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 »
Loose B-Nut: Accident During Helicopter Maintenance Check Flight Another investigation by the US National Transportation Safety Board (NTSB), published on 13 July 2015, has highlighted poor maintenance standards and continuing airworthiness management in a US helicopter operator. The NTSB report that on 1 January 2014, Airbus Helicopters EC130B4, N133GC, operated by Papillon Airways Inc (PAI), was
Loose B-Nut: Accident During Helicopter Maintenance Check Flight Read Post »
‘Procedural drift’ in the operating detachment was noted by the Service Inquiry into a British military helicopter accident in Afghanistan that killed 5 service personnel. This drift is said to have allowed standards to dilute during sustained operations in theatre.
‘Procedural Drift’: Lynx CFIT in Afghanistan Read Post »
Performance Based Regulation (PBR) and Detecting the Pathogens At a time when Performance Based Regulation (PBR) is a hot topic in the aviation industry, a series of rail accidents in North America help demonstrate the type of poor performance that PBR must successfully detect. These accidents were what James Reason, Professor Emeritus, University of Manchester described as ‘organisational accidents’ in his
Performance Based Regulation and Detecting the Pathogens Read Post »
An unstabilised approach and a late change of control were critical in an accident that resulted in a SWA B737 nose gear collapse at La Guardia say NTSB.
Southwest Unstabilised Approach Accident Read Post »
What the HEC?! – Human External Cargo Winching (or hoisting), used for Search & Rescue (SAR) or for personnel transfer to and from otherwise difficult to access locations, is the most widely known form of what is known as Human External Cargo. Some operators however transfer personnel by harnesses on long-lines. Here Southern California Edison
What the HEC?! – Human External Cargo Read Post »
Crashworthiness and a Fiery Frisco US HEMS Accident (Airbus Helicopters AS350B3e, N390LG of Air Methods) Shortly after take-off from a hospital in Frisco, Colorado, on 2 July 2015, Airbus Helicopters AS350B3e helicopter, N390LG, operated by Air Methods as ‘Flight for Life’, crashed in a parking lot 120m away. This was a daytime, Visual Meteorological Condition (VMC), Part 135
Crashworthiness and a Fiery Frisco US HEMS Accident Read Post »
Metro-North: Organisational Accidents and Shelfware An NTSB study into five accidents on US railway (‘railroad’) Metro-North gives a unique perspective on organisational accidents. Metro-North was described as having an “invisible safety department”, that kept its SMS on the shelf until external audits and assumed on-time performance would give them safe operations. Organisational Accidents James Reason, Professor Emeritus, University of Manchester popularised the
Metro-North: Organisational Accidents and Shelfware Read Post »
Inadequately Secured Cargo Caused B747F Crash at Bagram, Afghanistan The US National Transportation Safety Board (NTSB) has determined that a National Airlines Boeing 747 Freighter N949CA that crashed on take-off on 29 April 2013 did so because the five armoured military vehicles (2x12t and 3x18t) on-board were inadequately restrained. As the NTSB explain: These vehicles were considered a special
Inadequately Secured Cargo Caused B747F Crash at Bagram, Afghanistan Read Post »
A319 Double Cowling Loss and Fire – AAIB Report The UK Air Accidents Investigation Branch (AAIB) has published their report into an Airbus A319 that lost both engine fan cowlings and suffered an associated fire on take-off from London Heathrow in 2013. We look at the circumstances of the previous evening’s maintenance on this aircraft,
A319 Double Cowling Loss and Fire – AAIB Report Read Post »
UK CAA Helideck Developments The UK Civil Aviation Authority (CAA) are considering changing how offshore helidecks are approved and assessing the fire-fighting provision on Normally Unattended Installations (NUIs). The former activity is subject to a public consultation and that latter is being examined by a Offshore Helicopter Safety Action Group (OHSAG) working group. Helideck Qualified
UK CAA Helideck Developments Read Post »
DuPont Reputational Explosion Chemical company DuPont (E.I. DuPont de Nemours & Co Inc.) has been feted for its safety performance for many years (for example winning the National Safety Council‘s 2013 Robert W. Campbell Award). Its reputation in the field of safety stretches back to the founding of the company as a gunpowder manufacturer in
DuPont Reputational Explosion Read Post »
Helicopter Underslung Load: TV Transmitter HESLO In 2014, RF communication infrastructure specialists, The Bridge Network North (now merged into Virtua), undertook a major engineering project at Arqiva’s Croydon TV Transmitter in South London, UK. Arqiva operate much of the UK TV and radio broadcast infrastructure. The project included the replacement of the 10 tonne, 16m, top antenna
Helicopter Underslung Load: TV Transmitter Read Post »
