ATR72 Control Problems in Severe Icing, Norway, 14 November 2016
ATR72 Control Problems in Severe Icing, Norway, 14 November 2016 The Accident Investigation Board Norway (AIBN – the Statens Havarikommisjon for Transport [SHT] in Norwegian) has opened an investigation into this serious incident. As the northern winter develops investigation is a reminder of the possible seasonal weather related threats. On Monday 14 November 2016, Scandinavian Airlines Flight SK4144, ATR-72-212A (ATR72-500), OY-JZC, operated by Danish airline Jettime, was en route from Bergen to Ålesund when it “experienced control problems after the flight had encountered severe icing”. AIBN say the aircraft: …was climbing towards the planned cruise altitude 17 000 ft, when it became unable to continue the climb due to severe icing at approximately 15 000 ft. This in spite of the aircraft anti- and deicing systems being activated. The crew decided to head towards the coastline, partly in order to escape the icing conditions, and partly to avoid flying over the mountainous terrain below. Just after having initiated the turn, the crew experienced problems controlling the airplane, which banked uncontrollably and lost significant altitude. The crew regained control of the airplane and got out of the icing area. The ice on the airframe disappeared, and the flight continued along a more westerly track than originally planned. The airplane subsequently landed normally at Ålesund Airport, Vigra. Both the French and the Danish national accident investigation authorities have appointed Accredited Representatives who, together with advisors from ATR, will assist the Accident Investigation Board Norway with the investigation. We will return to this Serious Incident as information emerges from the investigation. In unrelated news: Jet Time has discontinued its cargo and ACMI business units for SAS Scandinavian Airlines in an effort to save the carrier. As a result, 278 positions will be cut, reducing staff by 35% over the next nine months. According to a Nov. 29 statement, Jet Time will phase out the two business units in 2017. [CEO Jørgen] Holme said the company wants to return to Jet Time’s original core business—charter flights—which paved the way for the airline’s initial success. “The cargo and ATR 72 ACMI businesses have created too much complexity for Jet Time, and they are the direct reason why the airline has in past years operated with a deficit”. Jet Time is a Danish-owned airline that was established in 2006. Over the years it has become the largest Danish carrier with an annual turnover of more than DKK 1.7 billion ($243 million) and more than 700 employees. UPDATE 10 September 2020: NSIA Final Report The AIBN, since renamed the Norwegian Safety Investigation Authority (NSIA) has published their final report and a video: The AIBN is of the opinion that the control loss was the result of insufficient planning and inappropriate decisions en route, such as the attempt to climb above the icing conditions despite degraded aircraft performance as well as use of the autopilot in altitude hold mode. Recovery of control of the aircraft may have been impeded by the commander’s initial response, pulling the control wheel back as the stick shaker activated. The commander is likely to have become startled when the aircraft stick shaker activated and the autopilot automatically deactivated, while the aircraft banked sharply, pitching its nose down. He may consequently have pulled on control wheel as the result of a temporary startle effect. Another factor that contributed...
read moreMilitary Airworthiness Conferences: EDA and DASA
Military Airworthiness Conferences: EDA and DASA Two recent conferences have been held on the topic of military airworthiness, in Europe and Australia. Both highlight the importance of the European Military Airworthiness Requirements (EMARs), both in Europe and beyond, and the value in going further and creating a more formal ‘JAA’ style arrangement. We discuss a few of the highlights below. EDA MAWA Conference In October 2016 there was the 8th annual conference, organised by the European Defence Agency (EDA) Military Airworthiness Authorities (MAWA) Forum. This event in Lisbon together 120 delegates from 28 EU and non-EU nations. In 2008 the EDA, an intergovernmental Agency of the European Council, created the MAWA Forum to help harmonise the airworthiness requirements and processes of the EDA’s 27 Participating Member States (all EU states except Denmark). The existing MAWA Task Forces that have been developing EMARS are to transition to Advisory Groups: Airworthiness Regulatory Advisory Group – April 2017 Design and Production Advisory Group – January 2017 Maintenance and Licensing Advisory Group – June 2017 MAWA document update progress in 2016 includes: MAWA Document Production and Approval Process Edition 1.1 EMAR 21 Edition including AMC and GM EMAD MFTP Edition 1.0 EMAR 145 Edition 1.2 incl. AMC and GM EMAR M AMC and GM in progress EMAR Forms Edition 2.1 EMACC update phase II – 2 out of 4 work packages will be delivered this year EMAD R Edition 2.0 The Military Aviation Authority of the Czech Republic commented that in setting up a multi-national helicopter training centre, the “EMAR[s] proved to be very good ‘toolbox’ for bilateral recognition”. In the context of the Eurofighter Typhoon, the UK Military Aviation Authority said: Reducing resources drive the need to work together. Need to build trust and respect. Not only among Regulators but also with Industry. Harmonised regulations are a great idea, but only if used in the same way. European industry industry association ASD further commented on the: Remarkable progress evidenced through achievement of Mutual Recognition as fundamental basis for successful implementation of EMAR21 on Eurofighter Typhoon nations. Meanwhile the European Aviation Safety Agency (EASA) discussed the range of military programmes they have and expect to be involved in: In addition there are many other military types, passenger transport and helicopter types in particular, that are simply civil certified aircraft purchased from the production line. EASA commented that: EASA has been a pioneer in identifying and utilising synergies between civil and military activities in several projects EASA involvement in military products and matters benefits both the EU industry and the end users (savings) The implementation of a Performance Based Environment is an opportunity for military In challenging times, civil-military cooperation is a key factor The Netherlands Military Aviation Authority discussed the challenges they faced applying EMAR-21 the the Airbus A330 based Multi Role Tanker and Transport Capability (MRTTC) project. MAA-NL has recently signed a new contract with ADSE for continued support. ASD asked a series of questions on the possible evolution of the MAWA Initiative: Is there scope for a true single European Military Airworthiness Organisation that co-exists with existing NMAAs? What could be its scope and which generic aspects of regulation could be proposed for a central organisation? Could the role of EDA include involvement in outlining a strategy leading up to the formation of a European Military Airworthiness Organisation under EDA/MAWA? As a first step could a central organisation have its powers enhanced particularly in the areas of...
read moreStabilised Hover Prevents Loss of Control Accidents Say FAA
Stabilised Hover Prevents Loss of Control Accidents Say FAA The US Federal Aviation Administration (FAA) has issued Safety Alert for Operators SAFO 16016, Helicopter Stabilized Hover Checks Before Departure. The FAA say that several recent occurrences had followed pilots: …not bringing the helicopter to a stabilized hover before initiating takeoff. Rather, pilots elected to immediately and rapidly takeoff from the ground. In some cases, this has led to a [Loss of Control] LOC where the result was either an incident, or an accident resulting in significant damage to the helicopter and/or fatalities to those onboard. Post-accident analysis indicated that the accident sequence began with indications that were evident when the helicopter was light on the skids, yet the pilot elected not to abort the takeoff by reducing collective. Instead, the pilot continued pulling in collective (or continued manipulating the controls) resulting in a complete LOC. In one notable case: One accident resulted from a pilot attempting a takeoff from the surface without completing a hover power check. As the aircraft lifted from a roof top helipad and over the edge of the rooftop, the aircraft lost altitude and crashed into a parking lot below. It was discovered that one of the two engines was in the “fly” position but the other engine was still in the idle position. If a hover check was performed before takeoff, this accident could have been prevented. While the NTSB don’t identify which accident they refer to, it appears to be an accident involving a HEMS Airbus Helicopters EC135P2+ N238AM operated by Air Methods Corporation on 30 May 2008 in Pottsville, PA. The NTSB report says: After taking off… the twin-engine helicopter climbed approximately 75 feet. The pilot lowered the nose, but the helicopter would not climb or accelerate normally… The pilot also noticed that one torque indication was declining to “near zero” percent, and the helicopter began to yaw. The pilot was able to correct the yawing moment with anti-torque inputs, and remembered lowering the collective and “pulling pitch” before the helicopter impacted the ground in a level attitude. The No. 1 engine was running as the pilot exited the helicopter, but the No. 2 engine was not. Examinations at the accident site revealed that the helicopter, after lifting off from the heliport, flew out of ground effect over down-sloping terrain, settled, then struck a parked semi-trailer about 80 feet below the heliport. As part of the pre-takeoff confirmation check, the pilot was required to ensure that both main engine switches were in the FLIGHT position; however, onboard recorded data revealed that the No. 2 main engine switch was in the IDLE position during the takeoff. The National Transportation Safety Board determines the probable cause(s) of this accident as follows: The pilot’s failure to ensure that both engine switches were in the FLIGHT position for takeoff. After that accident the Type Certificate Holder issued a safety alert, noting that the high OEI power of the EC135 can be sufficient for the aircraft to take off. There was a SAFO issued in 2006 after that accident. We suspect however the SAFO has really been prompted by a couple of recent accidents were take offs have been made with incorrect hydraulic switch settings. The FAA recommendations include: Using strict discipline and without compromise…an appropriate checklist. Unless prohibited by environmental conditions such as the possibility of...
read moreChallenge Assumptions: ATSB on A330 with a u/s GPS
Challenge Assumptions: ATSB on A330 with a u/s GPS The Australian Transport Safety Bureau (ATSB) have issued their report on an occurrence were after take off, a ‘gut feeling’ resulted in challenging assumptions that had been made during flight planning, resulting in a change to the mid-Pacific alternate. The Occurrence Flight The ATSB say that: On the morning of 4 August 2016, Qantas Flight QF61, an Airbus A330 aircraft, registered VH‑QPC, was prepared for departure from Brisbane Airport, Queensland, for a flight to Narita Airport, Tokyo, Japan. The flight was dispatched with one of the aircraft’s two global positioning systems (GPS) units recorded as unserviceable using Saipan Airport as their enroute alternate. There had been a pre-flight discussion about this: The captain initially thought that two GPS units were required at dispatch because the Saipan Airport runway 25 approach procedure required GPS. However, after further discussion they decided that they were mistaken as maintenance and flight dispatch were aware one GPS was unserviceable and the captain had very few past experiences of an incorrect serviceability requirement at dispatch. One flight crew member then mentioned that the flight crew operating manual indicated one GPS unit was required. The captain referred to the MEL [which] indicated only one GPS unit was required at dispatch. However, the associated operational procedures indicated that ‘primary means GNSS approval’ was required at dispatch if the alternate airport arrival procedure requires GPS navigation. ‘Primary means GNSS approval’ indicated the requirement for two operational GPS units. …the captain…considered the reference to ‘alternate’ to be a reference to destination alternate airport and not to an [Extended Diversion Time Operation] EDTO alternate airport. They planned to use Saipan as an EDTO alternate airport …[which]…fitted with their expectation that the unserviceable GPS 2 MEL item was acceptable for their flight. Satisfied, the aircraft departed from Brisbane with 12 crew and 231 passengers on board. As QF61 travelled north along the east coast of Australia, the captain became uncomfortable with their decision to accept the aircraft with an unserviceable GPS. The captain reviewed the flight plan and the publications, and concluded they needed two serviceable GPS units for their planned flight to use Saipan Airport as an alternate. The captain identified Guam Airport as a suitable alternate airport in lieu of Saipan Airport and the flight continued to Narita Airport and landed without further incident. ATSB Comment The ATSB notes that in large organisations there may be multiple departments with responsibilities for the dispatch of an aircraft. Whereas procedures are normally executed within a department, processes often involve multiple departments. Cross-checks occurred within the [Integrated Operations Centre] IOC and separately among the flight crew during this incident flight, but the cross-checks were not conducted between the departments, where personnel had a different mental model of the situation. The flight dispatcher believed the GPS 2 MEL item would be cleared before flight and the captain believed the flight was planned to be released with the GPS 2 as an unserviceable MEL item. ATSB Safety Message This incident highlights the importance of personnel challenging their own assumptions when something does not appear right in the environment. After the dispatch of QF61 from Brisbane Airport, the captain experienced a ‘gut feeling’ that something was not right. Rather than ignore their sense of unease, the captain reviewed the flight plan and company documents,...
read more‘Competitive Behaviour’ and a Fire-Fighting Aircraft Stall
‘Competitive Behaviour’ and a Fire-Fighting Aircraft Stall The Transportation Safety Board of Canada (TSB) has released its report into the accident on 14 August 2014 in which a fire-fighting Air Tractor AT 802A Fire Boss Amphibian C-GXNX, operated by Conair, stalled on takeoff and crashed into Chantslar Lake, British Columbia. The accident highlighted what TSB called “competitive behaviour” that resulted in eroding safety margins. The pilot received minor injuries and the aircraft was substantially damaged. The Accident Flight The aircraft, operating as Tanker 685, was carrying out wildfire management operations. It was in a group of four single-engine air tankers (SEATs) coordinated by a Cessna 208 Caravan ‘Bird Dog’. On one of Tanker 685’s scooping runs [as second aircraft], control was lost during liftoff, and the aircraft’s right wing struck the water. The floats then struck the water and separated from the fuselage as the aircraft yawed 270 degrees to the right. The aircraft remained upright and slowly sank. The pilot exited the cockpit and inflated the personal flotation device being worn. The fourth aircraft jettisoned its load, rejected its takeoff, and taxied to pick up the pilot who had been slightly injured. The aircraft’s Emergency Locator Transmitter (ELT) was activated by the impact, but the aircraft sank before a COSPAS-SARSAT satellite picked up the signal (a “common occurrence” say the TSB). The Safety Investigation The TSB found that: …a wing stalled, either independently or in combination with an encounter with a wing-tip vortex generated by the lead aircraft. This caused a loss of control moments after liftoff and resulted in both the right-hand wing tip contacting the water and a subsequent water-loop. The takeoff procedure used, with the aircraft being heavy, its speed below the published power-off stall speed and a high angle-of-attack, contributed to loss of control at an altitude insufficient to permit a recovery. The pilot’s takeoff procedure complied with company procedures, but the procedure contained elements of risk which exposed the pilot and the aircraft to the hazard of a power-on stall…. It is possible that pre-stall buffets due to handling errors, which were common for years, were misdiagnosed and mistakenly attributed to other causes such as wake turbulence, mechanical turbulence, or wind gusts. If the aircraft is operated outside of the demonstrated flight envelope, there is a risk that pilots will be exposed to aircraft performance for which they are not prepared. Additionally, during the wreckage examination two potential control interference hazards were identified (though neither influenced the accident): One was exposed rudder control cables on the floor that ran along both sides of the pilot’s seat. These cables may be subject to interference by items placed on top of them. The other was the exposed elevator control push-pull tube, which is attached to the control stick about 4 or 5 inches above the floor under the pilot’s seat and runs parallel to the longitudinal axis of the airplane. The push-pull tube may be subject to interference by loose objects on the floor becoming lodged on its left side and preventing full left roll control input. Organisational Factors and SMS While the TSB could have stopped here they also examined organisational matters in depth. Conair is a well respected specialist aerial firefighting company that: …employs about 250 people (including 80 pilots) and has a fleet of 65 fixed-wing aircraft. For the 2014 fire season,...
read moreEASA Opinion on Technical Records (Opinion 13/2016)
EASA Opinion on Technical Records (Opinion 13/2016) The European Aviation Safety Agency (EASA) has recently issued Opinion 13/2016 on technical records. EASA say: This Opinion addresses a safety issue linked with a wrong airworthiness assessment of the aircraft status due to incomplete technical records and is additionally related to a safety recommendation (SR) from the Air Accidents Investigation Branch (AAIB) (ref.: UNKG-2007-091), which recommends that the maintenance and overhaul records must be part of the logbook and retained until the aircraft/engine/propeller/component has been destroyed or permanently removed from service. The UK AAIB recommendation was one of 7 made after an accident to Reims Cessna F152, G-BHCP in January 2006 following an engine failure. The EASA Opinion, which results from RMT.0276 (MDM.076), has gone to the European Commission as part of the rule making process for the 32 EASA Member States. It proposes: a reorganisation of the related requirements in Regulation (EU) No 1321/2014 (Part-M M.A.305 in particular); the provision of clearer requirements on components; the establishment of a consistent record-keeping period; the introduction of various forms of record-keeping (e.g. digital) and commonly used information technology (IT) systems; and amendments to AMC/GM to Part CAT, Part NCC, Part NCO and Part SPO of the Air OPS Regulation. This Opinion follows the NPA 2014-04 consultation, which resulted in 350 comments. The timeline of this rule-making activity is as follows: Ironically, considering the UK AAIB recommendation followed an accident to a light aircraft, EASA do also note: …the general aviation (GA) community opposed the amendments initially proposed by the related NPA 2014-04. As a result, this Opinion does not propose any amendments to the forthcoming Part-ML. Part-ML is a ‘light Part-M’ proportionate to the much lower complexity and risks of the lighter end of the GA sector. It was proposed in Opinion 05/2016 following the task force for the review of Part-M for General Aviation (PHASE II). Aerossurance has extensive air safety, design, certification, airworthiness, regulation and safety analysis experience. For aviation advice you can trust, contact us at: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest...
read moreMilitary Airprox in Sweden
Military Airprox in Sweden The Swedish Accident Investigation Board (the Statens Haverikommission [SHK]) has published its report on a airprox on 5 May 2015 between between a Swedish Air Force Saab JAS 39 Gripen and a Norwegian Air Force Lockheed Martin F-16 Fighting Falcon near Luleå/Kallax during the tri-national 2015 Arctic Fighter Meet. The aircraft passed just over 30m apart in cloud. The Incident Flight The intended method of separation was using radar set at the minimum distance of 2 nautical miles. The SHK say: The incident occurred when the aircraft were on the way home from the exercise area. The pilot of the Norwegian aircraft was the flight leader and the Swedish pilot was the wingman. The approach towards Luleå/Kallax was commenced with STRIL [Swedish Fighter Control] instructing the two-ship formation to fly on a certain heading, “descend to flight level 150 or below” and to contact Kallax Control on channel “Charlie Two”. The aircraft then began to descend and entered the cloud as they passed FL 160. The flight leader has indicated that he first perceived the phrase “descend to flight level 150 or below” as a clearance, but then he became uncertain as the phrase did not contain any minimum height. Since he perceived the clearance to be incomplete, he aborted his descent at FL 150 and ordered the wingman to switch to the “chat frequency”. Since the flight leader did not have immediate access to the frequency for Kallax Control nor recognised the expression “Charlie Two”, he asked his wingman if he had the frequency in question. The wingman first responded to the question in the negative, but then nevertheless began to look for the frequency in his knee board. While the wingman was looking for the frequency, the flight leader chose to remain at FL 150. Unaware of this, the wingman also stayed at FL 150 with the intention of maintaining a safe height above his flight leader, whom he thought would continue to descend towards FL 70. When the wingman had found and communicated the frequency to the flight leader, he saw on the radar information that he had lost radar contact with the flight leader. The flight leader had in turn just announced his intention to come in for landing to Kallax Control and had been cleared for approach when he suddenly saw a dark blurred shadow in the cloud beside and slightly ahead of him. The flight leader performed a sharp evasive manoeuvre and reported “near miss” to Kallax Control. At the same time, the wingman reported “broke lock”. Safety Analysis The SHK say: The minimum distance between the aircraft has been estimated by the Norwegian pilot to be 30–60 metres. SHK’s investigation notes that there had in fact been another near collision earlier during the flight home, which was not perceived by either of the pilots. On that occasion, the distance between the aircraft is estimated to have been about 60 metres. The event was caused by the distance to the aircraft in front not being monitored by the wingman, which resulted in the risk of collision not being noticed. A contributing factor was that a less appropriate setting for the occasion had been chosen in the aircraft and that the consequences of this had not previously been mentioned at the division or been known to the pilot. Another factor contributing to...
read moreBrexit and Aviation
Brexit and Aviation Following the ‘advisory’ referendum held on 23 June 2016, it is currently expected that the UK government (‘HMG’) will activate Article 50 of the Lisbon Treaty to commence negotiation on leaving the European Union (EU) in February or March 2017. As the Chancellor‘s Autumn Statement approaches on 23 November 2016, we look at a joint industry/government announcement on the implications of Brexit for aviation. The government are challenging a recent high court ruling that they need parliamentary agreement prior to that action, which in turn may result in extra conditions being imposed on the negotiations or even require other legislation first. The Supreme Court hearing is expected to last four days, starting 5 December 2016, with the decision expected in the new year. Article 50 sets a time limit of 2 years for those negotiations, something that can only be extended if all other 27 EU members agree. In his Times column this morning, Philip Collins suggests that the Prime Minister, the Rt Hon Theresa May MP, should openly acknowledge that full ‘Brexit’ of the UK from the EU can’t be achieved before the 2020 UK general election. Its also been observed that the prospect of President Trump makes the context for Brexit more challenging: Britain is caught between a retrograde American administration with which it no longer shares a world view and a frustrated Europe it is trying to divorce. This is not a recipe for international influence. There remains strong opposition to leaving the EU and of the associated ‘European single market’, that might result in a proposal for a second referendum on independence in Scotland for example, or even a different status for Scotland. Scotland’s senior law officer, the Lord Advocate, has been invited to address the Supreme Court the relevance of points of Scottish law in the coming hearing. The Single Market & Aviation The European single market “refers to the EU as one territory without any internal borders or other regulatory obstacles to the free movement of goods and services”. These freedoms of movement also extend to workers and capital and provide significant economic opportunities and benefits to industry. This is especially true for the European aviation and aerospace industries that over the last generation has also been on a journey of regulatory harmonisation and standardisation for a generation (first through the Joint Aviation Authorities [JAA] and later the European Aviation Safety Agency [EASA]), as well as through Eurocontrol in the air traffic domain and the European Defence Agency (EDA) in relation to the new European Military Airworthiness Requirements (EMARs). Additionally there is the European Common Aviation Area (ECAA), that aims to allow “gradual market opening between the EU and its neighbours linked with regulatory convergence through the gradual implementation of EU aviation rules to offer new opportunities for operators and wider choice for consumers”. Additionally for manufacturers there are a web of EU trade agreements around the world. Immediately after the referendum vote dire consequences of Brexit have been forecast for aviation and the International Air Transport Association (IATA) commenting: Preliminary estimates suggest that the number of UK air passengers could be 3-5% lower by 2020, driven by the expected downturn in economic activity and the fall in the sterling exchange rate. The near-term impact on the UK air freight market is less certain, but freight will be affected by lower international trade...
read moreSerious Injury During Aircraft Maintenance
Serious Injury During Aircraft Maintenance The Royal Canadian Air Force (RCAF) have reported on an serious injury that occurred during maintenance of an Airbus A310 (known as a CC-150 Polaris) that occurred on 25 August 2013. The RCAF have 5 CC-150 Polaris aircraft at 8 Wing at CFB Trenton, Ontario. During maintenance at Trenton: A contractor technician was lockwiring the drainplug of the left no. 4 flap screwjack gearbox while another technician, who was concurrently working on the right main landing gear brake system, applied hydraulic power to the aircraft. When the hydraulic system was activated, the left no. 6 wing spoiler closed onto the lockwiring technician, seriously injuring him. The preliminary investigation revealed deficiencies in aircraft maintenance safety procedures and equipment. These concerns were immediately brought to the attention of both the RCAF technical authority and the contracted air maintenance organization, which undertook numerous rectifying and prevent actions to ensure this accident would not reoccur. The investigation then focussed on supervision and organizational factors that preceded the accident. The investigators identified “numerous organizational safety stressors” including: contract, facilities, organization and personnel disruptions; training and supervision of apprentices with too few supervisors; and a mismatch between contractor resources and operational demands which cumulatively increased the safety risk being incurred to meet these demands. Additionally, the investigation determined that the contracting and accreditation mechanisms were insufficient to detect this situation and reliance on the contractor to self-identify the risk could create a potential conflict of interest within an incentivized performance contract. This highlights a safety assurance gap for contracted maintenance that should be addressed by the RCAF. Safety Resources Boeing discuss Avoiding Airplane Hazardous Energy Electrical, Thermal, Pneumatic, Hydraulic and Mechanical) in maintenance: Exposure to energized airplane systems can result in serious injury to maintenance technicians if proper controls are not followed. Hazardous energy controls are required when technicians could be exposed to unexpected energization, startup, or release of hazardous energy during service or maintenance activities. Boeing has made internal process improvements to control airplane hazardous energy within Boeing factories and on Boeing flight lines and is making these improvements available to the aviation industry through updates to the aircraft maintenance manual (AMM). Boeing primarily discuss the concept of lockout, tagout, and tryout (LOTO). Other Aerossurance articles that have discussed injuries during maintenance include: Dangers of Aircraft Tyre Inflation: we look at a number off accidents while inflating aircraft tyres UPDATE 3 August 2019: Hurried Door Inspection Results in Fall From Aircraft UPDATE 8 September 2019: B747-400F Tyre Explosion During Inflation UPDATE 15 March 2017: Inflite Engineering Services were fined £160,000 in court after an incident at Stansted Airport on 10 June 2015. Two workers were injured when the mobile elevated work platforms they were using were knocked over when another employee closed the wrong circuit breaker, inadvertently operating the air brake. The Health and Safety Executive (HSE) commented: Aircraft maintenance companies are reminded that not all risks are covered by the Aircraft Maintenance Manual and additional measures need to be introduced. The HSE investigation found: “no suitable risk assessment was in place and there was a lack of effective monitoring.” In Ireland the High Court awarded a widow €425,000 in 2009 after the death of her husband in January 2003, who fell while carrying out maintenance work on a CHC Ireland S-61N helicopter in Dublin. UPDATE 6 July 2017: We discuss one...
read moreAAIB Annual Safety Review for 2015
AAIB Annual Safety Review for 2015 The UK Air Accidents Investigation Branch (AAIB) has published their Annual Safety Review for 2015 in a new format. It contains information on the AAIB’s investigations during 2015, an analysis of occurrence types and an overview of the 47 new Safety Recommendations and Safety Actions (the detail is now being uploaded online in a more timely way). The report also includes articles on the timeline of AAIB investigations and on drones. Investigations in 2015 The AAIB recieved 596 notifications in 2015 (down from 685 in 2014 and 654 in 2013), however the number of UK fatal accidents is up (18 in 2015 versus 10 and 13 in the preceding years) as is total fatalities (39 versus 16 and 30). In 2015 the AAIB reported on 28 field investigations [probably actually 24 + 4 formal reports mentioned above], nine of which were fatal accidents and 19 were non-fatal accidents or serious incidents. The analysis of the CICTT factors for each of these reveal that the overall the major factor in fatal accidents reported on in 2015 was Loss of Control inflight (LOC-I) and the major factor in non-fatal accidents and serious incidents was system or component failure which was not powerplant related (SCF-NP). Correspondence investigations are usually conducted on non-fatal accidents on General Aviation aircraft and to some serious incidents on Commercial Air Transport aircraft. This is reflected in the factors in that the majority of the reports were classified as Loss of Control on the ground (LOC-G) and Abnormal Runway Contact (ARC) as well as powerplant failure (SCF-PP). Investigation Timelines In 2015, 80% of AAIB reports were issued in under a year. The simple correspondence (Air Accident Report Form) investigations were published in around 3 months on average, the more complex field investigations in a bout 10 months on average and the full, formal reports in 28 months on average (though with a noticeably long consultation period). Safety Recommendations In 2015 the AAIB issued 47 Safety Recommendations from 12 investigations, around third of the number made 10 years ago. Of the 47 Safety Recommendations issued in 2015, 11 responses were adequate, 19 were not adequate and 17 partially adequate. As of the end of July 2015, 22 were closed and 25 remain open. Certification, design and equipment issues make up the bulk of the recommendations, followed by rescue, fire fighting and survivability matters according to this chart in the Annual Safety Review. Its not clear if this chart covers more than just the new recommendations raised, or if multiple classifications have been made. Very positively the AAIB also recognise the safety actions take pro-actively by organisations too in their report. Final Words from Keith Conradi In the foreword, the outgoing Chief Inspector of Air Accidents, Keith Conradi, comments: Accident investigation is a necessary function of an aviation safety system and I am justly proud of the contribution the AAIB delivers. Ultimately our reputation stands on the quality of our investigators and support staff; their passion, drive and complete objectivity in pursuing the reasons that lie behind every tragic event. I have every confidence that as the organisation enters its second century and appoints its 13th Chief Inspector, this will continue undiminished. Aftre 6 years heading the AAIB Conradi is to become the founding Chief Investigator of the new Healthcare Safety Investigation Branch...
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