Beware Last Minute Changes in Plan
An NTSB report on an EC130 helicopter wirestrike accident that illustrates the need fully plan and risk assess last minute changes in plan.
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Misfuelling Accidents
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
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French Skyscraper HESLO: Helicopter Underslung Load
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,
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Aerossurance Sponsors HF in Aviation Safety Conference
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
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Critical Maintenance Tasks: EASA Part-M & -145 Change
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
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The Missing Igniters: Fatigue & Management of Change Shortcomings
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).
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B787 GEnx Fan Shaft Failure
The failure of a GE GEnx engine shaft on an Air India Boeing 787 during engine runs at the factory in 2012.
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Gulfstream G-IV Take Off Accident & Human Factors
Fatal G-IV runway excursion: take off with gust lock engaged. Contributing: habitual noncompliance and inadequate certification.
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Loss of MV Derbyshire 9th September 1980
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
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HTAWS Technology: Friend or Foe?
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
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The Contrarian Director
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
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Mid Air Collision Typhoon & Learjet 35
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
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Moerdijk Explosion: “Failure to Learn”
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
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ISASI Seminar 2015 – ‘Independence does not mean Isolation’
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
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CHIRP – Independent Review
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
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USAF RC-135V Rivet Joint Oxygen Fire
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.
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Rockets Sleds, Steamships and Human Factors: Murphy’s Law or Holt’s Law?
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
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Fuel System Maintenance Error: Tuniter ATR72 TS-LBB Ditching 6 August 2005
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
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Loose B-Nut: Accident During Helicopter Maintenance Check Flight
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
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‘Procedural Drift’: Lynx CFIT in Afghanistan
‘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.
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Performance Based Regulation and Detecting the Pathogens
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
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Southwest Unstabilised Approach Accident
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.
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What the HEC?! – Human External Cargo
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
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Crashworthiness and a Fiery Frisco US HEMS Accident
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
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Metro-North: Organisational Accidents and Shelfware
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
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