Plan Continuation Bias & IIMC in Kenyan Police AW119 Accident
A police helicopter presses on for a second time into deteriorating weather.
Plan Continuation Bias & IIMC in Kenyan Police AW119 Accident Read Post »
USAF MQ-9A Reaper Lever Confusion: Human Factors
We look at a takeoff accident to a USAF UAS where the engine condition lever was retarded instead of the flaps being retracted.
USAF MQ-9A Reaper Lever Confusion: Human Factors Read Post »
The Curious Case of the Missing Shear Pin that Didn’t Shear: A Fatal Powerline Stringing Accident
A key component was never recovered, investigators seem to have misunderstood their own laboratory’s report on another and the NTSB conclusions omit to identify the evident failure of a shear pin to correctly perform its safety function as a factor.
Fatal 2019 DC-3 Turbo Prop Accident, Positioning for FAA Flight Test: Power Loss Plus Failure to Feather
NTSB suggest an air lock in the fuel system plus an auto-feather system failure which may have occurred if the power lever was manually retarded during the auto-feather sequence. The DC-3 was below the airspeed required to maintain lateral control after an engine failure with an unfeathered propeller.
Windscreen Rain Refraction: Mountain Mine Site HESLO CFIT
Did you know that rain on a windscreen, in addition to causing poor visibility, introduces a refraction error that can make objects appear lower, by up to 5 degrees?
Windscreen Rain Refraction: Mountain Mine Site HESLO CFIT Read Post »
AS350B3 Ditching Japan
An accident that highlights the benefit of practical emergency drills and careful consideration of survivability issues.
AS350B3 Ditching Japan Read Post »
SAR AW139 Dropped Object: Attachment of New Hook Weight
JTSB comment: “When introducing new equipment, it is necessary to confirm in advance, the usage including appropriate selection, and sufficiently identify the risk factors”.
SAR AW139 Dropped Object: Attachment of New Hook Weight Read Post »
ATR 72 Rudder Travel Limitation Unit Incident: Latent Potential for Misassembly Meets Commercial Pressure
An ATR72 suffered an uncommanded yaw and roll as it accelerated through 185 knots. The cause was traced to misassembly during a prior maintenance check. A cam in the rudder Travel Limitation Unit could be reversed, and pressures during the check triggered that misassembly.
S-76A++ Rotor Brake Fire
Fire after activating the rotor brake while the No. 2 engine was still set to govern the power turbine speed.
S-76A++ Rotor Brake Fire Read Post »
BEA Point to Inadequate Maintenance Data and Possible Non-Conforming Fasteners in ATR 42 Door Loss
At top of descent a 15 kg MLG door separated causing damage. Maintenance data “complex and contained error” and allowed “allowed nuts to be reused without checking their self-locking capability”.
Wire Strike on Unfamiliar Approach Direction to a Familiar Site
Weather conditions forced an unfamiliar approach direction to a familiar landing site. The lack of a site recce first increased risk as did the inaudibility of an obstacle warning system.
Wire Strike on Unfamiliar Approach Direction to a Familiar Site Read Post »
Prior Engine Mount Damage Lead to Fatal Aerial Saw Crash
The fourth accident to this H369D proved fatal. NTSB identify that undetected prior engine mount damage was the cause of a clutch failure while using an aerial saw at low level.
Prior Engine Mount Damage Lead to Fatal Aerial Saw Crash Read Post »
Unanticipated Yaw: Loss of Control During Landing Site Survey
A LOC-I during a tight, decelerating turn downwind while a low time pilot was doing a recce of a possible golf course landing site.
Unanticipated Yaw: Loss of Control During Landing Site Survey Read Post »
Flybe Fume Event (Part 1): Compressor Wash Maintenance Human Factors Case Study
A series of systemic maintenance human factors issues emerge from a detailed AAIB investigation into cockpit/cabin fume event.
Flybe Fume Event (Part 1): Compressor Wash Maintenance Human Factors Case Study Read Post »
Human Factors of a Mali Mid Air Collision
BEA-E deconstruct a helicopter Mid Air Collision (MAC) during combat operations in Mali and look at human factors that affected situational awareness as the Air Mission Commander wrestled with resolving a Rules of Engagement (ROE) dilemma.
Human Factors of a Mali Mid Air Collision Read Post »
RCAF Investigate Defect on Newly Delivered CH-148 Cyclone (S-92)
Terminal wire lugs T1, T2 & T3 were found unsecured. T1 was missing its securing nut, washer and lockwasher but was still contacting its terminal stud. T2 & T3 were found hand tight.
RCAF Investigate Defect on Newly Delivered CH-148 Cyclone (S-92) Read Post »
Inexperienced IIMC over Chesapeake Bay: Reduced Visual References Require Vigilance
A low time pilot sets out to photograph a fishing boat in IMC that they are not qualified to fly in & the helicopter is not certified for.
The inevitable happens…
Inexperienced IIMC over Chesapeake Bay: Reduced Visual References Require Vigilance Read Post »
Engine Shutdown Results in Revised SOV Rigging Instructions
A rare engine failure mode related to miss-rigging a Shut Off Valve. The investigation triggered enhancing maintenance instructions.
Engine Shutdown Results in Revised SOV Rigging Instructions Read Post »
Fatal US Helicopter Air Ambulance Accident: One Engine was Failing but Serviceable Engine Shutdown
PSM+ICR: A propulsion system malfunction (a failing No 2 engine) was followed by an inappropriate crew response (shutting down the No 1 engine). The NTSB show how the pilot may not have been familiar with how the helicopter’s displays respond in emergencies.
BK117 Impacts Sea, Scud Running off PNG
Pressing on in bad weather this helicopter descended during an over sea transit to stay in VMC but ultimately impacted the water as visibility deteriorated further.
BK117 Impacts Sea, Scud Running off PNG Read Post »
US Air Ambulance Near Miss with Zip Wire and High ROD Impact at High Density Altitude
NTSB points to a failure to consider the Density Altitude in this spectacular air ambulance accident caught on video. But there are wider lessons about planning and landing site hazards.
US Air Ambulance Near Miss with Zip Wire and High ROD Impact at High Density Altitude Read Post »
Grand Canyon Air Tour Tragic Tailwind Landing Accident
A Loss of Control – Inflight during a downwind approach to a busy remote landing site. The helicopter crashed in a difficult to access gully and caught fire. It took almost 10 hours for survivors to reach hospital. Five of the 7 occupants died.
Grand Canyon Air Tour Tragic Tailwind Landing Accident Read Post »
NZ Firefighting AS350 Accident: Role Equipment Design Issues
The sling for the underslung fire-fighting bucket contacted the tail rotor resulting in a loss of control. Investigators identified a vulnerability in the bucket’s design and shortcomings in promulgating essential design data to operators.
NZ Firefighting AS350 Accident: Role Equipment Design Issues Read Post »
Inspection UAS Collides with PNG LNG Export Jetty
A quadcopter collided with the jetty it was inspecting as the remote pilot tried to maintain visual contact from inside the wheelhouse of a pilot vessel 100 m away.
Inspection UAS Collides with PNG LNG Export Jetty Read Post »
Korean Kamov Ka-32T Fire-Fighting Water Impact and Underwater Egress Fatal Accident
Distracted by radio calls and with a poor split of duties the fire-fighting flight crew missed their high descent rate during their third attempt to uplift water. After the water impact there were survivability issues and one of the crew was unable to escape underwater.
Korean Kamov Ka-32T Fire-Fighting Water Impact and Underwater Egress Fatal Accident Read Post »