Wasp Stung By Lack of Lubrication
Wasp Stung By Lack of Lubrication An accident involving civil registered ex-military Westland Wasp HAS1 G-KAXT on 23 September 2016 highlights the importance of a thorough review of an aircraft’s maintenance programme when there is a major change in role or utilisation. The Aircraft G-KAXT was delivered to the Royal Navy in February 1967 with the UK military registration XT787. The helicopter was transferred to the Royal New Zealand Air Force (RNZAF) in 1982, where it remained in service until May 1998. It was acquired by a private owner in 2000 at approximately 2,660 flying hours and registered as G-KAXT. It had accumulated a total of 3,012 flying hours and was operating on the UK civil register with a valid Permit to Fly. The AAIB say: The helicopter was maintained in accordance with the Ministry of Defence (MoD) Master Maintenance Schedule (MMS), reference AP101C-0601-5A1; this was a condition of the CAA approval for the Permit to Fly. The scrap life of the main rotor gearbox is 2,400 hours and the overhaul periodicity depends on the equipment modification state. In the case of G-KAXT, the overhaul period was 600 hours. The manufacturer advised that typical usage for the Wasp helicopter in UK military service was in the order of 200 hours per year, which would equate to a gearbox overhaul calendar period of approximately three years. Accident Flight The AAIB explain that while en route from AAC Middle Wallop to RNAS Yeovilton on 23 September 2016: Southwest of Salisbury, at approximately 1,150 ft and 80 kt, the pilot felt a two to three second vibration in the collective lever. Shortly thereafter, the pilot realised that he no longer had collective pitch control, so he turned away from rising ground in preparation for a diversion to a landing site in the Chalke Valley. The pilot made a PAN call and informed Air Traffic Control (ATC) of his intention to land as soon as possible. He was offered diversionary airfields, but with increasing concern over the ability to control his altitude he decided to land in a field near the village of Bishopstone. After a slow speed handling check, he initiated his final approach and selected manual throttle control at a height of approximately 300 ft. His ability to flare was limited and he was unable to cushion the landing, with one wheel touching down first and significant bouncing between all four wheels as he shut the helicopter down. The tail rotor struck the ground but the helicopter remained upright and both occupants, who were uninjured, were able to exit normally. The Safety Investigation AAIB established that the collective pitch control rod in the main rotor gearbox had broken. The failure occurred in an area where the rod passes through an aperture in a metallic ‘guide’ (by design, the rod should not touch the guide say AAIB). However, this was secondary to a universal joint failure in the cyclic control circuit. That failure was due to lack of lubrication and a build-up of corrosion deposits. The corrosion deposits indicated that the failure was not recent. The exposed bearing surfaces of the trunnion showed extensive corrosion and wear. The evidence indicated that that the universal joint had been operating with insufficient lubrication for a considerable period of time. According to AP101C-0601-5A1, a new universal joint must be installed every 600 hours....
read moreDispatcher Forced to Run After Distracted Pushback
Dispatcher Forced to Run After Distracted Pushback A dispatcher was forced to run when an aircraft started to taxi while he was still connected to it. On 25 January 2017, a Jetstar Airbus A320-232, VH-VGJ was being prepared for pushback from bay 4 at Newcastle (Williamtown) Airport, NSW. The Australian Transport Safety Bureau (ATSB) report that: At about 1836, the crew received a clearance from the surface movement controller to pushback, which placed VGJ to the right rear quarter of an aircraft parked on bay 5. The aircraft dispatcher walked beside the aircraft and was connected to the nose of VGJ by a headset for communications with the flight crew. At about 1838, the crew of the aircraft on bay 5 requested a clearance to taxi for departure. At this stage, the crew on board VGJ interrupted their ‘after start flows’ to monitor the other aircraft, which they believed posed a collision risk. At about 1840, the crew on board VGJ requested and received a clearance to taxi for departure. The dispatcher for VGJ was still connected to the aircraft nose with their headset and waiting for their clearance from the flight crew to disconnect. They observed the taxi lights for VGJ illuminate, then they heard the engine noise increase, and then the aircraft started to taxi. …they immediately disconnected their headset from the aircraft and ran clear to the left of the aircraft towards the terminal… Once the dispatcher was clear of the aircraft, they turned around to display the nose wheel steering pin to the flight crew, but the captain was not looking towards them. Flight Crew Procedures After starting both engines, the crew conduct ‘after start flows’. These are memory item checks split between the pilot flying and pilot monitoring. The announcement to the dispatcher that they are clear to disconnect is the penultimate item. The last ‘flow’ item is for the flight crew to complete the challenge and response ‘after start checklist’. The last item on that five point checklist is confirmation that the dispatcher has been sighted clear of the aircraft. Only after completion of the ‘after start checklist’ should the crew request taxi clearance and turn on the taxi light. ATSB Analysis The ATSB explain that after the distraction of the aircraft on bay 5 the captain of VH-VGJ misidentified the dispatcher for the bay 5 aircraft as their own dispatcher. At this time, the tug, which would normally wait beside the departing aircraft for the dispatcher, had moved away from VGJ towards the terminal to avoid a conflict with the bay 5 aircraft. Therefore, the dispatcher sighted by the captain, was next to the tug used for the pushback of VGJ. This potentially provided an association between the tug and the dispatcher in the mind of the captain, who assumed the dispatcher had removed the nose wheel steering pin and moved away from the aircraft. The diversion of the flight crew’s attention away from their ‘after start flows’ probably resulted in the pilot flying not completing their memory items. This was not detected in the ‘after start checklist’ because the captain had misidentified the dispatcher for the bay 5 aircraft as the dispatcher for VGJ. Consequently, the dispatcher connected to VGJ was not cleared to disconnect prior to VGJ starting to taxi. ATSB Safety Message Following this serious incident the captain...
read moreRCAF Production Pressures Compromised Culture
RCAF Production Pressures Compromised Culture We look at the production pressures that affected the culture of a Royal Canadian Air Force (RCAF) training unit according to accident investigators. The Accident Flight On 24 January 2014 Beechcraft CT156 Harvard II (T-6A Texan II) 156102 suffered a hard landing during a student’s second practice forced landing (PFL), in a flapless configuration in strong winds. The aircraft was from 2 Canadian Forces Flying Training School (2 CFFTS), of 15 Wing at Moose Jaw, SK, part the NATO Flying Training in Canada (NFTC) Program. The Qualified Flight Instructor (QFI) took control and initiated a go-around. A chase plane confirmed that the left main landing gear (MLG) side-brace had become detached from the MLG. Unsuccessful attempts were made to attain a symmetrical gear up configuration for a possible belly landing. Consequentially, it was decided that a controlled ejection was the safest option. Both crew successfully ejected, with only minor injuries, overhead the airfield at 5400’ mean sea level (MSL) (approximately 3400’ AGL) and an indicated airspeed of 139 kts. The aircraft was destroyed in the subsequent crash in farmland approximately 2 nm south of the airfield. Conclusions of the Safety Investigation The RCAF investigators say in their report (available saved as a PDF here): Investigation by Quality Engineering Test Establishment (QETE) found sufficient evidence to conclude that this bolt failed in tension overload during the hard landing allowing the side brace which controls movement of the LMLG strut and provides a down lock to become detached. Furthermore: The investigation found that a need to increase pilot production at 2 CFFTS had resulted in a revised TP [Training Plan]. The new TP was put into effect coincidental with the QFI’s pilot training in 2012. The revised syllabi made significant modifications to the previous syllabi; most noteworthy was a significant reduction in the number of flying missions that could include PFL training. The 2012 reduction of in-flight PFL training was not recognised as significant and so no risk mitigating measures such as applying more restrictive limitations to PFLs has been introduced. The investigation concluded that the practice of completing PFLs in a flapless configuration with no formal training was contributory to this accident, as was the decrease in PFL training which likely resulted in this QFI having significantly less PFL experience following the Flying Instructor Course (FIC) than previous pipeline QFIs in 2 CFFTS. A preventive measure (PM) was implemented following this accident which established a safety window restricting the practice of flapless PFLs. Additional PMs relating to Aviation Life Support Equipment (ALSE), the Integrated Data Acquisition Recorder (IDAR), QFI personal limits and unit culture are recommended. While the report discusses in depth matters such as course design, training procedures and operations, data recording, safety equipment etc, we will look closely at their examination of unit culture. Unit Culture, Production Pressures and Instructor Currency The investigators say: While it is difficult to assess and measure the culture of a unit, there was sufficient testimony to indicate the likelihood that the 2 CFFTS culture was unhealthy at the time of the occurrence. The investigators say that interview evidence and results from these 2 CFFTS Flight Safety (FS) Surveys in 2012 & 2014… …indicate that flying student missions routinely took priority over QFI proficiency missions. The surveys also highlighted concerns about QFI and student workloads, length of work days, fatigue, quality of life,...
read moreHuman Factors of Dash 8 Panel Loss
Human Factors of Dash 8 Panel Loss We look at the human factors lessons after Flybe Bombardier DHC-8-402 / Dash 8 Q400 G-PRPC was damaged by the loss of an engine access panel on departure from Manchester Airport on 14 December 2016. The UK Air Accidents Investigation Branch (AAIB) discuss the circumstances of the panel loss in their report. The aircraft… …night-stopped at Manchester Airport…parked on a remote stand. The operator’s contracted maintenance organisation [at Manchester] completed a routine daily check on the aircraft that evening. This included checking the oil content of the No 1 engine, accessed by opening the outboard main access panel on the engine nacelle. The main engine bay of each engine nacelle has two large forward access doors, one inboard and one outboard. These access doors are made from a carbon/epoxy composite material with integral foam-filled stiffening ribs. Each door is hinged at the top, has a single telescopic hold-open strut and is secured in the closed position by four quick-release lock pin latches. Each latch, when closed, engages a pin into a receiver mounted within the engine nacelle structure. The outboard door on the No 1 engine and the inboard door on the No 2 engine allow access to service the engine oil system. The check was concluded by approximately 2115 hrs… The aircraft Technical Log entry for the daily check was signed by the engineer at 0010 hrs. At 0550 hr…the commander conducted the pre-departure inspection. As it was still dark, he used a torch to supplement the ambient airport lighting during his inspection. The inspection had a total duration of 3 minutes. He did not identify any issues with the aircraft and the crew continued with their normal departure routine. The ground crew, who were responsible for pushing the aircraft back off the stand, subsequently arrived and conducted their own walkround check of the aircraft, also identifying nothing of note. The aircraft departed for Hanover and on arrival there about 90 minutes later it was noticed that the No 1 engine access panel was missing. A search was initiated at Manchester and… …the panel was recovered from a grass area to the side of the runway, approximately 440 m from the runway threshold. Sections of the panel hold-open strut were also recovered from the runway and adjacent paved areas in the same vicinity. On inspection of the recovered panel all four latches were found to be in the closed and latched position. There was no damage to the latch bolts or the receiving fixtures on the nacelle. As there was no damage to the latches the AAIB concluded the panel latches had been closed correctly. Inspection of the aircraft vertical stabiliser showed puncture holes in the skin on both sides, with impact marks also present on the leading edge de-icing boot. There was also impact damage to both VOR/LOC antennas. Other Incidents and Earlier Action According to Bombardier there have been nine other engine access panel losses in-flight worldwide on the Q400 fleet in similar circumstances. One in South Africa on ZS-NMO in July 2014 was subject to a more basic investigation by the South African CAA, who finally reported on 8 January 2018. However in that case the lower two latches were found unlatched and only the two upper/middle latches were in the latched position. One occurrence had been on the same Flybe aircraft, G-RPPC. The AAIB say...
read moreRJ85 Landed Alongside Runway Obscured by Dust
RJ85 Landed Alongside Runway Obscured by Dust The Australian Transport Safety Bureau (ATSB) have reported on an incident involving a BAE Systems Avro RJ85 landing alongside an unsealed runway at Darlot, WA on 20 January 2017. Cobham‘s VH-NJW was conducted a FIFO (Fly In Fly Out) charter flight from Perth to the airport located next to the Darlot-Centenary Gold Mine. It landed on the graded runway strip* to the left of the runway itself, due to raised dust obscuring the markers on the right side of the runway and runway strip. The Airport Darlot has no electronic approach path guidance. The ATSB explain that the airport: …used identical white frangible cones as markers for both the runway and the runway strip. The runway was 30 m wide and 1,969 m long. The runway strip was 90 m wide. Therefore the lateral spacing of the cones for the runway and the runway strip either side of the runway were equidistant. [A]aiming point markers are not required…on unsealed runways [but] the airport operator can elect to ‘implement an aiming point marking by providing an appropriate marking.’ Darlot Airport used three frangible white cones, either side of the runway on the edge of the runway strip, as aiming point markers. * A runway strip, for a runway without an instrument approach, includes a graded area around the runway and stopway, intended to: (1) to reduce the risk of damage to aircraft running off a runway; and (2) to protect aircraft flying over it during take-off or landing operations. The Incident Flight When the aircraft joined the final approach leg, the captain noticed dust in the vicinity of the runway. Although this was initially suspected to be due to a vehicle… …at about 2.5 NM (4.6 km) from the runway the captain concluded that the dust was from the strong easterly wind… The aircraft landed without incident. However, as the aircraft slowed to taxi speed, the PF [Pilot Flying] observed cones and runway lights on the right side of the aircraft, but only cones on the left side of the aircraft. The PF then noticed that the raised dust on the right side of the runway strip [had] covered both the runway markers and runway strip. They had landed the aircraft on the graded area of the runway strip to the left of the runway. The PF manoeuvred the aircraft back onto the runway, taxied to the apron and shutdown… The aircraft was not damaged. The aircraft operator provided services to three other airports with unsealed runways. Following this incident, the operator reviewed the other airports and found that at two airports the aiming point markers were located inside the runway strip (one used gable markers and the other cones), either side of the runway… … and at the third airport the aiming point markers had been removed. Therefore, the aiming point markings were inconsistent between all four airports. ATSB Analysis The PF advised that the final approach to land at Darlot, was a period of high workload because the aircraft was flown manually with cross-checks of distance and altitude used to manage the descent profile. On the incident flight, the PF’s attention was initially captured by raised dust… About halfway down the final approach, the PF discounted the presence of a vehicle, but then incorrectly identified the left runway strip markers as the left...
read moreA320 Collided with Two De-Icing Trucks
A320 Collided with Two De-Icing Trucks The German accident investigation agency, the BFU, reported in December 2017 on a serious incident in Munich on 20 January 2016 when an Iberia Airbus A320, EC-LVD, almost knocked two de-icing trucks over. The loaded aircraft had taxied from its stand to go to de-icing area DA14: The Cockpit Voice Recorder (CVR) recordings showed that the co-pilot listened to ATIS during taxiing and then informed the Pilot in Command (PIC) about the content while the aircraft at 0745:32 hrs taxied straight past the turn-off to taxiway B14 with approximately 20 kt. About 60 m east of the turnoff the speed of the airplane began to decrease and at 0745:50 hrs had reached approximately 6 kt. After the ground controller had noticed that the airplane had taxied past the cleared taxiway he instructed the flight crew at 0745:52 hrs: “Hold position […]”, and about 20 seconds later added: “[…] you missed de-icing area one four in bravo one four. Are you able to turn sharp right for bravo one four and de-icing area?” The flight crew answered that they could do that. The aircraft turned and taxied back to DA14, establishing radio contact with the de-icing vehicles at 0748:08 hrs. The vehicles were standing at their respective taxiway edge markings facing inwards. At 0748:30 hrs the pilots began to complete the Before De-icing Checklist. At 0748:49 hrs the PIC requested the copilot to select the DITCHING switch to On and added: “Confirma, ditching?”. Three seconds later the pilots began a conversation about the fact that just now the fire extinguishing system for the cargo compartment had been activated instead of the DITCHING switch. Over the next few minutes the crew investigate and decide they need to return to the stand. A number or radio calls were made, initially to the de-icing team and then the ground movements controller. The FDR recording showed that at 0756:57 hrs the parking brake was released and the thrust levers of both engines were pushed forward. The engine thrust N1 started to increase at 0757:00 hrs and the airplane began to move. The speed increased to approximately 3 kt. At 0757:10 hrs the FDR recorded a change in longitudinal acceleration from 0.2 g to -0.15 g. Two seconds later the wheel brakes were actuated and at 0757:16 hrs the parking brake was set again. At 0758:23 Hrs the PIC informed the controller that the airplane had collided with both de-icing vehicles. The aircraft’s winglets had collided with the booms of the de-icing vehicles and were slightly damaged. The vehicles had tipped by about 20° and the drivers trapped in the cabs c6m from the ground. The BFU say “the probability of severe injuries of the de-icing personnel was great”. Both were rescued by fire-fighters unharmed. Personnel Comments After the controller had issued the taxi clearance the flight crew had looked right and left and seen no obstacles. Then the PIC began taxiing. He had had the impression that the parking brake had still been set. Therefore he actuated the wheel brakes. The [icing] team leader stated [that] …he de-icing vehicles had been positioned left and right of the airplane in a distance of 4 – 5 m in front of the wings. Immediately before the de-icing would have started, the cockpit reported a technical problem. The team leader had responded: “… we will...
read moreEnron and the Hubris of the “World’s Leading Energy Company”
Enron and the Hubris of the “World’s Leading Energy Company” The Enron Saga Though dwarfed by the 2008 global financial crisis, in January 2006 the trial was getting under way of the key executives behind the November 2001 bankruptcy of Houston based energy company, Enron. Enron was originally a relatively pedestrian regional natural gas pipeline company, formed by the merger of Houston Natural Gas and InterNorth in 1985. It transformed itself into from an infrastructure operator to primarily an energy trading company, exploiting the deregulation of the energy sector. Many were taken in. Enron was voted “America’s most innovative company” in Fortune magazine’s annual poll from 1996 to 2001, the year the company imploded. This was after it emerged that huge debts had been concealed, giving investors a false image of the company. As The Guardian notes: Enron went from being a company claiming assets worth almost £62bn to declaring bankruptcy within a period of three months. Share prices collapsed from about $95 to $1. The company used ‘mark-to-market accounting’ to hide their losses: This is a technique used when trading securities where you measure the value of a security based on its current market value, instead of its book value. This can work well for securities, but it can be disastrous for other businesses. The mark-to-market practice led to schemes that were designed to hide the losses and make the company appear to be more profitable than it really was. Enron [used] off-balance-sheet special purpose vehicles (SPVs), also know as special purposes entities (SPEs) to hide mountains of debt and toxic assets from investors and creditors. The SPVs involved dubious partnerships run by their own CFO. This was all signed off by accountants Arthur Anderson, who voluntarily surrendered its licenses to practice as Certified Public Accountants in the US in 2002 as the scandal developed. Enron’s collapse led to new rules on the financial reporting. In July of 2002, President George W. Bush signed into law the Sarbanes-Oxley Act. The Act heightened the consequences for destroying, altering or fabricating financial records, and for trying to defraud shareholders. Perhaps its therefore a surprise that Enron had an extensive Code of Ethics! Enron’s Code of Ethics Enron’s July 2000, 62 page Code of Ethics opens with with a letter from Enron founder and former Chairman Kenneth Lay, who assured employees that he conducts business “in accordance with all applicable laws and in a moral and honest manner.” Lay was convicted after the scandal but died before sentencing. In the Code the company states: We treat others as we would like to be treated ourselves. Ruthlessness, callousness and arrogance don’t belong here. Bethany McLean, a reporter who identified before the collapse that all was not what it seemed at Enron, described Enron as having a ‘culture of arrogance’ and cited their large lobby banner ‘Enron: The world’s leading company’ (which replaced the ‘The world’s leading energy company’ slogan just prior to the collapse, almost as hyperbole had to be increased as the cover-up grew bigger). In one interview before the collapse with CEO Jeff Skilling: Asked by the interviewer: “You’re the good guys?” Skilling responded: “We are the good guys… We are on the side of the angels.” Skilling even suggested in a 1999 interview that the company could be managed ‘loosely” to foster innovation because of their ‘tight’ internal controls. The same article suggested Skilling was pressing employees to “find new ways to take...
read moreEasyjet A319 Heavy Landing
Easyjet A319 G-EZAW Heavy Landing The UK Air Accidents Investigation Branch (AAIB) have reported on a heavy landing involving Easyjet Airbus A319 G-EZAW at Munich Airport, 3 July 2017: The aircraft was established on an ILS approach [but] at about 1,500 ft aal, the commander’s Flight Management Guidance Computer (FMGC)1 failed. The crew were unable to alter the target approach speed, and the engines began to spool up un-commanded. The pilot flying disconnected the autopilot and autothrust and the rest of the approach was flown manually. Below 50 ft the pitch attitude of the aircraft was reduced slightly just before the aircraft was flared for landing, and it touched down heavily in a relatively flat attitude. The normal acceleration recorded at touchdown was 3.01 g [and 11.9 ft/sec], which is classified as a Severe Hard Landing. The aircraft was inspected for a Severe Hard Landing as required by the manufacturer’s Aircraft Maintenance Manual. This inspection revealed damage to the nose landing gear and the right main landing gear as well as some cracking of the paint and sealant in the nose gear bay and avionics bay. The landing gear was sent to an overhaul shop for inspection which… …revealed that both the nose landing gear and the right main landing gear had suffered excessive loads during the landing and could not be returned to a serviceable condition. The nose landing gear shock-absorber cylinder was found buckled (below) with the barrel and forestay lower arm pin found to be out of tolerance. The right main landing gear sliding tube and shock-absorber were also found to be outside acceptable tolerances when measured. AAIB Conclusions …neither pilot realised that the aircraft was in the incorrect attitude for landing until it was too late to take corrective action. It is possible that distractions and high workload during the approach contributed to the nose-down pitch input being made immediately before touchdown. Other Safety Resources A Germania A321-200 D-ASTP made a 3.32 g heavy landing Fuerteventura, in the Canary Islands on 16 July 2016. Unfortunately in that case: Due to the absence of maintenance support at the Fuerteventura airport and, in the absence of a criterion on the meaning of landing report code ‘Hard’, the crew decided to make the return flight to Dusseldorf. Consequently in their final report the CIAIAC (Investigación de accidentes e incidentes de aviación civil) recommend that Germania “improve the aptitude of its MOC personnel to ensure they provide correct support so that safe decisions are made in every aerodrome at all hours of operation”. We discuss this in more detail here: A320 Flown on After Damaging Heavy Landing UPDATE 14 April 2018: Air Mandalay Embraer ERJ-145 XY-ALE was damaged after a heavy landing during an unstabilised approach on 18 Sept 2017. the First Officer did a walkaround but did not spot the damage so the aircraft flew 2 more sectors before an engineer found the damage, according to the Aircraft Accident Investigation Bureau (AAIB) of Myanmar report. UPDATE 2 May 2018: Flight Data Services discuss the analysis of hard landing FDM data. UPDATE 11 July 2018: The TSB of Canada has released their report on the hard landing during wind shear of Jazz Aviation Bombardier Dash 8 Q400 C-GYJZ on 9 November 2017 which substantially damaged the aircraft and generated enough load to trigger the CVR/FDR crash switch. They report that the flight crew were unsure if this 5.7g touchdown was a hard landing or not. Rather than wait...
read moreOverworked Yuletide Loading Error
Overworked Yuletide Loading Error The Australian Transport Safety Bureau (ATSB) report into a loading incident during a busy-pre Christmas period on an Airbus A320 highlights the effect of high workload on data input errors, as well as the importance of system feedback of incorrectly entered data. The Incident On 21 December 2016, Jetstar A320 VH-VGI was being loaded at Melbourne Airport, Victoria. At 05:00 Local Time, a clerk at a freight organisation commenced their shift say the ATSB. The organisation recently introduced a new processing system, however a decision was made to use the old system due to the amount of freight for processing and [technical] system issues. The team was short one person. The replacement clerk was starting work at 0700. Until then, the clerk was responsible for processing freight on all narrow-body flights from Melbourne. The clerk spent about 20 minutes on the radio, and processed freight for 9 or 10 flights over half an hour. During this time, the clerk identified two pieces of freight (flowers and meat) to be sent to the Sunshine Coast [VH-VGI’s destination], weighing a total of 93 kg. The clerk put the freight in a unit loading device (ULD) and wrote the ULD number on the same page with the details of a ULD destined for Adelaide. The clerk entered the ULD as going to the Sunshine Coast in the office. However, they inadvertently put the Sunshine Coast freight card on the ULD (containing medical goods, weighing 245 kg) destined for Adelaide. This ULD was subsequently loaded on the Sunshine Coast flight. The clerk realised the error when the ULD destined for Adelaide could not be located. The clerk who commenced at 0700 noticed the ULD on the Sunshine Coast flight paperwork. Once the error was detected, the clerk rang the Sunshine Coast freight office. They were informed the incorrect container had been sent and provided them with details of the freight so the ULD could be sent back to Melbourne, then to Adelaide. The aircraft remained within weight and balance limits. However the ATSB comment that: The same error involving heavier weights could have a significant impact on the handling and performance of an aircraft. The clerk provided the following comments: They felt very busy. Within the first hour, they would have processed freight for about 9 to 10 flights, which was double the usual workload. They had to process all flights to Adelaide, Brisbane, Canberra, Alice Springs, and Townsville, as well as all other narrow-body flights. Normally this role would be divided between two clerks. If there is a person unable to work their shift, they try to find a replacement. They had done so in this case, but the replacement could not start until 0700. Normally at Christmas time, they would have extra staff rostered, but that year they did not. On the day, they felt under stress due to the busy time of year. Analysis In the old manual system, the same ULD number can be entered twice and the ATSB found that in this case both ULDs had the same ULD number. Encouragingly: In the new system, this would result in an error feedback. Without the error feedback, the clerk would not have known that the same container was entered twice. Furthermore, this data cross check is completed by the same...
read moreA Railroad’s Cult of Compliance
A Railroad’s Cult of Compliance We look at some of the safety culture lessons from a fatal rail accident in the US and how a more sophisticated approach has been taken in the UK. On 3 April 2016 an Amtrak New York to Savannah express train struck a backhoe construction vehicle near Chester, Pennsylvania supporting track ballast-vacuuming work. The 532t, 278m train had been authorised to operate at the maximum speed (110 mph) despite ongoing adjacent track works. As the train approached the works the driver (or locomotive engineer) saw equipment and workers and applied the emergency brake. The US National Transportation Safety Board (NTSB) in their investigation report say: The train speed was 106 mph before the emergency brake application and 99 mph* when it struck the backhoe. [* note some NTSB documents say impact was at 88 mph] Two roadway workers were killed, and 39 other people were injured. Amtrak estimated property damages to be $2.5 million. For comparison: the kinetic energy of the train at impact was equivalent of a backhoe striking a parked train at a near supersonic speed. The NTSB determined the probable cause was: …the unprotected fouled track that was used to route a passenger train at maximum authorized speed; the absence of supplemental shunting devices, which Amtrak required but the foreman could not apply because he had none [SSDs are a simple device to connect the two rails and cause the proceeding signal to display STOP]; and the inadequate transfer of job site responsibilities between foremen during the shift change that resulted in failure to clear the track, to transfer foul time [i.e. the time that adjacent tracks would be temporarily occupied during the works], and to conduct a job briefing. Allowing these unsafe actions to occur were the inconsistent views of safety and safety management throughout Amtrak’s corporate structure that led to the company’s deficient system safety program that resulted in part from Amtrak’s inadequate collaboration with its unions and from its failure to prioritize safety. Also contributing to the accident was the Federal Railroad Administration’s failure to require redundant signal protection, such as shunting, for maintenance-of-way work crews who depend on the train dispatcher to provide signal protection, prior to the accident. It is noticeable that SSDs were a recommendation after a 29 January 1988 accident when a northbound Amtrak train struck engineering equipment in the same town. The NTSB say “Amtrak management failed to issue SSDs to the night foreman, despite their own rules mandating the use of the safety equipment”. Furthermore, NTSB investigators concluded that “there was wide acceptance at Amtrak of not using SSDs” and they were still not a regulatory requirement. The NTSB say the Amtrack procedure for transfer of ‘fouls’ was “cumbersome” and routinely subject to work arounds. Fourteen safety recommendations were made after the 2016 accident. In this article we are going to look at some of the safety management, cultural and training lessons, that have relevance beyond the rail industry. Senior Management Perspectives on Safety The NTSB say: Investigators interviewed Amtrak senior executives and division heads… The managers had a variety of attitudes about best safety practices. Some managers showed little interest or concern about safety beyond the demands of their immediate job responsibilities, others expressed awareness of safety principles but lacked detailed knowledge of them or experience in applying them, and a few managers enthusiastically espoused...
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