Report lists multiple factors in fatal accident

  • Published
ROBINS AIR FORCE BASE, Ga. (AFPN) --  An Air Force report concluded multiple safety violations led to an August accident resulting in the death of one Airman and the serious injury of another.

Senior Airman Jesse Williamson Jr. died, and Senior Airman Ryan Robinson sustained serious injuries when the boom lift from which they were working from toppled Aug. 23.

According to the report, the boom lift had been raised earlier that morning to change a light bulb about 58 feet above the hangar floor, and the operators were in the process of positioning it for a subsequent bulb change when the incident occurred. Although both Airmen were wearing harnesses and were secured to the lift platform by lanyards, they were using the incorrect type of lanyard and were ejected from the basket.

“This tragedy should never have happened,” said Maj. Gen. Michael A. Collings, Warner Robins Air Logistics Center commander here. “This report shines a bright light on the culture of risk-taking that grew over the years at the Warner Robins Air Logistics Center. It is a culture that we are attacking head-on through an effort we call operation risk reduction. We started this operation soon after this accident occurred.

“We will not rest until we have established a culture here that embraces the idea that safety is everyone’s responsibility, where training is valued and where people understand the need for discipline, accept accountability and responsibility and embrace the Air Force core values,” he said.

The accident report indicates “multiple failures at various levels,” from the individuals of the work crew, to supervisors and leaders in multiple chains of command and in multiple areas. “While it is arguable whether some of these failings were instrumental in leading to the (accident), they nonetheless indicate multiple failures that contributed to an unsafe work environment,” the report stated.

The report makes several mentions of “culture” as a factor in the accident. “When actions/behavior, whether positive or negative, occur over an extended period of time or geography, they become recognized as ‘the way we do things …’ As these actions/behaviors become more ingrained, they tend to become accepted as cultural and continue to exert an influence that often is not even discernible,” the report stated.

The report also noted the failure of safety interlocks designed to prevent elevation of the boom above horizontal and extension of the boom beyond 10 feet when the axles were not extended.

Additionally, the report found inadequate training and experience as a probable cause in several areas. It listed failure to recognize the lift was being placed in an out-of-balance condition, the strong possibility the lift was being operated in a nonstandard configuration, and failure to recognize unacceptable configuration of the lift until it was too late. The report also listed failure to wear hard hats, failure to ensure correct lanyard attachment and failure to perform a daily safety check of the lift, including axle extension as directed on the ground control panel door of the lift and required in the operator’s manual.