News & Comment

Aerossurance Sponsors HF in Aviation Safety Conference

Human Factors / Performance, Resilience, Safety Culture, Safety Management

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

Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Regulation, Safety Management

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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Loss of MV Derbyshire 9th September 1980

Accidents & Incidents, Design & Certification, Safety Management

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?

Accidents & Incidents, Design & Certification, Helicopters, Human Factors / Performance, Regulation, Safety Management, Special Mission Aircraft

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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City of London (Credit: Andy Evans)

The Contrarian Director

Human Factors / Performance, Resilience, Safety Culture, Safety Management

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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Learrjet Typhoon Mid Air Collision Germany

Mid Air Collision Typhoon & Learjet 35

Accidents & Incidents, Fixed Wing, Human Factors / Performance, Military / Defence, Regulation, Safety Management, Special Mission Aircraft

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”

Accidents & Incidents, Human Factors / Performance, Oil & Gas / IOGP / Energy, Safety Culture, Safety Management

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’

Accidents & Incidents, FDM / Data Recorders, Safety Management

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

Fixed Wing, Helicopters, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, News, Safety Management

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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Rockets Sleds, Steamships and Human Factors: Murphy’s Law or Holt’s Law?

Human Factors / Performance, Safety Management

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

Accidents & Incidents, Fixed Wing, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Safety Management, Survivability / Ditching

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

Accidents & Incidents, Helicopters, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Safety Culture, Safety Management

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

Accidents & Incidents, FDM / Data Recorders, Helicopters, Human Factors / Performance, Military / Defence, Safety Culture, Safety Management

‘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

Accidents & Incidents, Human Factors / Performance, Regulation, Resilience, Safety Culture, Safety Management

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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What the HEC?! – Human External Cargo

Helicopters, Logistics, Mining / Resource Sector, Safety Management, Special Mission Aircraft

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

Accidents & Incidents, Airfields / Heliports / Helidecks, Crises / Emergency Response / SAR, Design & Certification, Helicopters, Maintenance / Continuing Airworthiness / CAMOs, Safety Management, Special Mission Aircraft, Survivability / Ditching

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

Accidents & Incidents, Human Factors / Performance, Regulation, Safety Culture, Safety Management

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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Inadequately Secured Cargo Caused B747F Crash at Bagram, Afghanistan

Accidents & Incidents, Fixed Wing, Human Factors / Performance, Logistics, Regulation, Safety Management

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

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A319 Double Cowling Loss and Fire – AAIB Report

Accidents & Incidents, Design & Certification, Fixed Wing, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Safety Culture, Safety Management

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,

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UK CAA Helideck Developments

Airfields / Heliports / Helidecks, Crises / Emergency Response / SAR, Helicopters, Offshore, Oil & Gas / IOGP / Energy, Regulation, Safety Management, Survivability / Ditching

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

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