Another US business jet accident highlights poor checklist use and SMS ‘shelfware’ according to the BEA report into the 2012 accident.
Fatal G-IV Runway Excursion Accident in France – Lessons Read Post »
AAIB: The helicopter was operated for a “sustained period” with the fuel transfer pumps off despite low fuel warnings being triggered and acknowledged.
AAIB Report on Glasgow Police EC135T2+ Clutha Helicopter Accident Read Post »
Misloading Caused Fatal 2013 DHC-3 Otter Accident The US National Transportation Safety Board (NTSB) investigation into a fatal accident to Rediske Air de Havilland DHC-3T Otter N93PC in Soldotna, Alaska on 7 July 2013, has determined it was caused by misloading. A passenger iPhone video of the aircraft’s take-off was recovered from the wreckage and analysed. The full report can be
Misloading Caused Fatal 2013 DHC-3 Otter Accident Read Post »
EASA Annual Safety Review 2014 Published The European Aviation Safety Agency (EASA) Annual Safety Review for 2014 is now available at: https://www.easa.europa.eu/newsroom-and-events/general-publications/annual-safety-review-2014 Worldwide in 2014, 16 fatal accidents involved Commercial Air Transport (CAT) aeroplanes (excluding MH17, that was considered to be a hostile act). This was two more than 2014, but still significantly below the average number of fatal accidents
EASA Annual Safety Review 2014 Published Read Post »
Aircraft Maintenance: Going for Gold? We pose the question: Can aviation maintenance learn lessons from championship athletes? Aerossurance is pleased to have sponsored the Royal Aeronautical Society (RAeS) conference Human Factors in Engineering – the Next Generation at Cranfield University on 12 May 2015. In his opening address Cranfield University’s Professor Dave King (a former Chief Inspector of Air Accidents with
Aircraft Maintenance: Going for Gold? Read Post »
Fatal Night-time UK AW139 Accident Highlights Business Aviation Safety Lessons The UK Air Accidents Investigation Branch (AAIB) has published their report into the fatal accident to AgustaWestland AW139 G-LBAL on 13 March 2014. This accident reinforces many important past lessons on business aviation safety, managing clients, training, human factors and learning from previous accidents. The helicopter, owned by Haughey Air, departed from a
Fatal Night-time UK AW139 Accident Highlights Business Aviation Safety Lessons Read Post »
BA Changes Briefings, Simulator Training and Chart Provider After B747 Accident According to a recently released UK Civil Aviation Authority (UK CAA) FACTOR (Follow-up ACTion on Occurrence Report), British Airways (BA) have enhanced their simulator training and changed chart provider in response to a ground accident in South Africa. The Accident On 22 December 2013, BA G-BNLL sustained substantial
BA Changes Briefings, Simulator Training and Chart Provider After B747 Accident Read Post »
An NTSB report on an EC130 helicopter wirestrike accident that illustrates the need fully plan and risk assess last minute changes in plan.
Beware Last Minute Changes in Plan Read Post »
Misfuelling Accidents Misfuelling aircraft with kerosene based Jet A-1 rather than Aviation Gasoline (AVGAS) continues to be a source of accidents. PA31 15 Sept 2015 Manitoba The Canadian Transportation Safety Board (TSB) has recently released an update on the 15 September 2015 accident involving twin engined Keystone Air Service Piper PA31-350 Navajo C-FXLO at Thompson, Manitoba. Shortly after takeoff the aircraft experienced a
Misfuelling Accidents Read Post »
French Skyscraper HESLO: Helicopter Underslung Load A stunning video, from Bouygues Construction, shows the construction of the the tower on top of the €124 million Incity building in Lyon, the third highest in France. The last two components of the tower were lifted into place by an Airbus Helicopters AS332C helicopter on Sunday 21 June 2015 as a Helicopter External Sling Load Operation (HESLO). The spire,
French Skyscraper HESLO: Helicopter Underslung Load Read Post »
Aerossurance Sponsors Human Factors in Aviation Safety Conference Aerossurance is pleased to sponsor the Chartered Institute of Ergonomics & Human Factors’ (CIEHF) Human Factors in Aviation Safety Conference that takes place at the Radison Blu Hotel, East Midlands Airport, 9-10 November 2015. Aerossurance was keen to sponsor this event as it is such an excellent independent professional
Aerossurance Sponsors HF in Aviation Safety Conference Read Post »
Critical Maintenance Tasks: EASA Part -M & -145 Change Commission Regulation (EU) 2015/1536 was issued on of 16 September 2015. Technically it amends Regulation (EU) No 1321/2014 “as regards alignment of rules for continuing airworthiness with the ‘Basic Regulation’ Regulation (EC) No 216/2008“. Critical Maintenance Tasks (CMTs) One of the most important parts of the amendment relates to CMTs, which
Critical Maintenance Tasks: EASA Part-M & -145 Change Read Post »
This dual engine incident highlights maintenance fatigue and Management of Change at both a macro level (corporate restructuring) and the micro level (a new task).
The Missing Igniters: Fatigue & Management of Change Shortcomings Read Post »
The failure of a GE GEnx engine shaft on an Air India Boeing 787 during engine runs at the factory in 2012.
B787 GEnx Fan Shaft Failure Read Post »
Fatal G-IV runway excursion: take off with gust lock engaged. Contributing: habitual noncompliance and inadequate certification.
Gulfstream G-IV Take Off Accident & Human Factors Read Post »
Loss of MV Derbyshire 9th September 1980 On 9th September 1980 the Bibby Line OBO (oil/bulk/ore) carrier MV Derbyshire sank during Typhoon Orchid in the South China Sea. All 44 people on board died. The Derbyshire, at 90,000 gross registered tons, remains the largest UK registered ship ever to be lost at sea. Until 1994 the location of
Loss of MV Derbyshire 9th September 1980 Read Post »
HTAWS Technology: Friend or Foe? Technology has great potential to reduce aviation risk. The European Helicopter Safety Team (EHEST) issued a study in October 2014 on the safety value of technology. Terrain Avoidance and Warning Systems (TAWS) have proved highly effective at fixed wing Approach and Landing Accident Reduction (ALAR). On 20 February 2014, the Federal Aviation
HTAWS Technology: Friend or Foe? Read Post »
The Contrarian Director Public companies should appoint a “Contrarian Director” to systematically challenge management recommendations, says Australian corporate lawyer Siobhan Sweeney. Sweeney won the 2015 Cambridge-McKinsey Risk Prize at the Centre for Risk Studies at University of Cambridge Judge Business School for her paper on the subject: In the current economic climate marked by volatility and uncertainty, risk oversight
The Contrarian Director Read Post »
Mid Air Collision Typhoon & Learjet 35 During ‘Renegade’ air interception training a civilian Learjet 35, D-CGFI, collided with a Luftwaffe Eurofighter Typhoon. The German Federal Bureau of Aircraft Accidents Investigation (BFU) have issued their final report and we attended an excellent briefing by the BFU at the ISASI 2015 conference. In Germany, as in the UK, air
Mid Air Collision Typhoon & Learjet 35 Read Post »
Shell Moerdijk Explosion: “Failure to Learn” On 3 June 2014 two major explosions and a fire occurred at a Shell petrochemical plant in Moerdijk, Netherlands. Two employees were injured in the explosions that were heard 20 km away. Debris was found 800 metres away. The Dutch Safety Board has investigated this incident. Currently only the investigation summary
Moerdijk Explosion: “Failure to Learn” Read Post »
International Society of Air Safety Investigators Seminar 2015 Aerossurance will be attending the 46th annual seminar of the International Society of Air Safety Investigators (ISASI) 24-28 August 2015, in Augsburg, Germany. Organised by the society’s European chapter, the European Society of Air Safety Investigators (ESASI), this year’s theme is ‘Independence does not mean Isolation’. Programme Aerossurance has
ISASI Seminar 2015 – ‘Independence does not mean Isolation’ Read Post »
CHIRP – Independent Review The results of an independent review on the work of CHIRP (the Confidential Human Factors Incident Report Programme) have just been published by the British charitable trust. CHIRP Chief Executive Ian Dugmore commented that the review: …reaffirmed the requirement for an independent and confidential reporting system for the UK and recommended that
CHIRP – Independent Review Read Post »
A military accident investigation has paradoxically determined that a $62.4mn fire was due to a maintenance error but that no human factors were involved.
USAF RC-135V Rivet Joint Oxygen Fire Read Post »
Rockets Sleds, Steamships and Human Factors: Murphy’s Law or Holt’s Law? Murphy’s Law: Whatever can go wrong, will go wrong. To some a pessimistic inevitability, to others a call to arms for defensive design to prevent opportunities for failure. We look at how that ‘law’ was named and how the origins of the ‘law’ actually stretch back to a Liverpool ship-owner
Rockets Sleds, Steamships and Human Factors: Murphy’s Law or Holt’s Law? Read Post »
Fuel System Maintenance Error: Tuniter ATR72 TS-LBB Ditching 6 August 2005 On the 6 August 2005 a Tuninter ATR72 turboprop aircraft, TS-LBB, flying from Bari, Italy to Tunis, Tunisia, ran out of fuel and ditched off the northern coast of Sicily. Of the 39 people on board, 16 died. The aircraft had been erroneously fitted during maintenance with
Fuel System Maintenance Error: Tuniter ATR72 TS-LBB Ditching 6 August 2005 Read Post »
