Hard Landing after VRS on Approach to a Hospital Site
Hard Landing after VRS on Approach to a Hospital Site On 15 April 2016 a HEMS Airbus Helicopters AS350B2, N561AM, operated by Air Methods Corporation, was substantially damaged in a hard landing at the Piedmont Mountainside Hospital. Jasper, Georgia. The pilot and three medical personnel, who were inbound to collect a patient, were uninjured. The US National Transportation Safety Board (NTSB) explain in their safety investigation report that “the helicopter completed an orbit over the hospital heliport about 800 ft agl prior to beginning a descent for landing”. In his statement the pilot explained that: Since a trainee was aboard, I began to explain the procedures to be followed. I explained hazards found at hospitals, pointed out the windsock, and pointed out large power lines… These lines are estimated to be about 100 ft above ground level. The NTSB explain that: The helicopter was approaching the helipad with a direct 11-knot tailwind gusting to 16 knots [from 120°]. About 250 ft above ground level, the commercial pilot lost tail rotor and cyclic authority, and the helicopter pitched forward and accelerated toward the ground. The pilot recognized the onset of vortex ring state, reduced engine power, and attempted to initiate a go-around; however, insufficient altitude remained to complete the maneuver, and the helicopter landed hard, resulting in a partial separation of the tailboom. Images show the aircraft on what appears to be a vacant lot SE of the helipad. The NTSB say that: A vortex ring state may be entered during any maneuver that places the main rotor in a condition of high upflow and low forward airspeed, including near-vertical descents of at least 300 ft per minute, and a horizontal velocity slower than that for effective translational lift. A fully developed vortex ring state can be “characterized by an unstable condition in which the helicopter experiences uncommanded pitch and roll oscillations.” According to representatives from Airbus Helicopters, the maximum allowable engine torque setting was for the helicopter was 100 percent continuous. The Vehicle Engine Multifunction Display (VEMD) was reviewed under federal supervision and the data indicated overtorque events at 107 percent for 2 seconds and 113 percent for 1 second. So Why That Approach? The NTSB don’t examine why the approach was flown as it was. Our first reaction was that the approach direction was influenced by the power cables the pilot mentioned. These initially appear to follow the highway, which runs NW to SE. However examination of Google Maps data, they actually run N to S (despited being described as “located to the SE” in the rather crude helipad ‘briefing document’) and thus were overflown, though perhaps forcing a steeper approach than desired. This document restrictively suggests a Northerly approach and Southerly departure “to avoid overflying the hospital”, even though strictly the building is to the NW of the helipad. With the wind from 120° an into wind approach would have been directly over the hospital. Another factor that might have influenced decision making is that the hospital is located on the perimeter of the Pickens County airport, an uncontrolled airfield, with the heliport less than 500m from the threshold of Runway 34. NTSB Probable Cause The pilot’s loss of helicopter control due to vortex ring state, which resulted in a hard landing. Contributing to the accident was the pilot’s decision to conduct the landing approach with a tailwind. Other Safety Resources UPDATE 18 August 2018: Inappropriate Autorotation Training UPDATE 8 September 2018: Torched...
read moreFire After O-Ring Nipped on Installation
Fire After O-Ring Nipped on Installation On 7 July 2016 Delta Air Lines (DAL) Pratt & Whitney PW2040 powered Boeing 757-200, N706TW, experienced a right engine fire shortly after takeoff from John F. Kennedy International Airport (JFK). The flight crew declared an emergency after receiving a right engine fire warning in the initial climb, approximately 400 feet agl. They shut down the right engine and observed the fire warning extinguish and so neither fire bottle was discharged. The flight returned to JFK and landed safely. Thermal damage was limited to the right nacelle. The damage included a hole in the inboard core cowl consistent with a burn-through. Safety Investigation According to the US National Transportation Safety Board (NTSB) safety investigation report, the flammable fluid source was fuel leaking at the fuel flow transmitter (FFT)-to-fuel OUT tube joint. On the morning of the flight the right engine FFT had been replaced. A rubbery blue-colored substance was found protruding from the top and left sides of FFT-to-fuel OUT tube joint. The NTSB say that: The FFT, fuel IN line and fuel OUT line were removed as an assembly. Pressure was applied to the assembly and leakage was observed at the suspect joint. The fuel OUT tube was removed. The tube O-ring was found eroded and with a 90° arc of material missing. Both ends of the O-ring separation exhibited shallowly angled separations. Parker Aerospace was asked to assess the O-ring separation. Parker reported that the similar angle/plane cuts on both ends of the O-ring is a commonly-observed damage condition that results from installation error. Safety Analysis It therefore was concluded the O-ring had been ‘nipped’ during installation that morning. During the takeoff, high-pressure fuel had therefore flowed past the damaged seal and sprayed into the engine compartment, contacting hot surfaces and igniting. NTSB Probable Cause Maintenance personnel’s failure to ensure proper installation of a fuel tube O-ring, which resulted in an undercowl engine fire during initial climb. Maintenance Instruction Review and the Fallacies of Compliance and Reporting The NTSB go on to note that a review of the B757 Aircraft Maintenance Manual (AMM) FFT installation procedure found the following: AMM Task 73-31-01-404-018-P00 did not include an instruction to lubricate the tube O-rings prior to installation: Note that: Parker Hannifin Publication ORD5700, Parker O-Ring Handbook pg. 3-4, paragraph 3.1.5 states that “use of a suitable grease or oil during assembly helps protect the O-ring from damage by abrasion, pinching, or cutting” and “helps the O-ring to seat properly”. AMM Task 73-31-01-404-018-P00 incorrectly directs that the fuel IN and fuel OUT tube O-rings to be installed on the FFT rather than into the fuel tube O-ring glands. AMM Task 73-31-01-404-018-P00 did not specify a torque value for the tube attachment bolts. Boeing has since revised these instructions to correct these errors. The NTSB note that: The FFT installation task used by the DAL technician to install the FFT directly aligned with the Boeing AMM and so included these omissions/errors. So a focus purely on maintenance compliance monitoring would likely not have detected this prior to the incident, although the documentation anomalies probably should have attracted attention and been reported previously. While the NTSB do not discuss if any reports had been raised previously, its not uncommon for personnel to not report such issues because they assume that someone else already must have spotted the problem. Obviously,...
read moreHF Lessons from an AS365N3+ Gear Up Landing
Human Factors (HF) Lessons from an AS365N3+ Gear Up Landing A French Navy Airbus Helicopters AS365N3+ Dauphin helicopter F-XGAL / 6928 suffered a wheels up landing in the South Pacific on 30 May 2017. The aircraft departed from Tahiti Faa’a airport for the near-by island of Moorea in French Polynesia according to the BEA-Etat safety investigation report (available in French only). The purpose of the flight was to gain experience of the One Engine Inoperative (OEI) Training Mode that is unique in the French Navy AS365 fleet to the N3+s in the South Pacific. The investigators highlight the highly experience crew and opine that resulted in over-confidence and a: “laissez-faire” [approach] leading to a loss of synergy within the crew. The crew were discussing the training during the downwind leg when the Pilot Non Flying should have lowered the gear and both were briefly distracted by a light aircraft also entering the circuit. They then focused on flight parameters during the approach when the checklist called for a check of the landing gear lights (i.e ‘3 Greens’). The investigators comment that while the checklist allocates responsibilities, it was ambiguous during a training flight, something the crew did not anticipate. Below 55 knots with the landing gear retracted the orange LGEAR caution light flashes at 1.6Hz. Unlike earlier AS365 versions where caption is written on the orange indicator in black, in the NVIS compatible N3+ cockpit only the text LGEAR is lit in orange, against a black background. The investigators established that the bright sunlight during the approach did not result in obscuring the LGEAR light but with tinted visors the light would have been difficult to discern. There is also only one light, to the extreme right of the instrument panel and no aural warning, making cross checking from the left hand seat even more difficult. The rearcrewman is seated facing aft behind the right hand pilot’s seat, offset towards the centreline and so would also not be able to spot the light. Additionally, as the airport is a civilian airport, they do not follow the military practice of visually checking the landing gear is down on the approach. The investigators discuss the busy crew workload in the two months running up to the accident (with multiple audits and inspections, flooding of their hangar and domestic accommodation and a temporary relocation of base). They contrast this with the days immediately before being particularly ‘calm’. They comment that: Hypovigilance following a strong peak in activity in the previous two months contributed to at the event. The BEA-E has investigated 6 other cases of wheels up landings (2 helicopters and 4 aeroplanes) since 2003, noting some similarities. BEA-E Safety Recommendations Six safety recommendations were raised, relating to: using this accident as a training case study reviewing the squadron workload cockpit ergonomics changes for the LGEAR caution, such as adding an aural alert and a repeater indicator on the left hand side greater certification attention to cockpit modifications consideration by the State aircraft operating agencies of the risk operating from civil airports in relation to the lack of landing gear verification continued attention on introducing flight recorders Other Safety Resources Distracted B1900C Wheels Up Landing in the Bahamas Dim, Negative Transfer Double Flameout BK117 and NVIS cockpit Tail Rotor Pitch Control Loss During Hoisting Taiwanese AS365 Final Report: AS365N3 9M-IGB Fatal Accident Night Offshore Training AS365N3 Accident in India An AW109SP, Overweight VIPs and...
read moreDistracted B1900C Wheels Up Landing in the Bahamas
Distracted B1900C Wheels Up Landing in the Bahamas After a wheels up landing the flight crew claimed they had lowered the gear. The evidence disagreed say investigators. History of the Flight On 30 September 2016 a US registered Beechcraft 1900C , N376SA, operated by Southern Air Charter, a Bahamas Air Operator Certificate holder, was involved in an occurrence at Deadman’s Cay Airport, Long Island, Bahamas. The aircraft was on a scheduled domestic commercial air transport flight when it landed on runway 09 with the landing gear retracted. The flight was in Visual Meteorological Conditions (VMC) with a crew of two (both US nationals and FAA Airline Transport Pilot License holders) and nine passengers. No injuries were recorded. The Air Accident Investigation Department of the Bahamas (AAID), who classified this as an incident, say in their ‘short investigation report‘ that: According to the pilot and first officer, 10 miles from landing the first degree of flaps were selected at which point they became aware that the flaps were not working. As they were so close to land and did not want to fly back to Nassau with the passengers, the decision was made to continue and land using a no-flap landing procedure as outline in the Quick Reference Handbook (QRH) and performance manuals on board the aircraft. The crew reported that the gear was subsequently selected down, both pilots stated that they confirmed “three greens” and then they continued the approach for landing. They further claimed that it was only upon touch down did they realize the gears were in fact, not down and locked when they started seeing the propeller disintegrate. The Evidence However this account did not match that of two eyewitnesses who voluntarily spoke to investigators. Both said that the landing gear was retracted during the approach. Further crew interviews… …revealed conflicting accounts of what took place on the flight deck… The operator was directed to secure the Cockpit Voice Recorder (CVR) for follow up analysis. Analysis of the CVR uncovered a possible intentional complete dump [i.e erasure] of the information contained on the CVR equipment. The aircraft was not fitted with an FDR. Photographic documentation of the runway after the gear up landing have revealed no signature marks of any tire trail or gouges in the runway as would be normal during a gear collapse and the aircraft gears coming in contact with the runway at such high speeds. [Beechcraft commented] that “for the green lights to illuminate in the cockpit, the landing gear drag braces must travel to the over-center position to activate the gear down and lock position switches,” therefore “it is practically inconceivable that the landing gears would fail in such a scenario.” The investigation also uncovered that the Ground Proximity Warning System (GPWS) which would alert the pilots to unsafe landing situation, had been inoperative for some time. No further comment is made over the maintenance or continued airworthiness of the aircraft (in relation to the flap failure and GPWS unserviceability). AAID Findings The flight crew failed to extend the landing gear as required prior to a landing. The GPWS warning system was unserviceable The flaps were inoperative Unknown distractions existed during the approach and landing that may have contributed to distract the pilot resulting in the aircraft landing with the landing gear in the retracted position. Both pilots gave differing and...
read moreLoad Lost Due to Misrigged HESLO Under Slung Load Control Cable
Load Lost Due to Misrigged HESLO Under Slung Load Control Cable On 27 April 2017, a Japanese Airbus Helicopters AS350B1, JA9743 of Nakanihon Air Service, lost an under slung crop spraying system while in flight at Toubetsu, Teshikaga Town, Kawakami-gun, Hokkaido. According to the Japan Transport Safety Board (JTSB) final report, released 31 May 2018, the Captain sat in the left seat and a pilot under training was in the right seat and pilot flying. At around 11:58, as returning to the loading site in order to load the fertilizer to the empty spraying device, the rotorcraft accelerated from the speed at about 25 kt for spraying to the speed at about 60 kt, then turned to right at the altitude at about 50 m. The under slung load was seen in the helicopter’s rearview mirror to fall away. The HESLO Hardware The JSTB explain that: The Cargo Swing is hung from the bottom of the fuselage by four steel wires, utilizing the rotorcraft structure. The Handle installed in the collective pitch lever is connecting to the [Control] Cable in order to actuate mechanically the Release Unit of the cargo hook device. The Maintenance Manual requires the Control Cable is routed via clamps at two locations. On this aircraft the cable was fastened at three locations. One was a regular routing position but the other two were fastened at non-standard positions. One location used a nylon tie wrap used instead of a clamp. No maintenance records could be provided that showed when this alternative routing had been done. This would generate greater bigger friction, would have stopped the Control Cable smoothly following the movement of the Cargo Swing. This alternative routing also meant the cable was 10cm short at the Release Unit end, resulting in less cable and therefore free movement when attached to the Release Unit. The Control Cable is a Bowden style cable, with a moving inner actuating cable. On detailed examination the outer protective cables of the Control Cable had broken, exposing the inner moving cable to damage. However an outer sheath would have prevented this being detected visually. It is possible that a large movement of the Cargo Swing, would have resulted in the shortened inner cable opening the Release Unit. JSTB Conclusions It is highly probable that the serious incident occurred because when the cargo swing was shaken due to the right turn following the acceleration of the rotorcraft to cause the outer cable of the cargo swing broke, the tension was applied to the inner cable, the release unit was activated to open the hook and the spraying device slung was dropped. Regarding why the outer cable of the cargo swing broke and the tension was applied to the inner cable, it is highly probable that [this was because] the cable routing configuration was different from the regular routing configuration. JTSB also comment: Maintaining the regular configuration is important for the safe operation, and it is necessary to reconfirm the method to maintain the appropriate configuration management, like how to maintain the configuration or how to keep the records of the configuration changes Safety Action The operator changed all their cables following special training for maintenance personnel on this equipment. They have also reiterated the importance of configuration management to all staff. No procedural, continuing airworthiness management or assurance changes are mentioned however. Other Resources HESLO / USL Also see our articles: What the HEC?! – Human External...
read moreB1900D Emergency Landing: Maintenance Standards & Practices
B1900D Emergency Landing: Maintenance Standards & Practices On 12 July 2016 an Air Georgian Beechcraft 1900D, C-GORF, made an emergency landing after its Nose Landing Gear (NLG) could not be lowered at the end of an Air Canada Express flight in Alberta from Lethbridge to Calgary. The resulting Transport Safety Board of Canada (TSB) safety investigation report (released on 29 May 2018) posses many questions on the management and oversight of aircraft maintenance and maintenance standards & practices. Air Georgian was formed in 1984 and operates a fleet of B1900Ds and Bombardier CRJ-100 and -200s, that carry over 500,000 passengers per annum. It is one of four carriers operating for Air Canada under the Air Canada Express brand. History of the Flight The TSB explain that: When the landing gear was selected down for the approach into Calgary, the flight crew observed that there was no gear-safe indication for the NLG. The flight circled east of Calgary for about an hour while the pilots attempted to rectify the problem. An emergency was declared. The aircraft landed at 0720 Mountain Daylight Time, during daylight hours, with the nose gear in a partially extended position. The nose gear was held off the runway with progressive aft control‑column input until the nose settled on the runway about 28 seconds after main gear contact…at approximately 52 knots indicated airspeed. The aircraft came to a stop 6050ft from the threshold. No fire occurred, and there were no injuries. Emergency vehicles reached the aircraft in 30 seconds, and all passengers and crew deplaned within 1 minute. Damage to the aircraft was limited to the nose landing gear components, the nose gear door and gear light, as well as 2 propeller tips on each side of the aircraft that contacted the runway. B1900D Landing Gear Description and Lab Findings The B1900D landing gear assemblies are retracted and lowered hydraulically. The TSB explain that: During extension and retraction, the nose gear actuator exerts pressure through an aluminum yoke fitting attached to the end of the actuator piston (see figure below). This yoke is attached to the middle of the upper and lower drag braces, and causes the drag braces, when folding or unfolding, to extend or retract the nose gear. The yoke (item 8) is attached and pivots through the braces by means of a pivot/stop bolt, part number 114-820107-1 (item 34). The failure of the retract-and-extend mechanism of the nose landing gear was initiated by a yoke lubrication problem. The bolt with part number 114-820107-1 (item 34)…was not lubricated as required. The yoke should turn freely around the yoke’s pivot/stop bolt; however, the occurrence yoke’s pivot/stop bolt was seized in the yoke due to deteriorated grease and corrosion for 2 reasons: First, the deteriorated grease did not provide lubrication. Second, insufficient lubrication allowed the penetration of moisture between the bolt and the bore surface, causing corrosion on both surfaces. The bolt seizure resulted in abnormal loading on the yoke’s pivot/stop bolt and the actuator clevis during retraction and extension of the nose landing gear. This led to fatigue cracking and failure of the yoke’s pivot/stop bolt ends. From 31 August to the end of September 2016, the operator examined the condition of nose landing gears in its fleet and found 5 more Beechcraft 1900D aircraft with non-airworthy nose landing gear yoke pivot/stop bolts, as well...
read moreHelicopter Ops and Safety – Gulf Of Mexico 2017 Update
Helicopter Ops and Safety – Gulf of Mexico 2017 Update The Helicopter Safety Advisory Conference (HSAC) has been publishing data on the Gulf of Mexico (‘GOM’) offshore helicopter fleet and its safety since 1995. We have looked at their 2014. 2015 and 2016 reports previously. Now we examine their 2017 data. Helicopter Operations: GOM Fleet Data HSAC report that flying activity continues to decline, with just under 189k flying hours in 2017, although the rate of decline is has decreased (4% down on the 196k in 2016 and vs 298k in 2014 and 410k in the peak year of 2007). The fleet is now 329 helicopters (down 4% on the 344 in 2016 but vs 453 in 2013). Flying hours, passenger numbers and flights have dropped by 38%, 41% and 39% respectively over the last 5 years. This is indicative of the economic decline in the small ageing coastal fields and delayed investment in deepwater exploration and production due to the drop in oil price from mid-2014 onwards. The number of operators remain unchanged from 2016 at 10 (vs 13 in 2014). The big three are Bristow, ERA and PHI, with RLC strong in the single engine sector. The number single engine helicopters fell by 6 to 182, down 27% over 5 years. The light twin fleet dropped by 10 to 29 and is down 46% over 5 years. Average utilisation hardly changed for singles but the average light twin is flying noticeably further and more often: Single engine – 639 flying hours with an average 19 minute sector length (vs 631 flying hours and 19 mins in 2016) Light twin – 375 flying hours with an average 29 minute sector length (vs 290 flying hours and 19 mins in 2016) The medium twin fleet went from 69 to 80, returning to the same number as 2016 but 34% lower than 5 years ago. The number of heavy twins (mainly Sikorsky S-92As) fell by 5 to 43, though still a 26% increase over 5 years. Their average utilisation shows a little less flying, but an increase in flight duration: Medium twin – 475 flying hours with an average 40 minute sector length (vs 577 flying hours and 34 mins in 2016) Heavy twin – 546 flying hours with an average 37 minute sector length (vs 554 flying hours and 35 mins in 2016) Helicopter Safety GOM While 2016 only the 4th fatality free year in HSAC’s 34 years of recorded data, 2017 was not as rosy with 3 accidents, 2 fatal: 6 February 2017 Bell 206B N978RH of Republic Helicopters, which crashed into water near Galveston while returning from an oil tanker with the loss of 1 of the 3 persons on board, notably at night (see our article Deadly Delay). The NTSB determined the probable cause as: “The pilot’s failure to recognize the flight had encountered instrument meteorological conditions at night, which resulted in an unrecognized descent and collision with water.” 27 February 2017 Bell 407 N1371 of Westwind Helicopters, which crashed into the sea while being positioned to shore for an engine cowling repair, with the loss of the pilot. The NTSB determined the probable cause as: “The pilot’s failure to maintain proper altitude resulting in a collision with water for reasons that could not be determined based on the available information.” 2 May 2017 Bell 407 N457PH of PHI suffered damage the NTSB classified as substantial after the loss of a tail rotor blade tip cap. A safe emergency landing was made. The NTSB is yet to release a probable cause. UPDATE 9 November 2018: The NTSB determined the probable cause was: “An in-flight separation of the tip block from the tail rotor blade due to an inadequate blade repair, which resulted in a...
read moreSingapore Airlines B777 41t Fuel Discrepancy Incident
Singapore Airlines B777 41t Fuel Discrepancy Incident The Singapore Transport Safety Investigation Bureau (TSIB) has released their safety investigation report into an incident that occurred on 16 April 2014 to Singapore Airlines Boeing B777-200ER 9V-SVC flying from Singapore to Johannesburg. The Refuelling Before departure the flight crew had requested the aircraft be fuelled to 86 tonnes. The Refuelling Dispenser Operator (RDO) proceeded to fuel the aircraft until the Lead Technician (LT) from the airline’s contracted maintenance organisation confirmed the aircraft’s total fuel had reached 86 tonnes. The LT was positioned under the aircraft wing at the aircraft’s Integrated Refuel Panel (IRP). The flight crew then confirmed that the figure tallied with the cockpit fuel indication. Based on the refuelling dispenser’s fuel flow counter, the RDO presented to the LT a receipt for 121.5 tonnes of fuel uplifted to the aircraft. Noticing the abnormally high fuel quantity stated on the RDO’s fuel receipt, the LT confirmed from the IRP that the final total fuel quantity was 86 tonnes. He informed the [Certifying Technician] CT of the fuel quantity discrepancy between the IRP and RDO figures. The RDO showed the CT that the 121.5 tonnes measured by the fuel flow counter (i.e. fuel through the hose) matched the refuelling dispenser’s start/end quantity totaliser gauge (i.e. the fuel transferred out of the dispenser). The CT queried if the fuel flow counter had been reset before fuelling. The RDO was unsure and accepted the suggestion. The CT informed the flight crew about the fuel discrepancy and that there would be a delay to departure. He then consulted his supervisor and was advised to perform a manual fuel quantity check for the aircraft’s fuel tanks using fuel measuring sticks [aka a ‘magnastick’]. Based on those results for the centre fuel tank and an assumption that the wing tanks were full, the CT arrived at a calculation of 86.001 tonnes, which confirmed the aircraft cockpit indication. The aircraft departed after a 30 minute delay. The Incident Flight The TSIB say that the crew were… …prompted with a “FUEL DISAGREE” aircraft system message one hour into the flight. The flight crew carried out the necessary checks and noticed that, at that point in the flight, the fuel quantity onboard as calculated by the Flight Management Computer (FMC) based on the quantity of the fuel that had burnt off during the flight was less than the fuel quantity as measured by the aircraft’s fuel quantity indicating system (FQIS), and the difference between these two quantities was increasing. After consulting the airline’s maintenance centre, the flight crew decided to return to Singapore. The aircraft landed in Singapore without incident. Investigations showed the aircraft had departed with approximately 127 tonnes of fuel, instead of 86 tonnes as displayed to the flight crew by the FQIS, a 41 tonne overload. The flight crew did not encounter any flight handling difficulties. The TSIB make no comment on the take off performance. The B777 Fuel System The Boeing 777-200 and 777-200ER (the Extended Range variant involved in this incident) have left and right wing tanks and a centre tank. The TSIB explain that: The left and right wing tanks of both models had approximately similar capacity. However, the centre tank of Boeing 777-200 was much smaller than that of Boeing 777-200ER because the former included a large dry bay and the difference was about 40.5 tonnes. The aircraft’s fuel quantity indicating system (FQIS) computed the total fuel quantity in the aircraft’s fuel tanks by way of a system of...
read moreHow ‘Sticky’ is Your Safety Software?
How ‘Sticky’ is Your Safety Software? Organisations are increasingly investing in software to support their Safety Management Systems. This might be in individual applications for managing safety reports, audits, risk assessments etc or integrated products. The use of software to manage large quantities of data is obvious. As was said about one system, developed by British Airways in the early 1990s: The strength of BASIS lies not in the storing of information, but in using it to ask questions about the operation and to provide some answers……a practical probing into all the available data with the intention of uncovering the unknown and undesirable. (The Basis for Safety Management, M Holtom, Focus Nov 1991, UKFSC) Another great premise of such software is that it increases workforce reporting. Certainly the ability for individuals to enter safety reports on-line increases reporting (in one case we are very familiar with, more than doubling the frequency of reports in three years). However we know other cases were similar increases have been achieved by dogged perseverance, trust building and promotion by the safety team. However: Quantity is not a substitute for quality of safety reports A report raised is not the same as a safety lesson shared. This is where software design and user interface are key… But is your safety software addictive or just plain dull? A 2013 study reported that smartphone users check Facebook 14 times per day on average, spending 32 minutes a day on the site (by 2016 this had increased to 50 minutes). A 2014 study stated that 70% of all Facebook users viewed the site every day and 87% at least weekly. LinkedIn scored a more modest 13 and 38% respectively (with an average usage of 2 minutes per day in 2016). Social media growth coincided with the widespread availability of smartphones. The average user in a 2016 study interacted with (i.e. touched, selected or swiped) their smartphone 2617 times everyday in 145 minutes of use. A 2013 study determined that 36% of Facebook users felt people shared too muchinformation about themselves which contrast with the common expectation of under reporting of safety issues. Ciarán McMahon has considered the psychology behind social media in a fascinating 2015 article in The Psychologist. It would be wildly optimistic to expect your safety software to be as ‘sticky’ and addictive. However, to be frank most safety software is purely transactional with a user interface as uninspiring as on-line banking! Safety software is often seen as a chore to use and for most users these systems are just sponges that soak up their input with little response or sense of community. Relatively few users tend to have access rights to let them ‘wring out’ the data (generally due to confidentiality concerns). There is rarely an easy way to share relevant information with peers (sharing being centrally controlled by management or safety specialists) or to ‘like‘, share and encourage the contributions of others (a key feature of social media). As one blog notes “social media can be a way of gaining virtual empathy”. Another study showed 49% of participants said that they shared “to inform other people about what they care about or to affect new opinions or encourage action”. A massive 84% shared to support a cause (and is safety not a worthwhile cause?). McMahon adds: In a holistic sense, the popularity of social media has been driven by how user-friendly and interactive it...
read moreItalian HEMS AW139 Inadvertent IMC Accident
Italian HEMS AW139 Inadvertent IMC Accident A leased Leonardo Helicopters AW139, EC-KJT, was operated by INAER Aviation Italia (a Babcock company) from L’Aquila in the Abruzzo region of Central Italy to provide a daytime Helicopter Emergency Medical Service (HEMS) service. It crashed into a mountain during a HEMS mission on 24 January 2017. The Agenzia Nazionale per la Sicurezza del Volo (ANSV) released their accident investigation report (in Italian only) in May 2018. The Accident Flight Operations Room 118 in L’Aquila made a telephone request for the helicopter to attend to a casualty at the base of the ski lifts at Campo Felice with a broken leg at 09:59 Local Time. According to a doctor on scene, they said that weather at the casualty’s location was better than the previous day, when a separate HEMS flight there had been abandoned. The duty pilot was very familiar with the Campo Felice ski facilities, as he had picked up casualties there many times (twice in January 2017 for example). The helicopter took off from L’Aquila Preturo airport at 10:06. On board was the single pilot and, in the cabin, a HEMS Technical Crew Member (TCM, i.e. a trained aircrewman), a mountain rescuer, a doctor and a nurse. Apart from the ski centre & hotel and the SS696 road in the valley, the terrain was blanketed in snow. Out bound the aircraft followed the SS696. En route to Campo Felice, near the town of Lucoli, the helicopter encountered a weather front. The pilot circled, changed heading, initially slowed to 50 knots and then accelerated back to 100 knots. As the aircraft subsequently approached the pick-up point the crew discussed the poor visibility. Witnesses indicate visibility was reducing with fog that “came and went”, with a 50 m cloud base and 500 m visibility. The aircraft however successfully landed at 10:16 and remained rotors running with only only the pilot aboard as the medics and TCM collected the patient. The helicopter took off from Campo Felice at 10:23:21 and soon took a route away from the SS696 road. Shortly after take off the helicopter appears to have entered cloud based on CVR comments. Witnesses suggest that the weather had deteriorated further by this point. The TCM, who was in the cabin, seemingly queried if they should land. The helicopter made several heading changes. The TCM asked the pilot what his intentions were, getting the answer “Ehh, let’s see where we can get to … “. The aircraft almost collided with terrain about this time (the minimum recorded radalt altitude was 24 feet). The impact was avoided and the aircraft climbed to 600 feet AGL and entered a turn. The torque values of both engines reached very high values (up to 144%) and remained very high and well beyond limits, never falling below 114%, until the final impact. After this escape manoeuvre, the helicopter flight is characterised by the ANSV as “one of significant instability of the main flight parameters”. The helicopter then turned towards high ground and impacted against the south-west side of Monte Cefalone at c10:25:43, less than 2.5 minutes after take off. The 6 occupants died on impact. The ADELT activated and the 406 MHz signal was received by the COSPAS-SARSAT satellite system. The wreckage was recovered under slung by Chinook. The Pilot and Training The pilot is described by his colleagues as a “serious professional”. At the time of the accident he had a total flight experience of 4674h, of which 3948h was on...
read more
Recent Comments