Reckless Flying Led To Swiss Ju-52 Crash
The Swiss Transportation Safety Investigation Board has determined a couple of highly experienced but reckless pilots flying a non-airworthy Ju-52 vintage aircraft entered a stall/spin that killed them, another crew member, and their 17 passengers on a sightseeing flight on Aug. 4, 2018. The aircraft was flown at low altitude and to close to the rugged terrain at low airspeed. The board deduced it was momentarily upset by turbulence that the pilots should have expected and accounted for in flying the plane in that area. The three-engine transport spun nearly vertically into a mountainside near Piz Segnas in the Swiss Alps. “The flight crew piloted the aircraft in a very high-risk manner by navigating it into a narrow valley at low altitude and with no possibility of an alternative flight path,” the board determined. “The flight crew chose a dangerously low airspeed as regard to the flight path.”
But the investigation also determined that the risky behavior was nothing new. “The flight crew was accustomed to not complying with recognized rules for safe flight operations and taking high risks,” the report said. Both pilots were high time former Swiss Air Force pilots who were well trained in mountain flying. The board said their decision to fly at about 300 AGL and about 100 feet horizontally from the ridges could not have been borne of ignorance. Rather, it said, it reflected a deficient safety culture that permeated every aspect of the company the operated that aircraft and its two sister Ju52s on hundreds of passenger flights every year.
“In particular, the air operator’s flight crews, who were trained as Air Force pilots, seemed to be accustomed to systematically failing to comply with generally recognized aviation rules and to taking high risks when flying Ju 52 aircraft,” the report said. It also found shoddy maintenance performed by technicians who were not up to the job and that the three BMW radial engines were not able to make full power. The tour company at the time of the crash, Ju-Air, went out of business in 2018 and a new company, Junkers Flugzeugwerke, is trying to regain government approval to operate the two remaining aircraft.
[Metro employees fear retaliation when reporting safety concerns, commission says] (wtop.com/tracking-…]
Some Metro employees fear retaliation for reporting safety concerns, according to the independent commission responsible for overseeing safety practices on Metro.
During a meeting Tuesday, the Washington Metrorail Safety Commission said that the rail agency still has a lot of work to do to improve its safety culture.
“What can we do about the fear of retaliation?” asked Chris Hart, chairman of the commission. “Has it been remedied or is it still a problem out there?”
The question came as the commission discussed a report detailing one incident from September when a crew conducted maintenance on the platform edge lights at the Tysons Corner station while the track was still energized, “putting the work crew at risk.”
“They felt that there was no potential for the workers to contact the third rail,” according to the report. “This is not accurate.”
Lawsuit alleges negligence in fatal medical helicopter crash
COLUMBUS, Ohio (AP) — A wrongful-death lawsuit has been filed against an air ambulance company over a medical helicopter crash in snowy weather that killed the three central Ohioans on board.
The suit alleges Survival Flight and operator Viking Aviation inappropriately and recklessly accepted a flight request from an emergency care facility in Pomeroy in January 2019 despite deteriorating weather conditions.
The case was filed this week in Franklin County by the estate of Rachel Cunningham, a 33-year-old flight nurse from Galloway. Pilot Jennifer Topper, 34, of Sunbury, and another medical crew member, 48-year-old Bradley Haynes, of London, also died.
The National Transportation Safety Board concluded that Survival Flight’s lax safety culture led the pilot to depart from Grove City without a thorough pre-flight weather evaluation. The helicopter crashed in rugged terrain near Zaleski, southeast of Columbus.
Survival Flight has said it learned from the tragedy and made changes recommended by the NTSB. In a statement in response to the lawsuit, a spokesperson didn’t specifically address the legal claims but said the company prioritizes safety and continues to improve.
Metro safety culture still needs work, board says
Metro’s safety culture came under scrutiny Tuesday as investigators disclosed that track workers were left vulnerable to train traffic or electric shock and other employees feared reprisal for raising concerns about safety. The Washington Metrorail Safety Commission, an independent panel Congress created three years ago to monitor safety at the transit agency, issued findings at its meeting from three investigations conducted last fall. The probes emphasized Metro’s need to create, update and reinforce safety standards — something the agency has pledged after the release of a September audit that included 21 safety failures or concerns within its Rail Operations Control Center. The commission’s audit included several safety concerns that have gone unresolved for years, but also noted cultural issues that investigators say created an atmosphere of racial and sexual harassment, willful ignorance of safety protocols, and low morale that has contributed to an understaffed control center.
Ep. 63 How subjective is technical risk assessment?
As risk assessment is such a central topic in the world of safety science, we thought we would dedicate another episode to discussing a facet of this subject. We loop back to risk matrices and determine how to score risks.
Join us as we try to determine the subjectivity of risk assessment and the pitfalls of such an endeavor.
Topics:
Risk matrices. Why the paper we reference is a trustworthy source. Scoring risks. How objective are we? How to interpret risk scores. What the risk-rating is dependent upon. Practical takeaways.
Quotes:
“The difference between an enumeration and a quantitative value is that enumeration has an order attached to it. So it let’s us say that ‘this thing is more than that thing.’ “
“I think this was a good way of seeing whether the differences or alignment happened in familiar activities or unfamiliar activities. Because then you can sort of get an idea into the process, as well as the shared knowledge of the group…”
“So, what we see is, if you stick to a single organization and eliminate the outliers, you’ve still got a wide spread of scores on every project.”
“We’re already trying pretty hard and if we’re still not converging on a common answer, then I think we need to rethink the original assumption that there is a common answer that can be found…”
Driving in India is a real-life video game
NEW DELHI: For Sunitha Dugar and her four companions who are part of a national “Safe Speed Challenge”, driving on Indian roads is nothing less than “playing a video game” in real life and one doesn’t know who will come from where on to the road. “When you are driving on the road, you should be prepared for surprises. So, it’s your responsibility to save yourself and save others. It’s actually a real video game on the road risking many lives,” said Sunita, an entrepreneur from Chennai. The five women from different walks of life are participating in the challenge that was flagged off by defence minister Rajnath Singh and road transport minister Nitin Gadkari from Wagah to Kanyakumari. Several factors, including poor infrastructure, unsafe driving, inadequate enforcement and trauma care have made Indian roads unsafe claiming 415 lives daily. Speaking to TOI, Neha Dua from Noida said, “We lack safety culture. More than speeding, speed management is the biggest challenge. You hardly find signage and road markings to help drivers”.
CCDI criticizes formalism, corruption in hotel collapse, chemical plant explosion
The Central Commission for Discipline Inspection (CCDI) of the Communist Party of China (CPC) criticized some government bodies and individual officials for engaging in formalism, bureaucracy, malpractice and corruption while disclosing details of the investigation into the collapse of a hotel used as a COVID-19 quarantine center in East China’s Fujian Province last year and the explosion at a chemical plant in East China’s Jiangsu Province in 2019.
Investigation details revealed in a TV series broadcast by China Central Television (CCTV) since Thursday exposed the problems in relevant organs in the collapse of an illegally constructed building used as a COVID-19 quarantine center in Quanzhou, East China’s Fujian Province on March 7, 2020, which caused 29 deaths, and the deadly explosion that struck a chemical plant in Xiangshui county, Jiangsu Province on March 21, 2019, which killed 78.
These problems show that official malpractice could inflict damages to people’s lives, health and property safety, and corruption is the biggest source of pollution in the political ecosystem, the CCDI pointed out.
According to the CCDI, former official Liu Deli from the fire department of Quanzhou failed to fulfill his responsibilities, abandoned his supervision responsibility for his own personal interests and connived in the illegal reconstruction of the hotel.
Department of Labor Awards Delta Air Lines Whistleblower $500,000 in Compensatory Damages
On December 21, 2020, a Department of Labor (DOL) Administrative Law Judge awarded a whistleblower $500,000 in compensatory damages and found that Delta Air Lines (Delta) violated the whistleblower protection provision of the Wendell H. Ford Aviation Investment and Reform Act for the 21st Century (AIR 21).
Karlene Petitt is currently employed as a First Officer for Delta. In March of 2011, Petitt “complained about Captain Thomas Albain’s simulator training.” Years later, in January of 2016, Petitt met with two Captains and provided Delta “with a 43-page written safety report entitled ‘Assessment of Delta Air Lines ‘Flight Operations’ Safety Culture,’” according to the decision. A different Captain presented Petitt with a March 17, 2016 letter that “advised her that she was removed from service…based on alleged concerns regarding [Petitt’s] mental health and whether she still met the standards required for a First Class Medical Certificate.”
Apple reportedly took years to drop a supplier that used underage labor
In 2013, Apple found that one of its suppliers, Suyin Electronics, a firm that made HDMI and USB ports for the company’s MacBook lineup, had employed underage workers. The manufacturer promised to clean up its act, but a follow-up investigation by Apple found three more underage workers, including one 14-year-old, on Suyin’s assembly lines. While Apple didn’t give Suyin new work in the aftermath of its findings, it continued to work with the firm due to some existing contracts, and it took the better part of three years before it finally cut ties.
In the other example, Apple conducted an investigation into Biel Crystal, a company that makes glass screens for the iPhone. After Apple found that “the environmental, health and safety culture in Biel is weak among all levels of management,” it called for more than two dozen corrective measures. However, one year after the investigation, Biel had yet to implement many of the improvements Apple ordered, and the two continued to work with one another partly because removing Biel from its supply chain would have left
Head of WorkSafe ACT concerned about repeated safety breaches
The head of the ACT’s workplace compliance watchdog has been appalled at the lack of safety across residential construction sites in Canberra and fears another construction site death without a cultural change.
The ACT work health and safety commissioner Jacqueline Agius has likened the reckless attitude of some builders to those who speed or drink drive.
She has been particularly shocked by the number of repeat offenders.
WorkSafe ACT has issued 282 safety notices to residential building sites over the past five months.
The watchdog has conducted mass inspections across the territory’s greenfield suburbs as part of a three-year campaign to crackdown and change the safety culture of Canberra’s residential construction sites.
The Operation Safe Prospect campaign was prompted following the death of two workers in separate incidents at Denman Prospect construction sites in early 2020.
Mexico AW109 Crash Now a Homicide Investigation
Mexican authorities detained four people on Friday in connection with the December 2018 fatal crash of a 2011 Leonardo AW109S (XA-BON) that killed all aboard, including National Action Party opposition party member and Puebla state governor Martha Alonso, her husband senator Rafael Moreno Valle, an aid to Valle, and both pilots. The helicopter crashed minutes after takeoff on a flight from Puebla to Mexico City.
The Puebla attorney general said the four detained—all employed by Toluca-based Rotor Flight Services (RFS) at the time of the accident—were being investigated for homicide and making false statements. Accident investigators, led by Mexico’s DGAC with assistance from both the NTSB and Canada TSB, concluded that a known, preexisting problem with the helicopter’s stability system should have grounded it from further flight before the accident.
A final accident report from Mexico’s Agencia Federal de Aviacion Civil found the helicopter crashed due to a sudden left roll, causing loss of control that deteriorated into inverted flight and impact into terrain. It said the uncommanded roll could have been caused by loose actuator screws contacting the stability system’s electronic card.
Listed contributory factors included “ineffective maintenance practices” by RFS, inadequate safety culture at operator Altiplano Air Services, pressure on the operator to continue flight operations despite intermittent malfunction of the stability system during prior flights, and insufficient governmental maintenance and operations supervision.
Pinoys need a safety culture to adapt to the new normal businessmirror.com.ph/2020/12/2…
The new normal demands a “safety culture” as preventing the spread of the Covid-19 virus is contingent on public compliance and private sector cooperation.
Dr. Arnold Tabun, National Auditor of the Philippine College of Occupational Medicine, however noted that the response to the Covid-19 pandemic by the different countries around the world vividly exposed the differences in the cultural values of Eastern and Western societies.
He cited that South Korea, Taiwan, Japan, Thailand, Singapore, Vietnam, and even Cambodia were able to manage the pandemic better than their Western counterparts.
Japan operator says human error caused Mauritius oil spill
TOKYO (AP) — The Japanese operator of a bulk carrier that struck a coral reef and caused an extensive oil spill off the coast of Mauritius said Friday that the accident occurred after the ship shifted its course two miles (3.2 kilometers) closer to shore than planned so its crewmembers could get cellphone signals.
Mitsui O.S.K. Lines said its investigation showed the accident was caused by human error, including inadequate nautical charts, navigation systems and risk awareness, and a lack of supervision and safety monitoring.
The company said the tanker’s nautical chart provided little information about depth and other necessary information. Crewmembers on duty also failed to conduct safety checks visually or by radar, it said.
The captain and crewmembers were also using their cellphones while on duty, the company said.
It said it will invest about 500 million yen ($4.8 million) to provide electronic nautical charts, training to strengthen safety culture and other systems to enhance safety.
The environmental disaster began July 25 when the ship MV Wakashio strayed off course and struck a coral reef a mile (1.6 kilometers) offshore. After being pounded by heavy surf for nearly two weeks, the ship’s hull cracked and on Aug. 6 began leaking fuel into a lagoon, polluting a protected wetlands area and a bird and wildlife sanctuary.
NTSB Investigation Into Fatal Plane Crash Reveals Mechanical Problem, Changing Safety Culture
The captain of flight 3296 had been flying into Unalaska for about three months. On the day of the crash, he had logged 131 hours in a Saab 2000 — less than half the historical requirement for PenAir pilots responsible for bringing flights into the Aleutian city. His first officer had a few hours more. Both had been hired by the company in May of that year.
The NTSB’s investigation describes the airline’s safety culture following PenAir’s sale to RavnAir Group. Ravn’s safety director told investigators he considered the overall safety culture as “still good,” but admitted that pilots had approached him saying they were “not as comfortable anymore” speaking freely about their concerns.
A Ravn VP of flight operations told investigators the requirement was not consistent with how other commercial air carriers operated in the Lower 48.
“I’m not convinced that it’s necessary because it’s not done elsewhere,” the VP said. “There are mountains around the country, around the world. Air is air. Physics are physics. Why is this different?”
Vazquez: Research shows drivers know it’s wrong, do it anyway
The AAA Foundation for Traffic Safety’s latest research finds drivers who have been in at least one crash in the past two years are significantly more likely to engage in risky behaviors like speeding or texting, even when they think the police may catch them. After months of staying at home, we at AAA urge drivers to keep everyone safe on the roads and warn motorists against falling back into dangerous driving habits.
The frequency of drivers in the United States engaging in improper behavior is too high. While drivers acknowledge certain activities behind the wheel like texting, are dangerous, some do them anyway, We need to be aware of the serious consequences of engaging in these types of dangerous driving behavior and change course.
The Foundation’s annual Traffic Safety Culture Index, which highlights the gap between drivers’ attitudes and their reported behaviors, found drivers perceive distracted, aggressive and impaired driving as dangerous. Yet many of them admitted to engaging in at least one of these exact behaviors in the 30 days before the survey. The numbers were even higher for those involved in a recent crash:
Ep.57 What is the full story behind safety I and safety II (Part 1)?
Quotes:
“Most theories are billed as critiques of other theories. So, any new theory implicitly, and usually, explicitly criticizes a lot of existing stuff. And it’s important to separate those two things out.”
“He says that success and failure are not opposites.”
“It means that every single data point, then, has a lot of uncertainty attached around to it, because they’re such isolated examples, such extraordinary events…”
After grueling hearings on Capitol Hill, the day before the final ruling from the FAA, the House unanimously passed a bill by voice vote that reforms the plane certification process.
The bill, among other things, requires an expert panel to evaluate safety culture and recommend improvements and mandates aircraft manufacturers to adopt safety management systems and to complete system safety assessments for significant design changes. The bill awaits a vote in the Senate.
Some consumers are still concerned that the extensive recertification process and changes to software and company culture are not enough. Airlines are allowing free flight changes to passengers worried about the Boeing 737 Max, and the company is fighting to repair its reputation.
Black Hat Europe: Hackers Need to Educate Policymakers
Governments are increasingly calling on security researchers and the academic hacking community to improve the state of cybersecurity by better informing policymakers. And businesses must do more to foster a “safety culture” in which input from security teams gets translated into ongoing problem-solving.
… Learn From Aviation’s Safety Culture Cooper also spoke from the perspective of his having served as a U.K. Royal Air Force pilot flying Tornado fighter aircraft. Subsequently, he became an air force safety officer in charge of creating an engaged “reporting culture” in which individuals felt comfortable enough to “readily report problems, errors and near misses” so the organization could target the underlying problems.
“Aviation had really huge accident rates until the sector really started digging into the culture and understanding of what was causing those accidents - and it absolutely transformed safety,” he said.
Many organizations, however, are not set up to foster the required levels of input and action from their cybersecurity teams. “Really, the final keystone of that culture is a questioning culture, empowering individuals to speak up if they see risks, mitigations or opportunities,” he said. “And if they think something isn’t right, even if they don’t know the solution, it’s really important to hear their voice.”
Japan court revokes permits at 2 reactors over quake safety
TOKYO — A Japanese court on Friday revoked the operating permits of two nuclear reactors for having inadequate earthquake safeguards, a ruling that challenges safety assessments conducted by the nuclear regulator and could influence the outcome of other court cases. The Osaka District Court revoked the permits of the No. 3 and No. 4 reactors at the Ohi nuclear power plant in Fukui in western Japan. Japan’s Nuclear Regulation Authority had approved the restart of the two Ohi reactors, run by Kansai Electric Power Co., in 2017 and granted them operating permits. Nuclear safety standards were tightened and reactors were reexamined after the 2011 Fukushima nuclear disaster, which highlighted what investigators termed lax oversight and a lack of a safety culture. In its ruling, the court upheld demands by about 130 plaintiffs that the two reactors be shut down because of insufficient resistance to major earthquakes.
Fire strikes Equinor plant in Norway that includes Europe’s largest ethanol facility
A fire broke out on Wednesday afternoon at An Equinor-operated industrial complex in Norway that includes Europe’s largest ethanol production facility.
The fire erupted at the Tjeldbergodden facility at 2.40pm local time time on Tuesday and, according to the state-controlled operator, was extinguished at 3:40pm.
According to the police department for the More and Romsdal district, there was much smoke associated with the fire. … The company’s statement on the fire, issued around 5pm local time on Wednesday, continued: “Equinor has clear priorities in a crisis. Our first priority is to attend to the people who are involved in the situation, then, the environment and our surroundings, and finally to protect the technical integrity of the plant and our industrial interests.”
Equinor recently experienced a serious fire at its Hammerfest LNG plant at Melkoya in Norway’s far north. That fire resulted in the facility being closed for at least a year.
The company has also been hit with some criticism over its safety culture in recent months.
Failures in following the SMS led to fatal accident
The MAIB has published the report into the Karina C accident which has found several contributing factors to the second officer’s death.
Ultimately it outlines the importance for shipping companies of ensuring all their vessels are compliant with their Safety Management System (SMS) at all times. It was found that there was a weak safety culture on board and that company procedures were not being followed, including the company’s drug and alcohol policy.
This is a pertinent reminder for all ship operators to ensure their SMS procedures are reviewed on a regular basis. It also outlines the importance of having an efficient employee confidential reporting system to enable crew to confidentially report problems on board and avoid the potential issues that may arise in the future.
New Zealand officials file charges over deadly White Island volcano eruption
New Zealand officials have filed charges against 13 parties that allegedly failed to meet their health and safety obligations when visiting an active volcano which killed 22 when it erupted last year.
White Island, which is also known by its Maori name Whakaari, is an active volcano off the coast of New Zealand’s North Island. It was a popular tourism destination before it erupted in December 2019, killing local guides and visitors.
The country’s workplace health and safety regulator, WorkSafe New Zealand, announced Monday that it had filed charges against 10 organizations and three individuals, alleging they did not do what was reasonably practicable to ensure the health and safety of workers and visitors to White Island.
The organizations each face a maximum fine of 1.5 million New Zealand dollars ($1.1 million), while the individuals face a maximum fine of 300,000 New Zealand dollars ($211,000).
“This was an unexpected event, but that does not mean it was unforeseeable and there is a duty on operators to protect those in their care,” said WorkSafe chief executive Phil Parkes.
In the weeks before the eruption, New Zealand volcano monitoring service GeoNet raised the alert level on White Island to Level 2 out of 5, meaning there was “moderate to heightened volcanic unrest.”
Forty-seven people were on the island at the time of the blast, including honeymooners and families, and Parkes said they had gone there with the expectation that systems were in place to make sure they made it home safely.
“That’s an expectation which goes to the heart of our health and safety culture,” he said. “As a nation we need to look at this tragedy and ask if we are truly doing enough to ensure our mothers, fathers, children and friends come home to us healthy and safe at the end of each day.”
The head of the Tennessee Valley Authority acknowledges that the commitment to excellence and safety by the managers and employees of the federal utility wasn’t what it should have been in the past, which contributed to TVA receiving record fines over the past year for previous safety violations at its nuclear plants.
But as a licensed nuclear engineer who has helped run three of North America’s biggest nuclear power programs, TVA President Jeff Lyash insists TVA can and is doing better today.
“TVA’s nuclear program in decades past was too accepting of mediocrity and just rising to the average,” Lyash said in an interview with the Times Free Press this week. “That’s not a nuclear program we want. We want a nuclear fleet that is best in the industry.”
Lyash said the penalties imposed against TVA earlier this month for regulatory violations five years ago during the restart of a Tennessee nuclear power plant underscore some of the deficiencies at TVA in the past. The NRC gave TVA three fines totaling $903,471 for providing inaccurate and insufficient information to regulators and violating proper procedures in November 2015 when pressurized water levels rose uncontrollably during the restart of the Unit 1 reactor at the Watts Bar Nuclear Plant.
House passes bill to reform plane certification process after two Boeing 737 Max crashes
The 737 Max has been grounded since March 2019 but the FAA is set on Wednesday to approve the plane’s return to service after a lengthy review, new software safeguards and training upgrades. The House bill, approved on a voice vote, requires an expert panel to evaluate Boeing’s safety culture and to recommend improvements. It also mandates that aircraft manufacturers adopt safety management systems and complete system safety assessments for significant design changes.
Why Would Uber Sell Its Autonomous Driving Group?
In November 2019, the National Transportation Safety Board (NTSB) issued a report on a March 2018 incident in which an Uber autonomous vehicle in Phoenix killed a pedestrian. Among the NTSB’s findings was this one: “The NTSB concludes that the Uber ATG did not adequately manage the anticipated safety risk of its automated driving system’s functional limitations, including the system’s inability in this crash to correctly classify and predict the path of the pedestrian crossing the road midblock.”
Further, according to the NTSB, “The Uber ATG’s inadequate safety culture created conditions—including inadequate oversight of vehicle operators—that contributed to the circumstances of the crash and specifically to the vehicle operator’s extended distraction during the crash trip.”
The COVID-19 pandemic has pushed Uber’s traditional ride-sharing business into the background and, had it not been for the company’s Uber Eats delivery service, the company’s results would have been much worse. Uber’s $2.65 billion acquisition of delivery service Postmates is expected to close this quarter.