EasyJet and Airbus Collaborate on ‘Big Data’ IVHM
EasyJet and Airbus Collaborate on ‘Big Data’ Integrated Vehicle Health Monitoring In a project, first revealed in mid 2015, EasyJet and Airbus are collaborating on ‘big data’ Integrated Vehicle Health Monitoring (IVHM) technology. At a SAE/RAeS/Cranfield University IVHM workshop Aerossurance participated in at the Farnborough International Airshow in July 2016, Ian Davies, EasyJet’s Head of Engineering & Technical Director commented how 20 years ago Health and Usage Monitoring Systems (HUMS) had become normal on offshore helicopters. The fixed wing sector is however he says still lagging behind (with the exception of engines were Engine Health Monitoring [EHM] has been routine for many years). Previously Davies had commented that EasyJet wants to carry out early prognostics “just like Formula One”, which uses telemetry to predict when maintenance is needed. At that time EasyJet, founded in 1995, had a fleet of 255 A319s and A320s across their UK and Swiss AOCs, which flew an average of 11.1 hours per day each in FY15, which is expected to expand to 350 in 3-5 years. Even with 99.3% technical dispatch reliability they currently 7 aircraft dedicated as spare aircraft, and when the fleet reached 350 they would need 10, worth $800 million. So although the fixed wing sector may be lagging behind in IVHM application, the potential prize is massive. EasyJet claim an engine In Flight Shut Down (IFSD) rate half of the average for the CFM56. However, although EHM has been in-use for years, they noted that they had 3 engines written off this year due to bearing failures, so their remain opportunities to improve EHM. Davies identified one typical problem being that of avionic cooling fans, which when they fail generate smoke and odour in the cockpit that can prompt a precautionary landing. The addition of a vibration sensor could give prior warning of a deteriorating bearing. At the SAE workshop it was said that two suppliers had been picked to demonstrate their solutions. Airbus have previously been working with IBM on Airbus Smarter Fleet Solutions (ASFS): …will integrate and also further develop Airbus’ current portfolio of software products (“e-solutions”). Presently, the latter comprise an extensive range of standalone applications… …will provide tailored fleet data management using an open, modular and flexible platform. This service will give customers visibility to plan ahead for smooth operations. It will also enable them to easily integrate existing and new services… “Today’s aircraft can generate up to a half terabyte of data per flight, an unprecedented volume and variety of data seen in few other industries,” said Timothy J. Wholey, Global Leader, Aerospace & Defense Industry, IBM Global Business Services. Airbus has recently disclosed work with Californian data specialist Palantir: Airbus taps Silicon Valley expertise to speed production of A350: Airbus began working with Palantir about 18 months ago, but has recently expanded the relationship…to eight projects across four countries… Palantir’s staff worked with Airbus to tie together data from several different countries and databases, so that engineers spread across the company are better able to learn from each others’ experiences when fixing quality issues. The secretive Palantir, which started out more than a decade ago working on national security projects, is valued at $20bn despite not yet delivering a profit. The multimillion-dollar [A350] deal with Airbus would help it reach its planned target of profitability this year, said Alex Karp, chief executive. We did very well last year,” he...
read morePerformance Based Oversight: Accountable Manager Meetings (CAP1508)
Performance Based Oversight (PBO): Accountable Manager Meetings The UK Civil Aviation Authority (UK CAA) has published a new leaflet on Accountable Manager Meetings (AMMs): CAP1508: Getting the most out of the Accountable Manager Meeting As the UK CAA focus more on Performance Based Regulation (PBR), and specifically Performance Based Oversight (PBO), AMMs are increasingly a key part of the UK CAA’s approach. Accountable Manager Meeting Guidance The aim is to ensure both the regulator and the Accountable Manager (AM) of an approved organisation or regulated entity have “a similar perspective on the major risks facing each entity”. They say: The key thing is that we have a constructive, two-way dialogue about the business context, safety risks and desired outcomes and importantly have a record of the discussions. The change from calling these ‘interviews’ to ‘meetings’ may be to encourage more dialogue. The AM will first be invited to give a short overview of their business and their operational context. The CAA say: A conversation should follow this around the entity’s performance on managing operational safety risks. This should be informed by our own analysis of their risks… …in other words what is discussed in the organisation’s own internal reviews. The CAA say they “want to ensure that Accountable Managers…have a consistent experience” whoever from the CAA meet them. They have therefore developed a set of core questions help guide the conversation: What are your top safety risks (current and future)?* How did you identify these safety risks? How do you assure yourself, as Accountable Manager, that these are your top safety risks? What outcomes do you want to see as a result of managing these safety risks? What actions are you taking to mitigate or remove the safety risks – and are relevant stakeholders involved? Are the outcomes achievable and measurable? How do you monitor and check that your actions are working (Plan, Do, Check, Review)? What do you do if your actions are not giving the desired outcome? How do you share knowledge and lessons learned in your organisation? * we note with relief that they are not insisting on a arbitrary set number of top risks (a now rather passé fad) The meeting should also cover: Progress against previously agreed actions Planned future oversight activity Sector risks and total risk trends and issues Where possible any other issues raised by the entity The CAA will produce a record of the meeting, including all agreed actions, outcomes, timeframes, owners and significant discussions. Other PBR Resources For more on the general topic of PBR see this 2002 paper from the Harvard John F Kennedy School of Government: Performance-Based Regulation Prospects and Limitations in Health, Safety and Environmental Protection See also our articles: Performance Based Regulation – EASA A-NPA & UK CAA Seminar Performance Based Regulation and Detecting the Pathogens UK CAA PBR Stakeholder Engagement (CAP1345) Safety Intelligence & Safety Wisdom High Reliability Organisations (HROs) and Safety Mindfulness UPDATE 1 March 2017: Safety Performance Listening and Learning – AEROSPACE March 2017 Organisations need to be confident that they are hearing all the safety concerns and observations of their workforce. They also need the assurance that their safety decisions are being actioned. The RAeS Human Factors Group: Engineering (HFG:E) set out to find out a way to check if organisations are truly listening and learning. The result was a self-reflective approach to find ways to stimulate improvement. UPDATE 22 March...
read moreEC130B4 Loss of Control on Take-Off in Dubai
EC130B4 Loss of Control on Take-Off in Dubai On 22 January 2014, Airbus Helicopters EC130B4 helicopter A6-DYR of Helidubai crashed after suffering a loss of control departing the heliport at the Atlantis Palm hotel in Dubai, UAE. The Accident Flight The Air Accident Investigation Sector (AAIS) of the UAE General Civil Aviation Authority (GCAA) say in their investigation report that the aircraft was positioning back to Dubai International Airport at the end of the day’s flying programme. Onboard were the Pilot and, as a passenger, the operator’s Helicopter Landing Officer (HLO) who was in charge of ramp handling at the hotel heliport. They say: The flight required lifting to a hover position [while orientated at approximately 200°], a pedal turn to a northerly heading, and a standard climbing departure from the heliport. On lift-off, the Pilot simultaneously pulled power into the climb while applying continuous left pedal, turning the Aircraft counter clockwise (to the left). This turn continued past the optimal northerly heading for departure, with the Aircraft turning rapidly counter clockwise. The turn rate accelerated, increasing to approximately 180° per second [threes time the Flight Manual Limitation] at a height of approximately 22 meters (72 feet) above the heliport. The Aircraft then descended rapidly, pitching forward, while continuing in a counter clockwise turn prior until impact with the heliport. The Aircraft impacted the heliport vertically, with a level attitude, minimal forward speed, with approximately 5° nose down attitude and a rapid rate of descent (ROD), until impact. …the skids failed under the vertical load…however they were splayed outwards with the area of the fuselage under the Aircraft between the skids in constant contact with the heliport surface. There was a fuel drain decanting sump with a water drain valve located in this area. There was significant fuel loss from the fuel tank water drain valve, which was damaged following the hard landing, which had dispersed around the Aircraft. There was no post-impact fire. The Pilot and HLO were both incapacitated from injuries resulting from the combination of the rapid vertical deceleration and that both crewmembers [sic] were unrestrained by their shoulder harnesses due to the crew seats lowering [as designed so as to absorb impact load, though the AAIS also comment that the inertia reel lock at above 1.5g and the rotational forces would have potentially induced some slackness]. …the Fenestron tail assembly was damaged. With the engine throttle control set to the ‘Flight’ indent position and with some pitch on the main rotor blades, the engine continued to develop power and torque. As the Aircraft was engaged in a counter clockwise rotation following the hard landing and the Aircraft was under power, it began an uncontrolled rapid counter clockwise rotation. The Aircraft remained on the heliport with the engine running with the damaged rotor blades turning while the Aircraft was moving along the heliport extended centerline . The rotor blades…contacted a row of trees adjacent to the heliport border causing further damage. The Aircraft rotated approximately 50 times on the heliport prior to contacting a drainage curb at the edge of the heliport which arrested the rotation and stopped the Aircraft from moving further. The Aircraft remained in that position with the engine running and the damaged rotor blades turning. The heliport ground crew were then able to shut down the engine and assist...
read morePower of Prediction: Foresight and Flocking Birds
Power of Prediction: Foresight and Flocking Birds On 15 January 2009, two minutes after take off from LaGuardia Airport (LGA), New York City, US Airways Flight 1549, Airbus A320-214, N106US, encountered a flock of Canada Geese. The US National Transportation Safety Board (NTSB) investigation report says: Both engines were operating normally until they each ingested at least two large birds (weighing about 8 pounds each), one of which was ingested into each engine core, causing mechanical damage that prevented the engines from being able to provide sufficient thrust to sustain flight. Consequently the aircraft was forced to ditch in the Hudson River. The 155 passengers and crew members successfully evacuated the aircraft and were rescued with only 5 serious injuries. The executive summary of the NTSB report covers many aspects of Crew Resource Management (CRM), training, ditching procedures / certification and survivability related to actions after a bird strike that prevent continued safe flight. The NTSB summary only briefly mentions mention engine certification standards and wildlife hazard mitigations to prevent critical damage. In this article we look at how hindsight from previous occurrences demonstrated the potential of such an accident and how prediction had shown the probability of a catastrophic bird strike outside the airport boundary was increasing. Canada Geese: the Large Flocking Bird Hazard Canada Geese (Branta canadensis), as a species are a major threat to aviation safety for there reasons: Their large size (at an average of c8lbs+) means that a Canada Goose strike is at the top end of certification requirements for large aircraft Their propensity to fly in ‘skeins’ (v-shaped flocks) which mean that multiple simultaneous strikes are possible While traditionally a migratory bird, they have increasingly become non-migratory Its this third factor that had been causing the risk of a double engine bird strike to increase. The NTSB published a chart of US Canada Goose population, which had increased from 1.2 million to 5.5 million over 38 years: The nearly 20 fold increase in resident geese is significant as that means even greater exposure throughout the year. This change in behaviour had come about because Canada Geese had increasingly been adapting to live year round in parks, golf courses and waterways in an around urban environments, while still flying in skeins to local feeding areas. Readers of the NTSB report might conclude that this was something of a surprise to the industry. Foresight not Hindsight and the Environmental Aspects of Bird Hazard Mitigation: Warning of Probabilities In fact, among others, the UK Civil Aviation Authority (CAA) had been paying close attention to the threat of large flocking birds and the probability of a catastrophic a multi-engine bird strike. In a paper authored by Aerossurance’s Andy Evans, then a UK CAA Surveyor, the UK CAA warned that: In some areas of North America, the risk of such an encounter may be approaching a critical level. This was 8 years before A320 N106US lost power from both engines and ditched in the Hudson River. At that time rule making to enhance engine bird strike resistance for new engines was already under way. As there was little that could be done to enhance existing designs this paper was intended to highlight the critical need to take proactive environmental action to manage bird habitats. While this included measures on and close to airports it also crucially included wider actions involving non-aviation stakeholders, the UK CAA paper...
read moreCHC Scotia Sikorsky S-92A Loss of Tail Rotor Control Events
Sikorsky S-92A Loss of Tail Rotor Control Events (CHC Scotia G-WNSR, Total West Franklin Installation, Central North Sea) The UK Air Accidents Investigation Branch (AAIB) have issued a Special Bulletin on an occurrence involving Sikorsky S-92A G-WNSR of CHC Scotia on 28 December 2016, which they have classified as an Accident. This involved the failure of both the tail rotor pitch change shaft bearing and the servo piston rod itself, resulting in a total loss of tail rotor control, fortuitously without injury. We look at the background to this accident. The Accident Flight The S-92A was on a four-sector routing from Aberdeen to Total’s Elgin-Franklin field in the Central North Sea and back as Flight 21N, which departed Aberdeen at 07:15. The second sector was from the Elgin Process Utilities Quarters (PUQ) to the West Franklin wellhead platform, 3.3 nm to the south, with 2 crew and 9 passengers on-board. The West Franklin, whose topsides were constructed by Rosetti Marino, has a Bayards 21m, 12.8t aluminium helideck. The meteorological observation from the Elgin PUQ at 06:08 was of a surface wind from 220° at 17 kt. The AAIB say: As the helicopter [on a heading of 270°] lifted from the Elgin PUQ helideck it yawed unexpectedly to the right through 45°. The commander applied full left yaw pedal, checked the rotation and landed back onto the deck. The flight crew discussed the likely cause, which they thought to have been the result of local turbulence or wind effects created by the platform structures which, anecdotally, is not uncommon for this helideck. They decided to continue and during the subsequent lift off into the hover the commander applied left yaw pedal, the helicopter responded and turned to the left; all control responses appeared normal. The commander then climbed to 500 ft for the brief transit… The helicopter made a normal approach and deceleration to the West Franklin and crossed over the helideck. During the descent to land, at approximately 4 ft above the helideck, it yawed rapidly to the right, reaching a maximum rate of 30 degrees per second. At the same time it rolled 20° to the left, at which point the left main landing gear contacted the helideck. It continued to yaw to the right on its left mainwheels and nosewheels before the right mainwheels contacted the surface [of the helideck, causing damage to deck and the left outer main wheel rim]. The helicopter came to rest on a heading of 041° having rotated through 187°. The helicopter was shut down and the crew and passengers disembarked; there were no injuries. The helicopter was subsequently craned from the helideck onto a ship [the Ben Nevis] and recovered to Aberdeen [arriving on the morning of 30 December 2016]. Reporting The operator transmitted a Mandatory Occurrence Report (MOR) to the UK Civil Aviation Authority (UK CAA) on 28 December 2016. It is understood that an industry lead investigation commenced promptly and the occurrence, and the damage to the helideck, was mentioned in the local press on 30 December 2016. The AAIB say they did not however become aware of it until 5 January 2017 (the same day that photographs of the damaged helideck emerged in the local press). Investigation Once the panels were removed it was immediately apparent that the tail rotor servo piston was damaged. The servo was removed and revealed that...
read moreS-92A Flying Control Restriction on Wiring Loom
S-92A Flying Control Restriction on Wiring Loom A pilot recently reported a restriction of main rotor cyclic movement in the forward left quadrant of a Sikorsky S-92A according to a Service Difficult Report (SDR) submitted to the Civil Aviation Safety Authority (CASA) in Australia. The subsequent maintenance investigation found that a cyclic wiring loom was preventing full movement to the stop. The wiring loom was rerouted to eliminate the restriction. The SDR provides no further details on how, when or why the loom became misrouted. See also our previous articles: C-130 Fireball Due to Modification Error B767 Engine Fire – Ignition from Misrouted / Chaffed Cables UPDATE 13 March 2017: The AIB Nigeria have only just released their report into a hydraulic pipe chafing event that caused a fire on 27 February 2013 on S-92A 5N-BOA. It is rather unfair however of the AIBN to complain that the operator did not did not challenge the serial number applicability of an earlier 2008 Sikorsky ASB that (by implication) was to address production defects with a once off inspection. Aerossurance is pleased to sponsor the 2017 European Society of Air Safety Investigators (ESASI) 8th Regional Seminar in Ljubljana, Slovenia on 19 and 20 April 2017. Registration is just €100 per delegate. To register for the seminar please follow this link. ESASI is the European chapter of the International Society of Air Safety Investigators (ISASI). UPDATE 6 August 2018: In-Flight Flying Control Failure: Indonesian Sikorsky S-76C+ PK-FUP UPDATE 30 May 2019: PA-34 Electrical Short Melted Rudder Cable UPDATE 18 November 2020: Embraer ERJ-190 EWIS Production Quality a Factor in Fire UPDATE 27 December 2020: Fire-Fighting AS350 Hydraulics Accident: Dormant Miswiring UPDATE 8 February 2021: RCAF Investigate Defect on Newly Delivered CH-148 Cyclone (S-92) UPDATE 17 September 2022: Canadian B212 Crash: A Defective Production Process UPDATE 25 May 2025: CHC Sikorsky S-92A Seat Slide Surprise(s) Aerossurance has extensive air safety, operations, SAR, airworthiness, design assessment, certification, 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 moreHROs and Safety Mindfulness
High Reliability Organisations (HROs) and Safety Mindfulness As part of research into ‘Resolving the Organisational Accident’, an EU aviation research project, called Future Sky, initiated by the association of European Research Establishments in Aeronautics (EREA), has been examining the topic of ‘Safety Mindfulness’. The concept is that if front-line staff are aware of the possible threats they can anticipate and mitigate most of them. However there is a traditionally a time delay after new threats emerge before all operational personnel received information on the threat. This Safety Mindfulness research “aims to provide much faster and effective processes to give operational people these types of information”. The authors of their first report on the concept are Nick McDonald, Tiziana Callari and Daniele Baranzini (all from Trinity College Dublin) and Rogier Woltjer and Björn Johansson (of FOI). NLR are programme managing the research and the project manager is Barry Kirwan of Eurocontrol. It also includes contributors from KLM. Another Future Sky project has recently investigated the concepts of organisational safety intelligence (the safety information available) and executive safety wisdom (in using that to make safety decisions). We discussed that study in our article: Safety Intelligence & Safety Wisdom 1) Origins of Mindfulness a) High Reliability Organisations (HROs) The Safety Mindfulness Concept develops the original Mindfulness concept from Weick and Sutcliff (2007) and aims to…: …develop and demonstrate a practical method of maintaining Safety Mindfulness in operational situations, by maintaining the (top-down) feed-forward of risk information from safety to operations, (bottom-up) feedback from operations to safety people, and (horizontal) safety information sharing in the operational layer, which includes supervisors. Weick and Sutcliff developed the High Reliability Organisation (HRO) concept were an: HRO can be referred to as a set of organising processes that allow an organisation to continuously operate under trying conditions, reduce the impacts of accidents, and help with the recovery process. HROs strive to avoid errors by stressing a commitment to consistently safe and reliable operations. Mindfulness is a collective capability comprises five HRO processes (Weick, et al. 1999; Weick and Sutcliffe, 2007) that the Future Sky team summarise as: (1) Preoccupation with failure (regularly and robustly discussing potential threats to reliability), (2) Reluctance to simplify interpretations (developing a nuanced understanding of the context by frequently questioning the adequacy of existing assumptions and considering reliable alternatives), (3) Sensitivity to operations (integrating the understanding into an up-to-date big picture), (4) Commitment to resilience (recognising the inevitability of setbacks and thoroughly analysing, coping with, and learning from them) and (5) Under-specification of structure (deferring to expertise rather than authority when making important decisions). The Future Sky authors note that: A fundamental idea in Weick’s writing is that organisations that encourage the sharing of narratives and storytelling will be more reliable than an organisation that does not, as “people know more about their system, know more of the potential errors that might occur and they are more confident that they can handle those errors that do occur because they know that other people have already handled similar errors” (Weick, 1987, p. 113). Weick goes as far as seeing storytelling and upholding narratives as a substitute for trial and error, pointing to the fact that in many organizations, error is not an option as it would have disastrous outcomes. Instead, near misses and successful performance or recovery is used to illustrate the kind of behaviours that is encouraged by the members of the organization....
read moreSafety Lessons from a Fatal Helicopter Bird Strike: PHI Sikorsky S-76C++
Safety Lessons from a Fatal Helicopter Bird Strike: PHI Sikorsky S-76C++ N748P Contracted to Shell Oil We look at a fatal accident that happened on 4 January 2009 that highlights a range of certification, modification, crew alerting, training and emergency response lessons. We also discuss current activity on helicopter bird strike certification requirements. The Accident Flight Sikorsky S-76C++ N748P of PHI took off from a heliport in Louisiana, destined for a Shell offshore installation in the Gulf of Mexico with two crew and 7 passengers aboard. The helicopter “established level cruise flight at 850 feet mean sea level and 135 knots indicated air speed” according to the US National Transportation Safety Board (NTSB) investigation report and: About 7 minutes after departure, the cockpit voice recorder recorded a loud bang, followed by sounds consistent with rushing wind and a power reduction on both engines and a decay of main rotor revolutions per minute. Due to the sudden power loss, the helicopter departed controlled flight… The helicopter crashed in marshland just 12 miles from the heliport. The Caledonian Airborne Emergency Locator Transmitter (ELT) activated. While there is normally a short delay until the COSPAS/SARSAT satellite system alerts the appropriate Rescue Coordination Centre (RCC), the USAF RCC only made contact with the operator 31 minutes after impact according to their accident report form. It was not until the wreckage had been visually identified (54 minutes after impact) by another of the operator’s helicopters that a US Coast Guard helicopter was dispatched. Miraculously one passenger was found alive, albeit very seriously injured. The NTSB N748P Accident Investigation The NTSB identified that the helicopter had suffered a bird strike: Examination of the wreckage revealed that both the left and right sections of the cast acrylic windshield were shattered. Feathers and other bird remains were collected from the canopy and windshield at the initial point of impact and from other locations on the exterior of the helicopter. Laboratory analysis identified the remains as coming from a female red-tailed hawk; The females of that species have an average weight of 2.4 pounds [1.1kg]. The acrylic windshield had been fitted in place of the production windshield after delivery (discussed further below). Located about 100mm behind the windscreen of the S-76C++ are two engine fire extinguisher T-handles. These… …are normally in the full-forward position during flight, and each is held in place by a spring-loaded pin that rests in a detent; aft pulling force is required to move the T-handles out of their detents. If the T handles are moved aft, a mechanical cam on each T-handle pushes the trigger on the associated [engine power control lever] ECL out of its wedge-shaped stop, allowing the ECL to move aft, reducing fuel to the engine that the ECL controls. The investigators determined: The impact of the bird on the canopy just above the windshield near the engine control quadrant likely jarred the fire extinguisher T-handles out of their detents and moved them aft, pushing both ECL triggers out of their stops and allowing them to move aft and into or near the flight-idle position, reducing fuel to both engines. A similar incident occurred on November 13, 1999, in West Palm Beach, Florida, when a bird struck the windshield of an S-76C+ [HEMS] helicopter, N276TH, operated by Palm Beach County. The bird did not penetrate the laminated glass windshield, but the impact...
read moreOur Top 10 Articles of 2016
Our Top 20 Articles of 2016 In 2016 Aerossurance’s digest of aviation and safety articles attracted twice as many readers as in 2015. As we prepare to start a new year we look back on the 10 most read articles in 2016 from the choice of over 400 on our website. In reverse order: Number 10: Retreating Blade Stall Incident During a patient transfer in Australia, an Emergency Medical Service Airbus Helicopters BK 117 dropped 4,000 ft after a loss of control in the cruise. No injuries were reported and the helicopter sustained minor damage the horizontal stabiliser end plates. These were struck by the main rotor blades, which themselves were undamaged. The Australian Transport Safety Bureau (ATSB) investigation report highlights the phenomena of retreating blade stall: The selected cruise speed of 115 kt was close to the calculated never exceed speed (VNE) for the conditions of 120 kt. In combination, the high all-up weight and speed required greater collective pitch, or main rotor blade angle. This placed the blades closer to their stalling angle of attack. The cruise altitude of 5,000 ft resulted in operation at a moderately high density altitude and in areas of moderate turbulence. These conditions, coupled with the effect of the already-discussed high all-up weight are known to be conducive to the onset of retreating blade stall at high speed. The uncommanded nose-up pitch and subsequent roll in the direction of the retreating blade indicated that retreating blade stall took place. Number 9: Fatigued Flight Test Crew Crosswind Accident The Icelandic Transportation Safety Board (ITSB), the RNSA, issued their report into a wheels up runway excursion accident that occurred on 21 July 2013 to Sukhoi RRJ-95B ‘Superjet 100’ 97005 during flight tests by Sukhoi at Keflavik airport. The RNSA concluded “that human factors played a significant role in this accident”. In particular significant fatigue was evident. Number 8: Fatal Wire Strike on Take Off from Communications Site The Transportation Safety Board of Canada (TSB) released their report on Airbus Helicopters AS350BA C-GBPS, operated by Canadian Helicopters (CHL), that departed a microwave communication site and fatally struck one of the microwave tower guy wires. The lack of effective risk assessment and landing site data jumps out in their report as does a casual approach to some pre-flight preparation. There are key survivability lessons too. Number 7: Critical Maintenance Tasks: EASA Part-M & -145 Change This article discussed Commission Regulation (EU) 2015/1536 . One of the most important parts of the change relates to Critical Maintenance Tasks (CMTs), which are defined as: …a maintenance task that involves the assembly or any disturbance of a system or any part on an aircraft, engine or propeller that, if an error occurred during its performance, could directly endanger the flight safety. The European Aviation Safety Agency (EASA) has said that this change: …addresses a safety issue related to the risk of errors made during the performance of critical maintenance tasks and the need for maintenance organisations to implement methods to capture those errors before the certificate of release to service is issued. The NPA was in part prompted by following three safety recommendations addressed to the Agency: AIBN recommendation 12/2006, Report on the aircraft accident at Bergen Airport Flesland, Norway, on 31 January 2005 involving ATR 42-320, OY-JRJ, operated by Danish Air Transport, when control problems were experienced an elevator bolts loosened and fell out. The self-locking nuts were not tightened with the required torque. UK AAIB Safety Recommendation 2005-123 in Report 3/2005 on the serious incident to Boeing 757-236, operated by British Airways, on 7 September 2003. Maintenance errors...
read moreCRJ-200 LOC-I Sweden 8 Jan 2016: SHK Investigation Results
CRJ-200 LOC-I Sweden 8 Jan 2016: SHK Investigation Results On 8 January 2016 Canadair CRJ-200 (CL-600-2B19) cargo aircraft SE-DUX of West Air Sweden was destroyed when it impacted remote terrain in Northern Sweden following a Loss of Control – Inflight (LOC-I). Both pilots were killed. The aircraft had departed Oslo-Gardermoen Airport, Norway 70 minutes earlier for Tromsø, Norway on a night mail and parcel service. The Swedish Accident Investigation Board (the Statens Haverikommission [SHK]) has recently published its accident report into an accident that is reminiscent of the LOC-I suffered by Airbus A330 F-GZCP operating flight AF447 in 2009. The Accident Flight The SHK say: The flight was uneventful until the start of the event, which occurred during the approach briefing in level flight at FL 330. The event started at 00:19:20 hrs during darkness without moonlight, clouds or turbulence. The lack of external visual references meant that the pilots were totally dependent on their instruments which, inter alia consisted of three independent attitude indicators. According to recorded data and simulations a very fast increase in pitch was displayed on the left attitude indicator. The pilot in command, who was the pilot flying and seated in the left seat exclaimed a strong expression. The displayed pitch change meant that the pilot in command was subjected to a surprise effect and a degradation of spatial orientation. The autopilot was, most probably, disconnected automatically, a “cavalry charge” aural warning and a single chime was heard, the latter most likely as a result of miscompare between the left and right pilots’ [primary] flying displays (PFD). Both elevators moved towards nose down and nose down stabilizer trim was gradually activated from the left control wheel trim switch. The aeroplane started to descend, the angle of attack and G-loads became negative. Both pilots exclaimed strong expressions and the co-pilot said “come up”. About 13 seconds after the start of the event the crew were presented with two contradictory attitude indicators with red chevrons pointing in opposite directions. At the same time none of the instruments displayed any comparator caution due to the PFDs declutter function in unusual attitude. Bank angle warnings were heard and the maximum operating speed and Mach number were exceeded 17 seconds after the start of the event, which activated the overspeed warning. The speed continued to increase, a distress call was transmitted and acknowledged by the air traffic control and the engine thrust was reduced to flight idle. The crew was active during the entire event. The dialogue between the pilots consisted mainly of different perceptions regarding turn directions. They also expressed the need to climb. At this stage, the pilots were probably subjected to spatial disorientation. The aircraft collided with the ground one minute and twenty seconds after the initial height loss. The Accident Site The accident site and the wreckage did not show any evidence of an inflight break-up. Debris was found up to a distance of about 150 meters from the crater. Most parts were found in the crater and to the northeast of it. The SHK Accident Investigation The SHK say: The flight recorders were recovered and readout. Calculations and simulations were performed to reconstruct the event and showed that the aeroplane’s flight control system operated normally. The erroneous attitude indication on PFD 1 was caused by a malfunction of the...
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