. My chairman, uh, has moved. And is there a second? I’ll second, Mr. Chairman, Mr. I remember Chapman seconds. Is there any discussion, um, Mr. Chairman? Uh, I did note, I believe it was on finding 11, uh, the statement, uh, the national weather service can not accurately forecast and I believe the term is the more extreme, localized, and I believe it was red, most extreme, localized, a minor point, but, uh, just for, for the record.
[01:52:55] Yeah. Thank you very much. Um, and, uh, as it’s written, it does say, as you pointed out by chairman does, so the national weather service can not accurately forecast the more extreme, localized, wind and sea conditions for the area. So thank you. Uh, any, thank you. Any other comments or questions? Okay. It’s been moved and seconded to adopt the findings as proposed.
[01:53:23] There’s no further discussion. We’ll do a roll call vote, uh, um, vice chairman Landsberg. I vote. I share my votes on. Remember Hamadie I number? How many votes? Remember Graham? I am a gram votes number Chapman I number Chapman votes. The chairman votes on the findings have been adopted unanimously. And now Mr.
[01:53:50] Mr. Curtis, if you’ll please read the proposed probable cause staff proposes the following probable cause the national transportation safety board determines that the probable cause of the capsizing and sinking the commercial fishing vessel Scandi is rose was the inaccurate stability instructions or the vessel, which resulted in a low margin of stability to resist capsizing combined with a heavy asymmetric ice accumulation on the vessel due to localize, wind and sea conditions that were more extreme than forecasted during the accident voyage.
[01:54:30] Sure. Mr. Curtis, thank you very much. Is there a motion to adopt the probable cause as presented,
[01:54:39] um, member Homedy moves? And is there a second, second number or member Graham seconds? Uh, is there any discussion? Okay, thank you. It’s been moved and seconded to adopt the probable cause as presented. There appears to be no discussion. All in favor, we show them again and again with a roll call, vote. Vice chairman Landsberg, vice chairman, bow tie likes chairman votes on.
[01:55:08] Remember how, how many votes? I remember Graham, I regram votes. I remember chap by Amber Chapman votes. Aye. The chairman buttocks, not the probable cause has been adopted unanimously. Now, as far as the recommendations are concerned, I believe Mr. Curtis will read recommendations one through seven for our consideration to vote.
[01:55:35] And after we voted on those, then, uh, he will then read the recommendations that are being reiterated, uh, in the report, but will not require a vote. And that’s my understanding, Mr. Curtis, did I get that right? That is right, sir. Okay. If that’s the case and, uh, Mr. Curtis, if you’ll please read the proposed recommendations as a result of this investigation, staff proposes the following seven new safety recommendations for the us coast guard.
[01:56:09] Number one, conduct a study to evaluate the effects of icing, including asymmetrical accumulation on crab pots and crab pot stacks and disseminate findings of the study to industry by means such as a safety alert. Number two. Based on the findings of the study recommended and safety recommendation, one revised regulatory stability calculations for fishing vessels to account for the effects of icing, including asymmetrical accumulation on a crab pot or pot stack.
[01:56:46] Number three, revised title 46, coded better regulations. 28.530. To require that stability instructions include the icing amounts used to calculate stability criteria. Number four, develop an oversight program to review the stability instructions of commercial fishing vessels, which are not required to possess a load line certificate for accuracy and compliance with regulations.
[01:57:16] One recommendation to the north Pacific fishing vessel owners association. And we’re five notify your members, parent Bering, sea Aleutian islands, crabbers fishing vessel fleet closed paren of the specifics of this accident. The amount of ice assumed when developing stability instructions and the dangerous wising one recommendation to the national weather to sorry to the national oceanic and atmospheric administration.
[01:57:44] Number six, increase the surface observation resources necessary for improved local forecasts for the WIC island and CEG bay region in Alaska. And one to the national weather service, number seven, make your own prediction center, freezing spray website, operational and promote issues industry, sir. Thank you very much.
[01:58:11] Um, so there were the recommendations, the new recommendations proposed. Is there a motion to adopt the recommendations as presented? My chairman moves. Is there a second? Second? Okay. Um, member Chapman seconds. Is it seconds the motion? Is there any discussion regarding recommendations one through seven saying none it’s been moved in second and to adopt the recommendations as presented there appears to be no discussion for a vote vice chairman Landsberg.
[01:58:47] Let’s say you as chairman bow tie as chairman votes on. Remember Homedy number comedy votes. Remember Graham by gram votes are number chap. I number Chapman votes on the chairman votes on the recommendations have been approved unanimously, um, as presented. And so Mr. Curtis, if you’d please read for the record, the previously issued recommendations that are reiterated in this report.
[01:59:22] Staff proposes reiterating the following two safety recommendations, which are currently classified open, unacceptable response, both to the us coast guard. First, M 1124, which reads require all owners, masters and chief engineers of commercial fishing industry vessels to receive training and demonstrate competency in vessel stability, watertight integrity, subdivision, and use the vessel stability information, regardless of plans for implementing the other training provisions of the 2010 coast guard authorization act.
[02:00:00] Secondly, M 1745 require that all personnel employed on vessels and coastal great lakes and ocean service be provided for the personal locator beacon to enhance their chances of survival, sir. Yeah. Thank you very much. Uh, so those recommendations of course, have already been adopted by the board, uh, by, uh, a board they’ve already been adopted.
[02:00:24] So, um, Mr. Curtis was simply reading those to get them on record that that is a part of the report. Um, does anyone have any additional issues related to this report? Uh, that they wish to discuss saying none? Is there a motion to adopt the report? I, so move, remember Graham moves. Is there a second? Vice chairman Landsberg seconds.
[02:00:53] Uh, it’s been moved. Is there any, is there any discussion regarding the final report? Okay. It’s been moved in second, the motion to adopt the report. Um, we have a motion to spend a second to approve the report as presented. There appears to be no discussion for vote vice chairman, Landsberg, chairman, chairman votes.
[02:01:19] So I remember how many number of how many votes on number gram I then were Graham boats member Chaplin. I am Mr. Chairman, before you proceed to your closing statement or reminder to turn your camera? Uh, my camera. Yes, sir. You know, it’s funny because my camera shows on now and it shows, it showed let’s say when I tried to turn it off it, um, you know, I can’t, so just mark that up, chunk that up to technology.
[02:01:56] Um, now I turn it off and I can’t even turn it back on. So while Brian was reading something a little while ago, my camera would not turn off. So anyway, that’s just technology, but thank you for that. Um, so, um, in vice chairman, I think you, uh, I’m sorry. Remember, cam, when you just voted to approve the report.
[02:02:19] Uh, presented, I believe you did. Yes, sir. And the chairman votes. Aye. So the, the final report for this candies rose has been adopted unanimously. Um, do any of my colleagues on the board wish to file a concurring or dissenting statement? Okay. And for the record, uh, since no one can see me, uh, I do not wish to file a concurring or dissenting statement.
[02:02:48] So, um, anyway, Carl, can you turn my camera back on? I don’t think you can then it’s great out completely on, on my computer, but anyway, that’s technology for us. Um, so I’ll now move to the closing statement. And before we do that, I’ll welcome any participants to turn off their cameras and mikes, if they are so inclined.
[02:03:14] Um, in closing, I want to thank my colleagues on the board for their great preparation, uh, going into the board meeting, uh, all of earned kicked out, but maybe, uh, maybe I’m back anyway. Um, want to thank, uh, all of my colleagues for. Uh, good, uh, comments going into the board meeting when they, when they all met individually with staff?
[02:03:38] Uh, certainly appreciate the good questions. Um, asked by staff, uh, asked by the board members and the responses by staff. Uh, we always liked the investigative staff to the staff of the office, Marine safety and the office of aviation safety. Uh, of course the office of aviation safety provided the, uh, weather, uh, expertise and the resources.
[02:03:59] But as I’ve always said, nothing around here gets done by just one person or one department. It is an entire, uh, group effort. And this meeting is a great example. Um, it takes an entire organization to conduct a board meeting and I’m so sincere thanks to the investigative staff, but to the program staff and the support staff, um, to pull it all together.
[02:04:24] The Scandi is rose did not capsize and sank because of a crew member or the captain did not do their, their jobs or because the vessel had been poorly maintained, it sank because the captain only had partial access to the information that he needed to make the decision and the information that he did have wasn’t there.
[02:04:50] The vessel was loaded, according to the stability instructions that were not conservative enough. The captain set out to say without the margin of safety required by the regulations because of these errors and the stability instructions and the vessel met weather conditions that demanded scary safety margin.
[02:05:10] The recommendations we issued today, if acted upon, would result in more accurate stability instructions that realistically consider the effects of icing on crampons and cramped pot stacks. They would also increase the surface weather, observation resources necessary for improved weather forecast, and they would result in the ocean prediction centers, freezing spray website, becoming operational.
[02:05:36] The recommendations that we reiterated today would result in required vessels stability training for owners, masters, and chief engineers, as well as other training, they would also result in personal locator, but it confirmed every member of a vessel’s crew and prove passenger fishing vessel safety is on the NTSB is most wanted list of transportation safety.
[02:06:02] Okay. In part because commercial fishing is routinely, one of the most dangerous occupations in America. But it doesn’t need to be the TV series, the deadliest catch air to special segment about Sandy’s rose. And in it a fishermen asked, have I been pushing my luck for the past 40 years? Am I any different?
[02:06:29] I hope so. He said, but hope is not enough. The recommendations that the NTSB issued in reiterated today need not be acted upon to make tomorrow’s catches. They need to be acted upon to make tomorrow’s catches less deadly on a personal note. This will be the last board member. The board meeting that I will participate in as tomorrow is my last day at the NTSB.
[02:06:56] It has been such an honor and privilege to serve with this agency. I will miss the people very much. I will miss the agency. Thank you. We stand adjourned.

Safety Investigations News 6/25/2021

Safety Investigations News 6/25/21 Safety Investigations Podcast

Safety Investigations news for 6/25/2021

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

NTSB

https://www.ntsb.gov/investigations/Pages/HWY21MH009.aspx

https://go.usa.gov/x6yGu

https://go.usa.gov/x6VtF

https://www.ntsb.gov/investigations/AccidentReports/Pages/MAB2113.aspx

https://www.ntsb.gov/investigations/AccidentReports/Pages/MAB2114.aspx

TSB

https://www.bst-tsb.gc.ca/eng/enquetes-investigations/rail/2020/r20h0082/r20h0082.html

http://www.tsb.gc.ca/eng/rapports-reports/marine/2020/m20p0320/m20p0320.html

AAIB

ATSB

http://www.atsb.gov.au/publications/investigation_reports/2021/aair/as-2021-015/

http://www.atsb.gov.au/publications/investigation_reports/2021/aair/ao-2021-024/

http://www.atsb.gov.au/publications/investigation_reports/2021/rair/ro-2021-007/

http://www.atsb.gov.au/publications/investigation_reports/2018/aair/ao-2018-056/

http://www.atsb.gov.au/publications/investigation_reports/2019/aair/ao-2019-050/

SIAA

http://www.aias.gov.ro/index.php/en/publicatii/rapoarte-de-investigatie-privind-siguranta/133-2016-10-13-incident-grav-atr-72-500-yr-ati-aeroportul-international-henri-coanda-bucuresti-otopeni-ilfov-romania 

CSB

https://www.csb.gov/update-on-chemtool-activities-/

OSHA

https://www.osha.gov/news/newsreleases/region4/06222021

Transcript

News Theme 1 by Audionautix is licensed under a Creative Commons Attribution 4.0 license. https://creativecommons.org/licenses/by/4.0/ 

Artist: http://audionautix.com/ 

Transcription

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

Safety Investigation News 21-06-25

This is your safety investigation news for June 25th, 2021. I’m your host Charles Current in this week’s episode, the U S NTSB is investigating seven new aircraft and one new fatal multi-vehicle highway crash. The NTSB also issued the preliminary reports for its ongoing investigation of the fatal June six, crash of a diamond da 40 NG in Darlington India.

[00:00:23] And for its ongoing investigation of the fatal June 13th, crash of a Piper, PA 32 to 60 in Madisonville, Texas, they say inadequate navigational assessment leads to contact with the Peter P cob Memorial bridge and severe weather led to barge breakaway and damage to the I 10 bridge Canada’s TSP is investigating the June 7th crash of a bell two 14 St.

[00:00:48] Near Nipigon Ontario. The TSB also launched a safety issue investigation into a higher rate of railway crossing accidents during the winter and Canada. And it released its investigation report on the Lafarge Eagle grounding on one November, 2020 in British Columbia. And the UK is AIB is investigating a nose gear collapsed at London Heathrow airport.

[00:01:12] The Australian transportation safety bureau is conducting a safety study into aerial firefighting in Australia. And it’s investigating the collision between a light engine and a coal train at Westwood Queensland on 18th of June and the crash of a Piper, PA 32, 300 aircraft in or near Morbin airport, Victoria on 22, June eight.

[00:01:38] DSB released reports on the depressurization and crew incapacitation of a Boeing 7 37, 3 76 SF in a new south Wales. And loss of control and collision with water involving a bell. EWH one H also in new south Wales, the Romanian, civil aviation safety investigation and analysis authority released its report on a serious incident at Bucharest on rake Honda international airport.

[00:02:06] CSB provides an update on chem tool activities and the U S department of labor sites to Koa plastic recycler for violating safety standards. After worker sustains fatal injuries from it.

[00:02:28] you can follow or subscribe to this podcast. On most podcast apps, you can find full show notes with links to the stories discussed@safetyinvestigations.net. This week, the U S national transportation safety board is investigating the June 17th crash of an air tractor, 84 0 2 B airplane. Kingston. Kinston North Carolina, the June 18th crash, but Piper, PA 28, 1 40 near rush valley, Utah, the June 18th crash of assess.

[00:02:59] Now one 50 L near for Nan DIA beach county, Florida. The June 18th, 2021 crash of a Cirrus Sr 20 near Conway, Arkansas, the June 20th crash of a Kitfox series C. Near likely California, the June 20 crash of a Piper, PA 22, 1 35 near white city, Oregon, the June 21st crash of a Cirrus Sr 22 near Mercer, Tennessee in the NTSB in coordination with the Alabama highway patrol is sending 10 investigators to conduct a safety investigation of a fatal June 19th.

[00:03:38] Multi-vehicle crash on  in Butler county, Alabama. The NTSB investigation will focus on vehicle technologies such as forward collision warning systems, CMV or commercial motor vehicle. I think fuel tank integrity, motor carrier operations and occupant survivability. On June 6th, 2021, about 10 20 Eastern daylight time, a diamond aircraft, D a 40 N G airplane, November 8, 5, 3.

[00:04:10] Lima was destroyed when it was involved in an accident near Darlington Indiana. The pilot and flight instructor were fatally injured. The airplane was operated as a title 14 code of federal regulations. Part 1 41 instructional. A review of automatic dependent surveillance broadcast, or a DSB data revealed the airplane departed from the Indianapolis international airport and flew Northwest at an altitude of about 4,000 feet.

[00:04:39] Mean sea level. At the time of the accident, the flight was not in contact with air traffic control, a witness located in a house nearby, heard the airplanes engine and impact. Another witness heard the airplane and looked up the airplane was in a nose down, left spin before it disappeared behind a tree line.

[00:05:00] He added that. It sounded like the propeller was at a high RPM before impact ground scars and wreckage were consistent with the airplanes impact with terrain in a slight right wing, low nose down attitude. The main wreckage was near its initial impact point on a heading of about 37 degrees. The wreckage was highly fragmented with scattered debris that extended for about 75 yards, a preliminary review of the garments G 1000 flight data also revealed the airplane departure and northwesterly track.

[00:05:36] The flight data revealed several turns, engine power, and altitude changes consistent with the airplane maneuver. The data also revealed the airplane was about 4,000 feet MSL. When engine power was reduced as the air speed decrease, the airplanes pitch attitude increased the airplanes pitch, then decreased to a nose down attitude, and the airplane made a right spiral.

[00:06:00] Turn consistent with a stall and spin entry on June 30th, 2021 at 2355 central daylight. A Piper, PA 32 to 60 airplane, November 3, 2, 5 8 whiskey was involved in an accident near Madisonville, Texas. The airplane sustained substantial damage. A private pilot was fatally injured and five passengers received serious injuries.

[00:06:27] The airplane was operated by the pilot under title 14 code of federal regulations, part 91 as a personal flight. The airplane impacted trees that were about 50 feet in height. About 680 feet south of the approach. End of runway three six at Madison bill municipal, airport Madisonville, Texas. The airplane was located about 550 feet south of the approach.

[00:06:52] End of the runway post accident examination of the airplane revealed that the propeller displayed S shaped, bending consistent with engine power, the trees along the wreckage path exhibited slash marsh, consistent with the propellers. Wing flaps were fully extended. Flight control. Continuity was confirmed.

[00:07:14] There were no mechanical anomalies that would have precluded normal airplane. Operation NTSB says inadequate navigational assessment leads to contact with Peter P cob Memorial bridge on August 19th, 2020. The towing vessel, all glory pushing the loaded barge Cole northbound on the intercoastal. Struck the protective fendering for the Peter P Cod Memorial bridge resulting in $646,000 in damages.

[00:07:45] There were no injuries. According to the United States coast pilot, there is a strong cross current at the Peter P Cub Memorial bridge. As the tow approached the bridge, the relief captain slowed the vessel, which reduced the maneuverability of the toe while the current pushed it outside. Towing vessel regulations require the officer of a navigational watch to conduct a navigational assessment, using all resources available to gather information on conditions that could impact the safety of navigation.

[00:08:18] Had the relief, captain Ben aware of the intercoastal waterway chart, cautionary note, and information contained in the United States. He would have been better prepared to address the risk of strong currents often seen near the Peter P Cub Memorial bridge. The report said the coast pilot and navigational charts are valuable sources to Mariners that contain amplifying information on local conditions, such as tides and currents, channel characteristics and bridge description.

[00:08:52] It is important to check the coast, pilot and charts when developing voyage plans to improve knowledge of the area and prepare for a safe passage. The NTSB also says severe rainfall and flooding from tropical storm. Imelda led to barges breaking away from their moorings and striking the interstate 10 bridge in Channelview, Texas.

[00:09:13] On September 19th, 2019 11 barges broke free from a San Jacinto river barge fleeting area north of the  bridge in Channelview during tropical storm Imelda, the fifth wettest tropical cyclone on record in the continental United States, six barges struck pier columns, supporting the  bridge resulting in more than 5.4, $6 million in damages.

[00:09:40] There were no issues. During the storm, San Jacinto river fleet, tow boats and crews worked to control the breakaway barges and return them to one of the tiers. A designated areas for grouping barges is what that is. The vessels could not hold the barges in the rising floodwaters and the barges subsequently struck the  bridge fendering system and pilot.

[00:10:05] As a result, the westbound bridge was closed for four months and the eastbound bridge did not return to normal capacity until five months after the accident, the NTSB determined that the San Jacinto river fleet should have implemented its severe weather plan and take an earlier action to secure the barges and in the fleeting area and TSP found Sheryl K Marine operator.

[00:10:30] Of the fleet did not follow their own safety management system policies related to severe weather and swift flood water plans. Canada’s TSB has deployed a team of investigators near Nippon, Ontario to gather information, following a crash involving a bell two 14 S T helicopter that occurred on Monday, June.

[00:10:52] A transportation safety board of Canada is launching a safety issue investigation into factors, leading to an increase in the rate of railway crossing accidents. During winter months and Canada, they say every year, approximately 23 people are killed and another 28 seriously injured at railway crossings in Canada in 2019 29% of the crossing accidents resulted in fatalities or serious injuries, making them one of the deadliest types of rail access.

[00:11:19] The TSP has identified a seasonal pattern in level crossing accidents involving motor vehicles where during the winter months, the average rate of accents increases by about 61%. The goal of the safety issue investigation is to compare the factors contributing to level crossing accidents that happen in non vacation, winter months, January, February, with those contributing to accidents that take place.

[00:11:49] Non vacation, non winter months may, June and September a secondary objective is to learn more about other factors contributing to accents at level crossings, whether the factors be human, environmental crossing, or roadway related drivers and eye witnesses to recent accents at level crossings will be interviewed by TSP investigators.

[00:12:12] So that firsthand accounts can be document. Those accounts as well as data from other sources will be compiled and compared statistically to identify and better understand the underlying causal factors to these occurrences results of the SII will be published in a final TSB investigation. A safety issue, investigation or SII also known as a class, one investigation and analyzes a series of occurrences with common characteristics that have formed a pattern over a period of time as AIS, which may include recommendations are generally completed within two years.

[00:12:54] For more information, you can see the TSB policy on occurrence classification. The TSB has released its investigation report into the grounding of the barge Lafarge Eagle while under tow of the tug Mona Mona LOA in the Fraser river, British Columbia on November 1st, 2020, the report highlights failures in risk management and communications.

[00:13:19] It reads vessel operators must be cognizant of the hazards involved in their operations and proactively manage them to reduce risks. To as low as reasonably practicable implementing effective risk management processes provides vessel operators with the means to identify hazards, assess risks, and establish ways to mitigate them a documented and systematic approach also helps ensure that individuals at all levels of the operation, including the master, have the knowledge, tools, and information necessary to make effective decisions in any operating.

[00:13:57] When the Mona LOA departed the Lefarge terminal with the barge in tow, there were several conditions present that were not viewed as hazards by the crew. The departure was in darkness. The channel in which the loaded barge was to be turned was narrow. The current was at a maximum EDD. Additionally, the Mount Allah single screw configuration increased the difficulty of the plan.

[00:14:25] As did the light fuel load and its forward distribution. Consequently, the tug was lighter AFT than usual resulting in the propeller, providing less thrust than the crew were accustomed to furthermore schedule changes resulting from loading issues had led to the engagement of an assist tug that had never assisted at this location or for this company.

[00:14:48] Finally, a training master was assigned to the Mount LOA. Even though the departure maneuver was challenging and had the potential for significant consequences in the event, it did not go as planned. Although salmon bay barge line Inc had voluntarily implemented a safety management system. The SMS did not contain any formal risk management processes and had not been audited by an external authority, no written guidance was provided to the master on assessing risks, such as.

[00:15:22] Current limitations for executing various towing, maneuvers, tug characteristics, and configuration and cyst tug requirements. The company relied solely on the experience and judgment of individual masters to make decisions about such factors without any formal risk management processes. The master did not have the benefit of a systematic approach to help with the identification of hazards and mitigate risk.

[00:15:48] TSB investigations have previously identified the absence of formal risk management processes by towing operators as causal or contributor contributary to an occurrence or as a risk factor. Effective communication is key to the success of maneuvers that involve the coordination of multiple vessels.

[00:16:09] During towing operations. The lead tug is often out of sight of the assistance. And therefore maintaining oral communications is essential, effective communication includes among other things. The use of pre towing safety briefings and the clear transfer of instructions between the lead tug, the vessel being towed or assisted and any assist tugs.

[00:16:31] The absence of effective communication is a factor that the TSP has frequently identified as causing or contributing to access. In this occurrence after the pre towing safety meeting, the training master on the Mount of LOA was assigned the controls and the responsibility for communicating, communicating with the CMP, the assist tug during the departure, when the amount of LOA came under the influence of the current and began to deviate from the intended track, there was no communication between the two.

[00:17:05] During the four minutes from the time, the amount of load master took control from the training master until the barge is grounding. It was unclear who was responsible for communicating with the assist tug noise from the vent stack near the AFT conning station also make communications between the master and the training master more difficult.

[00:17:26] The assistant did not query the Mauna LOA when it became evident that the maneuver was not going according to plan. Which meant that the master of the Mount of LOA was not prompted about how the assist tug could help control the barge or stop its forward momentum. The full report can be falling honed at the link in the show notes, the UK air accident investigation brand says they have sent a team to London Heathrow airport to begin an investigation into the incident involving an aircraft that suffered a nose landing gear collapse, while being loaded with cars.

[00:18:02] The Australian air transportation safety bureau is conducting a safety study into aerial firefighting in Australia. They say an a TSP statistical report into aerial firefighting occurrences between July, 2000 and March, 2020. Found an increase in occurrences per year. Over recent years, the report also found an increase in average size of aircraft and complexity of operations.

[00:18:27] Within the data was the 20, 19 to 2020 bushfire season, which the national aerial firefighting center advised demanded activity of around four times the usual rate. Additionally, the CSI R O has projected an increase in land use putting people into conflict with Bush fires and increased, dangerous bushfire weather over the coming year.

[00:18:51] The at TSB, consider this an appropriate time to conduct a more detailed examination of aerial firefighting activities to identify any systematic safety issues and other learning opportunities that could enhance the safety of future operations. As part of the investigation, investigators will conduct a detailed review of recent occurrences to identify common characteristics, obtain aircraft activity, data, to evaluate the rate of occurrences over recent years.

[00:19:20] Meet stakeholder organizations to understand their processes and challenges. Consider previous reviews of aerial firefighting activity and survey a sample of operational personnel involved in aerial firefighting activities. A final report will be published at the conclusion of the investigation.

[00:19:38] Should any safety critical information be disclosed at any time during the investigation, the TSB will immediately notify operators and regulators so appropriate and timely action can be. And the HTSP announced it is investigating the collision with terrain of a Piper, PA 32, 300 aircraft, Victor hotel, Charlie whiskey, kilo near moribund airport Victoria on 22, June at 1205.

[00:20:04] The aircraft had been conducting circuit operations at moribund airport and collided with train approximately one kilometer north of the airport at Heatherton. Emergency services attended the accident site shortly afterwards and rescued the pilot. The sole occupant from the wreckage, the pilot had been seriously injured and was transported to the hospital.

[00:20:25] The aircraft was destroyed by the impact. The evidence collection phase of the investigation will include examination of the accident site and wreckage by eight investigators and the collection of other relevant evidence, including recorded data and communications, air traffic control surveillance.

[00:20:43] Weather information, witness reports, aircraft operator procedures, and maintenance records, and interviewing the pilot. A final report will be released at the conclusion of the investigation. The TSB is also investigating the collision between a light engine and a coal train at Westwood Queensland on 18, June, 2021.

[00:21:05] They say a light engine, a diesel locomotive with no other rolling stock attack. They say the light engine, which they define as a diesel locomotive with no other rolling stock attached was being used by Queensland rail for driver tuition. There was a tutor driver and two other drivers on board. And the light engine was being operated westbound with the long end leading that is in the reverse direction of normal operation.

[00:21:33] The Caltrain was operated by Aurizon and was stationary at the Westwood. 45.05 kilometers from Rockhampton at about 1126 Eastern standard time. The light engine struck the stationary Coltrane, the light engine and five wagons of the Coltrane were significantly damaged of the light engines. Three occupants, one sustained minor injuries.

[00:22:00] One was seriously injured and one was fatally injured. The two drivers of the coal train were uninjured. The ATSB deployed three investigators to the site to examine the site and wreckage. As part of the investigation, the TSP will also interview the drivers and train controller, analyze recorded data from the light engines, data logger and other sources participate in more detailed examination of the light engine and gather additional information.

[00:22:27] And a report will be published at the conclusion of the investigate. The TSB has released their report on the depressurization and crew incapacitation of a Boeing 7 37, 3 76 SF in new south Wales on 15, August, 2018. And it reads on the evening of 15, August, 2018, a Boeing 7 37, 3 76. Special freighter registered Victor hotel.

[00:22:55] X-ray Mike Oscar operated by express freighters. Australia was transporting freight from Brisbane airport Queensland to Melbourne airport in Victoria when the master caution and right-wing body overheat and unseat are illuminated, the non-normal checklist was actioned, followed by further troubleshooting in consultation with maintenance personnel.

[00:23:19] This resulted in a reduction of cabin. The crew dawned oxygen masks and the aircraft was entered into an emergency descent. During the initial part of the descent, the captain was temporarily incapacitated by a reaction to the increased supply of breathing oxygen from the mask a made a was declared by the first officer and the aircraft was diverted to Canberra airport, Australia capital territory.

[00:23:46] During the diversion, the first officer also experienced incapacitation. The aircraft landed at Canberra airport under the control of the captain with no further issues. The HTSP found that faults in the right wing body overheat detection system likely led to intermittent flickering of the master caution, light and elimination of the right wing body overheat, an unsafe.

[00:24:12] The operating flight crew conducted the appropriate non normal checklist. However, the overheat indication could not be rectified due to the fault in the wing body overheat detection system and additional fault with an isolation valve in the aircraft pressurization system prevented isolation of the right wing body pressure duct.

[00:24:36] This led the crew to conduct further troubleshooting during which the cabin air supply was reduced. In conjunction with a higher than normal Kevin leak rate that reduced air flow also lessen the cabin pressure. The flight crew responded to the cabin pressure reduction by donning their oxygen masks and descending the aircraft.

[00:24:56] During the descent, the captain selected emergency flow on the oxygen mask resulting in an ingestion of gaseous oxygen causing temporary incapacitation. After the flight was diverted to Canberra. The first officer experienced symptoms consistent with hyperventilation leading the captain to declare the first officer incapacitated, post occurrence medical testing and assessment were carried out on the flight crew with no effects from the flight identified.

[00:25:25] During post flight inspections, Quantis engineers identified a range of serviceability issues with the aircraft fuselage cabin drain valves, peace lodge Dorsey. And the auxiliary power unit ducked bellows seal that affected the capacity for aircraft to hold Kevin pressure. The operator advised the, at TSB that following the occurrence amendments were incorporated into the approved scheduled maintenance program to incorporate a functional check of the cabin drain valves, specifically verify the integrity of the auxiliary power unit duct bellows C.

[00:26:03] Introduce an enhanced aircraft cabin pressurization system. Check the operator implemented an inspection regime to ensure timely detection and rectification of faults compromising the operation of the wing body overheat detection system. And the operator also advised that flight troubleshooting outside the non-normal checklist procedures and flight crew operations manual is now prohibit.

[00:26:28] The HSB says this occurrence is a reminder to flight crews of the hazards of dealing with system malfunctions that are not resolved using the approved non-normal checklist procedures in such circumstances associated system effects need to be taken into account when electing to conduct further troubleshooting outside of the non-normal procedures, even with the assistance of external maintenance specialist.

[00:26:54] Configuration changes to an aircraft system may induce other effects due to underlying unserviceable components that may not be immediately apparent. The NTSB also reminds flight crews to be cognizant that non-normal situations can lead to misapplication of emergency equipment in the moment that is actually needed in this case, the selection of the emergency flow setting.

[00:27:20] Fixed oxygen system resulted in a temporary incapacitation of the captain. Finally, a sequence of non-normal events in conjunction with the use of emergency equipment can add pressure and workload to the flight crew. So it would seem unlikely to occur. These pressures may result in hyperventilation, increasing the potential for incapacitation during a critical phase of.

[00:27:44] And the TSB also released their report of the loss of control and collision with water involving a bell EWH  in new south Wales on six, September, 2019. They say on six, September, 2019 at 1430 Eastern standard time. The pilot of a bell helicopter company, U H one H helicopter registered Victor hotel, uniform, Victor, Charlie departed, Archerfield airport Queens.

[00:28:12] On a private flight with four passengers, four banks, town, new south Wales. Following a refueling stop at Coffs Harbor new south Wales. The pilot made contact with Williamstown air traffic control while Northeast of Broughton island and requested clearance to track south via the visual flight rules, coastal route the initial radio calls between the pilot and Williamtown ATC.

[00:28:41] Occurred about six minutes prior to the published time of last light, the radio calls indicated that the helicopter was being affected by turbulence. And as a result, the pilot was having difficulty maintaining a constant altitude in response to controller issue the clearance for the aircraft to operate between two thousand four hundred and three thousand five hundred feet once passed and a bay.

[00:29:04] And about 11 minutes past published last night. Uniform Victor. Charlie was observed on Williamtown ATC radar to make a left turn to the south, depart the coastal route and head off shore on a direct track to bank town, airport. The turn likely resulted in the pilot losing visual cues and encountering dark Knight conditions.

[00:29:30] The helicopter continued to track off shore to the Southwest for about 90 seconds, maintaining between about two thousand five hundred and three thousand two hundred feet before commencing a rapid descending left spiral. Turn it disappeared from Williamtown radar coverage. About 12 minutes after published last light attempts by the controller to contact the pilot were unsuccessful and authorities were subsequently advised of a missing helicopter.

[00:29:58] On 25, September, 2019 wreckage from the destroyed helicopter was located in about 30 meters of water, five kilometers Southwest of Anna bay. Two of the five persons onboard the helicopter were confirmed to have received fail injuries. The bodies of the pilot and two passengers were not found, but they are presumed to have similarly not survived the area.

[00:30:20] The NTSB found that the pilot continued to fly after last light, without the appropriate training and qualifications, and then into dark night conditions that provided no visual clues that significantly reduced the pilot’s ability to maintain control of the helicopter, which was not equipped for night flight.

[00:30:38] Once visual references were lost, the pilot likely became spatially disoriented and lost control of the helicopter resulting in a collision with one. Further the pilot did not disclose ongoing medical treatments for significant health issues to the civil aviation safety authority that prevented specialist consideration and management of the ongoing flight safety risk, the medical conditions and prescribed medications posed the NTSB, says various ATS be research and investigation.

[00:31:09] Investigation reports refer to the dangers of flying after last light without appropriate qualifications. And. NTSB report avoidable accidents. Number seven, highlights. The risks of visual flight at night. Risks include reduced visual cues, increased likelihood of perceptual illusions and spatial disorientation.

[00:31:33] A VFR flight in dark conditions should only be conducted by a pilot with instrument flying proficiency. As there is a significant risk of losing control. If attempting to fly visually in such conditions. If Dave VFR rated pilots find themselves in a situation where last light is likely to occur before the plan destination has reached a diversion or precautionary landing is probably the safest option.

[00:31:58] Air traffic control assistance with available landing options is also available. This accident also highlights the importance of aviation medical certificate, certificate holders, reporting, relevant conditions and medications to their designated aviation medical exam. A full understanding by the civil aviation safety authorities, aviation medical specialists of a pilots, medical conditions, and use of medications enables management of the risk for both the individual and flight safety.

[00:32:29] Overall, the Romanian civil aviation safety investigation and analysis authority released its report on a serious incident at Bucharest Henri Quanda international area. On October 13th, 2016, the aircraft type ATR 72 dash 2 1 2, a registered Yankee Romeo alpha tango, India carrying 38 passengers and four crew members was scheduled to perform the commercial flight on the route from Bucharest, Henri, Conda international airport to yes, airport after passengers boarding, taxing and aircraft lineup on runway.

[00:33:11] Zero eight left for takeoff. The aircraft started the takeoff roll, but after a short time, the crew rejected the takeoff due to strong vibrations in the nose gear area. After a boarded take-off the aircraft vacated the runway at the end on taxiway Oscar continued taxing on taxiways, Papa, and Charlie, and returned to the apron on the same parking spot, a thorough check of runway zero eight.

[00:33:40] Was performed. And there was found metallic elements and glass, which were identified as elements of the lateral runway edge lights. It was found that some runway edge lights on the south side of zero eight left runway were missing. The findings of the report are after performing the procedures for aircraft cleaning insecurity.

[00:34:03] The flight deck crew did not resume the check-ins. From the item of preliminary cockpit preparation, according to the flight crew operating manual, which states all steps have to be performed before the first flight of the day or following crew change or maintenance action. After the taxi clearance was received, the flight crew did not apply the sterile cockpit concept as stated in the operations man.

[00:34:29] According to declarations the pilot and command, which performed the taxi did not wear the spectacles requested by her medical license limitations. When entering the zero eight left runway, the aircraft initially follow the central yellow line of the whisky taxi way. But after the entrance on the runway, it turned to the left, leaving the yellow line, then turned to the right and did align on the right-hand runway.

[00:34:58] The aircraft initiated the takeoff, but after 700 meters at a speed of 82 knots indicated the crew rejected takeoff. The reason for that being vibrations at the nose wheel, after the rejected takeoff, the aircraft vacated the runway on taxiway Oscar then continued with taxi on Papa and Charlie until the parking position.

[00:35:22] The airport personnel performed a runway check entering the runway via Viktor taxiway. Then towards the displaced runway zero eight left threshold along the north side and turning before the aircraft aligned for takeoff turning on and following on the south part of the runway until the intersection with Victor taxi.

[00:35:43] Where from the run was on the taxiway center line, vacating the runway at its end on Oscar taxiway. During this control, nothing abnormal was found during the time interview of 2129 through 2133 from zero eight left runway three more. Commercial flights took off and the runway edge light system issued three defect alone.

[00:36:10] The airport personnel requested a technical check of the aircraft in its parked position. Following these check, the closing down of zero left and two six, right runway was requested during a thorough control of zero eight left runway elements of runway edge light system have been found, metallic elements and glass, which have been identified as debris of runway edge light system.

[00:36:33] It was identified that six runway edge light. We’re completely missing from their positions numbers 3, 4, 5, 6, 14, and 16. All of them on the south edge of zero eight left, they list the causes as lack of crew concentration during this flight phase, distraction of cruise attention during this fight phase and the aircraft did not follow the yellow line, marking the center line of the whiskey taxiway until the intersection with the runway center.

[00:37:05] The U S chemical safety and hazard investigation board, but are known as the CSB deployed two of its senior leadership members to chem tool, Inc. In Rockton, Illinois, where they met with Kim tool, regional and site leadership, the onsite federal and local emergency responders, the environmental protection agency and the occupational safety and health agents.

[00:37:28] On June 14th, the CSB began tracking, documenting and coordinating this incident with federal counterparts. They CSB determined. The first opportunity for the agency to engage on scene would follow the fire and environmental emergency response efforts. Those emergency efforts continue as several hotspots are still burning incident commander.

[00:37:50] Brockton fire chief Kirk Wilson said these fires are being extinguished, but could continue to burn for another 24 to 48 hours. CSB is grateful. No one was seriously injured inside or outside the fence line. The concern about the environmental release was also quickly mitigated by the emergency responders.

[00:38:09] The site remains closed to investigators, correct. Tracking monitoring, investigating the causes of, and preventing accidental chemical releases remains the top priority for the CSB. And we would like to congratulate all the first responders who worked to save lives and protect the environment. They say that’s all the information we have currently on that.

[00:38:30] And that is actually a couple of days, the U S department of labor sites to COA plastic recycler for violating safety standards. After worker sustains fatal injuries from. They say with the holiday fast approaching a 56 year old worker at a Tacoma plastic processing facility could never have known. He would spend Christmas day in the hospital and die from a head injury after falling more than six feet from an elevated place.

[00:38:58] And inspection of the December 21st, 2020 incident by the us department of labor, occupational safety and health administration found that while scrap masters in CAD installed some fault protection on the platform, it failed to meet federal safety standards. OSHA cited the company for failing to equip stairs and platforms with guard rails to prevent falls.

[00:39:20] In addition, Oser determined the employer failed to Mount and mark fire extinguishers, exposing workers to fire hazards. The employer also did not implement a training program for the use of fire extinguishers. They failed to repair powered industrial trucks and ensure workers wore seatbelts when operating a fork.

[00:39:40] Failed to provide a training program on powered industrial trucks that consists of formal and practical training, as well as evaluation of the employee’s performance in the workplace. They failed to develop and utilize specific procedures for employees, performing service and maintenance activities on machines, exposing them to amputation hazards, and they failed to prevent workers from being exposed to occupational noise levels above the allowed time.

[00:40:06] Wait. In all OSHA cited, scrap masters with eight serious and five repeat violations and proposed $164,308 in penalties. Scrap masters, Inc. Recycles plastic, automobile gas tanks, and has a sister office in Manchester. Michigan OSHA has inspected the company five times in the past five years with four of the inspections occurring at the Tacoma facility.

[00:40:34] Of those four inspections, three resulted in citations being issued. And that’s it for this week’s news. Remember, you can find full show notes with links@safetyinvestigations.net. You can follow our subscribe to this podcast on most podcast apps. Thanks for listening and have a safe week.

Safety Investigations News 6/18/2021

Safety Investigations News 6/18/2021 Safety Investigations Podcast

Safety Investigations news for 6/18/2021

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

NTSB

https://go.usa.gov/x6Ncm

https://www.ntsb.gov/investigations/AccidentReports/Pages/RRD21FR010-preliminary-report.aspx

https://go.usa.gov/x6RjR

AAIB

https://www.gov.uk/aaib-reports/aaib-investigation-to-sikorsky-s-92a-g-lawx

ATSB

http://www.atsb.gov.au/publications/investigation_reports/2021/aair/ao-2021-023/

http://www.atsb.gov.au/publications/investigation_reports/2021/rair/ro-2021-006/

http://www.atsb.gov.au/publications/investigation_reports/2021/aair/ao-2021-016/

http://www.atsb.gov.au/publications/investigation_reports/2018/aair/ao-2018-026/

CSB

https://www.csb.gov/chemtool-rockton-il-explosion-and-fire-/

OSHA

https://www.osha.gov/news/newsreleases/region1/06152021

https://www.osha.gov/news/newsreleases/region2/06162021

https://www.osha.gov/news/newsreleases/region6/06152021-1

Transcript

News Theme 1 by Audionautix is licensed under a Creative Commons Attribution 4.0 license. https://creativecommons.org/licenses/by/4.0/ 

Artist: http://audionautix.com/ 

Transcription

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

SIP News 21-06-18

This is your safety investigations news for June 18th, 2021. I’m your host Charles Grant in this week’s episode, the NTSB announced it is investigating five new crashes and they issued the preliminary report for the ongoing investigation of the May 29th, 2021 fatal crash of a Cessna 1 72 S near Ogden, Utah.

[00:00:19] The aunties be issued the preliminary report for its ongoing investigation of the mate. 1922. Accident that killed Pan-Am railways worker during a switching operation near Newington New Hampshire. The AA be released its report on a Sikorski S 92. A controlled flight towards terrain at TSB also is investigating a separation issue involving Augusta Westland.

[00:00:45] AWU 1, 3, 9, and a Piper PA 44 dash 180 near Mangalore airport Victoria on six, June, 2020. The HTSP is also investigating a safe work breach near crystal Brook, south Australia on 10, June, 2021. And they released their preliminary report on the loss of control and collision with terrain involving assess.

[00:01:08] Now our 1 72 K near Sutton new south Wales on 13, April, 2021. They also released their report on the loss of control and collision with water involving a Eurocopter

[00:01:24] Uh, near Hardy reef, Whitsundays Queensland on 21, March, 2018. The U S CSB is monitoring an explosion and fire event at the chem tool plant in rock Rockton, Illinois. That occurred on June 14, 22. I won the us department of labor sites, Rhode Island, medical practice owner for exposing employees to coronavirus in new province, west Greenland.

[00:01:51] OSHA sites, Bronx contractor. After 21 year old labor erecting scaffolding suffers a deadly fall at Brooklyn to building. And a federal inspection finds San Marcos tortilla manufacturer repeatedly exposing workers to amputation dangers

[00:02:16] U S national transportation safety board announced it is investigating five new crashes this week, a June 13th crash of a Piper, PA 32 dash two 16 year Madisonville, Texas. The June 16th crash of a Landcare evolution in lone tree, Colorado, June 15, the crash of an experimental vans RV six near Doylestown, Pennsylvania, the June 15th crash of a air tractor.

[00:02:44] near Paragould, Arkansas, and the June 15th crash of a Cirrus Sr 20 near Truckee, Calvin. And the end has be issued a preliminary report for its ongoing investigation of the May 29th, 2021 fatal crash of a Cessna 1 72 S near I’ve been Utah on May 29th, 2021 about 1,000 hours. Mountain daylight time, a Cessna 1 72 S airplane, November one seven to seven.

[00:03:14] Tango was destroyed when it was involved in an accident near Ogden. The flight instructor and student pilot were fatally injured. The airplane was operated as a title 14 code of federal regulations, part 91 instructional flight, according to the airplane operator ATP flight school. This was an introductory training flight designed to assess the student’s skill level from preliminary automatic dependent surveillance broadcast eight ESB data showed the instructor and student pilot departed the flight schools, local base at.

[00:03:49] Hickory airport Ogden, Utah, about oh 9 41 and immediately turned to an easterly heading the AASB data. Ceased five nautical miles east of the departure airport at oh 9 46 and was subsequently picked up by radar nine out of 10 miles east. Ogden at oh 9 49, the airport flew south of pine view reservoir and then turned Northwest while maintaining an altitude of about 2000 feet AGL at oh 9 55.

[00:04:22] The airplane turned to the Northeast into a canyon where it began to climb over rising train in the next 60 seconds. The airplane descended to about 1000 feet AGL. Or about 7,550 feet MSL below the Ridge lines on either side of its flight path. The flight track ceased at oh 9 56 and 40 seconds. The airplane was located in mountain is trained at an elevation of about 8,000 feet.

[00:04:49] MSL. All major sections of the airplane were accounted for at the accident site. The debris field was small and comprised of mostly windshield fag. The first point of impact was marked by a tree located 30 feet west of the main wreckage, which came to rest on a northerly heading and was consumed by post impact fire.

[00:05:09] The wreckage was retained for further examination and they also issued the preliminary report for their ongoing investigation of a May 19th, 2021 accident that killed a Pan-Am railways worker during a switching operation near Newington, New Hampshire. And that report reads. A Pan-Am railways conductor of train Pan-Am local  was fatally injured while dropping off and picking up rail cars in the sub comm industrial track ne in Newington, New Hampshire, the train consisted of two locomotives and two loaded rail cars.

[00:05:48] The train crew consists of one engineer with 34 years of experience, one conductor with 42 years of experience. The train crew was tasked with picking up three empty rail cars and setting out two loaded rail cars. The sub comm industrial track is approximately 200 feet long with an east to west descending grade.

[00:06:10] Immediately. Before the accident, the train crew moved the two loaded rail. East into the industrial track and successfully coupled them to the first rail car in the track. Preliminary information indicates that two of the three rail cars to be picked up were not properly coupled together after five previous attempts to couple them, the conductor was pinched between the two coupling mechanisms during the sixth attempt to couple of the rail cars.

[00:06:37] The conductor was transported to the hospital by ambulance, where he died from his injury. National transportation safety board, investigative team examined the accident location collected and gathered preliminary information, conducted interviews, inspected equipment, and completed the accident.

[00:06:53] Reenactment. While on scene, the anti-ice investigation into this accident is ongoing. Future investigative activity will focus on causal factors and railroad worker safety and industrial facility. Parties to the investigation include the federal railroad administration. Pan-Am railways, brotherhood of locomotive engineers, and train men, and the international association of sheet metal, air rail and transportation workers.

[00:07:20] The UK is air accident. Investigation branch released their report on a Sikorsky  controlled flight towards terrain and Warburg star. It says. On approach to a private landing site in conditions of reduced visibility shortly before night, the pilots of a Sikorsky  golf, Lima, alpha whiskey x-ray became uncertain of their position.

[00:07:45] And the helicopter descended to within 20 feet of rising train, close to a house during the subsequent emergency climate lo indicated airspeed engine torque increased to 131%. And the pitch attitude of the helicopter was unstable. The helicopter made another approach to the landing site and landed without damage or injury to the occupants.

[00:08:07] The investigation identified the following factors, standard operating procedures for altitude alert, setting, stabilized approach criteria and crew communication were either absent or not effective, a strong desire as a customer facing director, not to inconvenience the client, which was. Potentially intention with his obligation as the coach to ensure a safe flight uncertainty about the rules of air when landing and attitudes, behavioral traps, and biases likely to have contributed to the occurrence.

[00:08:44] The circumstances of the serious incident indicate the need for greater awareness of hazards, of operating in degraded visual conditions and highlight the potential safety benefits of point and space approaches. Atlantis. The AIB made eight safety recommendations in these areas. It recommended that the civil aviation authority published guidance on the meaning and intention of the phase of flight alleviations in UK S E R a were detailed as, except for takeoff and landing to better enable pilots to plan and act on minimum height requirements for safe operation.

[00:09:23] It recommended that star speed limited specify in its operations manual stabilized approach criteria for visual approaches, including at off airdrome landing sites. It recommended that the civil aviation authority encourage the development and deployment of point in space operations at landing site.

[00:09:45] And it recommended that the civil aviation authority revise its guidance on helicopter flight in degraded visual conditions to include further information on managing the associated risks. It recommended that star speed limited. Describe in its operations manual for the Sikorsky S 92 helicopter. The criteria for setting barometric altitude alert values at each stage of flight.

[00:10:11] It recommended that star speed. Specify in its operation manual, a formal process for crew members to monitor escalate concerns. And if necessary take control during a flight, it is recommended that the civil aviation authority ensure that operators show clear evidence within their system for operational control as required by UK Oro dot G E n.one one oh.

[00:10:39] Of how the tasking process separates the customer from the flight crew. And finally it recommended that the civil aviation authority assess the safety benefits and feasibility of helicopter flight data monitoring programs for onshore helicopter operators, conducting commercial operations, or non-commercial complex operations and publish.

[00:11:00] It’s fine. The operator informed the AAB that it has conducted a training day, focusing on the occurrence, gained approval from the client to install cloud base and visibility monitoring equipment at the landing site transferred the role of safety manager from the commander to the compliance manager and has begun the process of delegating responsibilities for the SMS, from the accountable manager to the compliance manager.

[00:11:32] Added the following note to the front page of the GL three procedure on the EFB note, the GL three is not an aid for poor or marginal visual conditions to be used as visual approach aid in VMC only and included inadvertent IMC at low level and low IAA. As an additional training requirement to be delivered during simulator training issued a flying staff instruction, updating the OEM part, a section to address operations in marginal weather conditions.

[00:12:11] The FSI covered the following areas. Definition of marginal conditions by day and night departure at night in VMC air speeds to be flown indicated airspeeds to be. Assessments of cloud base at off airfield landing sites, light levels, and time of year planning and briefing of approaches and departure routes.

[00:12:37] Use of the GL three, the requirement for an alternate plan, operational control and supervision of the go no-go go decision in marginal conditions, operational control and supervision of management, post holders. The operator stated that it intends to revise the OEM parts, a B, and D to include NSLP on deviation calls in multi pilot operations and explore the feasibility to install cloud-base and visibility equipment.

[00:13:10] At other landing sites, the Australia and transportation safety bureau is investigating a separation issue involving two aircraft, a a Maura been aviation services, PA 44 1. And a Babcock mission critical services. AWU 1 39 above Mangalore airport in Victoria on six, June, 2021 at 1556. The AWU 1 39 was flying southbound toward Mangalore at 3,100.

[00:13:42] At 1556, the AWU 1 39 was flying southbound toward Mangalore at 3,100 feet above mean sea level. At the same time, the PA 44 was conducting a practice instrument approach to Mangalore the PA 44 commenced, a missed approach from below 3000 feet in a northerly direction towards Mangalore and the pilot broadcast at the aircraft would climb to 3,900.

[00:14:07] Shortly after the PA 44 began climbing the pilot of the AWL, 1 39 received a traffic collision and avoidance alert, a TKs alert and maneuvered the aircraft to increase separation between the two aircraft. Both flights continued without further incident. The evidence collection phase of the investigation will include reviewing recorded communications, air, traffic control, surveillance, data, and weather information, and interviews with the flight crew.

[00:14:36] The final report will be released at the conclusion of the investigation. And the TSB is also investigating a safe work breach near crystal Brook, south Australia on 10, June, 2021. The protection officer obtained an authority to undertake ultrasonic testing between crystal Brook and Konami. However, the road rail vehicles on tract between Rocky Creek and crystal Brook, about three kilometers prior to where the authority was to.

[00:15:05] As part of the investigation, the TSB will obtain a report interview the protection officer and involved crew and gather additional information. The report will be published at the conclusion of the investigation. The TSB issued its preliminary report on the loss of control and collision with Trane involving a Cessna R 1 72 K near Sutton, new south Wales on 13th, April, 2021.

[00:15:33] It says on 13, April, 2021 at about 1324 Eastern standard time. The pilot of a Cessna, our 1 72 K aircraft registered Victor hotel, Delta Lima, alpha departed Canberra airport, Australia, capital territory with an observer on board to conduct power line survey, work to the north of Sutton new south Wales at 1622 Delta Lima alpha.

[00:16:01] Tele D’Andrea lane and proceeded with survey work, concentrating on power lines, servicing properties to the east of the lane. Following the completion of two orbits at 1624, the pilot initiated a right turn and track to the Northeast witnesses in the area, described the aircraft flying lobe of the trees before commencing a left banking turn followed by a steep descent and collision with.

[00:16:27] The witness reports indicated that the loss of control and entry into the S a span preceded the ground impact the pilot and the observer were fatally injured analysis of recorded Garmin GPS and Oz runways flight data identified that the last garment GPS data point at 1624 and 48 seconds show the height of the aircraft to be about 164 feet above ground.

[00:16:53] And about 115 meters from the wreckage, the final Oz runways data point at 1624 and 50 seconds was about 80 meters from the accident site. The wreckage was located in an open field about 30 meters east of Telegu Andrea Lane, and about 10 kilometers to the west of . There was little spread of wreckage and few parts liberated in the accident, sequence, larger items, including the propeller and the right under care’s leg were found next to the fuselage items from the luggage locker were located within five meters of the initial impact point.

[00:17:34] The most distant item from the main wreckage was the aircraft battery, which was found near the edge of Telegu Andrea. Examination of the records show that the aircraft impacted the ground in a near vertical nose down attitude that the Lima alpha was a single engine Cessna, 1 72 K aircraft. It was manufactured in the United States in 1977 with serial number Romeo, 1 7 2 2 8 0 Niner and was first registered in Australia in 1978.

[00:18:06] To date the HTSP has examined the wreckage collected items for further examination, interviewed witnesses, retrieved flight related, electronic data, collected weather data from the bureau of meteorology and interviewed the operator. The investigation is continuing and will include further examination and analysis of the aircraft fight path, including analysis of recorded flight data, pilot qualifications, experience, and medical history, pilot flight, and duty period.

[00:18:34] Aircraft weight and balance aircraft maintenance records, flight survey, operational procedures should a critical safety issue be identified during the course of the investigation. The HTSP will immediately notify relevant parties so that appropriate and timely safety action can be taken. Final report will be released at the conclusion of the investigate.

[00:18:55] It is B acknowledges the assistance of the new south Wales police force in supporting the TSPs onsite investigation team through the evidence collection phase and operation, and the HTSP released its report on the loss of control and collision with water involving a Eurocopter ISI one 20 B here, Hardy reef with Sunday’s Queensland on 21, March, 2018.

[00:19:20] They say on 21, March, 2018. Eurocopter  helicopter registered Victor hotel, whiskey, India, India, and operated by wit Sunday air services, departed Hamilton island, airport Queensland on a charter flight to Hardy reef onboard where the pilot and four passengers, the pilot conducted the approach to the pontoon landing site at Hardy reef into the wing.

[00:19:48] During the approach, the pilots slowed the helicopter to allow birds to disperse. The pilot was then planning to yall. The helicopter left into the intended landing position. And there was about 20 knots crosswind from the right of the intended position. When the helicopter was yawing left into position, just over the pontoon, the pilot noticed a message eliminate on the helicopters vehicle engine malfunctioned.

[00:20:15] And elected to conduct a go around during the go round. After the helicopter climb to about 30 to 40 feet, there was a sudden and rapid Yar to the left in response to the unanticipated rapid yacht. The pilot lowered the collective, but was unable to recover the situation. In the limited time available after the unsuccessful action to recover the rapid left jaw, the pilot did not deploy the helicopters, floats and conduct a controlled ditching.

[00:20:43] The helicopter collided with the water in a near level attitude with forward momentum and front right corner. Almost immediately, the helicopter rolled to the right and started rapidly filling with water, the pilot, and two of the three rear seat passengers evacuated from the helicopter with minor injuries.

[00:21:03] Although impact forces were survivable. The other two passengers were unconscious following the impact and did not survive the accident. The helicopter sank and associated with unfavorable weather conditions. In the days, following the accident, subsequent searches were unable to locate and recover the elephant.

[00:21:20] Although, none of the possible VEMD messages required immediate action by the pilot, the pilot considered a go round to be the best option. Given the circumstances at the time during the go round, the helicopter continued yawing slowly to the left and the pilot very likely did not apply sufficient right pedal input to correct the developing Yar and conducted the go round into the.

[00:21:46] The helicopter then continued yawing left towards a downwind position until I sudden and rapid yaw to the left occurred in response to the rapid yaw. It is very likely that the pilot did not immediately apply full and sustained right pedal input the operator complied with the regulatory requirement for training and experience of pilots on new helicopter.

[00:22:10] However, the HTSP found the operator had limited processes in place to ensure that pilots with minimal flight time and experience on a new and technically different helicopter type, had the opportunity to effectively consolidate their skills on the type required for conducting the operators, normal operations, two pontoons.

[00:22:31] In this case, the pilot of the accident flight had 11 hours experience in command of the  helicopter. And had conducted 16.1 hours in another and technically different helicopter type during the period of acquiring their  experience associated with this limited consolidation on the , it is likely the pilot was experiencing a high workload during the final approach and a very high workload during the subsequent goal.

[00:23:02] In addition to limited consolidation of skills on the type, the HTSP found that the safety margin associated with landing the helicopter on the pontoon at Hardy reef was reduced due to a combination of factors. Each of which individually was within relevant requirements or limits. These factors included the helicopter being close to the minimum, all up weight, the helicopter’s engine power output being close to the lowest allowable.

[00:23:29] The need to use high power to make a slow approach in order to disperse birds from the pontoon and the routine approach and landing position on the pontoon requiring the pallet to turn left into a right crosswind. Anyhow, copter with a clockwise rotating main rotors. The HTSP also identified that the passengers were not provided with sufficient instructions on how to operate the emergency exits and the passenger seated next to the rear left sliding door emergency exit was unable to locate the exit operating handle during the emergency.

[00:24:05] And as a result, the evacuation of passengers was delayed until another passenger was able to open the exit. The nature of the handle’s design was such that its purpose was not readily apparent. And the plaque card providing instructions for operating the sliding door did not specify all the actions required to successfully open the door.

[00:24:26] The investigation also identified safety factors associated with the operators. Use of passenger volunteered weights for weight and balance calculations. The operator system for identifying and briefing passengers with reduced mobility, bird hazard management at the pontoons and passenger control at the pontoon.

[00:24:46] What has been done as result in July, 2019, the helicopter manufacturer released a safety information. Notice about unanticipated left yard in helicopters with a clockwise rotating main motor system. The notice provided detailed advice regarding the circumstances were unanticipated y’all can occur and the importance of applying full opposite.

[00:25:08] Right? Rudder pedal. If it occurred. The notice also stated that for helicopters with a clockwise rotating main motor system, to prefer your maneuvers to the right, as much as possible, especially in performance limited conditions. Following the accident, the operator implemented several additional processes for pilots transferring to new helicopter types and for operations on at pontoon.

[00:25:36] This included pilots conducting only into wind operations at pontoons until they had completed 20 hours on type the operator also introduced a safety management system, revised processes for obtaining accurate passenger weights and introduced training for pilots in how to avoid birds and how to inspect blades.

[00:25:57] Following a bird. In addition, the operator revised their pre-flight safety briefing, video and passenger briefing cards to include all types of seatbelts and instructions on how to operate all emergency exits and address other matters. The civil aviation safety authority revised its passengers, safety briefing guidance, which now contains information specific to helicopter operator.

[00:26:23] The civil aviation safety regulation part 1 33 manual of standards applicable to helicopter operators also requires that passengers seated in an emergency exit row are briefed about what to do when an exit is required to be used. In addition, all passengers must be verbally briefed on the location of exits and brace.

[00:26:46] The U S chemical safety and hazard investigation board is monitoring an explosion and fire event at the chem tool plant in Rockton, Illinois. That occurred on June 14th, 2021 at 7:15 AM. Central time. All 70 workers in the facility were evacuated without injury. One firefighter suffered a minor injury and was transported to a local hospital for evaluation.

[00:27:12] The facility manufacturers petroleum based lubricant. The CSB will continue to monitor the incident and tentatively plans to deploy a team to the area early next week, to expand dialogue with federal and state partners to include EPA personnel, regional OSHA personnel, and fire emergency management personnel.

[00:27:33] At this point, assessments appear to indicate that the incident is a fire event and not a chemical process safety event. Interviews with employees may provide more clarity to the events leading up to this incident and the potentially severe impact to the community and environment warrant concern. The air quality at ground level continues to be in the acceptable range.

[00:27:58] The incident commander reported yesterday that the plan was to allow the volatiles to burn off since the facility is adjacent to the rock river. And there was a significant concern surrounding release of firefighting water and suppression foam into the waterway. This initial poach has been reassessed and the plan is now to berm and boom, the access to the river and extinguish the remaining blaze.

[00:28:19] This may add an environmental impact element into the incident. Dynamic. Additional updates will be released as available. The U S department of labor’s occupational safety and health administration has cited the owner operator of, for Rhode Island medical facilities for failing to protect workers from exposure to coronavirus and implement proper safety measures.

[00:28:41] After six employees tested positive for the corner fires in the fall of 20. OSHA investigators found that the owner of north Providence urgent care, Inc. North Providence primary care associates, Inc. Center of new England urgent care, Inc. And center of new England primary care Inc willfully exposed employees to coronavirus the agency determined the owner, continued to interact with workers and did not fully implement safeguards after he exhibited symptoms of the coronavirus and later tested.

[00:29:13] The owner and his company, his face, a proposed fine of $136,532 for failing to implement engineering controls, such as portable, high efficiency, particulate air fan filtration systems and barriers between adjacent desks, failure to implement administrative controls, such as cleaning and disinfecting and symptom screening for all employees and failure to manage.

[00:29:42] Contact tracing or quarantine periods after employee exposure to the Corona virus exposed patients. OSHA also cited a Bronx contractor after 21 year old labor erecting scaffolding suffered a deadly fall at a Brooklyn building. They say falls are the leading cause of fatalities in construction. A fact, sadly illustrated by the death of a 21 year old laborer who fell nearly 50 feet as he installed a supported tubular welding frame scaffold during construction of a seven story, Brooklyn.

[00:30:18] And OSHA investigation of the November 13th, 2020 incident determined, ever scaffolding Inc of the Bronx failed to ensure the labor’s fall arrest harness was attached as required. OSHA provost $300,370 in penalties for two willful and two serious safety violations. The agency found the company failed to evaluate the feasibility.

[00:30:45] Of using fall protection and failed to use feasible fall protection during the erection of a support scaffold, they did not properly train employees on fall hazards associated with scaffold work. They failed to inspect fall arrest systems before use, and they did not determine if the Anchorage for employees personal fall arrest systems could support at least 5,000 pounds.

[00:31:10] The company has contested OSHA’s findings to the independent occupational safety and health review commission, and a federal inspection finds a San Marcos tortilla manufacturer, repeatedly exposed workers to amputation dangers, previous inspections by the us department of labor’s occupational safety and health administration have given the operators of the family owned tortilla factory, south of Austin.

[00:31:34] Every opportunity to resolve its safety issue. Yet OSHA has found the accompany still exposing workers to the risks of amputation and other serious injuries. Worker complaints of dangerous amputation hazards led OSHA to again, investigate conditions at El Milagro of Texas, Inc. And the agencies inspectors chairman that the company, once again, failed to follow hazardous energy control procedures to prevent sudden machine start-up or movement during maintenance and service.

[00:32:05] As a result, inspect your sighted Elm Allegro for three repeat violations related to energy control and for serious violations for failing to follow lockout, tagout procedures, OSHA RSL side of the company for a repeat violation for failing to fit test workers, using respirators and a serious violation for not performing medical evaluations for respirators.

[00:32:30] The agency has proposed $218,839 in fines. OSHA sided the company for the same violations in 2015 and 2018. And that’s it for this week’s news. Remember, you can find full show notes with links@safetyinvestigations.net. You can follow or subscribe to this podcast on most podcasting apps. Thanks for listening and have a safe week.

Safety Investigations News 6/11/2021

Safety Investigations News 6/11/2021 Safety Investigations Podcast

Summary

Safety Investigations news for 6/11/2021

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

NTSB

https://go.usa.gov/x6bpZ

https://go.usa.gov/x6bpr

https://go.usa.gov/x6bpa

https://go.usa.gov/x6bVt

http://go.usa.gov/x6ZXp

https://go.usa.gov/x683F

ATSB

https://www.atsb.gov.au/publications/investigation_reports/2021/aair/ao-2021-016/

http://www.atsb.gov.au/publications/investigation_reports/2020/aair/ao-2020-064/

http://www.atsb.gov.au/publications/investigation_reports/2020/rair/ro-2020-002/

Argentina’s Civil Aviation Accident Investigation Board (Jiaac)

https://jst.gob.ar/files/informes/55314916-2019.pdf

OSHA

https://www.osha.gov/news/newsreleases/region/06072021

https://www.osha.gov/news/newsreleases/region2/06102021

Transcript

News Theme 1 by Audionautix is licensed under a Creative Commons Attribution 4.0 license. https://creativecommons.org/licenses/by/4.0/ 

Artist: http://audionautix.com/ 

Transcription

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

SIP News 21-06-11

This is your safety investigation news brief for June 11th, 2021. I’m your host Charles Current in this week’s episode, the U S GSB announced it is investigating three new plane crashes and one new multi-view vehicle crash. They showed five new preliminary reports and completed documentation of its investigation of derailed tank car performance.

[00:00:23] The Australian ATSB has released a preliminary report. From a fatal accident involving a Cessna 1 72 conducting power line survey work. They issued an investigation progress update on the loss of control and collision in with terrain involving a Robinson  and released an interim report outlining planned safety action.

[00:00:46] Following Wilin X, P T derailment. Argentina’s civil aviation accident. Investigation board says a Cessna six 80 landed gear up after crews, silence, cockpit alarms, and the us department of labor cited Cambridge green facility for workplace safety failures. Following engulfment death of a manager in corn silo, and they cited pharma biotech manufacturer for failing to protect workers from coronavirus at Monmouth county facility.

[00:01:26] if he can find full show notes with links to stories discussed@safetyinvestigations.net, there might be a slight delay between when the episode goes up and when the shownotes arrive on the website as it’s a manual process, but I do my best to get them up as quick as I can. As usual, straight off the news this week with the NTSB, they are investigating the June six crash of a Switzer S G S one dash three five glider in Wirtz borough, New York, and the June six crash of a diamond D a four zero N G airplane in Darlington, Indiana, and the June 7th, 2021 crash of a vans RV  near Porterville, municipal airport in Porterville, California.

[00:02:13] And in cooperation with the Arizona department of public safety, the NTSB is sending nine investigators to conduct safety investigation into the June 9th, 2021. Fail multi-vehicle crash on loop 2 0 2 red mountain freeway in Phoenix, Arizona. And they issued their preliminary report for the ongoing investigation of the fatal May 21st, 2021 crash of a Piper, PA 31 P airplane in Myrtle beach, South Carolina.

[00:02:42] And it reads on May 21st, 2021 at 1814 Eastern daylight time, a Piper, PA 31 P November 5 7, 5. Bravo, Charlie. Was destroyed when it was involved in an accident near Myrtle beach, South Carolina, their airline transport pilot was fatally injured. The airplane was operated as a title 14 code of federal regulations, part 91 personal flight.

[00:03:10] The flight was the airplane’s first flight after maintenance was performed. And prior to the flight, the airplane was fueled with 167.5 gallons of 100 low lead aviation fuel. The airplane departed, Myrtle beach international airport, Myrtle beach, South Carolina at 1812 with the intended destination of grand strand airport, north Myrtle beach, South Carolina, according to preliminary ads B and air traffic control radio communications data prior to take off the pilot established communications and reported that he was ready for departure from runway one eight.

[00:03:51] He was instructed to fly runway, heading climb to 1,700 feet and was cleared for takeoff. Once airborne, the controller instructed the pilot to turn left. However, the pilot stated that he needed to return to runway one eight. The controller instructed the pilot to enter a right closed traffic pattern at 1,500 feet.

[00:04:11] As the airplane continued to turn to the downwind leg of the traffic pattern, it reached in an altitude of about 1000 feet, mean save level. While on the downwind leg of the traffic pattern, the airplane descended to 450 feet mean sea level climb to 700 feet means sea level. And then again descended to 475 feet mean sea level prior to the loss of radar contact.

[00:04:36] About one minute after the pilot requested to return to the runway, the controller asked if any assistance was required to which the pilot replied. Yes, we’re in trouble. There was no further radio communications from the pilot. The airplane impacted in a field about 0.1 mile beyond the last radar return at an elevation of 20 feet, a post impact fire ensued and debris field was about 400 feet long by 150 feet wide.

[00:05:04] All major components of the airplane were located in the vicinity of the main wreckage. Each engine came to rest in about a five foot crater and remained attached to the fuselage. The left engine crankcase was impact damaged in multiple locations. The gearbox was impact separated. All valve covers remained intact and attached to the cylinders.

[00:05:28] The valve covers were removed and no anomalies were noted. Cam shaft and crankshaft continuity were confirmed by using a lighted borescope. To examine the internal components of the engine. In addition, the cylinders were examined using a lighted borescope and no alarm. No anomalies were noted. All engine accessories were impact, separated and fragmented.

[00:05:51] The left engine turbocharger was impact separated would bind when it rotated and scoring was noted on the casing. The right engine crankcase was impact damaged in multiple locations. All valve covers remained intact and attached to the cylinders. The valve covers were removed and no anomalies were noted.

[00:06:12] Crank shaft and cam shaft continuity were confirmed by using a lighted borescope to examine the internal components of the engine. In addition, the cylinders were examined using a lighted borescope and no, no anomalies were noted. All engine accessories were impact separated and fragmented. The oil suction screen was removed and was not the right engine turbocharger was impact separated and would bind when it rotated the left Heller was impact separated from the engine.

[00:06:44] Two of the three blades were separated from the hub. All blades exhibited. One blade was bent forward. One exhibited tip curling, and last blade was bent AFT. The blade that was bent AFT remained attached to the propellor hub. The right propeller was impact separated from the engine. Two of the three blades were impact separated from the hub.

[00:07:08] All blades exhibited polishing one blade was bent forward. One blade was bent AFT and one blade remained straight. The straight blade remained attached to the propellor hub. Bike control cable continuity was established from all flight control surfaces to the cockpit through multiple. Overload breaks in the cables.

[00:07:29] A majority of the wings and fuselage were consumed by fire, the remaining skin and structure, exhibit accordion, like impact damage that was symmetrical on both wings. The landing gear was in the extended position. The flaps were in the retracted position. The empanada was separated from the fuselage and located about 50 feet from the main wreckage.

[00:07:52] The top section. Of the vertical stabilizer and the rudder were impact crushed downward. The elevator remained attached to the right horizontal stabilizer. The right trim tab remained attached to the right elevator was deflected up, but was impact separated from the connecting rod. The left trim tab remained attached to the left elevator.

[00:08:14] The connecting rod remained attached to the flight controls and it was deflected up. Further examination of the elevator trim tabs revealed that they were installed upside down and reversed the connecting rod that attached the trim tab to the trim drum that should be located on the top of the trim tab was located on the bottom side.

[00:08:35] The airplane’s most recent annual inspection was completed on May 19th, 2021 maintenance performed at that time included, removing repainting and reinstalling the primary and secondary flight control surfaces. The NTSB also issued the preliminary report for its ongoing investigation of the fatal May 22nd, 2021 crash of a flight design, CT SW airplane in Winterville, North Carolina.

[00:09:00] And it reads on May 22nd, 2021 at about 1742 Eastern daylight time. A flight design CT S w November 7 0 8. Juliet. Mike was destroyed when it was involved in an accident near Winterville North Carolina. The sport pilot and one passenger were fatally injured. The airplane was operated as a title 14 code of federal regulations, part 91 personal flight, according to federal aviation administration, uncorrelated radar track data, the flight departed runway two three Sierra uniform tango at 1627.

[00:09:35] After takeoff, the flight returned left or after takeoff, the flight turned left. To a Northeast heading for about 21 nautical miles. It then turned slightly left to a north Northeast heading and proceeded towards zero five November while in route to zero five, November, the passenger sent her son a text message, which stated it’s 5 27 right now.

[00:10:02] And we are 12 minutes from landing in Aiden, had a headwind that slowed us down a little bit. We’ll text when we get settled. If I continued towards zero five November, but the radar track data was lost at 1735 and 52 seconds. When the flight was about 6.2 nautical miles and 181 degrees from zero five November.

[00:10:25] According to video recorded from a house located south of the runway at zero five November. The airplane landed about 122 feet from the approach end of runway to five and remained on the ground for about 340 feet. The video depicted the airplane in a nose, high tail, low attitude. It then became airborne about 464 feet past the approach end of the runway, and entered a shallow climb, which appeared to decrease while the plane turned to a southerly direction, the airplane then banked left and began descending in a nose, low attitude before it was lost from the view of the camera.

[00:11:05] A pilot rate of witness who was in his house near the departure. End of runway two, five reported hearing a noise and seeing the airplane from his window. He noted it was banking left and trying to climb, describing the bank angle as between 15 and 20 degrees. He then heard a snapping sound like breaking tree limb followed by ground impact.

[00:11:27] He went to his porch and about 10 seconds after impact observed a fire. His wife called 9 1 1. And he went near the accident site, but the fire precluded him from rendering assistance. He further added that the smoke from the post-crash fire rose vertically consistent with his account of no or numb or consistent with his account of no or minimal wind at the time of the accident, the wreckage, which was mostly consumed by post-crash fire was recovered for further examination.

[00:11:59] The NTSB also issued a preliminary report for its ongoing investigation of the fatal May 24th, 2021 crash of a Munson. Roger J R V eight airplane in van cleave, Kentucky on May 24th, 2021 at about 1330 central daylight time and experimental amateur built rans R V eight, November 2 84. Romeo Mike was destroyed when it was involved in an accident near van cleave, Kentucky.

[00:12:29] The private pilot was fatally injured. The airplane was operated as a title 14 code of federal regulations, part 91 personal flight. The flight originated from green Cove Springs, Florida with a fuel stop at Pickens county airport. Pick in South Carolina. According to air traffic control data provided by the federal aviation administration.

[00:12:49] After a departure from Pickens county airport, the airplane made a climbing left turn and a series of turns gradually climbing in route until reaching about 9,000 feet means sea level. When the airplane reached the vicinity of van Cleve, Kentucky, the pilot declared an emergency stating he had lost oil pressure and the engine failed.

[00:13:12] Air traffic control advised the pilot of an airport at his two o’clock and three miles. The pilot stated he did not have the airport insight and opted to perform a forced landing in a field. The airplane was observed on radar in a 270 degree turn while descending with decreasing ground speed until flight track data was lost.

[00:13:34] According to a witness, the airplane flew over the top of a mountain and was smoking prior to ground impact. The airplane was in a left bank and the nose of the airplane hit the ground with the engine area on fire. Shortly after the airplane came to rest, the witness started to walk towards the airplane.

[00:13:54] Then he heard an explosion and observed the airplane on fire. The airplane came to rest on a heading 353 degrees, all four corners of the airplane and all flight control surfaces were accounted for at the accident site. The fuselage from the firewall to about two foot forward of the empanada was destroyed by the post impact fire light control continuity was observed from the flight control surfaces to the fire damaged area within the cockpit, the flight instruments and flight controls within the cockpit were destroyed by the fire initial examination of the engine revealed that the accessory section was fire damaged.

[00:14:36] The airplane was recovered for further examination and they issued the preliminary report for the ongoing investigation of a fatal May 25th, 2021 crash of a Gulf stream. America Corp AA five airplane in Crossville, Tennessee. And that one reads. On May 25th, 2021 at oh seven 30 central daylight time. A Gulf stream, American AA  November 2, 6, 8, 8.

[00:15:03] Niner was destroyed when it was involved in an accident near Crossville, Tennessee, the student pilot was fatally injured. The airplane was operated as a title 14 code of federal regulations, part 91 instructional flight. Preliminary radar data obtained from the federal aviation administration and interview with the student pilots flight instructor, and telephone records reveal that the airplane departed Crossville Memorial airport Crossville Tennessee on the second leg of its flight, about 0 7 15.

[00:15:35] The airplane’s next planned stop was Cleveland regional jet port Cleveland, Tennessee, about 50 miles to the south of Crossville Memorial airport. The airplane climbed on a southerly track to 3,700 feet MSL before beginning a gradual descent about 0 7 18. The airplane continued its descent on its southerly track until about 0 7 23 and 3000 feet MSL.

[00:16:03] When the airplane entered a 450 degree descending right turn. At 0 7 26, about 2,300 feet MSL. The student pilot placed a telephone call to his uplight instructors cellular telephone. According to his instructor quote, he called me from the air. He said the airplanes engine was not making full power.

[00:16:25] Making 75 knots at 1,700 RPM. Normal cruise was around 2,400 RPM at 95 Nazi air speed. Initially his demeanor was quite calm and he remained calm while he was talking to me. I helped him with troubleshooting. I asked about fuel state magnetos on carb heat position and the instruments were all in the green, but the Angela was not making full power and the airplane could not climb from there.

[00:16:53] I asked where he was, what is your closest airport? And he thought he was 40 to 50 miles from Crossville. And didn’t think he could make it back. I remember telling him to land at the nearest airport and I would pick him up, but he said he had slowed to 70 knots. I told him to make an emergency landing in a field.

[00:17:14] And he said there were trees and mountains. I asked if he was talking to ATC and he said he was not soon after I heard the sound of trees and impact. And the connection went dead. The airplane completed its course reversal about eight miles south of Crossville and traversed, a large open. Cultivated field before impacting rising terrain on heavily wooded bridge line, the student pilot had begun flight lessons about one month prior to the accident, according to his instructor, the student had accrued 44 hours of flight experience.

[00:17:46] All of which was in the accident airplane. The student pilot was a conscientious student who flew an average of three times per week. Instructor stated that the student was enrolled in an online ground school and that they would discuss the lessons before each flight. The accident flight was the student’s first cross country solo flight airplane’s.

[00:18:07] Most recent annual inspection was completed December 11th, 2020 at 5221.84 total aircraft hours. Examination of the airplane at the accident site revealed the wreckage path was about 1,800 feet elevation oriented about 0 3, 0 degrees magnetic. And was about 75 feet long. The initial impact point in a tree about 50 feet tall and pieces of angerly cut wood were found along the wreckage path.

[00:18:41] The airplane was consumed by post-crash fire remnants of each wing, and the main wing spars were found adjacent to main fuselage area. The tail section was. Impact damage, but remained largely intact control cable continuity was established from the control column and rudder pedals to rudder and elevators continuity was established from the control column through breaks at each wing route out to the ailerons.

[00:19:10] The cable breaks displayed features consistent with overload failure. The instrument panel and its contents were consumed by fire. The engine displayed significant fire damage and accessories along with their associated wires. Hoses fittings were consumed by fire. One propeller blade displayed after bending and the other appeared intact and undamaged by fire.

[00:19:35] The engine was rotated by hand at the propeller. It was subsequently recovered and retained for further examination. And the NTSB also issued the preliminary report for its ongoing investigation of the fatal May 20th, 2021 crash of a Lance air evolution airplane in ma Dermot, Ohio. That one reads. On May 20th, 2021, about 10 48 Eastern daylight time.

[00:20:03] A Lance air evolution airplane, November 5, 1 5 Delta Lima was destroyed when it was involved in an accident near at McDermott Ohio. The private pilot and passenger were fatally injured. The airplane was operated as a title 14 code of federal regulations, part 91 personal flight, a review of preliminary air traffic control information revealed the airplane departed at about 10, 14 from.

[00:20:27] Bel Fontaine regional airport in Bel Fontaine, Ohio on an instrument flight rules, flight plan with destination of Charleston international airport Charleston, South Carolina, after departure the airplane climb to flight level 2 5, 0, and accelerated to 215 knots ground speed. During the next one minute and 43 seconds while in level flight on a southeasterly heading the airplane gradually decelerated to 146 knots ground speed.

[00:20:59] The air plane subsequently made a left turn and rapid descent. During this timeframe, the pilots transmitter became stuck in a distressed conversation between the pilot and his passenger was audible. The controller made unsuccessful attempts to contact the pilot and radar contact was lost. A ground witness observed the plane in a spiral dissent, and that it may have been missing a wing.

[00:21:26] The airplane impacted into forested terrain with a vertical nose down attitude and fire ensued. The airplane was equipped with a parachute recovery system, the ballistic charge for the system expended during the fire. The right wing outboard, nine feet was located about half mile Northeast of the main wreckage examination revealed engine and propeller rotational signatures, consistent with the engine producing power during ground impact, no mechanical malfunctions that would have precluded normal operation were observed.

[00:22:01] And airmen for icing was valid up to 22,000 feet. And an airmen for moderate turbulence was valid from 25,000 to 42,000, both aromats covered Bel Fontaine and the accident area. And this week, the NTSB announced completion of its investigation to document the performance of  rail tank cars involved in the December 22nd, 2020.

[00:22:28] Derailment near Custer Washington, the NTSB conducted a limited investigation of the accident focused solely on the performance of the DLT dash 1, 1 7 rail tank cars as such the NTSB did not determine probable cause for the derailment and did not publish a brief or report. The NTSB is documentation of its investigation into the performance of the tank.

[00:22:52] Cars is documented in a factual report. No injuries were reported in connection with the derailment. However, 120 people were evacuated from a half mile radius around the accident site. About 29,000 gallons of petroleum crude oil was discharged from three tank cars. The oil ignited and burned uncontrolled for two hours.

[00:23:16] Damage was estimated to exceed $1.5 million information collected. By the NTSB for its investigation is publicly available in the docket. Online docket contains 23 items, totaling 224 pages in its factual report. The NTSB states nine of the 10 derailed tank cars were originally constructed to DLT 1, 1, 1, a 1 0 0 WUI specifications.

[00:23:43] With enhancements to the association of railroad standards, CPC dash 1 2 3, 2 industry standard for crude oil and ethanol service tank cars ordered after October 1st, 2011, the CPC 1232 tank cars were converted to DLT 1, 1 7 R 1 0 0 w in 2019. NTSB investigators did not travel to Custer to examine the tank cars due to COVID-19 travel restrictions.

[00:24:14] However, the investigators relied on close communication with the federal railroad administration and the Washington state utilities and transport commission to collect derailment damaged data. Robert J. Hall director of NTSB, his office railroad pipeline, and hazardous materials investigations said the NTSB.

[00:24:33] His intent for this investigation was to gain damaged data from the  rail tank cars involved in the derailment because our investigation was limited to data collection. We have not issued any findings or safety recommendations. The data we gathered in this investigation will assist us. As we evaluate the performance of tank cars, carrying flammable liquids involved in other rail accidents.

[00:24:58] The Australian transportation safety bureau has released a preliminary report for its ongoing investigation into the fatal accident involving a Cessna 1 72 conducting power lines survey work near Sutton north of Ken Canberra on 13th, April. The report says on. 13, April, 2021 at about 1324 Eastern standard time.

[00:25:24] The pilot of a Cessna R 1 72 K aircraft registered Victor hotel, Delta Lima, alpha departed Canberra airport, Australian capital territory with an observer on board to conduct power line survey, work to the north of Sutton new south Wales at 1622 Delta Lima alpha crossed. Talla again, DRA lane and proceeded with survey work, concentrating on power lines, servicing properties to the east of the lane.

[00:25:56] Following the completion of two orbits at 1624, the pilot initiated a right turn and track to the Northeast witnesses in the area, described the aircraft flying low above the trees before commencing a left banking turn followed by steep descent and collision with terrain. Witness reports indicated that the loss of control and entry into the spin proceeded ground impact the pilot and the observer were fatally injured analysis of the recorded garment, GPS and Oz runways flight data identified that the last garment GPS data point at 1624 and 48 seconds.

[00:26:34] Show the height of the aircraft to be about 164 feet above ground level. And about 115 meters from the wreckage. The final Oz runways data point at 1624 and 50 seconds was about 80 meters from the accident site. The wreckage was located in an open field about 30 meters east of tele Kendra lane, and about 10 kilometers to the Northwest of Sutton.

[00:27:03] There was little spread of the wreckage with few parts liberated in the accident, sequence, larger items, including the propeller and the right under carriage leg were found next to the fuselage items from the luggage locker were located within five meters of the initial impact point. The most distant item from the main wreckage was the aircraft battery, which was found near the edge of telling Kendra lane.

[00:27:28] Examination of the records show the aircraft impacted the ground in a near vertical nose down attitude. Delta Lima alpha was a single engine Cessna. Our 1 72 K aircraft. It was manufactured in the United States in 1977 with serial number Romeo, 1 7 2 2 8 0 Niner and first registered in Australia in 1978.

[00:27:53] To date the HTSP has examined the wreckage collected items for further examination, interviewed witnesses, retrieved flight related, electronic data, collected weather data from the bureau of meteorology and interviewed the operator. The investigation is continuing and will include further examination and analysis of the aircraft flight path, including analysis of recorded flight data.

[00:28:18] Pilot qualifications experience and medical history, pilot flight, and duty periods, aircraft, weight, and balance aircraft maintenance records and flight survey, operational procedures should a critical safety issue be identified during the course of the investigation. The ATSB will immediately notify relevant parties, so appropriate and timely safety action can be taken.

[00:28:40] The final report will be released at the conclusion of the investigation. And the HTSP also issued an investigation progress update on the loss of control and collision with terrain involving a Robinson  for Victor hotel hotel, Oscar Bravo near Claire, south Australia on 22, December, 2020 says. On the morning of 22, December, 2020, the pilot of a Robinson R 44.

[00:29:08] Helicopter was conducting aerial agricultural spray operations on a property, 13 kilometers Southeast of Clara valley aerodrome south Australia. After completing numerous spray runs throughout the morning, the pilot was preparing to land the helicopter adjacent to a loading vehicle for punishment of chemical product by ground crewman.

[00:29:29] When he loud bang emanated from the rear of the helicopter. The pilot reported that following the noise, the helicopter descended rapidly and there was significant resistance from flight controls, the helicopter collided heavily with the loading vehicle coming to rest on its side. The pilot and crewmen were uninjured.

[00:29:50] The operators preliminary onsite assessment of the substantially damaged helicopter identified that a mechanical disruption had occurred to the drive system. The TSPs preliminary metallurgical examination of the drive train components identified that the clutch shaft forward the Oak and fractured the fracture occurred at the bolt hole on the yolk lug that connected with the Ford flex plate and was due to the development of a fatigue cracking that progressed almost entirely through the yolk cross section.

[00:30:21] The fracture resulted in the loss of engine drive to the main rotor system. Corrosion product and fretting damage were identified in the vicinity of the bolt hall, adjacent to the fatigue fracture surfaces. The airworthiness of the yolk is not limited to total time in service and is required to be inspected at every 100 hour or annual inspection.

[00:30:44] The opportunity to conduct a detailed examination of the contact surfaces for defects is generally limited. To those occasions when the bolts are removed and the yolk is separated from the forward flex plate that is only scheduled to occur during 12 year, 2,200 hour overhaul inspections, a general visual inspection of the assembled clutch shaft yoked during the 100 hour or annual inspection may not identify defects such as corrosion, fretting and or cracking.

[00:31:16] The investigation is continuing and will include. A review of the helicopter maintenance records and maintenance schedule and assessment of components from the hydraulically assisted flight control system. Further examination of the main rotor drive, train assembly. Should any safety critical issue be identified during the investigation?

[00:31:37] The ATSB will immediately notify relevant parties so that appropriate and timely safety action can be taken. And then they also released the. Interim report outlining planned safety action. Following the Wallen XPT derailment, the announcement reads a number of safety actions are planned and proposed as a result of the derailment of an XPT passenger train near Wallan Victoria on 20 February, 2020 Melbourne bound XPT passenger train S T 23 operated by NSW train link.

[00:32:11] Derailed after entering a passing loop at the speed, probably between 114 and one or 27 kilometers an hour. The interim report notes that the speed limit for entering the loop was 15 kilometers an hour with the train, unable to negotiate the turnout at that speed, the lead power car rolled onto its side and all five passenger cars derailed only the rear unoccupied power car did not derail.

[00:32:39] And they published the interim report on their website and they say the interim report details, factual information established in the investigations evidence collection phase, and the HTSP interim observations of that evidence and interim report has been prepared to provide progress information to the public and rail industry and information on safety actions.

[00:33:00] So far taken the interim report does not contain findings or safety factors that will be detailed in the final report. The information contained in the interim report is released in accordance with section 25 of the transportation safety investigation act 2003. Our next story is out of Argentina. The Argentinas civil aviation accident investigation board says a Cessna six 80 landed gear up after crew silence, cockpit alarms.

[00:33:28] I am probably going to do a horrible job of pounding, announcing the names in this. It says the Cessna six 80 citation sovereign took off from San Fernando international airport bound for a private airstrip near Chuck kin. The Gonzalez a stop  was made at Salta airport. The aircraft took off from at 12, 15 local time and after 15 minutes of flight.

[00:33:57] With the runway insight, the cruise silence, the oral alarms of the tos in order to avoid such alarms since the aerodrome was not registered in the aircraft database. In the final landing phase, the crew observed a block of medium sized birds that diverted their attention close to touchdown after checking instrument, readings, and speed.

[00:34:17] The crew sense that the aircraft continued to descend without making contact with the runway at the altitude. It normally did. While the aircraft was making contact with the runway. The commander in the non-flying pilot role lowered the landing gear lever, but was unable to complete the extension. The aircraft decelerated on the fuselage for 500 meters over the runway, and then exited the runway to the left with the aircraft stopped evacuation, took place.

[00:34:44] The passengers and crew were uninjured. The accident occurred during daylight and in good weather conditions. Conclusions regarding factors related to the accident are as follows prior to takeoff. The cockpit speaker mute function was activated, which was only enabled on the pilot and copilot headset.

[00:35:05] All warning entering proximity system audios were muted. The crew removed their headsets. During the final approach phase, the presence of birds during landing could have been a distracting factor in one of the most critical phases of flight. Procedural checklists were not used. And the landing gear was not extended back in the U S the U S department of labor sites, Cambria grain facility for workplace safety failures.

[00:35:31] Following engulfment death of a manager in corn silo from Cambridge to Wisconsin. After I worker who was clearing corn debris from the unsafe silo, failed to arrive for a regularly scheduled meeting employees called 9 1 1 when they could not find him at the silo. Nor reach him by phone. It took emergency services, nine hours to recover the body of the 52 year old manager found engulfed in the silo, operated by Didion milling, Inc, and Cambridge and OSHA investigation of the December 8th, 2020 fatality found that the manager entered the unsafe grain bin.

[00:36:10] Despite recently having an external process underway to remove corn from the clogged silo. OSHA also determined that the external process should have continued for several more days before allowing anyone to enter the grain bin. The agency issued four willful and 10 serious safety citations, most involving requirements for safe entry into grain storage structures and proposed $676,808 in penalties.

[00:36:39] Acting OSHA, regional administrator, William Donovan in Chicago said Didion. Milling’s failure to learn from recent incidents and follow industry standards and their own company policies cost this worker’s life. Six of every 10 workers trapped in grain Benz. Don’t make it out alive. This is a frightening and tragic reality safety standards are in place to protect workers from serious and fatal injuries.

[00:37:06] Didion Milling’s recent history includes a May, 2017 explosion that killed five workers and in and injured as many as 15 others and a large grain shelf claps in October, 2020, that nearly engulfed an employee who is cleaning the inside of a grain bin. Sun Prairie based Didion milling has been in operation since 1972.

[00:37:29] The company operates a corn milling and biofuels facility and Cambria. And production facilities in mark KZN and Johnson Creek and in New Jersey, us department of labor cited pharma biotech manufacturer for failing to protect workers from coronavirus at a Monmouth county facility and Eaton town manufacturer fail to protect employees adequately from workplace exposure to coronavirus the U S department of labor’s occupational safety and health administration determined.

[00:38:02] After an investigation into the deaths of two workers and hospitalization of two others who contracted the coronavirus in the fall of 2020 OSHA’s inspection found that. Avant tour fluid handling LLC failed to ensure physical distancing and then employees wore face mask in common areas. The agency cited the company for violating OSHA general duty clause.

[00:38:26] That requires employers to ensure workplaces are free from recognized hazards that may cause death or serious physical harm. In November, 2024 company employees tested positive for coronavirus and required hospitalization. By January, 2021, two of the workers, the husband and wife died due to complications related to the virus.

[00:38:47] Two other workers recovered and total 30 out of 50 employees at the facility tested positive for coronavirus, OSHA initiated the workplace safety and health investigation. After the company alerted OSHA of the workers, illnesses, OSHA alleges that Avantor failed to enforce safety protocols, such as distancing and mask wearing.

[00:39:08] That would have mitigated further spread of coronavirus in the locker, growing and break rooms at the Eatontown facility, the employer faces $13,653 in proposed penalties area director, Paula Dixon Roderick in Burlington. New Jersey said two workers lost their lives and others were sickened because their employer failed to take precautions necessary to keep them safe.

[00:39:33] Tragically this case should remind all employers of the importance of fully implementing coronavirus prevention procedures.

[00:39:41] And that’s it for this week’s news. And remember, you can find full shots with links@safetyinvestigations.net. You can follow her subscribe to this podcast on most podcast apps.

[00:39:51] Thanks for listening and have a safe week.

Safety Investigations News 6/4/2021

Summary

Safety Investigations news for 6/4/2021

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

NTSB

https://twitter.com/NTSB_Newsroom/status/1398345486222909444?s=20

https://twitter.com/LorraineMMartin/status/1398443992551993347?s=20

https://twitter.com/NTSB_Newsroom/status/1399014530051723265?s=20

https://twitter.com/NTSB_Newsroom/status/1398729818427072513?s=20

https://twitter.com/NTSB_Newsroom/status/1399951372934656007?s=20

https://go.usa.gov/x624Khttps://go.usa.gov/x6TBPhttp://go.usa.gov/xH3g3

https://www.ntsb.gov/news/press-releases/Pages/NR20210603.aspx

ATSB

http://www.atsb.gov.au/publications/investigation_reports/2021/aair/ao-2021-020/

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

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

NBAAI

NATIONAL BUREAU OF AIR ACCIDENTS INVESTIGATION OF UKRAINE (NBAAI) PRELIMINARY REPORT of Investigation into Serious Incident, Whi

Dutch Safety Board

https://www.onderzoeksraad.nl/nl/media/inline/2021/6/3/waarschuwing_luchtvaartmaatschappen_en_onderhoudsbedrijven.pdf 

OSHA

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

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

News Theme 1 by Audionautix is licensed under a Creative Commons Attribution 4.0 license. https://creativecommons.org/licenses/by/4.0/ Artist: http://audionautix.com/

Transcription

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

21-06-04 News

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

News Brief 5/28/2021

Summary

Safety Investigations news brief for 5/28/2021

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

NTSB_Newsroom (@NTSB_Newsroom) 

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

NTSB Opens Public Docket in Scandies Rose Sinking

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

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

Medical Incapacitation Led to Fatal I-75 Crash

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

Federal Aviation Administration Announces Results of Mexico’s Safety Assessment

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

Air transportation safety investigation report A20C0037

19 May 2021 – Marine news release 

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

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

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

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

Learjet 31a Performed Roll on Descent to Faro Portugal

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

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

Transcript

News Theme 1 by Audionautix is licensed under a Creative Commons Attribution 4.0 license. https://creativecommons.org/licenses/by/4.0/ 

Artist: http://audionautix.com/  — Send in a voice message: https://anchor.fm/safety-investigations/message Support this podcast: https://anchor.fm/safety-investigations/support

Transcription

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

21-05-28 News

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A System Approach to Traffic Safety, NTSB MWL Roundtable May 20, 2021

Summary

Our roadways were designed to move motor vehicles safely and efficiently. They often do not fully meet the needs of pedestrians, bicyclists, and motorcyclists-our vulnerable road users (VRUs). As a result, we are seeing increasing dangers to this population and too many accidents involving vehicles and VRUs.

We must use a Safe System approach to better protect VRUs and ensure safe roads for all. A Safe System addresses all aspects of traffic safety: road users, vehicles, speeds, roads, and post crash care. We must make better safety investments, from road treatments, vehicle design, and collision-avoidance systems to strong traffic safety laws and robust education efforts to mitigate injury risks for all road users.

Unlike motor vehicles, VRUs lack an external structure to protect them when crashes occur, and they’re more likely to suffer a serious injury or even death. Proven, effective countermeasures are being underused at the federal, state, and local levels to protect pedestrians, bicyclists, and motorcyclists. We have long been concerned with the threat to VRUs. In 2018 and 2019, we published three reports on the risks to this vulnerable population and issued more than 30 new recommendations focused on reducing VRU traffic deaths.

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 https://youtu.be/k0XgHY82R0o posted on the NTSBgov channel.

You can find the 2021-2022 NTSB Most wanted list on their website here https://www.ntsb.gov/safety/mwl/Pages/default.aspx 

For full show notes with links and to subscribe to this audio podcast go to http://safetyinvestigations.net — Send in a voice message: https://anchor.fm/safety-investigations/message Support this podcast: https://anchor.fm/safety-investigations/support

Transcription