So You Think The GOM is Non-Hostile?
So You Think The Gulf of Mexico (GOM) is Non-Hostile? The Gulf of Mexico (GOM), off the coast of Mississippi, Louisiana and Texas in particular, remains a busy area for offshore helicopter operations with over 2 million passengers carried and nearly 300,000 flying hours last year (see our article: Helicopter Ops and Safety – Gulf Of Mexico 2014). It is a sea area generally thought as non-hostile, i.e. where: A safe forced landing can be accomplished [i.e. a controllable aircraft can make a ditching and escape is possible]; and The helicopter occupants can be protected from the elements; and Search and rescue response/capability is provided consistent with the anticipated exposure; Indeed for the vast majority of the time the GOM does meet the definition of non-hostile. But very occasionally not… While most observers would expect operations in the immediate vicinity of seasonal hurricanes to affect survivability, winter can do too, particularly if survivors are not able to board a life raft and Search and Rescue (SAR) is not prompt, as demonstrated by the US National Transportation Safety Board (NTSB) report on the loss a Bell 206L4, N180AL, owned and operated by Rotorcraft Leasing Company (RLC) on 11 December 2008. The Accident The pilot and four passengers on-board died after the helicopter impacted the sea approximately 8 minutes after departing Sabine Pass, Texas en route to a platform in the West Cameron 157 block of the GOM. According to the NTSB: The wreckage was located 2 miles offshore in 13 to 15 feet of water, along the helicopter’s route of flight. Damage was consistent with controlled flight into the water. The fuselage was broken into three pieces and the skids (on which were mounted floats and external liferafts) were broken off, suggesting a relatively high speed impact, not a controlled ditching. They go on to say: A cold front had just passed through the area several hours prior to the accident. The Aviation Weather Center…0500… forecast for coastal waters, including the accident helicopter’s route of flight, predicted scattered to broken clouds at 1,000 feet, broken clouds at 2,500 feet, with clouds tops at 5,000 feet. The surface winds were forecast to be out of the northwest at 20 to 25 knots. Occasional broken clouds at 700 feet with visibility three to five miles in rain and mist were forecast. The National Weather Service also had a full series of Airman’s Meteorological Information (AIRMET) current for the area. AIRMET Zulu for moderate icing conditions from the freezing level to 20,000 feet, AIRMET Tango for potential moderate turbulence below 12,000 feet, and AIRMET Sierra for instrument flight rules conditions with ceilings below 1,000 feet and/or visibility below three statute miles in precipitation and mist. The air temperature was recorded at 34 degrees Fahrenheit [1 degree Centigrade] and the water temperature was recorded at 64 degrees Fahrenheit [17 degrees Centigrade]. The pilot held a commercial certificate and an instrument rating; however, he was not approved for instrument flight under Part 135 and was not current. There was no record to indicate that the pilot had obtained a formal weather briefing from a recorded source. According to RLC, other flights in the area had been grounded or delayed due to the passing weather. The NSTB concluded the probable cause of the Controlled Flight into the Terrain (CFIT) was (rather unhelpfully): The pilot’s failure to maintain clearance from the water....
read moreBack to the Future: Error Management
Back to the Future: Error Management A year ago we published our article James Reason’s 12 Principles of Error Management. It set out set out the 12 systemic human factors centric principles of error management that James Reason, Professor Emeritus, University of Manchester defined in his book Managing Maintenance Error: A Practical Guide (co-written with Alan Hobbs and published in 2003). Recently we spotted a photograph of some text in a Tweet. It is from Reason’s earlier 1997 classic Managing the Risks of Organizational Accidents and was a timely reminder: While mention of TQM looks rather dated now, sadly we do wonder how far we have collectively moved as an industry since then: How many organisations still await occurrence or hazard reports from the front-line rather than conducting active oversight or encouraging safety improvement action? How many organisations spend more time analysing individual behaviour after an occurrence to determine culpability than analysing the factors that affect individual performance before an occurrence? We certainly see regular accidents reports that suggest we can do better: Fatal $16 Million Maintenance Errors Misassembled Anti-Torque Pedals Cause EC135 Accident The Missing Igniters: Fatigue & Management of Change Shortcomings A319 Double Cowling Loss and Fire – AAIB Report USAF RC-135V Rivet Joint Oxygen Fire Inadequately Secured Cargo Caused B747F Crash at Bagram, Afghanistan BA Changes Briefings, Simulator Training and Chart Provider After B747 Accident Gulfstream G-IV Take Off Accident & Human Factors Fatal G-IV Runway Excursion Accident in France – Lessons ‘Procedural Drift’: Lynx CFIT in Afghanistan Fatal Night-time UK AW139 Accident Highlights Business Aviation Safety Lessons Fatal Helicopter / Crane Collision – London Jan 2013 Misloading Caused Fatal 2013 DHC-3 Accident Metro III Low-energy Rejected Landing and CFIT Operator & FAA Shortcomings in Alaskan B1900 Accident Culture + Non Compliance + Mechanical Failures = DC3 Accident Mid Air Collision Typhoon & Learjet 35 Metro-North: Organisational Accidents DuPont Reputational Explosion Shell Moerdijk Explosion: “Failure to Learn” Further, as a society, we still see human error being defined as a cause: Saarbrücken flight: Human error determined as cause of accident Two workers quizzed over ‘human error ‘ in Alton Towers horror U.S. general: Human error led to Doctors Without Borders strike Of course we can take heart that many practitioners are making amazing strides in applying Reason’s 12 Principles, enhancing their organisation’s safety culture and looking at other ways to enhance human performance as we discussed here: Maintenance Human Factors: The Next Generation Aircraft Maintenance: Going for Gold? How To Develop Your Organisation’s Safety Culture The Power of Safety Leadership A follow up to the original book, entitled Organizational Accidents Revisited, is due to be published by Ashgate in January 2016 on the topic of what it abbreviates to ‘orgax’. It is reported that: Where the 1997 book focused largely upon the systemic factors underlying organizational accidents, this complementary follow-up goes beyond this to examine what can be done to improve the ‘error wisdom’ and risk awareness of those on the spot; they are often the last line of defence and so have the power to halt the accident trajectory before it can cause damage. The book concludes by advocating that system safety should require the integration of systemic factors (collective mindfulness) with individual mental skills (personal mindfulness). Contents: Introduction. Part 1 Refreshers: The ‘anatomy’ of an organizational accident; Error-enforcing conditions. Part 2 Additions Since 1997: Safety management systems; Resident pathogens; Ten case studies of organizational accidents;...
read moreBell 407 Power Loss GOM Ditching: NTSB
Bell 407 Power Loss GOM Ditching: NTSB (RLC B407 N373RL) The US National Transportation Safety Board (NTSB) has reported on the ditching of a Bell 407 offshore helicopter in the Gulf Of Mexico (GOM) on 11 November 2014. The aircraft, N373RL operated by Rotorcraft Leasing Company (RLC), ditched following a partial power loss shortly after take off from an installation in the Viosca Knoll 989 (VK 989) offshore block. The pilot and three passengers were uninjured. The helicopter reportedly sustained no damage during the ditching itself. It is not clear if it was recovered undamaged but it has re-entered service since. The Accident The NTSB say: …the pilot reported that approximately 30 seconds after takeoff at about 400 feet above sea level, a series of compressor stalls and engine surges began. The pilot adjusted the collective pitch and began a slow decent. After lowering the engine power, the surges and stalls ceased and the pilot’s plan, at this point, was to try to attempt to fly the helicopter back to VK 989. At approximately 250 feet – 300 feet, the pilot began increasing the collective to regain some power, but the engine surges and stalls reoccurred. The pilot reported hearing the low RPM horn and when he observed the rotor RPM gauge (Nr), the Nr was about 90 percent and the power turbine gauge (N2) indicated it was running high; at or near redline. At this point, the pilot made the decision to land the helicopter in the water in the Gulf of Mexico. He fully lowered the collective to salvage the RPM. The engine was still surging at flat pitch so he rolled the throttle to idle and entered an autorotation. The pilot prepared the passengers for the landing and radioed a mayday notification to the operator’s flight following station. He then activated the float inflation handle, pressed the aircraft quick position button, flared the helicopter, and landed on the water. The pilot estimated from the time of the initial compressor stall to water contact was approximately 15 to 30 seconds. The helicopter did not capsize (although sea conditions are not noted) and the: …pilot subsequently deployed the life rafts and got a verbal response from all the passengers that they were “ok.” He directed the passengers to collect their belongings and a first aid kit in case it was needed. They got into the life raft on the left hand side of the helicopter. The pilot boarded the right hand life raft. It is not clear what ‘belongings’ were taken into the life raft or if that odd instruction is part of the operator’s procedures. According to the operator’s report: The Pilot called RLC Operations on the sat phone to let them know his position and that they were all OK. The Pilot observed a fishing boat was making its way to his location from the [Stone Energy] Pompano [platform] about 1.5 miles away. As the boat arrived the Pilot asked the left front passenger to tell the boat to keep their distance for the moment so they don’t make contact with any of the aircraft’s floatation equipment… The Emergency Locator Transmitter (ELT) did not activate. The Investigation Under the supervision of the NTSB investigator-in-charge, the incident [250-C47B] engine was examined at Rolls-Royce… The examination revealed that the engine was shipped without its ECU...
read moreANSV Highlight Procedures & HF After ATR72 Landing Accident
ANSV Highlight Procedures & HF After ATR72 Landing Accident Italy’s Agenzia Nazionale per la Sicurezza del Volo (ANSV) has released their investigation report (in Italian) on a 2013 ATR-72 night landing accident. The Accident On 2 February 2013, ATR-72-212A (marketed as the 72-500) YR-ATS, sustained substantial damage landing at Roma-Fiumicino Airport, Italy. Of the 50 occupants, seven sustained minor injuries. The aircraft was operated by Romanian operator Carpatair on behalf of Alitalia under an ACMI (aircraft, crew maintenance & insurance) wet lease contract. Air Traffic had reported the winds at 22 knots gusting to 37 knots from 250 degrees and issued clearance to land on runway 16L. The Captain (58, ATPL, 18,522 hours total, 3,351 hours on type and the airline’s Chief Pilot), the Pilot Flying, advised he wanted to maintain an approach speed of 130 KIAS. The First Officer (25, CPL, 624 hours total, 15 hours on type plus 36 hours simulator time), the Pilot Monitoring, agreed. The landing gear was extended and 30 degrees flaps selected. The approach was stable as the aircraft descended through 1000 feet AGL, with the speed being around 130 KIAS fluctuating +/- 10 knots. After the autopilot was disconnected an airspeed of about 125 KIAS was maintained. The aircraft touched down 2.6 degrees nose down, nose gear first and bounced. While the crew recognised this, neither pilot called for a go-around. The Captain provided nose down inputs causing the aircraft to sharply touch down a second time on the nose gear, which collapsed, although the aircraft now bounced a third time. The pilots now provided conflicting control inputs. The Captain making further nose down inputs and the First Officer nose up inputs (triggering the interlock to separate left and right flying controls). Consequently the aircraft rolled slightly left and touched down heavily on the left main gear, damaging it, bouncing again with a right bank angle of about 10 degrees, touching down a fifth time causing the collapse of the right main gear. The aircraft slid for 400m, yawing around 170 degrees before coming to a stop. Even though the wreckage was 400m in front of an airport fire station it took the airport fire service ten minutes of searching in the dark to find the accident site because they were apparently not familiar with the taxiway designation passed by Air Traffic. The Safety Investigation The ANSV concluded that no technical factors contributed to the accident. The ANSV believe wind data transmitted to the crew exceeded the 35 knots demonstrated aircraft crosswind capability of the ATR-72 (though the crosswind gust level component was in fact marginally less) and state the Captain remained confident that he could manage a safe landing nonetheless. This confidence was reinforced as prior aircraft had managed to land safely. The ANSV conclude that in the light of the weather information available, the landing should have been aborted. The Descent Checklist was read and properly executed by the First Officer according to the ANSV, however, upon the item Landing Briefing the Captain incorrectly stated that this had already been done. The ANSV highlight that this briefing would have been crucial in identifying limits of the approach, reviewed performance data such as approach speed (Vapp), as well as establishing the criteria and procedure for a missed approach. The ANSV note that the omission of the landing brief led to the acceptance of a Vapp of 130 KIAS and prevented a discussion between the pilots whether landing in Rome or a diversion to the alternate was advisable. The...
read morePDG Helicopters Commence UK & Eire Lighthouse Support Contract
PDG Helicopters Commence UK & Eire Lighthouse Support Contract On 1 December 2015 PDG Helicopters commenced a £13mn helicopter support contract for the three UK and Eire General Lighthouse Authorities (GLAs): The Commissioners of Northern Lighthouses, known as the Northern Lighthouse Board (Scotland and the Isle of Man) whose history goes back to 1768 The Corporation of Trinity House, known as Trinity House (England, Wales, Channel Islands and Gibraltar), the oldest of the three, granted a royal charter in 1514 The Commissioners of Irish Lights, known as Irish Lights (the Republic of Ireland and Northern Ireland) dating to only(!) 1786 Up to 30 November 2015 the GLAs had three separate contracts: Trinity House: MD902 – Specialist Aviation Services NLB: EC135 – Bond Air Services (part of Babcock International) Irish Lights: EC135 – Irish Helicopters (which is owned by PDG Helicopters) PDG took delivery of a new Airbus Helicopters EC135T2+ G-GLAA, configured for lighthouse support, at Helitech in London on 6 October 2015 for the 7 year contract (with three optional one year extensions). The contract supports maritime navigation aids, mostly in remote locations, includes considerable HESLO / underslung load work (the requirement was for an aircraft that could move individual loads >500kg over 50nm to support construction projects), operation with GLA’s fleet of ships (four are ‘helicopter capable’), as well as passenger movements. The contract is expected to involve around 1000 flying hours per annum. This contract is a good example of three customers, with common specialist requirements, working together to place a cost effective long term contract. Some reports suggest this arrangement could save nearly £8mn. Aerossurance discussed the award of the contract in more detail back in October 2014. The UK Civil Aviation Authority (UK CAA) issued Safety Directive SD-2015/004, on 30 November 2015 which expands their earlier Offshore Operational Directive to include lighthouse / marine light support (as well as addressing medically incapacitated passengers). UPDATE 9 December 2015: This SD was replaced by SD-2015/005 on 9 December 2015 because the CAA had neglected to amend the definition of ‘offshore locations’ to actually include those related to marine lights. UPDATE 20 January 2016: A short video of PDG longline work. UPDATE 12 May 2020: Coronavirus: Keeping lighthouses working during the lockdown If you need specialist advice on efficient and safe contracting for specialist aviation tasks (such as HESLO or HHO) and assurance of your aviation contractors, contact aviation consultancy Aerossurance at enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest...
read moreS-92A Emergency Landing: MGB Oil Checklist Recommendation
S-92A Emergency Landing: MGB Oil Checklist Recommendation Earlier this month the Norwegian Accident Investigation Board (AIBN) issued their report into an emergency landing of Sikorsky S-92A LN-ONW, operated by Bristow Norway on 4 October 2013. The crew almost ditched due to false warnings created by a single tripped circuit breaker. The Incident The S-92A was returning from the BP Valhall offshore installation in the North Sea to Stavanger Sola airport, after abandoning landing on the Valhall due to poor weather. En route to Sola, the crew received MGB PUMP 1 FAIL and MGB PUMP 2 FAIL yellow cautions. According to the AIBN: …the oil pressure had decreased from a normal value of approx. 58 psi to 49, while oil temperature was rising. This was considered a confirmation that something had happened to the main gear box. However, the emergency checklists did not provide an answer to what had happened, or what action to take. In retrospect, the commander has described this as highly frustrating. The AIBN report that: The crew considered that it was too risky to continue toward land, and chose to make an emergency landing at the decommissioned [production platform] Yme. …the crew became aware of three additional yellow cautions for MGB OIL HOT, MGB OIL PRES and MGB MAN COOL. These cautions did not provide any further information to understand the situation. The possibility that there could be a critical failure in the main gear box, also made the crew consider a possible emergency landing at sea before the helicopter reached Yme. Wind and wave height were estimated at 40 kt and 7 to 8 m respectively [wave height being beyond the helicopter’s ditching certification]. As long as no red warning lights showed up, and oil pressure indicated above the 47 psi minimum requirement, they decided to continue towards Yme. Accordingly, they interpreted the situation as “Land as soon as possible” and not “Land immediately”. The crew seriously considered landing on the hatch covers of a passing ship, but due to the sea state decided to continue to the Yme. The crew noted two obstructions on the closed helideck, and were surprised to find these were two 3.5m tall marine transponders. However the crew were able to make a safe landing in the confined space. When the helicopter landed, the first officer read that the oil temperature on the main gear box was 152 °C. There was no damages during the emergency landing. The crew and passengers were later picked up by a rescue helicopter and flown ashore. The Safety Investigation The next day, technicians were flown to Yme in order do trouble shooting. Early it became clear that the indications received by the crew could be related to the tripping of the M XMSN OIL WARN circuit breaker. This was confirmed. After a temperature switch (Main Transmission High Temperature Switch, P/N 92351-15808-101) was replaced, and the helicopter had been thoroughly checked by running the engine while on the ground, the helicopter was flown to Sola on Sunday 6 October. The AIBN Comment: The investigation showed that several of the cautions the crew received were false, and were caused by a minor fault in the indication system. The crew became seriously concerned about the indications. Despite uncertainty that arose, the crew handled the situation in a good manner and made operational...
read moreMisassembled Anti-Torque Pedals Cause EC135P1 Accident
Misassembled Anti-Torque Pedals Cause EC135P1 Accident The US National Transportation Safety Board (NTSB) has recently determined that misassembled anti-torque pedals caused an accident to Airbus Helicopters (formerly Eurocopter) EC135P1 N911KB, during a post-maintenance check flight by Metro Aviation at Shreveport, Louisiana on 9 November 2013. The Accident The pilot and two mechanics sustained minor injuries and the helicopter was substantially damaged after the Loss of Control – Inflight (LOC-I) while transiting to a nearby field for a hover test. In their report the NTSB state: The pilot attempted to regain control of the helicopter using the antitorque pedals, but they were ineffective. The pilot reduced engine power and performed an autorotation to the field. The helicopter landed hard and rolled on its right side. The Investigation On examination of the wreckage the NTSB: …found that the antitorque pedals had separated from the antitorque levers. The attachment hardware was not located in the wreckage or the surrounding area. Neither the antitorque pedals nor the lever attachment holes displayed elongation, which is consistent with the hardware bolts not being in place at the time of impact. The NTSB report (emphasis added) that: A review of the helicopter’s log book found an entry dated October 31, 2013, that a mechanic performed the action “disassemble, inspect, and reassemble tail rotor pedals”. According to a statement provided by the company’s director of maintenance, after the accident a search of the area maintenance area was conducted. Near the area where the helicopter was previously repaired, a small parts bag was found tied to the tail rotor control cable that had been replaced. Inside of the bag were bolts similar to the bolts used to secure the anti-torque pedals. Circumstances The aircraft had been undergoing an 800 hour check and a scheduled engine change. Closer examination of the NTSB public docket reveals, in a statement by the facility’s then Director of Maintenance (DoM), that they were under pressure from the operator of the aircraft: The scope of work had originally been slated for a four to six week work schedule, but demand by the using customer dictated that the scope of work be shortened to the minimum time needed to complete only the inspections and any repair as needed to ensure airworthiness of the aircraft. They (the using customer) had requested that this work be completed in 5 days or sooner if possible. I explained this was not possible due to personnel availability, and depth of inspection requirement. Also, personnel shortages: …created a situation where repair station personnel were bouncing back and forth between aircraft undergoing other maintenance activities [and] helping those personnel who were working on this aircraft. This was not ideal and made job continuity difficult. The DoM goes on: I did observe one of the…technicians with the pilot pedal shaft assemblies in his hands shortly after removal performing the required inspection. I quizzed him to ensure he understood the inspection requirement on the pilot pedal shaft and support. He gave me enough information to make me believe he did In fact understand the inspection requirements. The NTSB do not unfortunately appear to have interviewed the technician, reducing the learning opportunity available. NTSB Conclusion The NTSB determines the probable cause to be: The mechanic’s improper installation of the antitorque pedals, which resulted in an in-flight loss of helicopter control. Observations This is a further accident that highlights the need...
read moreNorwegian Survival Suits: Suited for Safety
Norwegian Survival Suits: Suited for Safety The Norwegian Petroleum Safety Agency (PSA), has published a piece on the history of survival suits in Norway in their latest Dialogue magazine. Amusingly their first illustration highlights a hazard unique to early survival suits that we discussed after the 2014 Oil & Gas UK annual aviation seminar, namely cigarette burns, as smoking was still allowed! The article primarily concentrates on developments by Hansen Protection, including the development of the Sea-Air Barents suit, which can be fitted with a compressed air Sea-Air EBS (Emergency Breathing System): Sea-Air Barents Survival Suit (Credit: Hansen Protection) The material of the suit includes tiny capsules filled with microscopic particles of a paraffin wax specially developed by SINTEF. When the wearer’s skin temperature rises above 28ºC, the wax absorbs the body heat and changes from solid to liquid. The latent heat help keeps the wearer is cool in the helicopter cabin on warm days. When immersed in water, he wax releases the stored heat to the wearer as it returns to the solid state. Hansen Protection claim this ensures the wearer’s skin temperature never falls below 15ºC during six hours in a water temperature of about 2ºC. The suit will be used in operations to support the ENI Norge Goliat FPSO in the Barents Sea from Hammerfest. Another article in that issue discusses a collaboration to overcome the challenges of operating in the Barents Sea. Aerossurance has provided aviation support to two of the 16 companies involved in that effort. Background Survival suits are an area currently being examined as part of the European Aviation Safety Agency (EASA) Rule Making Team RMT.0120 that is working on enhancements to helicopter ditching and survivability. A Notice of Proposed Amendment (NPA) is due around the end of 2015. Aerossurance has previously discussed new helicopter survival suits being introduced in Canada, the standardisation of clothing policy in the UK and the introduction of Category A Compressed Air – Emergency Breather System (CA-EBS) the UK. The later two follow the publication of UK Civil Aviation Authority (CAA) ‘Safety Review of Offshore Public Transport Helicopter Operations in Support of the Exploitation of Oil and Gas’ (CAP1145). The article discusses the loss of the floatel Alexander Kielland in 1980 and three helicopter accidents: 9 July 1973 Sikorsky S-61N LN-OQA: Ditched and capsized after loss of tail rotor (4 fatalities, all post impact) – note the PSA incorrectly state this happened in June 1973 23 November 1977 Sikorsky S-61N LN-OSZ: Impacted the water after a main rotor damper failure (12 fatalities including one person who did reportedly escape the aircraft alive) 26 June 1978 Sikorsky S-61N LN-OQS: Impacted the water after a main rotor spindle failure (18 fatalities) All three aircraft were operated by Helikopter Service. The choice of helicopter accidents is interesting. In the first case survival suits would have been a definite advantage. The second case appears to have been a survivable water impact and so a survival suit would have been beneficial to the person who exited the aircraft and may have helped others. In the third accident (with over half of the fatalities), the loss of a main rotor blade in flight would have been non-survivable and so survival suits would have been irrelevant. While operating without survival suits over a hostile sea is inconceivable today, the above accidents also illustrate the inappropriateness of trying to justifying safety improvements on past accidents...
read moreHeliOffshore Launch HUMS Best Practice Guide
HeliOffshore Launch HUMS Best Practice Guide The offshore helicopter safety organisation, HeliOffshore, has today launched a Health & Usage Monitoring System (HUMS) Best Practice Guide to standardise and improve HUMS use worldwide. The main element of helicopter HUMS is Vibration Health Monitoring (VHM), designed to detect developing mechanical failures in safety critical transmission and rotor systems components. HUMS first entered service in 1991 and made a major contribution to improving offshore helicopter safety. While technology has advanced, HUMS remains a system that demands a high level of skill and careful management to achieve the maximum safety benefit. The new document sets out the best practice for managing the use of HUMS. The 41 page HUMS Best Practice Guide and a shorter Implementation Guide, are the result of more than 12 months of hard work and over twenty meetings between the HUMS specialists from CHC, Babcock, ERA, Bristow, PHI, Weststar, Cougar and Bell. The team was lead by Russell Gould (Director, Global Fleet Support, Bristow Group) and Malcolm Garrington (Manager HUMS Support, CHC). Aerossurance is delighted to have been invited to provide an input during the development process and comment on the final document. HeliOffshore CEO, Gretchen Haskins commented: The launch of HeliOffshore’s Health and Usage Monitoring System Best Practice is the result of a highly engaged industry putting momentum behind those actions that will make the greatest difference to safety. We know that those at the frontline of our operations want to use these tools to their total achievable effectiveness and this guidance is applicable to all types of offshore helicopter operator. To achieve real safety improvement, we now need all operators to read and implement this guidance, dedicating resource to assess your current practice and, thereafter, to deliver improvements so that you are using HUMS according to global best practice. The implementation guidance covers four areas: Safety Leadership Management Reporting Effective Training Employee Engagement As well as containing practical guidance, the authoring team has agreed more demanding requirements than even the primary regulatory guidance document (UK Civil Aviation Authority [CAA] CAP 753). Aerossurance thinks this is an excellent example of how HeliOffshore members are openly working together on global safety improvement and not settling on the lowest common denominator. The document, written by HUMS subject matter experts, also sets out the detailed, practical expectations that intelligent oil and gas customers can use as the basis of their contractual requirements and assurance activity. To further enhance this collaborative working and sharing of experiences, the organisation has also launched the “HeliOffshore Space”, an online collaboration tool for its members. Haskins says: Through HeliOffshore Space, we’re empowering our industry experts to collaborate to the benefit of everyone at the frontline and everyone who travels offshore. HeliOffshore Space uses Jive software and is ideal for collaboration and knowledge sharing across multiple time zones. It will also be a key means of helping HeliOffshore ensure products like the HUMS Best Practice Guide don’t stagnate but are subject to continuous improvement. The HUMS part of HeliOffshore Space will also be the natural online successor to the UK CAA’s Helicopter Health Monitoring Advisory Group HHMAG), that ran for 20 years from the mid-1980s. As part of the launch a video on the HUMS Best Practice Guidance has been issued. UPDATE 16 July 2016: The team who produced the HUMS Best Practice Guide have been nominated for the Sharing and Learning Award at the forthcoming Offshore Safety...
read moreWhen Down Is Up: 747 Actuator Installation Incident
When Down Is Up: 747 Actuator Installation Incident The UK Air Accidents Investigation Branch (AAIB) has published their report into a serious incident involving Boeing 747-443 G-VROM on 29 December 2014. History of the Flight The AAIB report that: The aircraft departed from London Gatwick Airport for a scheduled flight to Las Vegas. Following retraction of the landing gear after takeoff, low quantity and pressure warnings occurred on hydraulic system 4, due to a hydraulic fluid leak. The required checklists were completed and the aircraft returned to land at London Gatwick Airport. As the landing gear extended during the approach, the right wing landing gear struck the gear door, preventing the gear leg from fully deploying. The crew carried out a go-around and, following a period of troubleshooting and associated preparation, a non-normal landing was successfully completed. The Safety Investigation The aircraft was towed from the runway to the operator’s hangar for further investigation. The AAIB report: The damaged wing landing gear door was removed and the right wing landing gear leg fully extended. The right wing landing gear actuator was found installed 180° out of alignment. The hydraulic port boss fitting on the head end of the actuator was distorted and damaged. The 85 kg actuator had been changed the day before following an earlier leakage from the piston rod gland seal. AAIB say: The actuator removal and installation was scheduled to be carried out in the operator’s hangar at London Gatwick Airport, during the day shift on Sunday 28 December. The certifying engineer who led the day shift team stated that he spent considerable time trying to locate the fishpole hoist specified in the AMM [for handling the actuator], but in the end withdrew a hoist designed for installation/removal of the aircraft Auxiliary Power Unit (APU) from the tool store. Due to difficulty in sourcing the correct tooling for this rare task the engineer raised a Ground Occurrence Report (GOR) to highlight this to the operator’s safety department. However, the team stated that the actuator was eventually removed from the aircraft without using either the sling or hoist. They identified that the [Boeing Aircraft Maintenance Manual] AMM did not contain instructions on how to use the sling or how to use the hoist and sling combination to manoeuvre the actuator. Once the unserviceable actuator had been removed from the aircraft, the associated fittings were transferred to the replacement actuator on the work bench. Delays caused by the late arrival of the aircraft to the hangar and a requirement for additional parts to be sourced for the replacement actuator, meant that it could not be installed by the day shift team, so the task was handed to the night shift team who came on duty that evening. An additional engineer, with some experience of installing a landing gear actuator, was reassigned to assist due to the additional workload this task placed on the team. The night shift team reported that the task handover provided by the day shift team was “excellent”. The installation procedure commenced at approximately 2145 hrs and began with the team positioning a set of steps and a lifter platform, carrying the replacement actuator, underneath the aircraft. In order to install the actuator it had to be passed through a section of structure in the wing. The team...
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