News & Comment

United Airlines Suffers from ED (Error Dysfunction)

Posted by on 11:31 pm in Accidents & Incidents, Design & Certification, Fixed Wing, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Safety Culture, Safety Management

United Airlines Suffers from ED (Error Dysfunction) We have previously discussed a long running series of around 40 events when Fan Cowl Doors (FCD) were lost from Airbus A320 series aircraft, including: A319 Double Cowling Loss and Fire – AAIB Report ANSV Report on A320 Fan Cowl Door Loss: Maintenance Human Factors Tiger A320 Fan Cowl Door Loss & Human Factors: Singapore TSIB Report In each case the cowls had inadvertently been left unlatched and this had not been subsequently detected before flight. Airbus introduced a...

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Crossed Wires: Online Maintenance Human Factors Training Video

Posted by on 9:56 pm in Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Safety Culture, Safety Management

Crossed Wires: Online Maintenance Human Factors Training Video In need of inspiration for your maintenance human factor continuation training?  Why not use this free CASA HF video?: ‘Crossed Wires’ The 8.5 minute video from 2013 portrays the incubation of an incident at the fictitious Perfect Twins maintenance organisation. As part of a workshop activity participants could note down the human performance influencing factors and risk inducing behaviours as they occur. Then discuss these as a group afterwards and consider what...

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Swedish NH90 CFIT: Pilot Experience and Skating on Frozen Lake

Posted by on 8:17 pm in Accidents & Incidents, Helicopters, Human Factors / Performance, Military / Defence, Safety Management

Swedish NH90 CFIT: Pilot Experience and Skating on Frozen Lake The Swedish Accident Investigation Authority (SHK) has issued their report (in Swedish but with an English summary) on an serious incident at Lake Gilten south of Namsos, Norway on 27 February 2016. A Swedish Air Force NH90 helicopter (designated HKP14D), serial number 1080 (052), came in contact with the ground when low flying, during the preparations for an international exercise in Norway. The helicopter was number two in a two-ship formation consisting of two NH90s. They had...

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Coking Causes Power Loss: Australian AS350BA

Posted by on 6:47 pm in Accidents & Incidents, Helicopters, Maintenance / Continuing Airworthiness / CAMOs, Safety Management

Coking Causes Power Loss: Australian AS350BA On 2 November 2015, Airbus Helicopters AS350BA VH-SFX of GBR Helicopters was performing a low-altitude aerial weed spotting operation over dense forest in the Whyanbeel Valley, QLD. On board the pilot, a navigator and two aerial spotters.  The Australian Transport Safety Bureau (ATSB) explain in their safety investigation report that: …during the fourth flight of the day, the helicopter momentarily yawed twice within a short period in an uncommanded and unusual way. The pilot, concerned with...

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Unexpected Load: B407 USL / External Cargo Accident in PNG

Posted by on 4:17 pm in Accidents & Incidents, Helicopters, Human Factors / Performance, Logistics, Mining / Resource Sector, Safety Management

Unexpected Load: B407 USL / External Cargo Accident in PNG Bell 407 P2-HSE of Niugini Helicopters was destroyed during take off at Kiunga in Papua New Guinea following confusion about an underslung load according to an investigation report published by the PNG AIC. On 15 February 2017, at approximately 05:00 UTC (15:00 local), the pilot…was commencing a normal translational-lift takeoff, to the south-south west, across the aerodrome apron, and over the terminal buildings.  The flight was a VFR charter operation carrying two passengers...

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Running on Fumes: Fatal Canadian Helicopter Accident

Posted by on 11:34 pm in Accidents & Incidents, Helicopters, Human Factors / Performance, Regulation, Safety Culture, Safety Management, Special Mission Aircraft

Running on Fumes: Fatal Canadian Helicopter Accident In its investigation report into a fatal accident to Bell 206B Jet Ranger C-GHHU operated by Ridge Rotors. the Transportation Safety Board of Canada (TSB) concluded that the absence of a specific minimum fuel quantity was a key factor in a survey helicopter’s loss of power and collision with trees. History of the Flight On 5 September 2016, the helicopter was operating a daytime flight to survey mountain pine beetle near Whitecourt, Alberta with the pilot and two surveyors on board. This...

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Luxair F50 LOC-I Accident 6 November 2002

Posted by on 7:25 pm in Accidents & Incidents, Design & Certification, Fixed Wing, Human Factors / Performance, Safety Management

Luxair F50 Loss of Control – In-flight (LOC-I) Accident 6 November 2002 Cockpit confusion, a rushed approach, procedural deviations and a design flaw featured in a fatal turboprop LOC-I accident in Luxembourg in 2002. History of the Flight Fokker 50 LX-LGB of Luxair was operating a Berlin to Luxembourg flight on 6 November 2002 with 22 persons on board. According to the revised accident investigation report of the Luxembourg Ministry of Transport released in 2009 (and its appendicies), the aircraft had been in a hold at 8 h 52 min 49s,...

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How a Cultural Norm Lead to a Fatal C208B Icing Accident

Posted by on 5:43 pm in Accidents & Incidents, Fixed Wing, Human Factors / Performance, Safety Culture, Safety Management

How a Cultural Norm Lead to a Fatal C208B Icing Accident At 09:00 on 11 December 2015 Cessna 208B Caravan C-FKDL, operated by Wasaya Airways, departed Pickle Lake Airport (CYPL) Ontario to Angling Lake / Wapekeka Airport (CKB6) Ontario as flight WSG127.  This was a cargo flight under visual flight rules (VFR) operated by a single pilot. According to the Transportation Safety Board of Canada (TSB) final report: The aircraft was certified for day and night VFR as well as instrument flight rules (IFR) flight, and it was prohibited from flight in...

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Contained Failure / IFSD of a PW4056 on 2 October 2015

Posted by on 4:07 pm in Accidents & Incidents, Fixed Wing, Maintenance / Continuing Airworthiness / CAMOs

Contained Failure / IFSD of a PW4056 on 2 October 2015 On 2 October 2015, while in cruise at 33,000 feet, Delta Air Lines Boeing 747-451 N662US experienced a loss of power from its Number 3 engine, a Pratt & Whitney PW4056. The US National Transportation Safety Board (NTSB) say in their safety investigation report that the flight crew heard a loud “pop” that was followed by the engine’s N1 (fan speed) decreasing while the exhaust gas temperature (EGT) increased.  The engine was shut down and the aircraft diverted safely....

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High G Drama at Cold Lake

Posted by on 5:57 pm in Accidents & Incidents, Fixed Wing, Human Factors / Performance, Military / Defence, Safety Management

High G Drama at Cold Lake On 20 June 2017 two Royal Canadian Air Force (RCAF) Boeing CF-188 Hornets, call signs Mig-1 and Mig-6, were returned to CFB Cold Lake, AB after Maple Flag 50 training missions. When overhead runway 13R at 1500 ft above ground level and 470 knots, the RCAF safety investigators report that: Mig-1 entered the overhead break in a right hand turn followed three seconds later by Mig-6 [CF-188 CF188796]. During the overhead break Mig-6 set the throttles to idle, initially set the bank angle to 81 degrees, and pulled up to...

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