News & Comment

UK CAA CAP1145: 2nd Update on North Sea Helicopter Safety (CAP1386)

Posted by on 1:04 pm in Accidents & Incidents, Airfields / Heliports / Helidecks, Design & Certification, Helicopters, Human Factors / Performance, HUMS / VHM / UMS / IVHM, Maintenance / Continuing Airworthiness / CAMOs, Offshore, Oil & Gas / IOGP / Energy, Regulation, Safety Culture, Safety Management, Survivability / Ditching

UK CAA CAP 1145: 2nd Update on North Sea Helicopter Safety (CAP 1386) The UK Civil Aviation Authority (UK CAA) have issued CAP1386, their second update to their CAP1145 report  (‘Safety review of offshore public transport helicopter operations in support of the exploitation of oil and gas’), issued in 20 February 2014.  The first update, CAP1243, had provided an update on the 10 months to 31 Dec 2014. CAP 1386: Introduction In his introduction, Mark Swan, UK CAA Group Director Safety and Airspace Regulation, comments: We are pleased that there continues to be a strong collective commitment…evidenced by the co-operation received from all parties… …we have continued to work closely with industry and the European Aviation Safety Agency (EASA)… We are pleased to be participating in the work currently undertaken by EASA as part of their Safety Risk Portfolio – Offshore Helicopter Operations. It is clear that EASA is devoting significant energy, time and expert resources into this activity. This work provides an opportunity for real and lasting progress in this area. The majority of the actions and recommendations are now completed and we have identified a number of ongoing workstreams to ensure that we continue to see improvements in offshore helicopter safety. Swan states “The ultimate aim is for rotary wing safety performance to be on a par with large commercial fixed wing operations”.  To achieve this ambitious goal: …the focus needs to be on prevention, as opposed to survival, through helicopter design improvements. In this regard, our ambition is to have a defined certification strategy where rotary wing can realistically approach commercial fixed wing safety and reliability performance. …we will continue to work closely with EASA and support all necessary EASA working groups to assist in this objective. In many ways the last comment demonstrates the critical importance to UK helicopter safety of remaining an EASA member State post-Brexit, 13 years since the UK CAA were last a ‘Competent Authority’ able to certify an offshore helicopter. CAP 1386: Passenger Safety and Survivability The UK CAA discuss a number of measures previously report in CAP 1243, and subsequently mandated by CAA Safety Directive SD-2014/001 (issued on 21 May 2014). Since then, significant progress has been made in introducing new requirements relating to the compatibility of passenger body size and underwater escape exit (window) size. Further work has also been performed in the areas of EBS [Emergency Breathing Systems] training and extending EBS to flight crew on offshore helicopters. The current Safety Directive (SD-2015/005 issued on 8 December 2015) introduced cover for support to Lighthouse Authorities and, in response to concerns raised by the industry, also introduced alleviation for the carriage of EBS for medically incapacitated passengers. An additional alleviation has been provided against the operating rules for such passengers in respect of life jackets and survival suits. They go on to discuss the activity to ensure passengers were seated next to windows compatible with their body size: From 1 April 2015, all passengers are now seated next to exits large enough for their body size and are checked by the helicopter flight and ground crews before takeoff as part of standard pre-flight procedures. They go on to say: Since 1 January 2015, all passengers have been required to wear suitable Cat A EBS (CAP 1034 Category A). In our previous progress report, we described how this had been introduced ahead of schedule for all passengers on 1 September 2014, and how the oil and...

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AAIB: Human Factors and the Identification of Saab 2000 Flight Control Malfunctions

Posted by on 5:46 pm in Accidents & Incidents, Design & Certification, Fixed Wing, Human Factors / Performance, Safety Management

AAIB: Human Factors and the Identification of Saab 2000 Flight Control Malfunctions The UK Air Accidents Investigation Branch (AAIB) has recently issued its report on a loss of control in flight incident, near Sumburgh Airport, on 15 December 2014 involving Saab 2000 G-LGNO: The aircraft was inbound to land on Runway 27 at Sumburgh when the pilots discontinued the approach because of weather to the west of the airport. As the aircraft established on a southerly heading, it was struck by lightning. When the commander made nose-up pitch inputs the aircraft did not respond as he expected. After reaching 4,000 ft amsl the aircraft pitched to a minimum of 19° nose down and exceeded the applicable maximum operating speed (VMO) by 80 kt, with a peak descent rate of 9,500 ft/min. The aircraft started to climb after reaching a minimum height of 1,100 ft above sea level. Recorded data showed that the autopilot had remained engaged, contrary to the pilots’ understanding, and the pilots’ nose-up pitch inputs were countered by the autopilot pitch trim function, which made a nose-down pitch trim input in order to regain the selected altitude. What the investigators found was that out of 22 airliner types examined, only the Saab 2000 had an autopilot which, when engaged: Applies an override force to the control column that will move the elevator but will not cause the autopilot to disengage Can trim in the opposite direction to the pilot applied control column input Has main pitch trim switches that will not cause the autopilot to disengage While the whole report is worthy of study but the AAIB discuss the identification of flight control malfunctions in a section that we feel is worth highlighting: In an aircraft with purely mechanical flying controls, a jammed flight control can be identified by resistance to movement of the control wheel or column. Failure of a control linkage will be apparent as the control will move without the usual resistance. In either case, the absence of the usual aircraft response to an input will be apparent. In this control system, the ‘loop’ from pilot input, to response felt through the controls, to aircraft response, is complete. In an aircraft with powered or fly-by-wire controls, and without any physical feedback, it may be harder to determine a malfunction because effect of control inputs can only be assessed from aircraft response. In manoeuvring flight or turbulence, this assessment may be more difficult. In the Saab 2000, the forces required to achieve particular control column displacement are greater when the autopilot is engaged, but this is not a usual mode of operation and pilots are unlikely to be familiar with it. A pilot feeling abnormal control resistance may not readily determine that the reason for the unusual forces is that the autopilot is engaged. Mental models are developed by experience and/or training, and more experience leads to more detailed mental models. Mental models guide interaction with systems: an accurate mental model can facilitate good performance, but poor mental models can lead to misunderstanding of system functioning, increasing the risk of error. AAIB note that: Designers can promote good mental models by optimising feedback, for example by providing indicators of system status and performance which are easily assimilated, even under stress. Automation surprise* can occur if the autopilot does not behave...

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Oil Spill Response Boeing 727s

Posted by on 8:57 pm in Crises / Emergency Response / SAR, Design & Certification, Fixed Wing, Offshore, Oil & Gas / IOGP / Energy, Special Mission Aircraft

Oil Spill Response Boeing 727s UK company Oil Spill Response Limited (OSRL) provide a global aviation aerial dispersant service.  OSRL has commissioned two Doncaster, UK based 727 dispersant aircraft with the 15,000 litre TERSUS dispersant system. Both OSRL 727s, operated by 2Excel Aviation, were in action for an exercise off the Isle of Wight today. OSRL say: The aircraft, two Boeing 727-2S2F(RE), are now central to OSRL’s aerial dispersant capability… Fitted with internal tanks, pumps and a spray boom to deliver dispersant liquid, the specially adapted Boeing 727-2S2F (RE) aircraft are truly a first-of-a-kind capability for the oil and gas industry. The Valsan engined 727-2S2F(RE) proved to be an ideal aircraft for OSRL: Because of their age the choice of the 727-2S2F(RE) aircraft offered a relatively low capital cost… Furthermore, the aircraft’s JT8D-217C Valsan high bypass ratio engines reduce the 727’s noise outputs to comply with Stage 3 noise levels, while offering between six and seven per cent reduction in fuel consumption. The tri-engine design of the 727-2S2F(RE) offers an important level of redundancy and if one were to lose an engine, the asymmetric effect is reduced and it can still climb away rapidly. Spraying is done at 150ft.  Operator 2Excel Aviation explain: In 2014, EASA ruled that for an aircraft spraying system, oil spill dispersant liquids are to be classified as ‘flammable fluids’. The FAA soon aligned with EASA, and as a result any system entering service now has to meet the stringent regulation set out by these agencies. TERSUS, the system on the B727, was designed and built from scratch by 2Excel’s EASA Part21J & G design and production organization Leading Edge.  Awarded an EASA STC in 2016, TERSUS is the only aerial dispersant system in the world that complies with the new EASA and FAA regulations. ORSRL video. It has since been joined by G-OSRB.  both were built as cargo aircraft for FedEx. UPDATE 21 January 2017: A new 10 minute mini-documentary on the 727s and their capability: For details of another special mission conversion see our article: BAe 146 & Avro RJ85 Fire Bombers UPDATE 28 April 2017: The 2Excel operation for OSRL features in the article ‘Ready to Respond’ in the May 2017 issue of AIR International. UPDATE 5 June 2017: A further exercise is announced: Oil spill company OSRL to run test flight over the Solent UPDATE 16 July 2018: OSRL extend the contract 10 years as the 727 is displayed all week at Farnborough 2018. UPDATE 17 August 2020: OSRL and 2Excel sign a contract with the MCA. UPDATE 18 August 2020: 2Excel have modified the 727s to enable flight in known icing conditions with spray booms fitted. For practical expert advice you can trust on contracting for, design & conversion of and operation of special mission aircraft, contact us at: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest...

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Delta MD-88 Accident at La Guardia 5 March 2015

Posted by on 10:19 am in Accidents & Incidents, Airfields / Heliports / Helidecks, Fixed Wing, Human Factors / Performance, Regulation, Safety Management

Delta MD-88 Accident at La Guardia 5 March 2015 (Delta Flight 1086, MD88 N909DL) The US National Transportation Safety Board (NTSB) have meet to discuss the accident to Delta Airlines Flight 1086, MD-88 N909DL, that suffered a runway excursion on a snow covered runway at New York La Guardia on 5 March 2015 (Final Report).  The use of excessive reverse thrust resulted in loss of direction control, but noticeably there was a significant delay to the evacuation (which took 17 minutes to complete). The aircraft broke the perimeter fence and came to rest on an embankment adjacent to Flushing Bay.  The left wing was damaged by the fence, causing a fuel leak.  The fuselage and interior were also damaged as were the main batteries. The 2 pilots, 3 cabin crew and 98 of the 127 passengers were uninjured.  The remaining 29 passengers received only minor injuries. The Landing The NTSB say: The captain and the first officer were highly experienced MD-88 pilots. The captain had accumulated about 11,000 hours, and the first officer had accumulated about 3,000 hours, on the MD-88/-90. In addition, the captain was previously based at LGA and had made many landings there in winter weather conditions. The NTSB found that: The flight crew was well prepared for the approach and established landing requirements that were consistent with company policies. The flight crew was concerned about the available landing distance on runway 13 and, while en route to LGA, spent considerable time analyzing the airplane’s stopping performance.  The flight crew also requested braking action reports about 45 and 35 minutes before landing, but none were available at those times because of runway snow clearing operations. The unavailability of braking actions reports and the uncertainty about the runway’s condition created some situational stress for the captain, the Pilot Flying. …the flight crews of two preceding airplanes (which landed on the runway about 16 and 8 minutes before the accident landing) reported good braking action on the runway, so the flight crew expected to see at least some of the runway’s surface after the airplane broke out of the clouds. Even though…observations of snow on the runway were inconsistent with the expectations…their decision to continue the approach was appropriate because the landing criteria had been met. …postaccident simulations showed that the braking action at the time that the accident airplane touched down was consistent with medium (or better) braking action. Although the runway was contaminated with snow, runway friction when the accident airplane landed was sufficient for stopping on the available runway length. …the snowier-than-expected runway, short runway length, and body of water off the departure end of the runway, likely exacerbated the captain’s situational stress and prompted him to make an aggressive input on the thrust reversers. When in reverse thrust, buckets deploy behind the rear-mounted engines of the MD-88 to deflect thrust forward. This reduces the airflow over the vertical stabilizer and rudder and reduces aerodynamic directional control, a phenomenon known as ‘rudder blanking’. Consequently, Boeing recommend limiting the Engine Pressure Ratio (EPR), a measure of engine thrust, to a maximum of 1.3 on contaminated runways, where direction control from nose steering is least effective. Delta’s Flight Crew Training Manual and MD-88/90 fleet bulletins issued in November 2014 and February 2015 however referred to this as a target. In this case, EPR reached 2.07 on the left hand engines and 1.91 on the right. The NTSB sampled data from 80 Delta MD-88 landings.  Boeing’s recommended maximum of 1.6 EPR on dry runways was exceeded...

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Helideck Safety Alerts: Refuelling Hoses and Obstructions

Posted by on 8:12 am in Airfields / Heliports / Helidecks, Helicopters, Offshore, Oil & Gas / IOGP / Energy, Safety Management

Helideck Safety Alerts: Refuelling Hoses and Obstructions Helideck safety alerts have recently been released by the Helideck Certification Agency (HCA) and the US Bureau of Safety and Environmental Enforcement (BSEE). Refuelling Hoses Left Out on the Helideck The HCA say in a safety alert, further distributed by Step Change in Safety: The hose winding mechanism on fuel cabinets can breakdown which makes it difficult to rewind the hose back into the cabinet after a refuelling operation. Consequently helideck teams are leaving the hose laying out around the perimeter of the helideck. This practise MAY be acceptable for a short term pending rectification of the system, PROVIDING an adequate & robust risk assessment is in place and the hose is PROPERLY MANAGED for EVERY helicopter movement. In a recent near miss, a helideck team had left the hose out on deck from a previous refuelling operation. A day or two later when the next helicopter arrived, the hose was left on the downwind side of the helideck which resulted it being under the tail rotor after the helicopter had landed. The helideck team attempted to retrieve the hose but came perilously close to the tail rotor in doing so! The safety concerns stated by the HCA are: When the pump is switched off the hose remains full of fuel so leaving 20-30m of hose out on deck can contribute around 200l of fuel to any incident on the helideck. The hose obscures the green perimeter lights which affects night operations. The hose suffers increased UV degradation & wear dragging across the deck. The hose can end up under the tail rotor putting the helideck team at risk of a rotor strike. HCA comment: Because of this near miss and the increasing tendency for installations to leave the hose out on deck; HCA are minded to take a much harder line on instances where the duty holder does not have a satisfactory risk assessment or a suitable rectification plan in place to bring the system back in to compliance promptly, say within 6-months. Upon notification that the system is not operating correctly, HCA will register the system as ‘Non-Compliant’ and issue a Temporary Limitation Notice (TLN) to helicopter Operators advising them of the situation and requiring them not to land with the hose laid downwind. Pilots will be asked to report all such occurrences. Where a suitable rectification plan is not available, refuelling operations will be suspended until the system is returned to full serviceability. Helideck Obstructions and Procedural Errors Contribute to Five Near Misses in US In 4 months over the summer there were “at least 5 near misses involving helideck hazards” on US oil and gas installations according to BSEE: 26 May 2016. A helicopter landed to a helideck that the Operator had closed by Notice to Airmen (NOTAM) but had not marked as closed…. 6 July 2016. After landing to the edge of a helideck (rather than to the aiming circle), the pilot saw a vent pipe sticking up two feet above and three feet beyond the edge of the helideck. The pipe was four feet from the tail rotor. The Operator had not issued a NOTAM or marked the obstruction. After the landing, the Operator removed the pipe. 19 July 2016. During an unannounced inspection, a pilot landed on the helideck before noticing the flashing red light indicating that...

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‘Uncontained’ CFM56-7 FBO Failures: Southwest B737-700s 27 Aug 2016 & 17 Apr 2018

Posted by on 7:01 pm in Accidents & Incidents, Design & Certification, Fixed Wing, Maintenance / Continuing Airworthiness / CAMOs, Safety Management

‘Uncontained’ CFM56-7 FBO Failures: Southwest B737-700s 27 August 2016 & 17 April 2018 (UPDATED) The US National Transportation Safety Board (NTSB) has issued a press release, in advance of a preliminary report, on a fan blade off (FBO) occurrence to Boeing 737-700 N766SW operating Southwest Airlines Flight 3472, from New Orleans, Louisiana to Orlando, Florida on 27 August 2016. A second, seemingly very similar FBO event occurred to N772SW operating Flight 1380 from New York-La Guardia, NY to Dallas-Love Field, Texas on 17 April 2018.  In that case debris penetrated a cabin window aft of the wing and one passenger is confirmed to have died (early reports suggest they had been partly sucked through the window).  This was Southwest’s first passenger fatality ever and the first Part 121 passenger airline fatality since February 2009 (although all 7 crew died in a B747F crash at Bagram, Afghanistan in April 2013). The NTSB originally called these uncontained failures, though the fan blades did not exit radially (the true definition of uncontained) but instead axially (i.e. forward).  The out of balance forces resulted in failure of the inlet structure. The First Accident Flight 27 August 2016: N766SW (Pensacola) One fan blade of the left hand CFM International CFM56-7B engine separated from the fan disc during the cruise.  The root of that blade remained in the fan disc hub but the blade was not recovered. Consequently the entire left engine inlet separated from the engine, with debris damaged the fuselage, wing and empennage.  A 5 x 16 inch hole was made in the fuselage just above the left wing and the cabin depressurised (though no engine debris penetrated the cabin). The aircraft diverted to Pensacola, Florida and made a safe landing, 18 minutes later.  None of the 99 passengers and 5 crew onboard were injured Investigation Findings The CFM56 fan blades are manufactured of titanium alloy and are coated with a copper-nickel-indium alloy at the root contact face. Initial findings from the NTSB Materials Laboratory metallurgical examination include: The fracture surface of the missing blade showed curving crack arrest lines consistent with fatigue crack growth. The fatigue crack region was 1.14-inches long and 0.217-inch deep, and The center of the fatigue origin area was about 2.1 inches aft of the forward face of the blade root. No surface or material anomalies were noted during an examination of the fatigue crack origin using scanning electron microscopy and energy-dispersive x-ray spectroscopy. The Flight Data Recorder (FDR) and the Cockpit Voice Recorder (CVR) have been down loaded by the NTSB. The NTSB’s Tim LeBaron is Investigator-in-Charge. The NTSB say: Parties to the investigation include the Federal Aviation Administration, Southwest Airlines, the Southwest Airlines Pilots Association, and CFM International. The French Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile has appointed an accredited representative who is supported by a technical advisor from Safran Aircraft Engines. CFM International is a joint venture between GE Aviation [US] and Safran Aircraft Engines [France]. Future work will include 3-D measurements of the contact areas of all the blades, a non-destructive examination of the blade surfaces for cracks, and a review of the engine maintenance records. UPDATE 25 August 2017: The FAA issued a Notice of Proposed Rule Making for an AD for comment with 15,000 cycles since last shop visit as the applicability criteria. UPDATE 10 October 2017:  Southwest was one of a number of respondees to the FAA NPRM consultation.  Southwest opposed a CFM proposal to reduce the FAA compliance time.  They said...

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Final Report: AS365N3 9M-IGB Fatal Accident

Posted by on 9:53 am in Accidents & Incidents, Airfields / Heliports / Helidecks, Business Aviation, Helicopters, Human Factors / Performance, Safety Culture, Safety Management

Final Report: AS365N3 9M-IGB Fatal Accident The Malaysian Air Accident Investigation Bureau (AAIB) has issued their final report on the accident to a privately operated Airbus Helicopters AS356N3 Dauphin 9M-IGM on 4 April 2015.  The helicopter was carrying VIPs from a wedding luncheon.  While in the cruise, the helicopter, with 6 persons on board was seen to dive into the ground.  There were no survivors. The Accident Flight The aircraft had earlier taken off with 7 persons on board: The Cockpit Voice Recorder (CVR) information revealed that after getting airborne, one of the passengers was not happy with the weather condition en-route to the destination. On several occasions, he was suggesting to the pilot to proceed direct to Kuala Lumpur. However, after a short discussion, they concurred to off load one of the passengers originally destined for Bandar Tun Razak, at any open field along the way. While flying along the road en-route to Kuala Lumpur, they spotted a football field and executed an approach for a landing. The AAIB report that while landing on the football field, the left main landing gear had sunk into the soft ground approximately 50cm. The helicopter had consequently tilted over 13 degrees to the left. The left hand (LH) horizontal stabiliser vertical fin and the tail section beneath the tail rotor fenestron had contacted the ground causing some damage to the inboard root of the LH horizontal stabiliser. Investigators also found evidence of a leaked hydraulic fluid on the ground.  The AAIB state that: Shortly afterward, the helicopter was seen to take off to a high hover and repositioned to approximately 10 meters to the front of its last position. One passenger disembarked the helicopter while both engines and the main rotors were still running and he exited via the right door escorted by the pilot. Shortly afterward at 1625 LT, the helicopter took off from the field. The pilot was seen by a witness to have exited the helicopter and accompanied the disembarked passenger clear of the main rotor area. However, he did not carry out any inspection of the helicopter. The helicopter was flown wheels down.  The CVR recorded the pilot commented to a friend on board: “we went all the way to the belly, it’s not good”. He further said “it’s definitely not normal for the wheels go down into the ground that far”. It’s definitely not good to tip like that”. He said “as a matter of fact, I saw hydraulic fluid leaking and that’s why I don’t want to put them up”. The AAIB comment: The most likely reason to press on for the flight was to accommodate the passenger request to arrive at the destination [Kuala Lumpur] without delay and to enable him to attend the formal dinner as planned. Analysis of the Flight Data Recorder (FDR) showed: …the helicopter was flying under auto pilot at 148 kts, the pitch of the helicopter unexpectedly and significantly decreased. The helicopter rapidly went beyond the flight envelop limits without any pilot input. AAIB explain: Inspection on the reconstruction of the wreckage revealed that the main rotor blades had struck the cowling, tail boom, fenestron and the left cabin door while the helicopter was still in the air. This action is considered consequential and there was no indication that the helicopter had struck terrain or any trees in flight prior to the impact. The helicopter decended [sic] almost vertically to the main wreckage area. The main wreckage was concentrated at one area in a ravine. The 4 main rotor blades were found...

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Loss of RAF Nimrod MR2 XV230 and the Haddon-Cave Review

Posted by on 12:01 am in Accidents & Incidents, Design & Certification, Fixed Wing, Military / Defence, Regulation, Safety Culture, Safety Management, Special Mission Aircraft

Loss of RAF Nimrod MR2 XV230 and the Haddon-Cave Review The Accident On 2 September 2006 Royal Air Force (RAF) Nimrod XV230, with 14 crew on board, departed for a surveillance mission over Afghanistan, in support of coalition forces engaging the Taliban. The aircraft rendezvoused with an RAF TriStar tanker for air-to-air refuelling (AAR), then turned towards the operational area. Eleven minutes after the AAR, a bomb bay fire warning and underfloor smoke warning were reported. Smoke entered the aircraft’s cabin.  Within a minute the aircraft de-pressurised as fire breached the pressure hull.  The crew donned their oxygen masks.  The aircraft turned towards Kandahar, the crew declared a MAYDAY and began a descent. Last radio contact was 5 minutes after the first warning.   Shortly after an RAF Harrier GR7 pilot, who was flying several thousand feet above, reported that the Nimrod had exploded. None of the 14 crew survived. The Investigations and Inquiries The accident resulted in an RAF Board of Inquiry, a Coroner’s Inquest and subsequently an independent review of the broader issues surrounding the loss. The BOI had found that the most probable physical cause of the loss of the aircraft was “the escape of fuel during Air-to-Air Refuelling” after which the fuel was ignited by “contact with an exposed element of the aircraft’s Cross-Feed/Supplementary Cooling Pack (SCP) duct”. Th Independent Review was then ordered by UK Secretary of State for Defence on 4 December 2007 with the following Terms of Reference: In light of the Board of Inquiry report:  To examine the arrangements for assuring the airworthiness and safe operation of the Nimrod MR2 in the period from its introduction in 1979 to the accident on 2 September 2006, including hazard analysis, the safety case compiled in 2005, maintenance arrangements, and responses to any earlier incidents which might have highlighted the risk and led to corrective action; To assess where responsibility lies for any failures and what lessons are to be learned; To assess more broadly the process for compiling safety cases, taking account of best practice in the civilian and military world; And to make recommendations to the Secretary of State as soon as practicable, if necessary by way of interim report. The review was to be led by London barrister Charles Haddon-Cave QC, who was widely recognised as a leading UK lawyer in the aviation field, having served on the defence team for the 1985 Manchester air disaster and having also represented survivors in the inquiry into The Herald of Free Enterprise ferry disaster. The Haddon-Cave Report, was published on 28 October 2009 with 90 recommendations. “Nimrod Review: A Failure of Leadership, Culture and Priorities” Haddon-Cave agreed with the Board of Inquiry: …that the ignition source was the Cross-Feed/Supplementary Conditioning Pack (SCP) duct in the starboard No. 7 Tank Dry Bay. As regards the fuel source, new evidence (not available to the Board of Inquiry or other agencies) has come to light which points to an overflow during Air-to-Air Refuelling being the most likely fuel source; although a leak from a fuel coupling remains a realistic possibility. The Review went on: There were a number of previous incidents and warning signs, potentially relevant to XV230, which represented missed opportunities. In particular, the rupture of the SCP duct in Nimrod XV227 in November 2004 should have been a “wake up call”. The Review focused primarily on: The inadequacies of the ‘Nimrod Safety Case’ which was prepared between 2001- 2005...

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Safety Intelligence & Safety Wisdom

Posted by on 4:23 pm in Human Factors / Performance, Regulation, Resilience, Safety Culture, Safety Management

Safety Intelligence & Safety Wisdom An EU aviation research 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) by interviewing 16 senior industry executives. The Future Sky project, initiated by the association of European Research Establishments in Aeronautics (EREA), has been examining the topic of “Resolving the organizational accident” and recently published a paper on Safety Intelligence & Safety Wisdom, which we think is a really useful contribution to the debate on Living Near Zero – New Challenges for Air Safety.  They defined these as: Safety Intelligence the various sources of quantitative information an organisation may use to identify and assess various threats. Safety Wisdom the judgement and decision-making of those in senior positions who must decide what to do to remain safe, and how they also use quantitative and qualitative information to support those decisions. The principal authors were Nigel Makins and Barry Kirwan of Eurocontrol.  The NLR managed project also included contributors from Airbus, Boeing Research & Technology-Europe, Deep Blue, ENAV, KLM and the LSE.  They say: Both Safety Intelligence and Safety Wisdom are needed. But while Safety Intelligence has been explored to some extent, the way in which top executives make decisions concerning safety is little understood and hardly researched. Consequently: Sixteen executives were interviewed from Airlines (3), Airports (3), Air Traffic Management (6), Regulation (2) and Research (2) sectors… …however not from the manufacturing sector.  The interviewees’ responses were organised into five key areas. 1) Safety first – but not at any cost The interviewees discussed safety as something non-negotiable.  However, they note that: …there are economic and performance pressures on the industry that could soon begin to affect safety – there is less and less ‘fat’ in the system, and the next cost-cutting exercise could impact safety. 2) Maintaining safety under pressure This is primarily the political and media pressure to act after an accident. Sometimes a quick reaction is clearly the right one to take, but other times it may be better to wait for more information, or not to react. 3) Accountability and Responsibility at the Top The senior executives interviewed strongly emphasised their feelings of accountability and responsibility for safety, and this translated into active leadership on safety in their organisations. One interviewee said: Taking responsibility for safety is also about demonstrating everyday leadership in building a strong safety culture. Dealing with risks is to lead by example: admit your own errors, do not get angry if people report issues, otherwise they won’t do it next time. A regulator said: The debate we’ve been having is where do our responsibilities begin and end. Our job is not only to look after safety from the areas that we have direct control but do our best to improve the overall safety. It is interesting that they use the term ‘direct control’.  The researchers comment: Regulators in particular need to be clear on their true accountabilities; if they take on too much accountability, this can disempower those they are regulating. We discuss some of the challenges in: Performance Based Regulation – EASA A-NPA & UK CAA Seminar, Performance Based Regulation and Detecting the Pathogens and Regulatory Reflections & Resisting the Seduction of the Risk Management Process 4) Searching for Evidence “Many organisations only look at data, but that’s not enough” said one executive.  The interviewees said that monitoring quantitative data, such as KPIs, is not enough and emphasised listening to post-holders and frontline staff, to help detect weak signals. This rich data flow only works if...

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First AW169 for Offshore Wind Turbine Support

Posted by on 10:04 am in Design & Certification, Helicopters, Logistics, Offshore, Oil & Gas / IOGP / Energy, Special Mission Aircraft

First AW169 for Offshore Wind Turbine Support The first Leonardo AW169 for use supporting wind farms, D-HHTJ, has been delivered to Emden based Heli Service International GmbH.  The aircraft, ordered in October 2015 and leased from LCI, will be used to support the giant Siemens Gemini wind energy project.  The aircraft is on a 5 year contract for winching maintenance personnel onto the wind turbines and is equipped with a UTC Goodrich winch. https://youtu.be/RYgq739wVD8 Managing Directors Oliver Freiland, Eberhard Herr, and Nils Herrmann say: After an extensive investigation of all relevant helicopter-types available, we are fully confident of having chosen the perfect match for our offshore customer´s demand for high-quality and safe operation, while being economically efficient. AW are marketing the 4.6t AW169 as the smallest of a ‘family’ of similar designs that “share the same common cockpit concept and design philosophy”, alongside the popular AW139 (now certified at 7t and with over 700 in service) and the 8.6t AW189, certified in 2014. Heli Service International, established in 1987 already operates fellow family member, the AW139, in the wind turbine Helicopter Hoist Operations (HHO) role: https://youtu.be/D09h8PNZm8o Operation of helicopters near wind farms will be one of the topics discussed at the EHEST Safety Workshop at Helitech in Amsterdam on 13 October 2016: The challenges of helicopter operations near wind turbines Siemens Gemini Project The EUR 1.5mn Gemini Project, off the Netherlands, features 150 turbines, with 130m diameter blades, delivering a total of 600MW (enough to power 800,000 homes). Siemens will be using an 84m, heli deck equipped, Service Operations Vessel (SOV), the Windea la Cour alongside helicopter operations.  Built by Ulstein, based on their SX175 design, it will be operated by BS Offshore.  The vessel can accommodate a crew of 20 and 40 maintenance personnel, and also features a walk-to-work gantry system.  A second will be launched later in the year to support another Siemens wind farm project. The in-field Offshore Transformer Station will be equipped with a helideck and refuelling facilities. UPDATE 26 September 2016: Airlift AS, an NHV company, has been awarded a contract to three AW169s for transporting Norwegian marine pilots for the Norwegian Coastal Administration (NCA).  The 6 year contract commences on 1 July 2017, with an option for a two year extension. AW169 Background  Launched at Farnborough International 2010, the AW169, powered by two Pratt & Whitney Canada PW210A 1100shp turboshafts, first flew in May 2012, with EASA issuing the Type Certificate in July 2015 (the TCDS is here). https://www.youtube.com/watch?feature=player_detailpage&v=Jmdq7Pvf_CE The AW169 features three 10×8 inch Rockwell Collins displays with touchscreen controls.  AW selected Rockwell Collins’ Helisure system in 2013 for a number of their product lines. In the offshore role the aircraft has a D-value of 14.7m, which puts it between the AS365/EC155 and the S-76.  The most likely offshore seating fit is an 8 seat cabin, with a large, accessible push-out window for every 2 passengers.  A more constrained forward facing configuration of 4 + 4 +2 layout is also offered.  The cabin volume is larger than an S-76D (6.5 m3 vs 5.8 m3) with a larger baggage bay too  (1.4 m3 vs 1.1 m3). UPDATE 27 December 2019: Leonardo delivered its 100th AW169 to Specialist Aviation Services for Cornwall Air Ambulance at Leonardo’s plant in Vergiate on 12 December 2019. Aerossurance has previously looked at other members of the Leonardo ‘family’: AW169 Update AW139 Global Fleet Passes 1 Million Hour Milestone The Rise of the ‘Super Mediums’: EC175 & AW189 AW189 Progress Heli-Expo 2015 Photo Report Heli-Expo 2015 ‘Super Medium’ Photo Report...

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