NASA ASRS at 40 and the Continued Challenge of Timeliness for Safety Reporting
NASA Aviation Safety Reporting System at 40 and the Continued Challenge of Timeliness for Safety Reporting On 16 April 16 2016 the National Aeronautics and Space Administration (NASA) Aviation Safety Reporting System (ASRS) celebrated 40 years of operation. Its origins highlights one major challenge of safety reporting, learning and action: timeliness. The Purpose and Administration of ASRS The ASRS collects, analyses, and responds to voluntarily submitted aviation safety reports. ASRS data is used to: Identify deficiencies and discrepancies in the National Aviation System (NAS) so that these can be remedied by appropriate authorities. Support policy formulation and planning for, and improvements to, the NAS. Strengthen the foundation of aviation human factors safety research. This is particularly important since it is generally conceded that over two-thirds of all aviation accidents and incidents have their roots in human performance errors. ASRS was set up under a Memorandum of Agreement between the Federal Aviation Administration (FAA) and NASA in August 1975. The FAA fund the programme and provide for its immunity provisions. The NASA set programme policy and administer its operations. Similar programmes now exist elsewhere, such as CHIRP (the Confidential Human Factors Incident Report Programme) in the UK (which we have previously discussed). With the lack of a mandatory occurrence scheme in the US, such as that required by Regulation (EU) 376/2014 Reporting, Analysis and Follow-up of Occurrences in Civil Aviation (and the earlier UK Mandatory Occurrence Reporting [MOR] scheme, which also commenced in 1976), ASRS also fulfils some of that role in the US. The UK CAA had issued an Aeronautical Information Circular on 2 October 1972 proposing expanded reporting requirements. Its predecessor, the Air Registration Board (ARB), had introduced defect reporting requirements in 1964 and voluntary reporting of other occurrences had been encouraged in part through the UK Flight Safety Committee (UKFSC). The CAA proposed expanding this to include mandatory ‘incident’ (i.e. occurrence) reporting. The Origin of ASRS The origins of the scheme are particularly interesting. On 1 December 1974, TWA Flight 514, Boeing 727-231 N54328 was inbound through poor weather to Washington Dulles in Virginia. The flight was originally destined for Washington National Airport but was diverting to Dulles due to high crosswinds. As NASA relate: The flight crew misunderstood an ATC clearance and descended to 1,800 feet before reaching the approach segment to which that minimum altitude applied. The aircraft collided Mount Weather, near Berryville, Virginia (near a major US government bunker) killing all 92 aboard. The NTSB investigation determined the crew’s decision to descend was “a result of inadequacies and lack of clarity” in air traffic control procedures and a misunderstanding between pilots and controllers regarding each other’s responsibilities during terminal operations and in IMC conditions. The accident is discussed fin the FAA Lessons Learnt Database. NASA go on: A disturbing finding emerged from the ensuing NTSB accident investigation. Six weeks prior to the TWA accident, a United Airlines flight crew had experienced an identical clearance misunderstanding and narrowly missed hitting the same Virginia mountaintop. The United crew discovered their close call after landing and reported the incident to their company. A cautionary notice was issued to all United pilots. Tragically, there existed no method of sharing the United pilots’ knowledge with TWA and other airlines. Following the TWA accident, it was determined that safety information must be shared with the entire aviation community. Thus was born the...
read moreC-130J Control Restriction Accident, Jalalabad
C-130J Control Restriction Accident, Jalalabad The US Air Force (USAF) Air Mobility Command (AMC) has released its accident report into the fatal loss of control (LOC-I) accident involving of Lockheed Martin C-130J 08-3174 during a night-time take-off from Jalalabad Airfield, Afghanistan on 2 October 2015. The accident was caused by the failure to remove a loose article that had been deliberately placed behind the control column during a night-time engines-running turnaround to aid loading. The Accident All 11 persons on-board died (four crew, two fly-away security team members of the the 66th Security Forces Squadron and five civilian contractor passengers), as did three Afghan Special Reaction Force (ASRF) personnel as the aircraft struck a guard tower. There was also a post crash fire. This was the worst USAF C-130 accident in the last 25 years. The aircraft was from the 317th Airlift Group, Dyess Air Force Base, Texas, and operated by the 39th Airlift Squadron, while assigned to the 455th Air Expeditionary Wing at Bagram Airfield, Afghanistan. In an AMC press release they say: While conducting engine running on-load/offload operations at Jalalabad Airfield, the pilot raised the elevators mounted to the horizontal stabilizer by pulling back on the yoke. This provided additional clearance to assist with offloading tall cargo. After a period of time in which the pilot held the yoke by hand, he placed a hard-shell night vision goggle (NVG) case in front of the yoke [or control column] to hold the elevator in a raised position. However, because the pilots were operating in darkened night-time flying conditions and wearing NVGs, neither pilot recognized and removed the NVG case after loading operations were complete or during take-off. Once airborne, the aircraft increased in an excessive upward pitch during the take-off climb. The co-pilot misidentified the flight control problem as a trim malfunction, resulting in improper recovery techniques. The rapid increase in pitch angle resulted in a stall from which the pilots were unable to recover. The aircraft impacted approximately 28 seconds after lift-off, right of the runway, within the confines of Jalalabad Airfield. The investigators say, surprisingly, they could not determine if a flight controls check would have alerted the pilots to the obstruction. Conclusions The accident investigation board identified the following causes: Inadequate Real-Time Risk Assessment (Hard-Shell NVG Case Placement) Distraction Wrong Choice of Action During an Operation (Misidentification of Malfunction) They identified the following contributory factors: Environmental Conditions Affecting Vision (i.e. night-time operations, use of NVGs, and reliance on the Head Up Display [HUD] and Advisory, Caution, and Warning System [ACAWS]) Inaccurate Expectation (in relation to take-off technique applied) Fixation (on a trim failure) Accident Sequence Video and Other Resources A brief 5s animation of the flight: AIB Report – C-130J, TN 08-3174 (Report) AIB Report – C-130J, TN 08-3174 (Tabs A – U) AIB Report – C-130J, TN 08-3174 (Tabs V – EE) UPDATE 24 April 2016: The Air Force Times has now covered this accident. They quote sources who observe that such a workaround “was not uncommon”, “there’s no official way to do that other than holding it up by hand” and sometimes items would be used to “prop up yokes”: It wasn’t sanctioned, it was just something you did. Not always, just sometimes. It’s the end of a long day and you’re tired. Someone wants to stand up and walk around, you’d use something artificial to hold that up. During an engine running turnaround:...
read moreCrew Bag FOD Shatters Hawk Canopy
Crew Bag FOD Shatters Hawk Canopy On 28 Jan 2016 Royal Canadian Air Force (RCAF) CT-155 BAE Systems Hawk Mk 115 trainer CT155219, based at CFB Cold Lake, Alberta, was performing a Cuban 8 manoeuvre. In an interim report from safety investigators: During the inverted 45 degree portion following the first loop the pilot’s unrestrained publications bag drifted upwards (relative to the cockpit) and aft. The pilot then rolled upright and pulled 5g to complete the Cuban 8. During the 5g pull, the bag dropped down towards the aft portion of the right console and struck the Miniature Detonation Cord (MDC) firing unit (red circle in the photos) with enough force to activate it, fragmenting the canopy. The pilot ceased manoeuvring, slowed the aircraft and [Returned to Base] RTB without further incident. The pilot received minor injuries from the MDC combustion products and canopy fragments and there was significant damage to cockpit equipment and external airframe structures. The engine ingested some of the canopy fragments but only received minor damage. The investigation so far has not identified any technical issues with the airworthiness of the aircraft or the fleet. The investigation is focusing on operational and human factors, primarily the procedures and requirement to carry and store a publications bag in the cockpit. The investigation is also looking at possible ways to protect the MDC firing unit from being inadvertently activated. While aerobatic aircraft are particularly sensitive to loose articles in the cockpit, non-aerobatic aircraft are also susceptible to this threat. We reported in June 2014 on a Royal Air Force (RAF) A330 Voyager ZZ333, that was involved in a loss of control (LOC-I) incident during a flight from Afghanistan in February 2014. The aircraft suddenly pitched nose down while in the cruise at 33,000ft. In 27 seconds, the aircraft lost 4,400ft, with a maximum rate-of-descent of approximately 15,000ft per minute, before recovering. The resulting negative g forces were sufficient for almost all of the unrestrained passengers and crew to be thrown towards the ceiling, resulting in a number of minor injuries. The aircraft diverted to Incirlik in Turkey. The UK Military Aviation Authority (MAA) issued a preliminary report on 17 March 2014 that said investigators: …found evidence to link the movement of the seat to the movement of the side-stick, in the form of a Digital SLR camera obstruction which was in-front of the Captain’s left arm rest and behind the base of the Captain’s side-stick at the time of the event. Analysis of the camera has confirmed that it was being used in the three minutes leading up to the event. Furthermore, forensic analysis of damage to the body of the camera indicates that it experienced a significant compression against the base of the side-stick, consistent with having been jammed between the arm rest and the side-stick unit. The full Service Inquiry report has since been published. UPDATE 17 April 2016: We also report on a US Air Force (USAF) Air Mobility Command (AMC) Lockheed Martin C-130J, 08-3174 that crashed at Jalalabad, Afghanistan after a loss of control (LOC-I) on 2 Oct 2015. That accident was caused by the failure to remove a loose article. a Night Vision Goggle (NVG)box, that had been deliberately placed behind the control column during a night-time engines-running turnaround to aid loading by holding the elevator displaced. UPDATE 12 February 2017: Flying Control FOD: Screwdriver Found...
read moreA319 Double Cowling Loss and Fire – AAIB Safety Recommendation Update
A319 Double Cowling Loss and Fire – AAIB Safety Recommendation Update The UK Air Accidents Investigation Branch (AAIB) has issued an update on responses to their safety recommendations from their investigation into British Airways Airbus A319 G-EUOE. G-EUOE, powered by IAE V2500s, lost both engine fan cowlings and suffered an associated fire on take-off from London Heathrow on 24 May 2013 after cowlings were left unlatched after an ‘aircraft swap error’ during maintenance. We have discussed that accident report and the causal factors in depth: A319 Double Cowling Loss and Fire – AAIB Report The AAIB had raised 6 recommendations: Safety Recommendation 2013-011 It is recommended that Airbus formally notifies operators of A320-family aircraft of the fan cowl door loss event on A319 G-EUOE on 24 May 2013, and reiterates the importance of verifying that the fan cowl doors are latched prior to flight by visually checking the position of the latches. This resulted in in communication by Airbus to all operators. AAIB Assessment – Adequate – Closed Safety Recommendation 2015-001 It is recommended that the European Aviation Safety Agency publishes amended Acceptable Means of Compliance and Guidance Material in Part 145.A.47(b) of European Commission Regulation (EC) No 2042/2003, containing requirements for the implementation of an effective fatigue risk management system within approved maintenance organisations. EASA has responded: The Agency is working on Rulemaking Task RMT.0251 (MDM.055) which is intended to introduce Safety Management (SMS) requirements for Part-145 organisations with one of the most important elements being the identification and mitigation of risks one of which is fatigue. The envisaged timeline for this task is to issue an NPA in 2017, with a final Opinion for 2018. AAIB Assessment – Partially Adequate – Open Aerossurance has previously written: Maintenance Personnel Fatigue Safety Recommendation 2015-002 It is recommended that the European Aviation Safety Agency requires Airbus to modify A320-family aircraft to incorporate a reliable means of warning when the fan cowl doors are unlatched. EASA responded last October: Airbus has developed a warning flag, as a design solution for retrofit, that will be more obvious to maintenance crews and pilots to indicate when the fan cowl doors are not properly closed. This flag solution will be available for retrofit for the majority of single aisle fleet in service. An EASA airworthiness directive is planned before the end of 2015 to mandate the implementation of this design change. AAIB Assessment – Partially Adequate – Open Safety Recommendation 2015-002 It is recommended that the European Aviation Safety Agency amends Certification Specification 25.901(c), Acceptable Means of Compliance (AMC) 25.901(c) and AMC 25.1193, to include fan cowl doors in the System Safety Assessment for the engine installation and requires compliance with these amended requirements during the certification of modifications to existing products and the initial certification of new designs. EASA responded: Based on the lessons learnt from in-service events, the Agency introduced, in 2013, a new Certification Review Item (CRI) providing Special Conditions (SC) for the retention of engine cowls. The SC requires a cowling design that minimizes any inflight opening or loss of cowling. It also provides some requirements for the retention system of each openable or removable cowling: Keep the cowling closed and secured under the operational loads and after improper fastening of any single latching, locking, or other retention device, or the failure of...
read moreC-130 Fireball Due to Modification Error
C-130 Fireball Due to Modification Error A botched modification program unnecessarily changed the original design for a hydraulic system modification when a drawing was misread. A longer hydraulic hose was necessary after that change but an inappropriate design process short-cut meant the shorter hose remained listed as an alternative. The shorter hose was fitted to the modified fleet and resulted in chaffed electrical wiring and a fire that damaged an aircraft beyond economic repair over ten years later. Introduction and the Accident Flight During a touch and go at NAS Key West, on 21 Feb 2012, a fireball erupted in the back of Royal Canadian Air Force (RCAF) Lockheed Martin CC-130 / C-130H(T) Hercules Air to Air Refuelling tanker CC130342, just in front of the 25,000 lbs, 3,600 US gallon cabin mounted AAR tank. According to the recently issued investigation report: Concurrent with the fire alert, the aircraft became airborne and reached 10 feet in altitude above the runway. With sufficient runway remaining, the Flying Pilot landed straight ahead and aggressively stopped the aircraft…all nine crewmembers quickly egressed and moved upwind of the aircraft. Crash Fire and Rescue services responded and expeditiously extinguished the fire. The aircraft was extensively damaged [beyond economic repair] and one crewmember received a minor injury. The aircraft had a hydraulic system modification (CF-378) to install ground test connections to the auxiliary hydraulic system, just below an electrically driven pump. This safety investigation identified routing and clamping deficiencies in the modification that resulted in chafing between the hydraulic pump electrical wiring and a hydraulic flexible hose. Electrical arcing resulted in a pin-hole breach of the hose, release of high pressure hydraulic fluid and ignition of the fire. A re-design followed, along with more education on the hazards associated with chafing. Other observations focused on the dual layer clothing principle for aircrew fire protection and improving communication between airworthiness authorities when imposing and lifting operational restrictions. The Modification and the Fireball Modification CF-378 was originally designed in 1976 for the first five Canadian C-130Hs. CC130342 was one of the third batch of RCAF C-130sHs, ordered in 1990 as tanker aircraft. The RCAF Weapon System Manager (WSM) subsequently requested that CF-378 be embodied on this batch and two further C-130H-30s during contracted base maintenance. However, the contractor noted that they could not embody modification CF-378….as the auxiliary hydraulic system on the CC130 H(T) and H-30 aircraft were different than depicted in the modification instruction… To facilitate the work, the third line contractor produced a Maintenance Production Permit (MPP) in which a “standard repair” was developed to change the CF-378 modification to accommodate the aircraft configuration. The WSM approved the MPP and the first aircraft to embody the MPP version of CF-378 was CC130341 in 2001. The modification was embodied on CC130342 on 1 February 2002. During the investigation the CF-378 modification’s flexible 28.25 inch steel braided hydraulic hose was found to be in contact with the hydraulic pump motor power cable. Lab examination: …revealed there was a 2 mm diameter hole in the stainless steel braiding, at the site where it was found in contact with the hydraulic pump motor power cable… Examination of the hose braid indicated deposits of copper and tin consistent with the material in the auxiliary hydraulic motor power cable. Examination of the hydraulic pump power motor cable revealed broken wire strands…consistent with...
read moreFatigued Flight Test Crew Superjet 100 Crosswind Accident
Fatigued Flight Test Crew Crosswind Accident The Icelandic Transportation Safety Board (ITSB), the RNSA, recently issued their report into a wheels up runway excursion accident that occurred on 21 July 2013 to Sukhoi RRJ-95B ‘Superjet 100’ 97005 during flight tests by Sukhoi at Keflavik airport. The Flight Test Objective and the Accident Flight The purpose of the flight test campaign was to expand the aircraft’s automatic approach capability from CAT II to CAT IIIA. Seven approaches and go-arounds with possible landing gear touchdown, had been conducted to RWY 20, followed by two to RWY 11. The RNSA explain that on the 9th approach: …the flight crew intended to execute a go-around at 2-3 feet radio altitude over RWY 11, under crosswind conditions [>19.5 knots], near the airplane‘s maximum landing weight, with one engine inoperative. Keflavik is a popular location for crosswind testing because of its exposed location and runways at 90ºs give a high probability of useful crosswind conditions. When the aircraft was at radio altitude of 17 ft the Automatic Flight Control System (AFCS) at 05:23:25, in accordance with its programmed logic, commanded both throttles to IDLE. One second later, as per plan, at about 10 ft the test pilot sitting in the jump seat shut down the right engine using the ENG MASTER SWITCH. This disconnected the AFCS autothrottle on that engine, while the left engine continued to reduce thrust to IDLE. A further second later, at about 4 ft, the pilot flying disconnected the AFCS autopilot. This resulted in the left autothottle returning to SPEED mode and advancing the left throttle. The pilot flying pressed the TOGA button on the right TQL [throttle lever] to initiate a go-around and, according to the cockpit voice recorder, called out “go-around”. Almost simultaneously, at 05:23:28.70, the main landing gear touched the RW and as a result of left main LG [landing gear] shock strut compression a/c avionics complex received WOW signal (weight on wheels) [for 0.4s]. However, in accordance with the Certification Specification for All Weather Operation (CS-AWO), after the WOW signal the left autothrottle disengaged (to prevent inadvertent selection of TOGA after landing), as did the AFCS flight director. The pilot flying spotted this and started to perform a go-around in manual mode, but erroneously set the right (i.e. the inoperative) engine throttle lever to TOGA, pitched-up the aircraft and ordered landing gear retraction. Consequently the aircraft started to loose speed, and having reached 27 ft stopped climbing and started to descend. The speed decreased further, below 120 knots and the pilot flying, reduced the pitch to prevent stalling. The “LANDING GEAR NOT DOWN” aural warning then triggered. The pilot flying realized after about 15 s that he had been controlling the inoperative engine, just moments before the aircraft (still wheels up) hit the runway at 05:23:47. The aircraft skidded 1600 m down the runway, overran the runway and came to a stop at 05:24:25. The RNSA comment: Video recording from the cockpit provided the investigators with visual evidence showing the inoperative engine throttle lever being advanced during the go-around procedure, as well as showing the work load and the task division between the individual flight crew members. During the evacuation the forward left door was opened, but as it had not been armed the emergency escape slide did not deploy. The forward right hand door was opened, and while the slide deployed, it was blown under the aircraft by the...
read moreUS Police Helicopter Night CFIT: Is Your Journey Really Necessary?
US Police Helicopter Night CFIT: Is Your Journey Really Necessary? On 27 March 2014, at 0147 local time, ex-military Bell OH-58A, N497E, operated by, the Kern County Sheriff’s Office (KCSO) collided with terrain near Tehachapi, California. The three occupants were uninjured, although the helicopter was substantially damaged. The Accident and Investigation The US National Transportation Safety Board (NTSB) say in their report that the flight commenced at 0121 to convey a police dog that had been shot in the leg three hours earlier the 87 miles to Lancaster for treatment as “the local veterinarian could not perform treatment due to the nature of the dog’s injuries”. The decision to task the helicopter was made at the “management level at the Incident Command Post” according to a statement by the Sheriff’s Office to the local press. The NTSB say the pilot (the chief flight instructor for the Air Support Unit [ASU]) had gone to sleep at 2130 for the three previous nights, and woken at 0530 on all but that day. He was on duty from 0800 to 1600 on both prior days. He was awakened that day by a phone call at 0015 calling him in for the flight and arrived at the ASU HQ in Bakersfield at 0100. He: …confirmed that visual meteorological conditions (VMC) prevailed at both the departure and arrival airports. He was aware that a weather front was moving through the area, and that he would most likely encounter instrument meteorological conditions (IMC) while en route. He planned to use Tehachapi airport, about 45 miles east of Bakersfield, as an alternate landing site should conditions deteriorate. At 0120, they loaded the dog into the rear left footwell, along with the K-9 Division Chief who was seated in the rear right seat. Both the pilot and the [Tactical Flight Officer] TFO were wearing Night Vision Goggles (NVG’s) throughout the flight. The departure was uneventful, but as they approached Tehachapi they encountered light rain, strong winds, and low clouds. The pilot decided to proceed, and wanted to see if Sand Canyon, east of Tehachapi, was passable. However, once they got beyond the lights of the city, he lost visual reference after flying into what he thought was clouds. He reported flying about 500 feet above ground level (agl) at that time, and was concerned that returning might cause them to collide with wind turbines and other obstacles in the area. The route was flanked by wind turbine-covered peaks. The pilot elected to slow the helicopter and initiate a gradual descent. However he wasn’t in cloud. The windshield had misted up due to a water leak. This limited the effectiveness of NVGs. During the descent, the TFO realized that the windshield had fogged up because he could still see out of the side window, and the pilot turned on the de-mister…and the TFO perceived that the helicopter was now performing gradual S-turns over the highway. He did not get the sense that they were descending… A few seconds later he [the TFO] looked out of the right window, and although he could not sense movement, they appeared to be rapidly descending. They transitioned over the eastbound lanes of the highway, and he immediately called for the pilot to pull up, however, a few seconds later the helicopter struck the ground…bounced back into the air, and rotated about 180 degrees. The...
read moreMetro 23 MLG Corrosion Causes Runway Excursion
Metro 23 MLG Corrosion Causes Runway Excursion On 20 February 2014 Fairchild SA227-DC Metro 23 (Metro IV) VH-UUB, was being operated on a charter flight from Avalon to Portland, Victoria by Sharp Airlines. Shortly after touch-down the aircraft veered off the runway at 75-80 knots. The 10 passengers and two crew were all uninjured. The Safety Investigation The Australian Transport Safety Bureau (ATSB) report that: The runway excursion resulted from failure of the lower torque link attachment lug on the left main landing gear’s yoke. This allowed the wheels to rotate through 90° with respect to the direction of aircraft travel and skid, producing a large braking effect on the left side. The Fracture The failure…resulted from pre-existing cracks that had progressively grown until the part had insufficient strength to support normal landing loads. The cracks initiated principally from areas of pitting corrosion in the lug’s bore and were propagated by cyclic stresses imposed during operation. The fractured [7075-T73 aluminium] yoke [manufactured by Klune Industries] contained four disused retaining pin holes (two each top and bottom) as a result of compliance with a service bulletin (SB) for installing a replacement [torque link shaft]TLS (CC7-32-012), released in 2002. The SB required drilling of a new pin hole in the lug to secure the replacement TLS and filling of the redundant holes with sealant. Sealing of the disused pin holes in this occurrence was not adequate as the sealant had either broken down over time or otherwise disbonded and come loose during service, providing additional entrance routes for moisture or other corrosives. Another entrance route was associated with wear on the yoke lug flanks where significant pitting was identified. Wear on the flanks and in the bore of the lug was sufficient to remove the protective anodic coating, which increased the susceptibility of the parts to corrosion. Corrosion pits act as stress concentrators and significantly reduce both the fatigue crack initiation life of the component as well as the crack initiation threshold stresses. Continued Airworthiness The Fairchild MLG yokes were maintained on condition and were not subject to any maximum service life restrictions. The aircraft was maintained using a 6-phase inspection program with an interval of 900 hours; this included a detailed inspection of the main landing gear at a phase 3 inspection (450 hours) and a routine inspection at a phase 6 inspection (900 hours). The most recent detailed (Phase 3) inspection was 436.5 hours prior to the occurrence, and a routine (Phase 6) inspection 37.3 hours prior to the occurrence. The operator advised that they performed a torque link freeplay inspection at the detailed inspection and if excessive freeplay was evident, then the components would be disassembled for further inspection. The ATSB report that a number of other similar lug failures in Australian and Canada. they say: With corrosion pitting being a precursor to the fatigue failure of the component, improvement of corrosion protection in the affected areas would further reduce the likelihood of this type of occurrence. ATSB Conclusions The runway excursion occurred as a result of fracture of the torque-link attachment lug on the aircraft’s left main landing gear yoke, which allowed those wheels to deviate from the normal direction of travel and cause asymmetrical braking forces that could not be countered by the flight crew. The torque link-to-yoke attachment lug fractured...
read moreSolent Hoegh Osaka Car Carrier Accident
Solent Hoegh Osaka Car Carrier Accident The Singapore registered 180m, 51,770 gross tonnage ‘pure car and truck carrier’ (PCTC) MV Hoegh Osaka, managed by Wallem Shipmanagement Pte Ltd, developed a significant starboard list when turning to port while departing Southampton on 3 January 2015. The Marine Accident Investigation Branch (MAIB) say in their recent report: As the list increased in excess of 40º, the ship lost steerage and propulsion, and subsequently drifted aground on Bramble Bank. A cargo shift as the ship listed resulted in a breach of the hull [caused by the tracks of a JCB excavator] and consequent flooding. Drone footage One crewman broke an arm and a leg after falling more than 18m as the vessel healed over. The MAIB explain that: All crew were safely evacuated from the ship and surrounding waters. There was no resulting pollution, and the ship was later successfully salvaged [by Svitzer Salvage under a Lloyd’s Open Form]. Stability modelling and analysis following the accident show that Hoegh Osaka listed heavily to starboard while turning around Bramble Bank as a result of having inadequate stability, which had not been identified prior to departure. The MAIB however have identified “that the practice of not calculating a departure stability condition on completion of cargo operations and before a ship sails extends…to the [pure car carrier] PCC/PCTC sector in general”. Why the Ship Listed In a statement to the media, Steve Clinch, the UK’s Chief Inspector of Marine Accidents stated: The MAIB’s investigation found that Hoegh Osaka’s stability did not meet the minimum international requirements for ships proceeding to sea. The cargo loading plan had not been adjusted for a change to the ship’s usual journey pattern and the number of vehicles due to be loaded according to the pre stowage plan was significantly different from than that of the final tally. The estimated weight of cargo was also less than the actual weight. Crucially, the assumed distribution of ballast on board, bore no resemblance to reality, which resulted in the ship leaving Southampton with a higher centre of gravity than normal. The Loading and Ballasting As is often the case in accidents, a late change in plan (due to New Year holidays) was critical in this accident. Southampton was originally to be the last of three port calls in NW Europe and stowage plans had been prepared on that basis. When the itinerary changed, the loading plans were not (though the ship was not bunkered with fuel, further reducing stability) . The cargo loaded in Southampton was loaded in the same location as it would have been had Southampton been the final loading port, not the first. In fact the MAIB state in their report: Although the chief officer advised the master that Hoegh Osaka’s GM [Metacentric Height] for departure was 1.46m and met the requirements of the loading and stability information manual, this advice was based on preliminary and, as it transpires, inaccurate figures. Given that the chief officer was re-entering the cargo figures into the loading computer as Hoegh Osaka was proceeding along Southampton Water, a thorough assessment of the ship’s stability had not been conducted prior to leaving the berth. Witness and anecdotal evidence suggests that this was a common practice and that final cargo figures were sometimes not received on board until after the ship had sailed....
read moreMarine Pilot Transfer Winching Accident
Marine Pilot Transfer Winching Accident (Brim Aviation AW109SP N361CR) During a night Marine Pilot Transfer (MPT) helicopter winching / hoist operation on 21 April 2014, the marine pilot being transferred, was injured. The marine pilot was being transferred from an outgoing ship to a container vessel, inbound to Astoria, Oregon, the 222 m, 27,437 gross ton MV Northern Vigor, by AgustaWestland AW109SP GrandNew N361CR operated by Brim Aviation under Part 133 (External Load Operations) for the Columbia River Bar Pilots. The fast flowing Columbia River divides Oregon from Washington State. The Columbia River Bar Pilots (CRBP) have been using a helicopter since 1996. Currently 70% of transfers, to ships typically 15nm out in the Pacific, are done using helicopters, the rest by pilot launch. The current AW109SP, radio call sign ‘Seahawk’, is flown with two pilots at night (one in daylight) and a winch operator for the single Goodrich hoist. The Accident Flight The marine pilot was lifted from the outbound vessel at 23:05 local and flown around 6 miles to the MV Northern Vigor. The US National Transportation Safety Board (NTSB) say in their report: Light rain and night meteorological conditions prevailed, and a company visual flight rules flight plan was filed for the flight. Per normal procedures, the helicopter’s crew planned to lower the ship [i.e. marine] pilot to the ship’s deck via a cable hoist while the ship was underway. When the helicopter arrived at the ship, dark night conditions prevailed, rain was falling, and the relative wind was blowing onto the starboard (right) bow of the ship. As explained in the CRBP’s report, the preference is normally to winch on to open hatch covers. However, the deck was almost completely covered by containers. The option of winching to the bridge wings was dismissed due to obstructions. The helicopter crew circled the ship to locate a suitable location to lower the ship pilot and settled upon a location close to the starboard bow. They identified that part of the starboard side of the Number 2 hatch was clear, albeit surrounded by containers, typically stacked two high (16ft). The ship pilot and the helicopter crew agreed that this was the best available location for the transfer. However, this location allowed the helicopter’s pilot to see and use only a very small portion of the ship as a visual reference for maintaining the helicopter’s position while lowering the ship pilot. The aircraft came into a hover at 20-25ft. The relative wind, the container locations, the right hand winch location and the risk of a tail rotor strike all made this choice demanding. There is no mention in the reports of the deck lighting. The Pilot Flying used the forward containers as a reference while the winch operator conned him into position. At 23:18: Just as the ship pilot made contact with the deck, the ship’s bow pitched down, and the helicopter pilot lost visual contact with the ship. Because the helicopter pilot was unable to see the ship, the helicopter began to move aft relative to the ship. The hoist operator was unable to release the hoist cable quickly enough to prevent pulling the ship pilot off the deck and had to cut the cable. The ship pilot fell a few feet to the deck… He recovered from the fall, and successfully piloted the ship thorough the Columbia River mouth to its destination. Upon...
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