Shell Pernis 11.2t Ethylene Oxide Leak
Shell Pernis 11.2t Ethylene Oxide Leak The Dutch Safety Board has reported (in Dutch) on the leak of 11.2 tonnes of ethylene oxide from a overhead pipe at the 550 hectare Shell Pernis oil refinery on 30 December 2013. The leak was detected by a site worker at what is Europe’s largest refinery, surrounded by 500,000 inhabitants. Ethylene oxide is toxic, carcinogenic, ignites easily and may explode. The DSB say their investigation shows that Shell was not prepared for such a leak of that size. The adjacent port had to be evacuated due to the level of airborne contamination, and a water curtain used had the side effect of increasing the ground contamination. The spill occurred because the insulated pipework joints has degraded internally over 18 years. The DSB say that Shell had assumed a 40 year design life and that the joints would be maintenance free for 20 years. Following the spill, Shell has taken a series of measures. The joints have been replaced by flanges which can be routinely inspected. Shell now uses technical means to detect leaks in a timely manner and emergency procedures have been revised. Not The Only Leak Shell had suffered leaks of the same chemical in 2007 and 2009. During the completion of this report, the DSB launched an investigation into the emission of another 25 tonnes of ethylene oxide at a sister plant at Shell Moerdijk. It is alleged that this leak, following a repair in November 2015, was only discovered 2.5 months later. We have also previously reported on an earlier explosion there: Shell Moerdijk Explosion: “Failure to Learn” UPDATE 10 August 2016: It is reported that the UK Health and Safety Executive (HSE) have issued an Improvement Notice to Shell in the UK on its Clipper Southern North Sea complex of five bridge linked platforms, after one of their inspectors warned that: …“significant changes” to the Clipper installation meant there was risk of loss of containment from corrosion under insulation (CUI). In one instance, a four inch condensate line had to be shut down after it was discovered the thickness of the wall was just 2.6mm – a significant decrease on its nominal measurement of 11.1mm. A notice from the HSE also said “certain hydrocarbon containing lines” were three years behind their planned inspection date while certain lines had not been inspected for more than 12 years. But further: It was also found Shell had reduced its CUI inspection and repair programme staffing in March from 24 persons to eight people, which reduced the “ability to execute inspection and repairs in a timely manner”. In the 2008 book Resilience Engineering Perspectives, Volume 1: Remaining Sensitive to the Possibility of Failure, John Wetherall writes: …one hallmark of a resilient organisation is that it is prepared not only for its own failures those of which it can learn from others – the more resilient it is, the ‘bigger’ are the lessons it has learnt from others. Aerossurance has extensive safety and accident 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 updates. TRANSLATE with x English Arabic Hebrew Polish Bulgarian Hindi Portuguese Catalan Hmong Daw Romanian Chinese Simplified Hungarian Russian Chinese Traditional Indonesian Slovak Czech Italian Slovenian Danish Japanese Spanish Dutch Klingon Swedish English Korean Thai Estonian Latvian Turkish Finnish Lithuanian Ukrainian French Malay Urdu German Maltese Vietnamese Greek...
read moreForgotten Fasteners – Serious Incidents
Forgotten Fasteners – Serious Incidents We examine three incidents where fasteners were forgotten during maintenance. It two cases these maintenance errors resulted in parts falling from the aircraft. In a third, a massive fuel leak occurred. Incident 1 – Twin Otter Mission Pod The Irish Air Accident Investigation Unit (AAIU) has recently reported on a serious incident that occurred on 15 August 2015 involving DHC-6-300 Twin Otter C-GSGF, used for aerial survey work by Sander Geophysics Ltd (SGL). Incident 1 – The Flight The aircraft was in Ireland for the low-level Tellus survey project of the Geological Survey of Ireland: The aircraft is equipped with three geophysical instruments which measure the magnetism, radioactivity and conductivity of the Earth below. It undertakes measurements as it flies at a speed of approximately 130 mph (approx 216km/h). The aircraft flies at 60 m (196 ft) above ground level… Survey lines are flown at a spacing of 200 m. The AAIU say: On take-off from Weston Airport, County Kildare the nose cone from the right hand mission equipment pod fell from the aircraft… The Flight Crew experienced a significant amount of yaw to the right which they felt through the flying controls. The aircraft diverted to Dublin Airport where it subsequently landed safely. There were no injuries. One of the three sensors in use was an Electro Magnetic (EM) system. A signal is transmitted from the right hand wing tip pod and the signal is received in the left pod. Incident 1 – The Safety Investigation The AAIU say: On 14 August 2015, the day before the event, in accordance with the maintenance instructions prescribed in the [mission modification’s Supplemental Type Certificate] STC, the aircraft underwent a 125 hour Supplementary Inspection. This inspection called, inter alia, for the removal of “the EM pod nose and tail cones” and inspection of “the pod internal frames for cracks or other damage”. …the Operator’s standard practice calls for the fitting of flagging tape when parts are removed and that the flagging tape should only be removed following re-installation of the removed part(s). On this occasion the personnel involved advised the Investigation that flagging tape was not fitted. It was reported that during the EM Pod maintenance, while the nose cone was being reinstalled, a fault was detected with its sensor system. Re-installation of the nose cone was halted pending identification of the cause of the fault and consequently only the top two nose cone retaining screws were re-installed. Troubleshooting subsequently traced the origin of the sensor problem to a location inboard of the pod and the fault was rectified. The Inspection was then completed but the 14 remaining nose cone retaining screws were not re-installed. The AAIU say: All personnel who completed walkaround inspections on the morning of the event had completed a third party, computer based Aviation Maintenance Human Factors course… There is no mention of the use of more interactive or tailored training. The check was recorded in the Tech Log but it would not necessarily have been apparent that the nose cone had been removed to the crew. The Flight Manual Supplement does have a requirement to “check that all visible attaching fasteners are installed and secure”. The Commander said that he “…there’s not any moving parts on the pods. I had a cursory look at the pods probably from about fifteen feet ahead...
read moreHeli-Expo 2016 Photo Report
Heli-Expo 2016 Photo Report News from HAI Heli-Expo 2016 in Louisville, Kentucky (1-3 March 2016): Airbus Helicopters H215 Airbus Helicopters had on show the newly designated H215, formerly the AS332C1e (i.e. an enhanced, short fuselage Super Puma) and AS332L1e (the long fuselage version), to be built in Romania and aimed at aerial work, disaster relief and other missions. The replacement of elderly SA330Js, S-61s and Mil Mi-8s being distinct targets. The Finnish Border Guard recently took delivery of its first H215, OH-HVP, with the second to follow in Apri 2016l. It has been suggested that a major current sales target is California’s Department of Forestry and Fire Protection (CAL FIRE), which has issued a tender for 15 helicopters. Airbus Helicopters AS350 / H125 Probably one of the oddest special mission modifications on show was this AS350B3 fitted for environmental research. The so called Helicopter Observation Platform (HOP), N350UM, is owned by the University of Miami Rosenstiel School of Marine and Atmospheric Science and operated by Helicopter Express. The aircraft was exhibited by Donaldson Aerospace & Defense as it is equipped with a Donaldson Inlet Barrier Filtration (IBF) system. Meanwhile Vector Aerospace and Robertson Fuel Systems were exhibiting their soon to be certified (by FAA and EASA) Crash Resistant Fuel System (CRFS) for the AS350 AStar and EC130B4. This direct replacement tank features a number of safety enhancements, including the introduction of modern fuel retention technology and the relocation of certain critical components to further enhance safety and ease of maintenance. Vector worked closely with Onboard Systems to ensure that the tank remained compatible with Onboard’s cargo swing options. For more on the value of this modification see our article: Crashworthiness and a Fiery Frisco US HEMS Accident Airbus Helicopters H130 Canadian operator Phoenix Heli-Flight took delivery of a spectacularly painted H130 at the show. Airbus Helicopters H160 and H175 While Airbus did not exhibit aircraft or mock-ups of the H160 and H175 this year they did offer attendees a virtual reality experience with both. Meanwhile it has been reported that Airbus Helicopters are planning a new lean production philosophy for the H160. ‘Major Component Assemblies’ will be produced in different locations before final assembly and flight test at Marignane in France. Production aircraft will have their tail booms produced Albacete, Spain, and main rotor blades would be produced at La Courneuve, near Paris. The central and front fuselages will be produced and pre-equipped by Airbus at its Donauworth facility in southern Germany. They will be mated together in Marignane with the main dynamic components that are also produced there. This could see the 36 week assembly process for the AS365 drop to 18 weeks for the H160, when the production line opens in 2017. UPDATE 10 October 2016: The H160 has now achieved 250 hours in flight test. Bell 505 Jet Ranger X Two Bell B505s were on display. The B505 first flew with a single, right hand side, horizontal stabiliser. The type has now a rather less elegant solution. The Bell 505 features a Garmin G1000H avionic suite. Bell 525 Relentless Bell also brought B525 Flight Test Vehicle 2 (FTV2) to the show. The second aircraft first flew on 21 Dec 2015. The 525 utilises fly-by-wire (FBW) controls. A third aircraft is due to join the flight test programme in the coming month, to be followed by two...
read moreMisrouted Engine Fuel Control Cable Hawker 800XP
Misrouted Engine Fuel Control Cable Hawker 800XP In Issue 4/2015 of TP 6980 – Canadian Aviation Service Difficulty Reports – Feedback an maintenance error involving a Hawker 800XP fuel control cable is reported: During a planned major structural inspection, the technician noticed that the no.1 engine high-pressure fuel lever cable was trapped under the cover of the electrical junction box. The box straddles the area beneath the floor. Luckily the cable was still able to move and function normally as there was only a slight cable deflection under a flexible plastic cover. The cable was inspected, found to be serviceable with no apparent damage. The cable was properly re-routed above the junction box as per the maintenance manual requirements. Transport Canada say: The mis-routing of this control cable was done at either its last replacement or re-installation from a past maintenance check or snag rectification. As it is with any primary flight or engine control, an independent inspection and dual sign-off would have been required as stated in CAR standard 571.10, maintenance release. Transport Canada Civil Aviation would like to advise all maintenance personnel that the inspection criteria includes an operational check and confirmation for correct assembly of the complete affected system. Our readers will know Aerossurance has previously discussed independent inspections several times, including: Critical Maintenance Tasks: EASA Part-M & -145 Change EC130B4 Accident: Incorrect TRDS Bearing Installation You may also find these earlier articles of interest: James Reason’s 12 Principles of Error Management Maintenance Human Factors: The Next Generation Aerossurance worked with the Flight Safety Foundation (FSF) to create a Maintenance Observation Program (MOP) requirement for their contractible BARSOHO offshore helicopter Safety Performance Requirements to help learning about routine maintenance and then to initiate safety improvements: Aerossurance can provide practice guidance and specialist support to successfully implement a MOP. Aerossurance has extensive air safety, airworthiness, human factors 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 morePitot Punctures Floats in Icelandic SAR Ditching
Pitot Punctures Floats in Icelandic SAR Ditching The ditching of Icelandic Coast Guard Aérospatiale SA365N Dauphin TF-SIF in the Atlantic off Reykjavik on 16 July 2007 highlights the importance of avoiding protuberances that can puncture emergency flotation systems, careful configuration management and establishing emergency drills. The Icelandic Transportation Safety Board (ITSB), the RNF, issued their report in December 2010. The Accident Flight The aircraft was on a winch training mission to hoist people from the Slysavarnarfélagið Landsbjörg (ICE-SAR) 16m Arun Class lifeboat BS Einar Sigurjónsson, a life raft and from the water at a training area about 8 minutes from their base at Reykjavik’s domestic airport. The RNF say that: …arriving at the training area, the aircraft was flown in a standard pattern at 200 feet and 60 knots IAS and then descended to 100 feet and 20 knots IAS. When the training session began, the aircraft was hovered at 45-50 feet and 0-5 knots GS. At this time a power check was made and the pre-hoist checklist was completed. According to the commander’s statement, all parameters were normal and the torque was approximately 85%. The commander announced to the crew that the aircraft was in Class 3 performance and the aircraft would be ditched in case of an engine or tail rotor failure. The aircraft was operating in a light wind (10 knots) and at ISA-1 (14°C). Being Performance Class 3 (PC3) highlights the risk of conducting live winching on an aircraft with limited One Engine Inoperative (OEI) performance. While in the hover at 45 feet, the crew commenced an operation to winch a rescue litter down to the lifeboat. About 3 seconds after the line was free from the litter the low Nr [main rotor speed] horn started to sound… [and]…the crew noticed a power loss followed by a reduction of Nr. The PF [Pilot Flying] directed the aircraft away from the ship and scanned the caution warning panel for warning lights but saw none lit. The PNF [Pilot Not Flying] looked at the Nr indicator and determined it to show Nr between 300 and 330 (Normal Nr is 355) rpm and the aircraft was losing altitude. About 10 seconds after the horn first sound, the crew deployed the floats and 7 seconds after that made a controlled ditching in water estimated to be Sea State 2-3. …the crew retarded the fuel flow control lever (FFCL) in order to shut off the engines. The pilot reported that when shutting off the right hand engine the engine seemed to be already on low rotation speed. The crew then stopped the main rotor by applying the rotor brake and then cut the hoist wire. After a short briefing the crew shut the battery off as well as the gyros. The crew then evacuated the aircraft through the right hand sliding door and swam to a boat from BS Einar Sigurjónsson. The RNF note the evacuation was a surprisingly unhurried 4 minutes after ditching. The floats had inflated correctly however the crew noticed when they evacuated that that the front floats were rubbing against the pitot tubes and shortly after the forward chamber of the right hand front float deflated. The aircraft capsized approximately 18 minutes after ditching. The Safety Investigation The helicopter was fitted with a Cockpit Voice Recorder (CVR), though not a Flight Data Recorder (FDR). Acoustic analysis of he CVR showed that one...
read moreFalcon 7X LOC-I Due To Solder Defect
Falcon 7X LOC-I Due To Solder Defect On 25 May 2011, Dassault Falcon 7X business jet, HB-JFN, operated by Jet-Link, suffered a pitch trim runaway that caused a 40° pitch up, rapid climb and temporary Loss of Control Inflight (LOC-I) over Malaysia. First flown in 2005 and certified in April 2007, after a 590 flight, 1600 flying hour test programme, the 7X features a fly-by-wire (FBW) control system. This Digital Flight Control System (DFCS) and the Falcon family’s EASY (Enhanced Avionics SYstem) flight deck design draw on Dassault’s 30 years of military fighter experience, especially its Rafale and Mirage 2000. The type had accumulated 75000 flying hours at the time of the incident. The French Bureau d’Enquêtes et d’Analyses (BEA), to whom the investigation was delegated, has now reported (in French) on this serious incident (commenting that the long duration was necessary to examine the organisational factors). The Incident Flight While descending through 13000 feet at the end of a positioning flight to Kuala Lumpur, over 15 seconds the elevator pitch trim began to move from neutral to the full nose-up position. The First Officer (Pilot Flying), a former military pilot with experience on Mirage IV and Mirage 2000, put the aircraft into a steep right-hand bank to aid recovery partially replicating the ‘palier-ressource’ military manoeuvre (which involves approaching a target in level flight before pulling up at 30° pitch to release the weapon, and then banking to 90° to reduce pitch and escape). At two points (for 9 and 12 seconds) both the Commander (Pilot Non-Flying) and the First Officer were simultaneously using their side stick. The First Officer used the priority button to override the Commander’s inputs and asked him to stop. The pitch subsequently decreased, as did the load factor (from a maximum of 4.6 g to less than 1.5 g). After about 2.5 minutes the crew regained control and landed safely. The aircraft had however climbed to 22500 feet. Immediate Response The incident prompted such concern that the next day that the European Aviation Safety Agency (EASA) published an Emergency Airworthiness Directive (EAD), prohibiting further flights by the Falcon 7X fleet until further notice. A further Airworthiness Directive (AD), in two stages, permitted operations to resume with modifications and operational limitations. A third AD with modifications and operational tests followed. The Safety Investigation The BEA found that a defective ‘cold’ solder joint at a pin of a component of the Horizontal Stabilizer Electronic Control Unit (HSECU) led this computer to sending erroneous signal to the actuator driving the horizontal stabiliser trim (HRT) and a simultaneous failures of monitoring channel which were not detected. The solder had not reached an adequate temperature because the board had acted as a heat sink, resulting in micro-cracking. They highlight a similar, but unconnected case in 2007 (Airbus A321 I-BIXK that suffered a braking failure after similar solder defects in its Brakes and Steering Control Unit). A number of contributory factors are identified by the BEA. One is the non-detection of the production fault. They also comment on the HSECU supplier’s Failure Modes and Effects Analysis (FMEA) which was not suitably comprehensive. They note that this FMEA was not subject to detailed review by the aircraft Type Certificate (TC) Holder. The TC Holder’s System Safety Assessment (SSA) in accordance with 25.1309, being partly based on that FMEA, was therefore incomplete. The BEA also reference safety assessment lessons from an Australian Transport Safety Bureau (ATSB) report into an upset involving a A330 VH-QPA in 2008 (in that case not...
read moreUK CAA CAP1145 North Sea Helicopter Safety Two Years On
UK CAA CAP1145 North Sea Helicopter Safety Two Years On Not long after the fatal loss of Eurocopter AS332L2 G-WNSB of Sumburgh Airport, Shetland Islands on 23 August 2013 with 4 fatalities (AAIB Special Bulletin), the UK Civil Aviation Authority (CAA) launched an rapid review on offshore helicopter safety. That CAA Review resulted in the CAP1145 report (‘Safety review of offshore public transport helicopter operations in support of the exploitation of oil and gas’), issued two years ago on 20 February 2014. Last year the CAA issued CAP 1243, the Offshore Helicopter Review Progress Report, which provides an update on the 10 months to 31 Dec 2014. The minutes of the 16 October 2015 meeting of the Offshore Helicopter Safety Action Group (OHSAG) suggest the next CAP1145 progress report is due in April 2016. When they refreshed their website in late 2015 the UK CAA introduced a blog section with the opportunity for public comment and questions. This includes one on offshore helicopter operations, which has had the most interaction to date (on two topics we have previously written about certified sea states limits and CA-EBS training). UPDATE 24 September 2016: The UKCAA has issued CAP1386, their second update on CAP1145. We have summarised that report. UPDATE 1 February 2017: An update of BARSOHO (Version 3), fully aligned with the HeliOffshore SPM, is now available. Aerossurance is pleased to be supporting both HeliOffshore and the Flight Safety Foundation in their work to improve offshore helicopter safety. UPDATE 6 March 2017: HSS3b is issued (initially in Norwegian, with an English Exec Summary). It features comment on CAP 1145 and survivability matters. UPDATE 23 January 2020: Without fanfare UK CAA publish CAP 1877: Safety Review of Offshore Public Transport Helicopter Operations in Support of the Exploitation of Oil and Gas Aerossurance is an Aberdeen based aviation consultancy. For expert advice you can trust on offshore helicopter safety, survivability, safety assurance, safety culture and contracting matters, contact us at enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest...
read moreUS Helicopter Accident Rate Analysis
US Helicopter Accident Rate Analysis Aerossurance recently looked at US Helicopter Emergency Medical Service (HEMS) accident data for the last 10 years and has also examined accident rates in Gulf of Mexico (GOM) oil and gas operations. We thought we would also look at published accident rates for all US helicopters and demonstrate the effects of choosing different start dates and different trending methods. To look, initially, at performance during the 21st century we choose to use data from the International Helicopter Safety Team’s (IHST‘s) US regional team, the US Helicopter Safety Team (USHST). This is topical as this data has recently been discussed in a magazine article: What We Don’t Know Has Hurt Us. We then take a take a longer historic perspective back to 1970. US Helicopter Fatal Accident Rates 2001-2015 In October 2015 the USHST published data for 2001-2015 (with the latter being a part year estimate) for fatal helicopter accidents per 100,000 flying hours. We’ve plotted this data (excluded the partial 2015 results) and added a linear trend line (i.e. a best-fit straight line): This shows an impressive improvement over the period. But what if we apply a rolling (or moving) average? A rolling average smoothes fluctuations to show a pattern or trend more clearly. If we choose a three year rolling average (i.e. we plot data based on the average of the last 3 years) then the results look very different: Here the poor start to the data set in 2001-2003 dominates the early rolling averages but in more recent years the data, while fluctuating, has essentially plateaued. Similar results are evident in 2 or 5 year rolling averages are selected. If we were to choose a different start point, say 2006, the first year after the IHST was created, and revert to a linear trendline the results are even more dramatic: Almost no change in fatal accident rate over 9 years is evident. If we use a 3 year rolling average: Here the rolling average has risen in recent years, very different to the liner trend. US Helicopter Accident Rates 2001-2015 In October 2015 the USHST also published data for 2001-2015 for helicopter accidents (fatal and non-fatal) per 100,ooo flying hours. Unfortunately 2001-2005 is presented only as an average: You will note that the USHST compare 2015 performance with the baseline 5 year average for 2001-20o5 (a 55% improvement). The 2015 data is however only 20% better than 2006. We can plot average data for 2001-2005 and annual data for 2006-2014 (again ignoring the partial data for 2015) with a linear trend: This shows a dramatic (over 50%) improvement. However, if we use a 3 year rolling average: Here, although the trend reduces during the middle part of the last decade, in recent years the rate has again essentially plateaued. If we focus just on 2006 onwards and apply a linear trend: A modest improvement is evident over the period. If we apply a 3 year rolling average: Very little improvement is now evident. US Helicopter Accident Rates 1970-2013 To take a more historic perspective we have take data from the Helicopter Association International (HAI). There website contains data from 2001 to 2013 (we have taken the most recent record for each year to allow for any revisions as any new, mostly usage data, has emerged). In the Aerossurance achieves we have HAI published data back to 1970. This data is generally...
read moreFirst Eleven: Guidance for Designers on Maintenance Human Performance
First Eleven: RAeS Guidance for Design Organisations on Maintenance Human Performance The Royal Aeronautical Society (RAeS) Human Factors Group: Engineering (HFG:E) has published a short guidance document on 11 steps an aviation Design Organisation (DO) can take to “deliver safer, more effective and reliable aircraft through improved design for maintenance”. The RAeS say: Aircraft safety and in‐service maintenance performance can be significantly improved through integrating maintenance Human Factors (HF) principles into aircraft design… Research shows that many aircraft incidents and accidents are caused or contributed to by maintenance errors that are induced or aggravated by aircraft design and technical documentation. Improved, user‐centred design and documentation reduces maintenance error and its consequences. Many DOs already recognise…their products can be improved through applying HF principles to reduce in the probability and consequences of maintenance errors, reduce lifecycle costs and improve operational reliability / availability. However, research by the HFG:E suggests that identifying practical steps to realise these benefits remains a significant challenge for many DOs. Consequently, the ‘First Eleven’ guidance was developed over several years of engagement with DOs, air accident investigators and regulators to be a practical series of steps for a DO to fully integrate the best practices for maintainer-centric design. A First Eleven gap analysis is a practical way to identify opportunities for improvement. The RAeS say: These are the ‘First’ Eleven because striving for enhanced maintenance human performance should be a continuously evolving process. The full guidance document can be found here. Aerossurance is pleased to have sponsored the RAeS HFG:E conference on 12 May 2015 at Cranfield University on Human Factors in Engineering – the Next Generation (as well as its staff actively participating in the HFG:E since 2005). We see the First Eleven as one way that DOs can contribute to next generation solutions that enhance maintenance human performance. Aerossurance is pleased to support the Chartered Institute of Ergonomics & Human Factors’ (CIEHF) Human Factors in Aviation Safety Conference that takes place at the Radison Blu Hotel, East Midlands Airport, 7-8 November 2016. Our presentation will discuss the importance of HCD. UPDATE 2 March 2018: An excellent initiative to create more HCD by use of a Human Hazard Analysis (HHA) is described in Designing out human error HeliOffshore, the global safety-focused organisation for the offshore helicopter industry, is exploring a fresh approach to reducing safety risk from aircraft maintenance. Recent trials with Airbus Helicopters and HeliOne show that this new direction has promise. The approach is based on an analysis of the aircraft design to identify where ‘error proofing’ features or other mitigations are most needed to support the maintenance engineer during critical maintenance tasks. The trial identified the opportunity for some process improvements, and discussions facilitated by HeliOffshore are planned for early 2018. A systems approach in healthcare: UPDATE 24 October 2022: The Royal Aeronautical Society (RAeS) has launched the Development of a Strategy to Enhance Human-Centred Design for Maintenance. Aerossurance‘s Andy Evans is pleased to have had the chance to participate in this initiative. Aerossurance has extensive airworthiness, design assurance, certification, maintenance error management and human factors experience. For professional design / maintenance HF support you can trust, contact us at: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest...
read moreSafety Data Silo Danger – Data Analytics Opportunity
Safety Data Silo Danger – Data Analytics Opportunity We recently enjoyed reading The Silo Effect by Gillian Tett. Tett, who has a PhD in social anthropology, is a journalist and senior editor for the Financial Times. Some organisations are, often by design, divided into silos (by project or by functional specialism). Silos however can restrict who we talk to and how we share information. Such ‘structural secrecy’ was noted by sociologist Prof Diane Vaughan in her examination of the disastrous NASA Space Shuttle Challenger launch decision. Tett (who discusses her work in this podcast) argues that the observational discipline of anthropology can also identify the unspoken silos within a organisation (as well as society as a whole). From a safety perspective the most interesting case study comes in the book’s introduction, a case study that is less about anthropological observations and more about data collation and analysis. Fighting Fire with Data On 25 April 2011 a fire a 2321 Prospect Avenue in the Bronx claimed three lives. The property had been “illegally subdivided, leading city officials to pledge a crackdown on a practice that can impede fire-fighters and imperil lives” in the resulting furore. New York City had a team of building inspectors and they were not short of complaints to investigate. Each year they received 20,000 complaints on the nearly 1 million buildings and 4 million properties in their remit via the city’s 311 phone line (which receives 30,000 calls on a host of topics every day). However, only 13% of those complaints when investigated wre valid, wasting time and limited resources. Another city department, the fiercely independent New York Fire Department (NYFD) had overlapping duties and its own data, effectively an inaccessible silo, but key data turned out to be split between many city departments and databases. In May 2011 New York City Mayor Michael Bloomberg appointed Mike Flowers to head a new Mayor’s Office of Data Analytics (MODA) and create what some have called ‘The Mayor’s Geek Squad’ of data analysts. They started to develop a way to use data from multiple sources (not just Dept of Buildings and NYFD data) to prioritise attention on the most probable reports of illegal conversions. Flowers said: Before we started, we didn’t know what we knew. The analysts did more than look at data. They spent time with building inspectors and fire-fighters to understand more about illegal conversions and fires. Flower’s explains that what they then did was: …come up with a way to prioritize those [complaints] which represent the greatest catastrophic risk… In doing that, we built a basic flat file of all 900,000 structures in the city of New York and populated them with data from about 19 agencies, ranging from whether or not an owner was in arrears on property taxes, if a property was in foreclosure, the age of the structure, et cetera. Then, we cross-tabulated that with about five years of historical fire data of all of the properties that had structural fires in the city, ranging in severity. After we had some findings and saw certain things pop as being highly correlative to a fire, we went back to the inspectors at the individual agencies, the Department of Buildings, and the fire department, and just asked their people on the ground, “Are these the kinds of conditions that you see when you go in post-hoc, after this catastrophic event? Is this the kind of place that has...
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