Incomplete Maintenance Leads to Fatal Collective Control Loss on B407
Incomplete Maintenance Leads to Fatal Collective Control Loss on B407 (N427 TVA) Bell 407 N427TV of the Tennessee Valley Authority (TVA) crashed on approach to a landing site in Kentucky on 11 July 2016 after maintenance errors during a critical maintenance task 38 flying hours prior. The Accident Flight The US National Transportation Safety Board (NTSB) report: A witness reported that there were no abnormalities…until it was approximately 75 to 100 feet above the ground. Suddenly, the main rotor tilted to the right. Immediately after, the entire helicopter banked to its right and fell to the ground on its right side, where it came to rest. The pilot was killed in the impact. The Safety Investigation Initial examination of the wreckage revealed that the collective lever, which connected the cockpit collective controls to the main rotor, was disconnected from the pivot sleeve. The collective lever is located to the front and bottom of the swashplate support. It is linked to the cockpit collective leaver and vertically moves the pivot sleeve to simultaneously change the pitch on all four main rotor blades. The collective lever pins and screws that attached the collective lever to the pivot sleeve were missing; …they were later found loose, near the main rotor area. The safety wires [i.e the wire locking] intended to secure the screws to the pins were missing. Examination of the hardware at the NTSB Materials Laboratory revealed that the safety wires not present, and the screws backed out over time, resulting in the complete loss of collective control in flight. The NTSB elaborate: The maintenance tasks performed during the inspections between May 31, 2016, and June 20, 2016 [38 flying hours previously], did not require the removal of the collective lever or the disconnection or inspection of the collective lever pins or screws. Although an inspection of the condition of the flight control bolts and nuts was one of the maintenance tasks performed, an inspection of the collective lever pins, screws, and corresponding lockwire was not included in that inspection. The maintenance and inspections of the helicopter’s flight controls, including the collective control, were performed by two TVA airframe and powerplant mechanics and one TVA foreman, who assisted in the work and supervised the operation. One of the mechanics re-installed an anti-drive lever assembly. He did not recall removing the lockwire on the collective lever pin screws or removing the pins. He stated that the other mechanic performed the 24-month inspection of the flight control bolts and nuts. He further stated that the collective lever pins were not part of that inspection. The other mechanic performed the 24-month inspection of the flight control bolts and nuts. When asked if he removed the collective lever pins, he responded, “No, I don’t remember doing it. If anyone would have done it, it would have been me, but I don’t remember doing it.” The foreman inspected the work performed in the area of the flight controls. He reported that the removal of the collective lever pins “…was not part of the required maintenance performed.” He was not aware that the pins were removed or that any lockwire was removed. He added further, “I could see why it could have been done. The 24-month flight control bolt inspection was being performed, why not pull them and look at them too. I’ve done it before.”...
read moreS-92A Collision with Obstacle while Taxying
S-92A Collision with Obstacle while Taxying The Norwegian Accident Investigation Board (AIBN) has issued their report into a collision of Sikorsky S-92A LN-OND with a parked truck at Stavanger Sola airport on 5 July 2016. During taxyng to a helicopter stand, the main rotor blades of the Bristow Norway helicopter hit the side of truck parked at the site on airfield works. All four main rotor blades were damaged. Two workers standing alongside and in the truck, were slightly injured by blade debris. The Scene of the Accident There was construction work in progress for new helicopter stands for Avinor AS (the airport operator) by their main contractor Stangeland AS and sub-contractor Microtrenching AS. Microtrenching had been working on stands 60-63. On the evening of 4 July 2016 they requested permission from Airport Operations to relocate to stand 64, on the opposite side of Taxiway D, but without discussing this with the prime contractor who were not on site at the time. They parked within a series of red and white concrete barriers on the stand. During the 5 July 2017 17 helicopters taxyed along Taxiway D without incident or raising a concern, even though the concrete barrier was just 7.6m from the centreline (in contrast the rotor diameter of an S-92A is 18.5m). However crucially, no risk assessment had been done for the apron works, contrary to local regulations. Furthermore, no Notification of Work (NoW) or associated Job Safety Analysis (JSA) was prepared or issued for the new location. The NoW would have contained specific requirements for the safe completion of the work and triggered a NOTAM. Being closer than 22m to the centre line would have meant, under Avinor’s procedures, the taxiway should have been closed. The Accident Just before 15:00 Local Time LN-OND was returning from the Draupner offshore installation. After landing on Runway 29, they were given permission to taxy to Apron 7 via Taxiway D. The Pilot Flying was in the left hand seat and the Pilot Monitoring in the right hand seat. They had used Taxiway H when they had heading for the runway that morning. They were heading for Stand 61 and encountered two parted helicopters to the right on Stands 62 and 63 and the construction work to the left on Stand 64. Two trucks were parked near the concrete barriers alongside the taxiway (8.4m from the centre line). Safety Analysis Both pilots commented that judging the clearance was difficult. However, being aware that other aircraft had been routed that way successfully earlier in the day were confident that if they followed the yellow centre-line markings they would remain clear of obstacles. The crew did also taxy slightly to the right however not enough to prevent the main rotor blades striking the vehicle. The AIBN note that: …the lack of project specific risk analysis lead to a lack of specific guidelines on how to handle the risk factors. AIBN misses safeguarding of safety distance from taxiing helicopters, plans for parking of vehicle and equipment, plans for closing off construction areas, and role clarifications for the personnel involved. Furthermore, several of the instructions in the handbook for Airside safety were not followed, which contributed to the accident. Heavy white and red concrete blocks where placed along the asphalt edge at new helicopter stand where the truck was wrongly parked. The concrete blocks had been positioned in April 2016 to prevent a repetition...
read moreElevator Failure: Moisture + Heat
Elevator Failure: Moisture + Heat The Royal Canadian Air Force (RCAF) have reported on the loss of part of an elevator from an Airbus A310 (known as a CC-150 Polaris), CC15004, on 8 May 2015. The aircraft departed an unspecified base in support of Operation IMPACT, the Canadian Armed Forces’ (CAF) support to operations against Daesh in Iraq and Syria at 15:10 Local Time. Upon successful completion of the mission the crew commenced their return home. Approximately 4 hours into the flight and 1 hour and 15 minutes from landing, the crew felt a significant, sudden vibration lasting approximately 3-4 seconds, and was felt in the control column, rudder pedals and throughout the entire aircraft. The crew checked all aircraft system pages on the Electronic Centralized Aircraft Monitoring (ECAM) system and nothing unusual was found. The flight continued without further incident and landed safely at 2024 (L). Upon landing, an exterior inspection revealed disbonding and in-flight departure of a portion of the right elevator trailing edge. Damage was assessed as minor. Safety Investigation The investigation determined that high surface temperature, due to the dark paint scheme, and moisture ingress affected the properties of the structural adhesive between the elevator skin and honeycomb core to an extent such that disbonds occurred under normal operation. Further Event Fourteen months following the original occurrence, two additional elevators sustained disbonding without separation of any portion of the elevator from the aircraft; these were also assessed as minor damage. The subsequent finding on 23 July 2016 was by Sean Askin, a civilian crew lead on a CC150 Polaris while deployed on operation and an employee of L-3 Communications – Military Aviation Services. Mr. Askin had been present during [the original incident] event and ever since, he took it upon himself to conduct an extra verification of the flight controls; an inspection not expected nor required as part of his routine duties. Such an extended post-flight inspection is made even more difficult by the extreme heat, with night-time lows of 43ºC on the ramp. Using his high powered flashlight, he examined the horizontal stabilizer from a distance and discovered an abnormality in the paint that that was not duplicated on the opposite elevator. His interest piqued, Mr. Askin requisitioned a high-stand for a closer inspection only to discover a delaminated area of approximately 12 by 60 inches. Safety Action A number of preventive measures have already been taken on the CC150 Polaris fleet, including: the application of a new light-color paint scheme on composite surfaces to minimize heating, increased frequency of elevator inspection, and revision of the preventive maintenance program to include X-ray on a regular basis as well as ensuring the condition of the sealant is part of each elevator inspection. In addition, a study on the potential effect of dark paint on the current RCAF inventory is in progress, along with a process review to ensure that a similar situation is not repeated. Background The RCAF have 5 CC-150 Polaris aircraft at 8 Wing at CFB Trenton, Ontario. As part of the Air Force Multi-Role Tanker Transport (MRTT) program, two CC-150s have been converted to strategic air-to-air refuellers for Canada’s fleet of CF-188 Hornets. These are painted in a dark grey colour scheme. As of 3 July 2017 CC-150s have flown 778 sorties in support of Operation IMPACT, delivered...
read moreDeliberate Action: A Mindful Method from the Nuclear Navy
Deliberate Action: A Mindful Method from the Nuclear Navy In his book Turn the Ship Around! David Marquet describes a technique developed while CO of the US Navy‘s Los Angeles Class SSN USS Santa Fe, to reduce errors and increase mindfulness during critical tasks. The Incident: USS Santa Fe, 29 January 1999, Pearl Harbour During the hook up to 440V shore power a Petty Officer violated the ‘red tag procedure’, intended to stop power being applied while a system was still in an unsafe condition. As he recounts: In this case, a sailor had energized breakers on the pier after the conditions for energizing them had been met (so there was no hazard), but he hadn’t cleared the red tag before doing so indicating we were just lucky). You don’t want to he accidentally safe. The Assumption It was widely assumed on-board that that being found to have violated of such a basic safety procedure would see the accused subject to the Captain’s Mast This is a process for judgement and non-judicial punishment, ‘pour encourager les autres’ to pay attention. But Marquet was a man on a mission to turnaround the USS Santa Fe, the worst performing submarine in the navy. The Investigation Marquet opened an investigative meeting: “Petty Officer M. can you tell me what happened?” “Well, I knew we met conditions to shut the breaker, and [was just thinking that was the next step in the procedure. We had the procedure out and had reviewed it. I knew the red tags were hanging but just moved them aside to shut the breaker. Not am what I was thinking.” Gasps. “You moved a red tag aside?” “Yes, it was hanging right in front of the breaker. There was one on each of the three pier breakers, three across, right then.” Murmuring. I’m sure he was expecting to go to captain’s mast and be fined. Yet, he was willing to tell us the truth quite bluntly without any attempt at obfuscation. This needed no be rewarded. “Thank you very much for your candor. You and the rest of the watch team can go home. Supervisors stay behind.” This caused a stir. What no recriminations? No captain‘s mast? No yelling? Marquet knew he was was taking a risk by behaving differently to expectations: However, I felt the candor and honesty of Petty Officer M were more important than continuing the current process of inquisition, fear, and punishment. So he turned to his supervisors: “Now, gentlemen, how are we going to prevent this from happening again?” And that’s what we spent the next seven and a half hours talking about. Developing a Solution The first suggestion? That old favourite: refresher training. Marquet dismissed this as there was no deficiency in knowledge. The next suggestion was more supervision. In discussion they realised that may have helped stop the second and third breakers being closed, but would have been too late to stop the first. Marquet pushed his team to come up with something that would prevented the initial error. Exasperated with my unwillingness to accept any of the rote answers, someone blurted out, “Captain, mistakes just happen!” Now we were getting somewhere. We discussed what it would take to reduce mistakes made at the deck plate level, at the interface between the operators and the equipment, not simply discover them afterward. These were mistakes such as...
read moreNorth Sea S-92A Helicopter Airprox Feb 2017
North Sea S-92A Helicopter Airprox Feb 2017 The UK Airprox Board (UKAB) has released their report into an airprox involving two Sikorsky S-92A offshore helicopters on 22 February 2017. While this was a relatively low risk Airprox their report does discuss some interesting human factors aspects. Information Reported to the Airprox Board S92(1) was inbound to Aberdeen from an offshore installation 132nm to the SE of Aberdeen, and S92(2) outbound to an offshore installation 180nm to the SE of Aberdeen. The Board say: The S92(1) pilot reports being in straight-and-level cruise in ‘good VMC’. He suddenly received a TA on TCAS with the target showing +400(ft). At the same time, the crew saw opposite direction traffic… slightly left of track, 400ft above. Both aircraft’s pilots took avoiding action by manoeuvering to the right. The S92(2) pilot reports that the crew transferred frequency as normal at 80nm outbound from the ADN [VOR beacon] and believed that they were instructed to set the McCabe regional pressure setting [RPS] of 997hPa at 90nm. This was read back, recorded on the OFP and set on the standby altimeter. At 90nm, 997hPa was applied and the aircraft descended to maintain 3000ft altitude outbound as standard procedure. The crew were alerted by a TCAS TA, and the handling pilot (captain) acquired the opposite direction traffic, an offshore helicopter, almost straight away. It had little relative movement but appeared lower and TCAS was displaying it as 400ft below. They turned approximately 30° to the right onto a diverging track… …subsequently the McCabe pressure was established to be 977hPa. The S92(2) pilot stated that, unusually, due to an increased sea state over most of the north sea and strong westerly winds there were very few aircraft operating in the area and apart from the initial contact with ATC there were very few opportunities to detect the incorrectly set McCabe pressure, if any. He also noted that communications were often problematic in the area, with transmissions only available ‘on test function’. Both aircraft turned right as per SERA.3210 Right-of-way (c)(1) Approaching head-on and both crew assessed the risk of collision as ‘none’. North Sea ATC Service Background The provision of ATC to offshore UK sector oil and gas helicopters is provided in a unique way. The Airpox Board explain: A surveillance system known as (WAM) is used to provide surveillance coverage down to very low altitudes over a vast area. Although the surveillance system is capable of monitoring aircraft to low levels, radio communications are more limited and the system architecture is not comprehensive enough for a full Deconfliction Service sufficient to meet regulatory approval. It is this factor that limits the type of ATC service available. Within 80nm of Aberdeen a Deconfliction Service is usually provided (by utilising land based radar and communications), but outside of this area, the highest level of service available is a Traffic Service. As the surveillance system being used beyond 80nm is based on Secondary Surveillance equipment only, then the Traffic Service is limited to SSR data only. Aircraft within the HELS and REBROS sectors can be assigned one of three QNHs depending on the area in which they are operating. The Aberdeen QNH is used within a range of 90nm from Aberdeen. Beyond 90 miles it is usual to use either the ‘Fulmar’ or ‘Miller’ QNH’s, which are obtained from specific off-shore installations. However,...
read moreHow do we Improve Human Performance in Today’s Aviation Business?
How do we Improve Human Performance in Today’s Aviation Business?: Aerossurance Supports 2017 HF in Aviation Safety Conference Aerossurance is pleased to be supporting the annual Chartered Institute of Ergonomics & Human Factors’ (CIEHF) Human Factors in Aviation Safety Conference for the third year running. We will be presenting for the second year running too. This year the conference takes place 13 to 14 November 2017 at the Hilton London Gatwick Airport, UK with the theme: How do we improve human performance in today’s aviation business? Aerossurance was keen to again support this excellent, independent, professional forum for discussion and exchanging of ideas on the latest research, development and application of Human Factors in Aviation Safety. The 2017 event will centre on five challenges in aviation safety human factors: How do we improve human performance in aviation systems? Are we managing fatigue in aviation? Is adaptive automation still a useful concept? Where are the human performance limits in remote operations (e.g. remote towers, drones)? Have maintenance human factors fallen off our agenda? Aerossurance will be presenting the Maintenance Observation Programme concept and promoting the RAeS Human Factors Group: Engineering Listening and Learning project with a poster. The format for the event has evolved with directed panel discussions following each section of papers. The aim is to: ….answer the questions above…as well as identifying ways forward which will create a closer connection between industry needs and aviation human factors research, so that the net result will be improved human performance in aviation. Aerossurance worked with the Flight Safety Foundation (FSF) to create a Maintenance Observation Program (MOP) requirement for their contractible BARSOHO offshore helicopter Safety Performance Requirements to help learning about routine maintenance and then to initiate safety improvements: Aerossurance can provide practice guidance and specialist support to successfully implement a MOP. We have previously discussed some of our thoughts, focused particular on airworthiness and maintenance matters here: Airworthiness Matters: Next Generation Maintenance Human Factors See also our LinkedIn Showcase on Maintenance Human Factors. UPDATE 24 June 2018: B1900D Emergency Landing: Maintenance Standards & Practices The TSB report posses many questions on the management and oversight of aircraft maintenance, competency and maintenance standards & practices. We look opportunities for forward thinking MROs to improve their maintenance standards and practices. Aerossurance has extensive practical experience in air safety management systems, aviation human factors, safety culture and safety leadership development. Contact us at: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest updates....
read moreImpromptu Flypast Leads to Disaster
Impromptu Flypast Leads to Disaster The Icelandic Transportation Safety Board (ITSB), the RNF, issued their report on a dramatic Beechcraft King Air 200 accident that occurred on 5 August 2013. The air ambulance, TF-MYX, operated by Mýflug Air, was heading back to its home base at Akureyri (BIAR) Airport, after completing an earlier ambulance flight, with two flight crew and a paramedic on board. The Accident Flight The ITSB say: During cruise, the flight crew discussed the commander’s wish to deviate from the planned route to BIAR, in order to fly over a racetrack area near the airport. At the racetrack, a race was about to start at that time. The commander had planned to visit the racetrack area after landing. The aircraft approached BIAR from the south and…made a request to BIAR tower to overfly the town of Akureyri, before landing. The request was approved by the tower and the flight crew was informed that a Fokker 50 was ready for departure on RWY 01. The flight crew of TF-MYX responded and informed that they would keep west of the airfield. After passing KN, the altitude was approximately 800 ft according to the co-pilot’s statement. The co-pilot mentioned to the commander that they were a bit low and recommended a higher altitude. The altitude was then momentarily increased to 1000 ft. When approaching the racetrack area, the aircraft entered a steep left turn. During the turn, the altitude dropped until the aircraft hit the racetrack. The accident occurred 2.5 nm NW of Akureyri airport at an elevation of 468 ft. The racetrack is located in the foothills of a mountain, where the land slopes down against the flight path, i.e. after the left turn. The aircraft collided with the ground with the left wing impacting first. The aircraft rolled to the left and down the racetrack and the wings separated from the fuselage. The fuselage broke into three main parts. The empennage came to rest left of the racetrack but the cockpit and the cabin came to rest in a grass area beyond the end of the racetrack, slightly left of its centre. The engines separated from the wings. The aircraft left a 400 m debris trail. The impact was captured on CCTV at the race track: Due to the fact that this was a high energy impact with an immediate fire explosion, the possibilities of survival were considered at a minimum. The paramedic was seated in the cabin section close to where the cabin broke from the cockpit. The cockpit and the cabin rolled down the racetrack and impacted a grass ridge at the end of the racetrack and came to rest on top of the ridge. However: The cockpit section around the co-pilot, sitting in the right side of the cockpit, was found to have incurred significantly less deformation than the left side. The commander and the paramedic were fatally injured and the co-pilot was seriously injured. The aircraft was destroyed. Investigation Data and Techniques There were no flight recorders or any other recording equipment fitted in the aircraft. There were two GPS receivers for navigation, Garmin GNS530 and GNS430, but these did not record useful data to the investigation. The investigation made use of three videos that captured the aircraft during its last phase of flight. One of the videos was from a CCTV...
read moreEASA Annual Safety Review 2017 Published
EASA Annual Safety Review 2017 Published The European Aviation Safety Agency (EASA) Annual Safety Review for 2017 is now available. In the introduction to the Agency’s 12th review, EASA’s Executive Director Patrick Ky says: 2016 has brought continued improvements in safety across almost every operational domain. It was the lowest year in terms of fatalities in airline operations in aviation history. However, the fatal accident involving a cargo flight in Sweden that took place in January highlighted the complex nature of aviation safety and the significance of addressing human factor aspects in further reducing accidents. Additionally, the tragic accident involving an EC225 helicopter in Norway in April 2016 shows the importance of joining forces and together maintaining safety as an aviation community. During the past year EASA has advanced and developed key strategic activities across a diverse range of new and emerging issues. …the Agency has further refined the way in which it applies Safety Risk Management principles. In particular, the collaborative analysis groups…in further underpinning a data-driven approach to managing safety, which is now also reflected in the latest edition of the European Plan for Aviation Safety (EPAS). These various efforts will help to ensure our continued vigilance and help improve safety for today and into the future. EASA says: The latest edition further extends the provision of safety risk portfolios through the addition of aerodromes/ground handling and ATM/ANS portfolios, bringing the total number of analysed aviation domains to 13. Overview of Air Accidents in EASA Member States EASA that in the 32 EASA Member States (the 28 European Union Member States plus Iceland, Liechtenstein, Norway and Switzerland): The only domain with an increase in fatalities in 2016 was Offshore Helicopters, where there was one accident with 13 fatalities. This is the first year that a fatal accident has been recorded in this domain since 2013. For the other domains, there has been a reduction in both the number of fatal accidents and fatalities. Because of the low number of fatal accidents in CAT [Commercial Air Transport] Aeroplanes, the median average is introduced to highlight that while the mean average number of fatalities is high, this is largely due to a small number of large accidents. The top 5 domains in terms of the number of fatalities for the past 10 years (2007-2016) were: Non-Commercial Aeroplanes: In terms of the average number of fatalities over the past 10 years, this domain has the highest with 173.5. In 2016, it was also the domain with the highest number of fatalities and fatal accidents, being 113 fatalities and 77 fatal accidents. In both cases, the figures for 2016 are lower than the 10 year average. [Note: the discrepancy between this text and the table has been reported and is expected to be corrected shortly] CAT Aeroplanes Airline (Passenger/Cargo): The second highest average number of fatalities over the past 10 years is in CAT Aeroplanes Airline (Passenger/ Cargo) with 66.0 per year. In 2016, there was one fatal accident, which led to 2 fatalities. This accident involved West Air Sweden Flight 294, a cargo flight using a Bombardier CRJ200 that crashed in Sweden on 8 January 2016. The final report for this accident was published by the Swedish Accident Investigation Board in December 2016. Gliders/ Sailplanes: In terms of the average number of fatalities, the gliding/sailplanes domain...
read moreIngestible Stomach Acid-Powered Health Monitoring Pill
Ingestible Stomach Acid-Powered Health Monitoring Pill When Aerossurance normally discusses Health Monitoring technology its typically the monitoring for failures in engines and helicopter gear boxes. A new development moves health monitoring into a new realm that offers exciting possibilities to human fatigue and alertness researchers. Researchers from MIT and Brigham and Women’s Hospital in Boston, Massachusetts designed a high-tech health monitoring pill can be swallowed by humans. It has an energy harvesting galvanic cell that runs on the acidic fluids in the stomach using zinc and copper electrodes, eliminating the risk of using battery power. Giovanni Traverso, a research affiliate at the Koch Institute for Integrative Cancer Research explained: We need to come up with ways to power these ingestible systems for a long time. We see the GI [Gastrointestinal] tract as providing a really unique opportunity to house new systems for drug delivery and sensing, and fundamental to these systems is how they are powered. It is reported that: The pill is small—about 40 millimeters long and 12 millimeters in diameter—though researchers hope to shrink it to a third of that size in the next prototype, as well as add other types of sensors and tweak it for long-term monitoring of vital signs. The device delivered an average power of 0.23 μW mm−2 of electrode area. …the device generated enough power to allow the transmitter to send a signal every 12 seconds to a base station two meters away. Once the device moved to the less acidic small intestine—it took an average of six days to travel the digestive tract—the amount of power fell to only 1/100 of what it produced in the stomach, though researchers hope to find a way to harness the power there as well. It is also reported that: Scientists have explored other techniques for powering ingestible electronics, but many of these methods are not well suited to these devices. One technique they tried was harvesting energy from the body’s heat. But they couldn’t generate enough of a thermal gradient in the gut to make this work. And because these capsules cannot easily be anchored to a moving surface, it has been challenging to harvest energy from vibrations. A study that tested the device on pigs was published recently in Nature Biomedical Engineering. Lead author Phillip Nadeau said in the statement: You could have a self-powered pill that would monitor your vital signs from inside for a couple of weeks, and you don’t even have to think about it. It just sits there making measurements and transmitting them to your phone. While such a device offers exciting possibilities for medical diagnosis, albeit with data privacy concerns, it also offers new ways to research human performance and alertness. British Airways have filed a patent to use such devices as part of a program to help reduce jet lag by optimising meal and rest times. See also our article: Maintenance Personnel Fatigue and Alertness UPDATE 17 August 2017: Discussing earlier technology: Army researchers hope device can improve safety for airborne soldiers Aerossurance has extensive air safety, operations, airworthiness, human factors, aviation regulation and safety analysis experience. For practical aviation advice you can trust, contact us at: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest...
read morePerception and Fatigue: RCAF CH124 Sea King Engine Failure
Perception and Fatigue: RCAF CH124 Sea King Engine Shutdown The Royal Canadian Air Force (RCAF) have reported on an incident during training of a new Maintenance Test Pilot (MTP) that lead to an engine failure on Sikorsky CH124 Sea King CH12428 on 11 May 2015 over the Strait of Juan de Fuca, South of Victoria, British Columbia. During the conduct of the number one engine manual throttle topping check, the MTP Trainee inadvertently bumped the manual throttle slightly forward and had to re-establish hand position on the manual throttle lever. The investigation determined that the AC [Aircraft Commander] misinterpreted the motion of the MTP Trainee gaining a better grip on the manual throttle control lever as the MTP Trainee closing the manual throttle. This perception error led to a cascade of subsequent events, which began with the act of lowering the collective and resulted in engine failure. They go on to say that: Fatigue was identified as a significant contributing factor leading to the perception error. The Royal Canadian Air Force (RCAF) is currently in the process of implementing a Fatigue Risk Management System (FRMS), which will be a multi-layered approach to preventing fatigue and managing fatigue-related risk. Full implementation of the RCAF FRMS is anticipated for mid-2017. Fatigue-modelling capability and FRMS are being developed as components of the RCAF Mission Acceptance / Launch Authorization (MALA) risk management tool. Although not directly causal to this occurrence, collateral findings and recommendations were also made regarding Aircraft Operating Instruction procedures and cautions for operating the manual throttle. The RCAF provide no further information on how the fatigue occurred or the specific engine damage. Safety Resources Embraer ERJ 170 FMS Error & Fatigue Maintenance Personnel Fatigue and Alertness Fatigued Flight Test Crew Superjet 100 Crosswind Accident UPDATE 4 August: 2018: US HEMS EC135 Dual Engine Failure: 7 July 2018 UPDATE 3 July 2020: Fatigue Featured in Anchorage Alaska Air Ambulance Accident UPDATE 26 September 2020: Fatal Fatigue: US Night Air Ambulance Helicopter LOC-I Accident UPDATE 9 April 2022: SAR Seat Slip Smash (RCAF CH149 Leonardo Cormorant LOC-I) Aerossurance is pleased to be supporting the annual Chartered Institute of Ergonomics & Human Factors’ (CIEHF) Human Factors in Aviation Safety Conference for the third year running. This year the conference takes place 13 to 14 November 2017 at the Hilton London Gatwick Airport, UK with the theme: How do we improve human performance in today’s aviation business? Aerossurance has extensive air safety, operations, airworthiness, human factors, aviation regulation and safety analysis experience. For practical aviation advice you can trust, contact us at: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest...
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