Procedural Drift at Saab 340 Operator Leads to Taxiway Excursion
Procedural Drift at Saab 340 Operator Leads to Taxiway Excursion Saab 340A LV-BMD, operated by SOL Líneas Aéreas was damaged beyond economic repair in a taxiway excursion accident at Mendoza-El Plumerillo Airport, Argentina on 2 January 2013. There were no injuries among the 31 passengers and crew. Argentina’s air accident investigation agency, the Junta de Investigación de Accidentes de Aviación Civil (JIAAC), issued their final report (in Spanish only) on 23 December 2015. The crew initially attempted to start the right-hand engine. This failed, but they were able to start the left-hand engine and then successfully start the right-hand engine after that. Upon taxying, the Captain encountered difficulties in maintaining directional control of the aircraft and in particular when trying to turn right found the aircraft was in fact turning left. The checklist was not consulted. Asymmetric braking and asymmetric engine power were both attempted but proved ineffectual. The aircraft left the paved surface of the taxiway and came to a halt 58 meters from the edge of the taxiway with both propellers contacting obstacles. The Saab 340 uses hydraulic power for landing gear retraction, braking, nose wheel steering and flaps. The investigation identified that the electric pump that powered the hydraulic system was not operating. Consequently, the HYD warning on the central panel warning (CWP) was illuminated (although it does not appear to have been noticed) The pump is controlled using a panel with three settings: OVRD / AUTO / OFF The switch would normally be in the AUTO position (and the loss of directional control checklist, if followed, would have first checked this switch was in AUTO). However, during post-accident interviews it emerged that an undocumented, but orally communicated and unnecessary practice had developed within the operator of setting the switch to OFF during engine starts. This was allegedly done with the intention of protecting the electronic system flight instrument system (EFIS) from electrical spikes. While the JIAAC don’t comment, its possible that the initial right-hand engine failure to start may have distracted the crew from reselecting AUTO. Procedural Drift / Practical Drift The accident investigators comment of the phenomena of procedural drift / practical drift. This is something we discussed in our article: ‘Procedural Drift’: Lynx CFIT in Afghanistan One major study of an accident that featured drift was by Scott Snook, then of the US Army. His book, Friendly Fire, examined the accident shoot down of two US Army Black Hawk helicopters on a peacekeeping mission in Iraq in 1994 by the US Air Force, and what he called ‘practical drift’. Such drift occurs when group norms and practices start to deviate from formal procedures. In some cases this may be because procedures no longer match operational circumstances, however practicality can be a factor too. These do not appear to have been factors here. Instead the practice seems simply to have been a misguided ‘improvement’. In The Field Guide to Understanding Human Error Prof Sidney Dekker lists several potential reasons for procedural drift: Rules or procedures are over-designed and do not match up with the way work is really done. There are conflicting priorities which make it confusing about which procedure is most important. Past success (in deviating from the norm) is taken as a guarantee for safety. It becomes self-reinforcing. Departures from the routine become routine. Violations become compliant behaviour with local norms. Safety Management System The JIACC note that the operator’s Safety Management System (SMS) did not detect this drift. The JIACC question the effectiveness of the SMS but provide...
read moreOur Top 20 Articles of 2015
Aerossurance: Our Top 20 Articles of 2015 As we start the new year we look back on the 20 articles that proved most popular with our readers in 2015. In reverse order: Number 20: Building St Helena Airport – An Industrial Scale ‘Grand Design’ This started with the building of the first airport on the volcanic British Overseas Territory of St Helena and has been updated through the year as the first calibration flights occurred. The new airport is expected to be licensed early in 2016. We will keep following the story into 2016! Number 19: Crashworthiness and a Fiery Frisco US HEMS Accident We are proud that this article, originally focused on an accident to a medical helicopter in Colorado and commercially available Crash Resistant Fuel System (CRFS) upgrades, came: DAYS BEFORE the NTSB recommended (A15-012) a change in regulations MONTHS BEFORE an association of US medical helicopter operators agreed to retrofit CRFS Again we have repeatedly updated this article with the latest developments. Below are a sequence of screen shots from security CCTV video (first shown by 9News): Number 18: DuPont Reputational Explosion Two process safety articles feature in the top 20. Chemical company DuPont has been feted for its safety performance for many years, and even formed its own safety consultancy to market its ‘secrets’. But David Michaels, who heads the US Occupational Safety and Health Administration (OSHA), said in one interview in May 2015: Based on what we saw in our inspection, if I were an employer, I would think twice before hiring DuPont to give me advice on safety. Between 1995 and 2007 DuPont suffered one fatality but from 2007 to date they had 8. We looked in particular at an accident in November 2014. Four workers were asphyxiated at a DuPont facility in La Porte, Texas when 20 tonnes of a flammable and highly toxic gas were released into a building. The US Chemical Safety Board, in an interim statement, identified serious process safety shortcomings at the plant. Number 17: USAF RC-135V Rivet Joint Oxygen Fire A US Air Force (USAF) accident investigation paradoxically determined that a $62.4mn fire was due to a maintenance error but that no human factors were involved. We look further at this accident, one of three top 20 articles that featured B-Nuts. Number 16: NTSB Report on 2013 S-76 Tail Rotor Blade Loss The US National Transportation Safety Board (NTSB) reported on a fatal Sikorsky S-76A++ accident. During a post-maintenance check flight (one of three in the top 20) 2 tail rotor blades separated and the TGB began to disintegrate. All 3 POB died. Number 15: Southwest Unstabilised Approach Accident An unstabilised approach and a late change of control were critical in an accident that resulted in a nose gear collapse of a Southwest Airlines (SWA) Boeing 737-700 at La Guardia say NTSB. Number 14: S-92A Emergency Landing: MGB Oil Checklist Recommendation The Norwegian Accident Investigation Board (AIBN) raises concerns over the S-92A emergency checklist after a Main Gear Box related incident that resulted in a helicopter making an emergency landing on the obstructed helideck of a disused offshore platform. We also look at sources of guidance for checklist design. Number 13: AW101 VVIP For the Very Very Important Person who wants a slight feeling of agoraphobia aboard their personal helicopter (or a shower!) we discussed the AW101. In the VVIP role the large AW101 cabin has the flexibility to be fitted out in a wide range of configurations. We also look at how 3-D printing can help visualise cabin layouts. The first flight took place...
read moreDangers of Aircraft Tyre Inflation
Dangers of Aircraft Tyre (US: Tire) Inflation The Royal Canadian Air Force are investigating two recent tyre inflation burst accidents. Both involve visiting aircraft using borrowed equipment: 25 August 2015 CT-114 Tutor CT114058 A Snowbird aircraft was diverted from the rest of the deployed team due to an in-flight emergency. The aircraft was repaired, including a successful maintenance flight test, and was refuelled for a later departure to re-join the Snowbird team. The aircraft tire was due for its 7-day inspection/refill and nitrogen tanks were borrowed from a local facility to service the aircraft. While topping up the right hand main tire with nitrogen, the tire was over pressurized and exploded. The force of the explosion seriously damaged the right hand main landing gear leg, the wing rear spar and the split rim was propelled into and crushed the right hand diesel tank. The aircraft sustained “Category B” damage, primarily due to the damage in the wing spar. There were no injuries resulting from this occurrence. The investigation determined that the technician misinterpreted the gauges on this unfamiliar equipment, and attempted to fill the tire to 150 Bars instead of 150 pounds per square inches (PSI). The wheel/tire assembly failed around 120 Bars (over 1700 PSI). The investigation is focussing on the human factors aspects surrounding this occurrence. UPDATE 25 November 2016: The RCAF say that during the maintenance “the pilot was showing it to students from the local Flight College”: The investigation concluded that all reasons why technicians elect to deviate from the Approved Maintenance Program by not using the inflator assembly kit, either because of lack of availability or familiarity with the kit, are avoidable. Preventive measures are recommended to alleviate those circumstances. Further it is recommended: …the inflating procedure manual be clarified to alleviate any potential confusion. And: The investigation also put forth safety recommendations with respect to showcasing aircraft that are being maintained. 13 October 2015 CH-124 Sea King CH12419 While at RAF Odiham, the main landing gear tires were found to be low. A dual-pressure inflation kit was used, the low side reported to be set for 60 psi. The high pressure side was reported to be around 500 psi. Normal tire pressure is 105 psi. During inflation, the left hand inboard tire ruptured. Rim fragments caused damage to the left hand and right hand landing gear as well as the fuselage. The investigation is focussing on human factors procedures for the use of unfamiliar equipment. Note the N2 GSE bottle trolley next to the aircraft. UPDATE 25 November 2016: This investigation is ongoing. UPDATE 2 November 2017: This incident and 4 others were discussed by the UK Military Aviation Authority (MAA) at an RAeS conference. A common thread was the use of GSE available on the line rather than tyre inflation kits from stores (due to stores being shut, kits unserviceable or a separate regulator needed with the kit not being available or issued). Other Cases In 2008 the UK Air Accidents Investigation Branch (AAIB) investigated a horrific accident that cost a visiting engineer at Manchester airport two limbs. The AAIB report: Whilst a technician was rectifying an under-inflated tyre, a pressure of approximately six times the normal tyre pressure was developed. The tie bolts on the wheel failed, the assembly exploded and the technician was seriously injured. It is not...
read moreUK BOSIET/FOET Cat-A CA-EBS HUET Update
UK BOSIET/FOET Cat-A CA-EBS HUET Update Category A Compressed Air Emergency Breathing Systems (CA-EBS) were introduced for helicopter passengers flying offshore over the UK Continental Shelf in September 2014. This followed the UK Civil Aviation Authority (CAA) North Sea Review, which resulted in the CAP1145 report. Oil and Gas UK, Step Change in Safety, OPITO, the International Association of Drilling Contractors (IADC) and the Trade Unions have recently agreed a joint statement on the current status of the Helicopter Underwater Escape Training (HUET): After extensive engagement with industry, regulators, training providers and workforce representatives, agreement has been reached on the new Basic Offshore Safety Induction and Emergency Training (BOSIET) and Further Offshore Emergency Training (FOET) standard to be applied across the UK sector. This new standard, which will be introduced early in 2016, will meet the manufacturer minimum training requirements specified by the CAA. The standard will involve ‘dry’ Cat A EBS training with in-water HUET breath hold exercises using the Survitec Mk50 [Sentinel] life jacket. This will remove the Lapp jacket and re-breather from the existing BOSIET/FOET standard for personnel travelling offshore in the UKCS. In the longer term, all industry stakeholders wish to work towards providing in-water training exercises using the Survitec Mk50 life jacket and Compressed Air Cat A EBS equipment. This will finally eliminate the anomaly of negative training using the former life jacket (the LAP (aka LAPP) jacket, a hybrid ‘Cat B’ EBS), 17+ months since the Mk50 was introduced (the first with an EBS to be approved by UK CAA in accordance with the Category A specification in CAP1034). UPDATE 25 January 2016: OPITO has issued an update that the ‘interim’ standard will be introduced across the UK on 15 February 2016. They have provided two sets of FAQs: Oil and gas workforce – BOSIET FAQs Training Providers – BOSIET FAQs The current Health and Safety Executive (HSE) restrictions (due to the applicability of Diving at Work Regulations when breathing pressurised gas) on in-water ‘wet’ CA-EBS training mean that the new interim training standard will feature fewer underwater escapes during HUET. With the LAP jacket for every scenario with breath hold another was also done using the Cat B air pocket within the LAP. This regulatory challenge was predicted by Survivex in their evidence to the UK CAA in Appendix 5 to Annex D of CAP1145 in October 2013. It has been eased by some time-limited concessions by the HSE in Q3 2015 (although they still require more than a basic offshore medical will involve). UPDATE 20 September 2016: The UK CAA today briefed the Oil and Gas UK Aviation Seminar the following: Mk51 Sentinel Aircrew Life Preserver Survitec have also designed an aircrew jacket with CA-EBS. Extra Resources If you found this article of interest you may also enjoy: Rapid Progress with a Category A EBS in the UK following CAP1145 OPITO Compressed Air Emergency Breathing System (CA-EBS) Initial Deployment Training Standard Helicopter Ditching – EASA Rule Making Team RMT.0120 Update on a new rule making initiative in Europe that will shortly proceed to a Notice of Propose Rulemaking Dramatic Malaysian S-76C 2013 Ditching Video probably the only video shot from within a helicopter during a real underwater escape The Hon Robert Wells QC’s Offshore Helicopter Safety Inquiry (OSHSI) following an S-92A accident offshore Canada in 2009, in which 17 people died and one passenger, Robert Decker, survived. The Dangers of Cold Water Immersion New Helicopter Survival Suits in Canada for oil and gas flights off the Atlantic coast...
read moreB1900C PSM+ICR Accident in Pakistan 2010
B1900C PSM+ICR Accident in Pakistan 2010 The Pakistan Civil Aviation Authority (CAA) has recently published the report into the loss of a Beechcraft B1900C in 2010. The aircraft, AP-BJD, was being operated by JS Air (as subsidiary of the JS Group) when it crashed on 5 November 2010, killing 21 people. The accident featured what a 1998 AIA/AECMA study termed a Propulsion System Malfunction + Inappropriate Crew Response (PSM+ICR). The 17 passengers worked for Italian oil and gas company ENI, who had chartered the aircraft. They were en route to work at the Bhit Shah gas field. The Accident Flight Shortly after take-off from Jinnah International Airport (JIAP), Karachi, the aircraft experienced a No 2 Engine anomaly. The crew decided to land back at Karachi. The aircraft could not sustain flight. It impacted the ground in a stalled state with a 45° right hand bank about 1 nm from the airport. The Captain (53, ex-Pakistan Air Force, ATPL, 8,114 hours total, 1,820 hours on type) was the Pilot Flying (PF) and the First Officer (FO: 33, ATPL, 1,746 hours total, 1,338 hours on type) was Pilot Monitoring (PM). Following analysis of the Cockpit Voice Recorder (CVR), the investigators comment that just before take-off: At 02:03:55.1 UTC [07:03:55.1 local time] FO told Captain “autofeather” and Captain acknowledged by saying “autofeather off”. It is important to note that autofeather switch should be in “Arm” position instead of “OFF” as per the OEM instructions and laid down procedures in [Flight Crew Operaing Manual] FCOM and QRH [to avoid the need for manual feathering]… At 02:04:02.8 UTC Captain told FO “all set, we are cleared for takeoff”. It is important to note that cockpit crew were supposed to carry out “run up checks” prior to entering the runway as per QRH however, those were not carried out. At 02:04:05 UTC, the engine torque and propeller RPM parameters began to increase and there was an increase in longitudinal acceleration indicating start of takeoff roll. At 02:04:14.2 UTC FO told Captain “power set autofeather light is ON”. At 02:04:18.7 UTC Captain said “off”. As the cockpit crew before takeoff intentionally selected the autofeather switch to “OFF” position, therefore the light was “ON” and the autofeather “OFF” position is confirmed by the Captain. The aircraft continued to accelerate and at 02:04:31 UTC it rotated. However, two seconds later the engine noise reduced. At 02:04:36.5 UTC the FO told Captain that the “right engine prop has gone”. At 02:04:41.1 UTC the FO said “it is feathering…should I select it to feather position?”. The Captain said “yes, put it to feather position” at 02:04:43.1 UTC. The investigators comment that: …probably [the] FO may have observed partial feathering due to which he wanted to feather the propeller of engine No 2 which was approved by Captain contrary to the documented procedures of no remedial action below 400 ft above ground level. The crew then decided to return to Karachi. The crew never raised the landing gear as per the FCOM/QRH, restricting aircraft performance. The investigators highlight that the Captain called Air Traffic and erroneously identified a No 1 engine problem. At 02:05:17.7 UTC Captain told FO “wait for a minute, wait for a minute”. As per the recorded data, at this particular moment the airspeed of aircraft was 98 knots with altitude recorded as 268 ft Above Mean Sea Level… [At] this stage, [the] Captain had not been able to achieve the minimum safe recommended flying parameters and the airspeed of aircraft was continuously decreasing with increasing pitch attitude as...
read moreSeason’s Greetings from Aerossurance
Aerossurance sends its Season’s Greetings to all its customers, partners, suppliers, colleagues and friends. We also wish you all a safe and prosperous New Year! Aerossurance has proven aviation safety, operations, airworthiness, regulation and accident analysis expertise. For aviation advice you can trust, contact us at: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest...
read moreCanadian Coast Guard Helicopter Accident: CFIT, Survivability and More
Canadian Coast Guard (CCG) Helicopter Accident: CFIT, Survivability and More (Bo105 C-GCFU) A fatal Arctic Controlled Flight Into Terrain (CFIT) accident to a Canadian Coast Guard (CCG) helicopter highlights a host of safety lessons, including: Low level operation with varying visual clues Compliance with approved maintenance data Survivability Alerting / Flight following Search and Rescue Data recorders Regulatory oversight The Accident The Transportation Safety Board of Canada (TSB) has recently issued their report into the accident to CCG Bo105S CDN-BS-4 C-GCFU in the M’Clure Strait, Northwest Territories on 9 September 2013. The aircraft was one of a fleet CCG use in support of various tasks and operated by Transport Canada, Aircraft Services Directorate (TC ASD). The CCG Bo105s are currently being replaced by Bell 429 under the CCG Fleet Renewal Plan. At 1638 local time, the helicopter departed from CCG Ship Amundsen for an ice measurement and reconnaissance flight. The ship was chartered at the time by ArcticNet in support of an 82-day scientific mission. The pilot was accompanied by the ship’s master and a scientist. Ice measurement requires low level flying. The TSB report that one hour later, at 1738:14, the pilot: …called the CCGS Amundsen to report that its estimated time of arrival (ETA) was in 10 minutes. At that time, the helicopter was in descent at approximately 390 feet. That was the last recorded message from the pilot. The helicopter continued its descent toward the survey altitude and levelled off at 36 feet at 1739:19, while eastbound. For a period of 3 minutes and 30 seconds, the helicopter maintained an altitude varying between 23 and 39 feet. It then made a slow descent for 13 seconds before colliding with water at 1743:02. The 3 occupants evacuated the helicopter before it sank… Upon noticing the helicopter had not arrived: At 1805, the helicopter’s position was checked on the flight following system, which displayed it as being 3.2 nautical miles from the vessel. At 1818, the Amundsen’s crew attempted several times to communicate with the helicopter without success and soon after proceeded to the helicopter’s last position. Debris was spotted and the three occupants were recovered [between 1854 and 1907]. None survived. The helicopter sank in 458 metres of water and was recovered 16 days later. The Safety Investigation – Low Level Operation and Visual Clues The aircraft was operating at low level (20-40ft typically), mostly over ice. Recovered video and still images showed that the ” visual cues and light levels varied considerably during the flight”. Shortly before the accident the helicopter fly over an area of open water, approximately 2.3 nm wide. …the winds were reported as light. Under such wind conditions, the smooth water surface presents a uniform appearance from above, somewhat like a mirror. This would have resulted in a significant reduction in visual cues available to judge height. The loss of references in the near visual field would have required the pilot to increase the scan of other available cues (distant visual field and instruments) in order to detect any change in altitude. Given the low altitude of the flight, this transition would have needed to be very quick, as a momentary loss of orientation could have resulted in contact with the surface. In addition, the dark overcast sky ahead would no longer have provided the distinct line of horizon against the water that would have been present when flying over the ice surface. Therefore, a pitch attitude change would have been difficult...
read moreUK OHSAG Oct 2015 Minutes
UK Offshore Helicopter Safety Action Group (OHSAG) October 2015 Minutes The UK Civil Aviation Authority (CAA) has just published the minutes of the 16 October 2015 meeting of the Offshore Helicopter Safety Action Group (OHSAG). This is the third and last of the year (compared to six in 2014), postponed from July 2015. The OHSAG was formed as a result of the ‘Civil Aviation Authority Safety Review of Offshore Public Transport Helicopter Operations in Support of the Exploitation of Oil and Gas’ (CAP1145). Among the items of note: An action regarding oversight of foreign helicopters operators in the UK from the January 2015 meeting remains open and two further actions on cooperative oversight and the risk of consistent application of UK CAA Safety Directives were raised. Further refinement and verification of the bow tie on Normally Unattended Installation (NUI) firefighting protection is underway (a topic we discussed in July 2015) . The proposed NUI policy is “centred on single engine failure accountability (i.e. in the case of a single engine failure on takeoff/approach, demonstrable clearances from deck edge and obstacles/water by 15 and 35 feet, respectively)”. The implementation date for new NUI firefighting protection policy will be 1 May 2016. The Helideck Certification Agency (HCA) will be asked to reference the resulting NUI criteria (“PC1/PC2e and/or crash resistant/fire fighting system”) on NUI helideck plates. It was noted that CAP437 Appendix D, on legacy NUI helideck firefighting provision, would be withdrawn at the next revision of CAP437, but that the 2011 UK CAA letter, contained within it, will remain valid. It was reported that ICAO is to introduce the terms Permanently Attended Installation (PAI) and Not Permanently Attended Installation (NPAI) into the next revision of ICAO Annex 14 Volume II Heliports, which is anticipated to be published in 2016. The UK CAA proposed an activity to classify NUI helidecks based on the quality of the surrounding visual environment when on approach/takeoff at night. However it was also suggested that many NUI owners/operators were generally “not inclined” to invest to comply with the new H and circle lighting requirements, which will effectively mean the end of night operations to those helidecks in 2018. The UK CAA consultation on helideck inspections (a topic we discussed in July 2015) was not debated. The CAA had however issued the following statement on 5 October 2015: “The CAA received twenty responses from the consultation. These responses are being used to assist in the determination of the next steps to address CAP 1145 Action item A13”. In July 2014 the House of Commons Transport Committee recommended that: “The CAA must undertake a joint review with its Norwegian counterparts to uncover why more occurrences are reported in Norway, despite its smaller fleet, and publish its findings within 12 months.” The resulting CAA report is still in draft. It was said that: “All agreed that the report was informative, however it was noted that there continued to be a difference between the numbers of reports and that further work was required to identify where the differences were.” The provision of “high fidelity” EBS training remains an issue and two further actions were raised. In Any Other Business, it was agreed that communication from oil and gas customers “needs to improve”, with a suggestion that it is currently mainly “tactical”. It was also agreed that clarification of the roles and responsibilities of various groups was required. Neither resulted in a formal action. The next CAP1145...
read moreSo 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;...
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