Review of “The impact of human factors on pilots’ safety behavior in offshore aviation – Brazil”
Review of: “The impact of human factors on pilots’ safety behavior in offshore aviation companies: A Brazilian case” (Dario Sant’Anna and Adriana Hilal of COPPEAD Graduate School of Business, Federal University of Rio de Janeiro in Safety Science 140 (2021)) Safety Science is the premier peer-reviewed safety journal. In August 2021 they published a paper on safety in the Brazilian offshore helicopter industry. In this article we summarise the context, methodology and key findings and then discuss the implications. Context Brazil’s offshore oil and gas exploration has driven one of the bigger offshore helicopter operation sectors. The main customer of these helicopters is state oil company Petrobras (described as the ‘Main Contractor’ in the paper). This IOGP member company has a dominant market position, contracting 80-90% of all offshore helicopter operations in Brazil. The authors say that there are three big helicopter operators “accounting for more than 85% of the entire sector” and a couple of smaller operators. Pilots typically work a roster with 15 consecutive days on duty for 12 hours per day and almost 8 hours flying each day according to the authors. Exploration of the deepwater ‘pre-salt region‘ had created a lot of oil and gas industry excitement and the potential was so huge that Brazil has started to open the sector to foreign investors operating offshore fields. It was predicted Brazil was heading for a fleet of 200 offshore helicopters in 2020, with particular growth in heavy helicopters for the long-range deepwater fields. The collapse in the oil price in Q3 2014 however had a catastrophic affect on the offshore helicopter sector in Brazil. The fleet declined from 100 helicopters to 70 in 2016, with a number of contracts terminated in 2015. One helicopter operator is reported to have made almost one third of their pilots redundant. New contracts also tended to be shorter two years rather than five. In 2020 Petrobras is reported to have used a reverse auction process to drive down prices. The authors also note that from 2014 onwards the company had been the centre of a major corruption inquiry (‘Operation Car Wash‘), which affected its own capital expenditure and may have further discouraged foreign investment in the oil and gas sector. Privatisation of Petrobas is now being considered. The last fatal offshore accident in Brazil occurred on 16 March 2022. Research Question and Methodology The authors state that the questions their paper was to address were: What are the main human factors that affect pilots’ safety behavior in offshore operations? How can offshore aviation companies manage to mitigate the adverse impacts of those human factors on their pilots’ safety behavior? The research was qualitative and based on transcribing structured one-to-one interviews of offshore pilots typically lasting 1.75 hours. This approach does ensure feedback is gathered from frontline personnel but such qualitative data will be of perception, opinions and more anecdotal facts. Some refer to such studies as being focused on ‘Thick Data‘ rather than ‘Big Data‘ from a more quantitative study. Both types of studies of course have their place. The authors explain that… Interviewees were encouraged to support their statements with examples, and the interviewer asked follow-up questions. The two authors then independently coded the interview feedback and collated their results into themes. Then, in a deductive way, evidence was gathered so as to support the themes and interpretations. Finally, the findings were compared to what...
read moreHeliOffshore 2022 Conference Review
HeliOffshore 2022 Conference Review After two years of virtual events, over 140 delegates from HeliOffshore’s international membership gathered in Cascais, outside of Lisbon, 23-24 April 2022 for the association’s annual conference. Aerossurance, as a committed HeliOffshore member, has attended all six in-person HeliOffshore conferences. HeliOffshore, founded in 2014, is the global collaborative safety association for the offshore helicopter industry. This year’s theme was “a safe and sustainable transition to 2040”. Offshore Helicopter Safety Performance Among the good news was that the industry has seen a significant positive improvement in safety performance in recent years (the subject of HeliOffshore’s eagerly awaited fourth safety performance report due out shortly). There have however been two fatal accidents in the offshore community in 2022 (one in the US and one in Brazil, with 3 fatalities in total). Safety Learning As part of a commitment to moving collaborative safety learning to a new level, two operators did a joint briefing on an lessons learning exercise they had done with HeliOffshore after one non-fatal accident and one serious incident in two different regions of the world that both involved approaches to helidecks at night. Further enhancements are also underway to the HeliOffshore Safety Intelligence Programme (HSIP), including a programme of proactive aggregated flight data analysis on the Sikorsky S-92A fleet. Safety Culture and Human Performance Sessions over both days discussed overlapping themes of sustainable safety culture and enabling human performance. This included mention of some particularly interesting research into “the re-design of the Just Culture process in an international energy company“. This excellent research, published in 2018, had already caught Aerossurance’s attention as a rare, peer reviewed, study that assessed how the implementation of Just Culture procedures were actually working in an organisation (looking at 353 cases). Spoiler alert: the procedures based on the original logic of James Reason were being routinely misapplied and the research went on to discuss how this was corrected. Such misapplication is something we commonly see in the aviation sector, with the process (often based on proprietary flowcharts) actually increases the focus on the capability (or not) of individuals rather than on driving system improvements. Safety Leadership An inspirational high point was a presentation by John Amaechi OBE, the psychologist, former former professional basketball player and author of The Promises of Giants (discussed in this VIDEO). He described a concept of ‘step theory’, namely that in life, everything you do is either a step closer to your vision or a step away from it and the direction you take is your choice. Amaechi advocates developing introspection, interpersonal and organisational abilities in order to enhance leadership skills and sharing ideas before you are ready (trusting your collaborators to contribute to refining the ideas). As he has explained in interviews: Leadership is not a title or role. It’s a promise of a kind of experience. It says if I only have the power to influence these two people, I will wield that wisely and well. After that presentation, HeliOffshore announced a new safety leadership bursary. Aerossurance immediately committed to co-funding that excellent initiative, more details of which will be announced later this year. Next Generation of People & Helicopters and the Rise of Renewables A number of participants commented on the need to thinking about developing the next generation of professionals in our community. Others highlighted that the average age of the offshore fleet is increasing due to the minimal number of new aircraft purchased in recent years (especially in...
read moreLoose Clothing Downs Marijuana Survey Helicopter
Loose Clothing Downs Marijuana Survey Helicopter (B206L3 N27TK) On 28 October 2021, Bell 206L3 N27TK, operated by Helico Sonoma, suffered substantial damage and made a forced landing during an aerial survey flight over illegal marijuana crops near Covelo, Mendocino County, Northern California. According to documents in the US National Transportation Safety Board (NTSB) public docket the Mendocino County Sheriffs Office had chartered the aircraft “explicitly to conduct aerial photography/film operations utilizing reporters from USA Today“. Indeed the newspaper published a feature in December 2021: Marijuana wars: Violent Mexican drug cartels turn Northern California into ‘The Wild West’: Lured by America’s push toward legalized cannabis, cartels have abandoned many decades-old marijuana farms in Mexico, moving their operations to Northern California where they can blend in seamlessly alongside legitimate grows… Mendocino, Humboldt and Trinity counties are known as the Emerald Triangle or Emerald Counties, a region that produces a significant portion of cannabis consumed in the U.S. through legal and illegal grows. Alderpoint, near the epicenter, is known as “Murder Mountain“…due to the prevalence of missing persons cases and shootings. During recent years, violence has intensified in Covelo, a remote valley town in Mendocino surrounded by mountains. The pilot, who was 29 with 1701 hours of flying experience (87 on type), described how: A standard weather briefing was gathered from my Foreflight account, and a company flight plan was filed. Three passengers were to be picked up at Ukiah Municipal Airport (KUKI). The pilot landed at 11:10 Local Time, briefed the passengers and they departed ay 11:40. The briefing included use of doors, headsets, emergency exits, smoking prohibitions, and hazards associated with doors-off operations. I specifically discussed that no loose articles in the cabin are authorization [sic] at any time, and each passenger verbally acknowledged the briefing. I personally inspected the cabin area and determined there were no loose items/articles of clothing that presented hazard to the flight. Only the photographer’s camera gear was present in the cabin, which was physically secured to ensure that it would remain in the aircraft. At 12:00, approximately 9 nm SE of Covelo… I heard the aft-right passenger gasp over the ICS [intercom] and exclaim that she “lost her jacket out the door”. Simultaneously with the gasp I felt something impact the aircraft. I became immediately aware of the potential danger and proceeded to assess the situation. I test the anti-torque pedals which responded normally. I then checked the fore-aft cyclic control to ensure freedom of movement. I experienced an increased amount of control forces associated with resistance against the elevator located on the trailing edge of the horizontal stabilizer. I immediately realized that the jacket had become lodged on the horizontal stabilizer, and therefore was placing the tail-rotor at risk of FOD ingestion. I then made the decision to make a precautionary landing at a gravel bar which was located within autorotative gliding distance at the aircraft’s 3 o’clock. I informed the passengers of the situation, made a distress call on the local CTAF, 122.8, and cautiously flew the aircraft in a circular right hand turn in order to descend and maneuver into the wind. I was deeply concerned the tail-rotor would fail at any moment and maintained an appropriate autorotative airspeed until about 200 agl. I reduced speed and altitude, terminating to a very gentle flare at 5 ft agl decelerating...
read moreUS Air Ambulance Helicopter Hospital Heliport Tail Strike
US Air Ambulance Helicopter Hospital Heliport Tail Strike (Arkansas Children’s Hospital Sikorsky S-76D N761AF) The US National Transportation Safety Board (NTSB) has recently (19 April 2022) opened the public docket on an accident that occurred to Sikorsky S-76D air ambulance N761AF of Arkansas Children’s Hospital on 12 March 2022 at Texarkana, Texas The helicopter was substantial damaged in a tail rotor strike while landing at dusk on an elevated helipad at the Wadley Regional Medical Center (64XS). The helicopter was inbound to do a patient transfer from the medical centre. This was the pilot’s first flight of the day, having come on duty slightly ahead of schedule at 17:08. The pilot was aged 54 with 3,212 flying hours in total, 174 on type. Two medical personnel were also on board. Their seating positions were not noted in the accident report form. The pilot had not been to 64XS before and examined information on an app on an iPad to gain familiarity with the site when en route. Crucially, the data currently in the public docket does not explain the level of detail available in this app. The pilot reported setting a waypoint 3 miles from the hospital “to establish a descent and deceleration point prior to the landing point to make a smooth transition from cruise flight to landing”. At the near-by Texarkana airport wind was reported as 11 knots, 160° and visibility 10 miles. He explained: Prior to reaching the 3-mile waypoint, I started slowing to 80 KIAS, and initiated a descent to 1500 ‘ MR. I made a call to Texarkana Tower that the hospital was in sight. I told the flight crew that we were about 3 minutes inbound. Upon reaching 80 knots, I lowered the gear and turned on the landing lights and search light. I slowed to approximately 60 knots, and descended to about 1000’. My course inbound…was originally 225 degrees. At about 25-30′ AGL on a very slow approach to the pad [at 18:30], I felt/heard a “thump” in the pedals and immediately the aircraft began to vibrate. We assume “25-30′ AGL” actually means a height of 25-30 feet above the helipad, which is a 50 ft square helipad (so slightly sub 1-D sized for an S-76D whose D-value = 52.5 ft) on the roof of a fourth storey building. The TR GBOX CHIP/TR OIL TEMP HIGH light illuminated and the aircraft yawed to the right. The pilot says: I instinctively lowered the collective and flew to the pad. At almost the point of landing, I pulled the collective for cushion, and the aircraft yawed right about 60 degrees as we settled on the pad. The helicopter was safely shut down without injury. The public docket images indicate the tail rotor struck a building that was an obstacle very close to the helicopter landing area. Examination of imagery suggest the helicopter passed very close to a structure sited to the north east as well as directly over a structure containing a lift shaft that was at c 10 ft above the helipad surface and c 25 ft from the deck edge. The aircraft pitch angle will also have needed to be relatively high too. Our Observations One of the key indicators of whether a safety investigation is competently and thoroughly conducted is whether the focus falls on the person closest to the accident or whether systemic issues are examined. A public inquiry chaired by Anthony Hidden QC investigated...
read moreNTSB: Ergonomics Explain Main Rotor Loss During Flight Test
NTSB: Ergonomics Explain Main Rotor Loss During Flight Test (Bell 206B N61PH) On 16 April 2019 Bell 206B N61PH of Van Horn Aviation was destroyed during a test flight evaluating developmental main rotor blades near Fort McDowell, Arizona. Both occupants were killed. The US National Transportation Safety Board (NTSB) issued their safety investigation report on 6 April 2022. The Accident Flight The NTSB explain the flight was being conducted as a Part 91 test flight and the aircraft was in the Experimental (Special) category. The helicopter was modified to have Van Horn Aviation’s 20635000-501 main rotor blades. These were constructed using carbon fibre/epoxy pre-preg woven fabric and unidirectional tape. The pilot was aged 52, held a Commercial Pilots Licence and had 1200 hours flying experience according to the NTSB. He was accompanied by a 28 year old engineer who had a Private Pilots Licence. Neither the NTSB report nor the public docket mention either having any flight test qualifications. The helicopter made the first test flight of the day between 05:45 and 06:20. After 100 lb of ballast was loaded, it departed again at 06:32 for a flight that was to consist of… …multiple autorotations at maximum gross weight, entered following a 1-second delay after a simulated loss of engine power. The operator reported that the [pilot] would perform all the flight maneuvers and the flight test engineer would perform several tasks during the test flight, which included holding a 17-inch, 7.72-lb [3.5 kg] engineering laptop with his left hand above the cyclic control while simultaneously using and stowing a clipboard and pencil to manage data collection. Flight cards are prepared for each test flight and listed the maneuvers to be performed during the flight. The accident flight was to be the last test flight of the main rotor blades before their certification process. Cyclic controls were installed at both seat positions, reportedly a deviation from procedures according to the operator (although no procedural documents are reproduced or referenced in either the NTSB report or the public docket). A review of the radar data revealed that the accident flight duration was about 34 minutes. The pilot executed multiple turns and descent maneuvers near the area of the accident site. The…final radar-recorded altitude was…about 3,000 ft above ground level (agl). A witness saw the helicopter falling from the sky and saw several other objects descending to the ground before losing sight of it behind trees. NTSB Safety Investigation The examination of the accident site revealed post-crash fire and impact damage consistent with a right side-down, nose-level attitude during ground impact. The main rotor hub assembly, vertical fin stabilizer, tail rotor assembly, tail rotor driveshaft, and forward induction cowl fairing separated from the main wreckage and was found in the debris field. One main rotor blade was found furthest from the main wreckage. The other main rotor blade was found near the main wreckage. The debris field was about 1 mile long and 1,000 ft wide… Damage found was consistent with a mast bumping event. …a phenomenon specific to the 2-bladed teetering or underslung rotor system where the rotor hub flap stops shear the mast. Mast bumping is the result of excessive rotor flapping. No evidence of any prior mechanical malfunctions was found. The NTSB comment on the challenging ergonomics: In order for the engineer to operate the computer or take notes on the clipboard, he would have to hold the computer with one hand while using the other to enter commands or take notes....
read moreBusiness Jet Apron Jet Blast Injury
Business Jet Apron Jet Blast Injury (GX N307KP, Augusta, GA) On 16 October 2019 a passenger being escorted across the apron of Augusta Regional Airport (AGS), Augusta, Georgia to a waiting Learjet operated by department store Dillard’s was seriously injured by the jet blast from Bombardier BD-700-1A10 Global Express XRS N307KP that had just started to taxi. The US National Transportation Safety Board (NTSB) issued their safety investigation report on 6 April 2022. According to the injured passenger, she and six other passengers were being escorted by one of their pilots to a Learjet. She stated that she was about 70 ft from the Bombardier when she was knocked over by the jet blast from the engine. The first officer of the Learjet stated that he was walking to the airplane with two passengers, and the five remaining passengers were following behind them. As some of the passengers were about to board the airplane, he heard a loud roar and felt a strong, warm gust. He turned around and saw one of the passengers on the ground. He stated he initially thought the Bombardier only had its auxiliary power unit running and believed the airplane was far enough away. The FO also stated the injured person was briefly unconscious, A second passenger was blow over but only suffered cuts to her knees. The Bombardier aircraft had arrived to drop one passenger off: They shut down the left engine and deplaned the passenger, restarted the left engine, and taxied back to the runway. During the entire stop, the rotating beacon was on and the right engine was operating. The captain stated that he used normal breakaway power to get the airplane out of the parking spot, then taxied at normal speeds. An FAA inspector commented that there was a procedure “for marshalling the transit aircraft in, but not marshalling them out of the ramp”. The NTSB Probable Cause was: The first officer’s failure to maintain a safe distance from a large turbine-powered airplane while escorting passengers, resulting in a passenger encounter with jet blast. Safety Resources You may also find these Aerossurance articles of interest: Fatal ATC Handover: A Business Jet Collides with an Airport Vehicle on Landing Pedestrian Seriously Injured by Air Ambulance Landing at Melbourne Hospital Challenger Damaged in Wind Shear Heavy Landing and Runway Excursion Pilatus PC-12 Collided with Pick-Up Truck During Dusk Take Off Ground Collision Under Pressure: Challenger vs ATV: 1-0 Visual Illusions, a Non Standard Approach and Cockpit Gradient: Business Jet Accident at Aarhus Gulfstream G-IV Take Off Accident & Human Factors Fatal US G-IV Runway Excursion Accident in France – Lessons Execuflight Hawker 700 N237WR Akron Accident: Casual Compliance Unstabilised Approach Accident at Aspen Business Jet Collides With ‘Uncharted’ Obstacle During Go-Around Disorientated Dive into Lake Erie Fatal Falcon 50 Accident: Unairworthy with Unqualified Crew G-III Attempted Takeoff Using Runway Edge Lights as Centerline G200 Leaves Runway in Abuja Due to “Improper” Handling Cockpit Tensions and an Automated CFIT Accident Global 6000 Crosswind Landing Accident – UK AAIB Report BFU Report on Dramatic Challenger Wake Vortex Accident Falcon 7X LOC-I Due To Solder Defect Misfuelling Accidents A320 Rolls Back on Stand: Incomplete Maintenance Procedures and Ground Handling Deviations Runaway Dash 8 Q400 at Aberdeen after Miscommunication Over Chocks A330 Starts to Taxi Before Tug is Clear Jetstar Dispatcher Forced to Run After Distracted Pushback A320 Collided with Two...
read moreHelideck Heave Ho!
Helideck Heave Ho! (CHC/BHS Sikorsky S-76C++ PR-CHI) On 16 February 2014 Sikorsky S-76C++ PR-CHI of CHC‘s Brazilian Helicopter Services was damaged when landing on the bow deck of the drillship Aban Abraham while on charter to Brazilian state oil and gas company Petrobras. According to the Centro de Investigação e Prevenção de Acidentes Aeronáuticos (CENIPA) safety investigation report (finally released 16 November 2021 in Portuguese only) the helicopter had departed Cabo Frio Airport (SBCB) at 07:12 Local Time. It was to route to Aban Abraham NS07 (9PDA), then the Petrobras P-63 FPSO (9PHD), back to the Aban Abraham and then returning to Cabo Frio. Details of the helideck pitch, roll and heave (P/R/H) was not available when the aircraft departed Cabo Frio but were to be radioed by each vessel no later than 20 minutes before landing. During the third sector from P-63 to Aban Abraham the drillship’s radio operator reported the P/R/H was “within the limits for landing”. The data came from the vessel’s Helideck Monitoring System (HMS) and limits had been set that “were known to the [helicopter] crew and [drillship] radio operator”. However, CENIPA do not detail the limits in use in their report. According to CENIPA: …minutes before, there had been variations in P/R/H greater than the maximum permissible for the operation of the aircraft, which were not reported. No document or standard was found that contained instructions for the radio operator about the time interval to be considered when reading the maximum P/R/H values of the helideck on the HMS… Indeed CENIPA state that the HMS also showed “several peaks of heave above the limits” shortly before the landing. However, the CENIPA report unhelpfully includes no HMS or FDR data. The flight crew “performed a direct approach for landing” and perceived “some more prominent movements of the helideck” once they were below 500 ft. They “considered the possibility of a go-around…about one minute before the occurrence” but decided to continue. Ultimately there was a heave that ‘surprised them”, followed by a second one about 2 seconds later that resulted in an abnormal contact between the helideck and the right main landing gear, which collapsed. The helicopter was shut down and all 12 occupants safely disembarked. The helicopters was subsequently removed as an underslung load by a Kamov Ka-32. CENIPA Analysis Firstly CENIPA state: …the lack of a time interval [defined in regulation] to be considered by the radio operator for reading the P/R/H data on the HMS…in order to determine a safe condition for landing inside operating limits, contributed to the occurrence, as it allowed the crew to proceed to the landing at the helideck with information different from that actually found by the aircraft at the time of landing. While this is a sound systemic focus, the investigators decided with hindsight bias, to use the crew’s candour against them by determining… …the piloting judgment of the crew also contributed to the event, since despite having perceived more relevant movements of the helideck and having been considered a go-around, the pilots decided to proceed with the landing, judging that the conditions were favourable, thus highlighting a deficiency in the assessment of the scenario… This is a classic case of Catch 22 in a safety investigation. A statement that indicated the crew had failed to notice high levels of heave would potentially have resulted in a determination that lack of attention was contributor, while mentioning worsening conditions is judged as a failure to act. Safety Actions...
read moreSAR Seat Slip Smash
SAR Seat Slip Smash (RCAF CH149 Leonardo Cormorant LOC-I) The Royal Canadian Air Force (RCAF) is investigating a Loss of Control – Inflight (LOC-I) accident that occurred to Search and Rescue (SAR) Leonardo CH149 Cormorant (AW101) CH149903 at Gander, NL on 10 March 2022. The SAR helicopter, callsign Outcast 903, of 103 Search and Rescue Squadron, 9 Wing was completing an onshore rear crew focused training flight, the first of two planned for the day at c15:42 Local Time. There were six crew members on board: two pilots, two Flight Engineers and two Search and Rescue Technicians. At the end of the first training mission, the crew conducted hover work in the vicinity of the intersection of Runway 31 and Runway 21. During the final clockwise hover turn sequence, the pilot flying’s seat unexpectedly descended to its lowest position. The aircraft flight vector immediately reversed from a clockwise rotation to an accelerated counter clockwise left yaw about the aircraft mast. As the aircraft continued to yaw left, the attitude of the aircraft became unstable resulting in an increasing right bank attitude. The aircraft rotated through approximately 400° and as the right rolling moment intensified, the right outboard wheel, the horizontal stabilizer assembly located on the right side of the tail section, and main rotor blades impacted the runway. Two of the crew received serious injuries, three minor injuries and one egressed uninjured. The aircraft was significantly damaged on impact with the ground (although AW101s, aka Merlins, have been successfully rebuilt after major accidents [in one case an accident in Afghanistan, followed by being dropped by a US helicopter during the recovery and being dragged into a compound by armoured vehicle!]). The RCAF report their safety investigation is focusing on “materiel and human factors“. We will update this article as they release more information. UPDATE 29 July 2023: The conclusions of the investigation have been published: The investigation determined that a combination of factors, including seat non conformances and the horizontal position that was maladjusted, allowed the seat to be in a false lock condition. When the seat dropped, the loss of outside visual references in combination with the severe vertical vibration resulted in an unrecognized spatial disorientation of the pilot flying. This caused the pilot flying to incorrectly perceive a right yaw and apply full left pedal input; this led to a severe left yaw and contributed to the change in roll attitude that likely rendered the helicopter unrecoverable. Multiple special inspections and aircrew information files were issued to address the seat non-conformances and avoid false lock conditions. Additional preventive measures have been identified to address deficiencies in fire fighting services, egress and tracking of armament as highlighted during this investigation. CBC have gone on to report that: The seat’s lock pins, which lock it in place, were shorter than manufacturing requirements… That could result in the pins not fully engaging with the locking mechanism…which could provide a false sense that the seat is locked. The pins can’t be seen when the seat is installed “meaning there is no opportunity for visual confirmation by the pilot to know the seat is locked in place”. The pilot checked whether the seat was locked before the flight by doing a “wiggle check,” according to the report, moving back and forth to make sure it was locked in place. CBC say that investigators… …also found that the...
read moreInvestigation into Collision of Truck with Police Helicopter
Investigation into Collision of Truck with Police Helicopter (AS350B2, PR-CJD, Brazil) On 18 January 2020 Airbus AS350B2 PR-CJD of the Public Security Department was hit by a truck while rotors running on a road in Rio Branco, Acre, Brazil. The two occupants and the truck driver suffered minor injuries. Three other occupants of the police helicopter and two passengers in the truck were unharmed. The Brazilian accident investigation agency CENIPA issued their safety investigation report on 9 February 2022. The Accident The tasking was to support a vehicle checkpoint. The helicopter had landed on one side of a two lane, 23 m wide, turning area between two carriageways, surrounded by overhead electric cables and lamp posts. The aircraft had remained on the ground for about 30 minutes. The tail was marked with a single traffic cone at that time. The collision occurred after the team had re-boarded the helicopter and was was rotor-running, preparing for departure. The crew believed that as turning vehicles would be travelling slowly and because the helicopter was “visible” and “noisy” it was not necessary for traffic to be stopped. The driver of a turning truck, approaching from behind the helicopter, did not notice the helicopter and struck the main rotor. Although not commented upon by CENIPA, the truck appears to have been carrying barrels of biological waste, some of which appear to have been damaged. The unit operated under RBHA 91 Sub-Part K regulations for Public Security / Civil Defence Operations as a ” Small Civil Aviation Service Provider”. 91.961 states in relation to operating from ad hoc urban sites: It is incumbent upon the [Public Security / Civil Defence] Agency to establish training programs and standard operating and flight safety procedures in order to guide the conduct of crews under such special conditions. The aircraft commander, who had a Commercial Pilots Licence, had 1142 hours flying experience, the co-pilot, who held a private Pilots Licence, 201. Neither had been formally trained in operating from public roads and the unit’s training manual did not cover the topic. They had only done this the day before for the first time. The unit also had no CRM training programme and recording irregularities were found in the aircraft’s technical records. CENPA Contributory Factors Analysis and Safety Recommendations Attitude: There was an inadequate assessment of the risks associated with the [start-up] while vehicles and people could move freely around the helicopter…which revealed a complacent attitude towards important procedures for the safety. Training: The lack of a formally implemented training program resulted in organizational failures that led to…operation on a public road, without the proper isolation of the area. Communication: …communication between the crewmembers and the crew on the ground (police checkpoint) did not involve the dissemination of relevant information about the operation. Crew Resource Management: There was inefficiency in the use of human resources available… Team dynamics: The inadequate evaluation of all parameters related to that operation…contributed to an inefficient performance by the team. Flight planning: The need to interrupt the traffic of vehicles, of people, and the [value] of carrying out a detailed briefing involving the crew and ground crew (police checkpoint) were not adequately considered. Management planning: [two occupants, wearing crewman’s ‘monkey’ harness but not strapped into their seats] were thrown out of the helicopter [which] revealed the inadequacy in the planning… with regard to the provision and control of the use of equipment. Organizational processes: The inefficiency…planning, documentation of standards and procedures, risk management and operational safety management led...
read moreDry Ice Packing Error Incapacitated Pilot on Taxiway
Dry Ice Packaging Error Incapacitated Pilot on Taxiway (West Air Cessna C208B N781FE) On 23 November 2018 the pilot of Cessna 208B N781FE, operated by West Air for FedEx, became incapacitated shortly before take-off at Meadows Field Airport (BFL), Bakersfield, California in a dangerous goods incident. The US National Transportation Safety Board (NTSB) has so far only published a preliminary report but did release the public docket on 23 March 2022. The Incident The aircraft was being operated single pilot. It landed at the airport at 16:10 Local Time and taxied to the FedEx ramp were FedEx personnel loaded cargo into the cabin. There were 41 boxes, marked as containing a total of 36 kg of dry ice (frozen CO2), among the cargo. A FedEx dangerous goods representative had approved the shipment as the dry ice mass furnished by the shipper was below the company’s limit of 76 kg for the C208B. The pilot stated that he infrequently flies with dry ice and when he does, he usually only has about 10 boxes with him (also at 0.9 kg per box) and usually places them in cargo zones 5 or 6 (near the back), not zones 1, 2, and 3, which are located right behind him. On the of the incident, the packages were placed behind the cockpit in zones 1, 2, and 3 for even weight and balance distribution. After the loading was completed, the pilot finished his paperwork and started the aircraft at 17:29. The evening was cool and so the pilot closed the ventilation. While taxing to runway 30R the pilot felt “strong sleepiness” accompanied by difficulty breathing. He stopped the aircraft at the runway run-up area and momentarily closed his eyes. Remarkably only after the pilot had failed to respond to repeated calls from air traffic for c20 minutes, did aid reach the aircraft. A firefighter on reaching the aircraft observed “an occupant with his head rolled back and his mouth open”. The fire service chocked the aircraft and shutdown the engine. The pilot was brought round by a ‘sternal rub‘ but initially his speech was unintelligible. Shortly after “he was able to demonstrate to the firefighter that he was coherent by answering a series of relatable questions”. Safety Investigation The boxes were found to be damp but in good condition. Some had frost on them. An FAA Inspector reported: Outer box had shipping and hazmat label, inside that box was thermal wrap/bag (see pics) which was basically bubble wrap with a Mylar coat, inside the thermal bag was the food product box and loosely placed dry ice pellets. The thermal bag was folded over and loosely taped closed. A driver/check-in clerk at a specialist food shipment company was interviewed by NTSB. They had worked in that post for 5 years and “also supported packing when the company needed help”. According to his understanding of the dry packing process at the time, for boxes that required 0.9 kg, he would place one and a half scoops of dry ice in the insulated packaging surrounding the box. They discovered after the incident that this was consistent with 3-4 lbs of dry ice instead of the 2 lbs prescribed by the label on the side of the box. For larger boxes, he would use 2 scoops of dry ice. The NTSB comment that: FAA calculations showed that the actual...
read more
Recent Comments