French Skyscraper HESLO: Helicopter Underslung Load
French Skyscraper HESLO: Helicopter Underslung Load A stunning video, from Bouygues Construction, shows the construction of the the tower on top of the €124 million Incity building in Lyon, the third highest in France. The last two components of the tower were lifted into place by an Airbus Helicopters AS332C helicopter on Sunday 21 June 2015 as a Helicopter External Sling Load Operation (HESLO). The spire, which is 50 metres high and weights a total of 25.9 tonnes, took the building to its final height of 200 metres. Aerossurance has previously written about the replacement of a TV antenna on a 153m tower in Croydon South London by helicopter, the use of helicopter human external cargo by a power company in California and a UK lighthouse support contract. Also see our articles: What the HEC?! – Human External Cargo, Keep Your Eyes on the Hook! Underslung External Load Safety UPDATE 2 July 2020: Erickson videos: Aerossurance has extensive air safety, helicopter operations (inc HESLO) and contracting experience. For practical aviation advice you can trust, contact us at: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest...
read moreAerossurance Sponsors HF in Aviation Safety Conference
Aerossurance Sponsors Human Factors in Aviation Safety Conference Aerossurance is pleased to sponsor the Chartered Institute of Ergonomics & Human Factors’ (CIEHF) Human Factors in Aviation Safety Conference that takes place at the Radison Blu Hotel, East Midlands Airport, 9-10 November 2015. Aerossurance was keen to sponsor this event as it is such an excellent independent professional forum for discussion and exchanging of ideas on the very latest research, development and application of Human Factors in Aviation Safety. The 2 day event is just £199 (or £129 for one day) excluding VAT and includes a period of free membership of CIEHF. To book a place click here. The conference was doubled from 1 to 2 days after the organising committee reviewed over 50 high quality submissions. Monday November 9th Time Title Presenter 09:30 Registration 10:00 Welcome Address TBC 10:10 Developing a safety culture at EasyJet Sian Evans, Easyjet 10:30 Human Factors and Aircraft Ground Handling Loading Activities Rebecca Grant, Coventry University 10:50 Culture and Decision-Making Steve Scott, Coventry University 11:10 The assessment of just culture in civil aviation – learning from work on High Reliability Organisations Colleen Butler, Health and Safety Laboratory 11:30 Removing the error, from pilot error Donough Wilson, Coventry University Technocentre 11:50 Discussion and questions 12:10 Lunch 12:50 Understanding and mitigating rate and scale of change within the aviation industry. Jocelyn Clark, NATS 13:10 Tightening the link between safety and human factors in design Andrew Kilner, Eurocontrol 13:30 NATS Automation Principles: The Practicalities of Advanced Air Traffic Controller Assistance Tools. Lisa Aldridge, NATS 13:50 Feeding Human Performance into Design – Learning Lessons from SESAR Renee Pelchen, Eurocontrol 14:10 Discussion and questions 14:30 Break 14:50 An Appropriate Framework For The Safety Assessment of UAS Ground Systems used in UK Civil Aviation Applications Bob Bastow, BAE Systems – Defence Information 15:10 Integrating Unmanned Aircraft Systems into current and future airspace Fiona Cayzer, BAE Systems 15:30 Key Human Factors trends in UK military aviation Victoria Cutler, Royal Air Force Centre of Aviation Medicine 15:50 Human-Computer Interactions in Aviation: Pilots’ Visual Behaviour, Attention Distribution, Situation Awareness and Decision-making during Flight Operations Wen-Chin Li, Cranfield University 16:10 ‘Doing more with less’ – Single operator control of multiple UAVs Dale Richards, Coventry University 16:30 – 17:00 Discussion, questions and close 17:00 Drinks reception Tuesday November 10th Time Title Presenter 08:30 Registration 09:00 Pilot Monitoring Skills – the final safety net Jo Davies, ESE Associates Ltd 09:20 By products of commercial pressure: Human factors implications of fuel savings policies for airline operations Jorge Delgado, Independent HF Consultant and A330 Captain 09:40 A Human Factors Review of Pilot Training in UK Aviation Georgina Fletcher, Frazer-Nash Consultancy 10:00 Putting the Science Back into CRM; Promoting Distributed Cognition on the Flight Deck Don Harris, Coventry University 10:40 Break 11:00 Team and Collective Training Needs Analysis for Single Pilot Operations John Huddlestone, Coventry University 11:20 The Challenges and Opportunities for Crew Human Factors Training David Moriarty, Zeroharm Solutions 11:40 Mode Confusion; the Nemesis of Uniformity David Thompson, Wessex Human Factors Ltd 12:00 Discussion 12:20 Lunch 13:00 Using STAMP to bridge the gap between Human Reliability Analysis and Technical System Safety Peter Gibson, BAE Systems 13:20 A systematic safety work method for addressing blind spots in accident / incident investigation Jonas Lundberg, Linköping University 13:40 The Geometry of NMAC Brian Peacock, SIM University 14:20...
read moreCritical Maintenance Tasks: EASA Part-M & -145 Change
Critical Maintenance Tasks: EASA Part -M & -145 Change Commission Regulation (EU) 2015/1536 was issued on of 16 September 2015. Technically it amends Regulation (EU) No 1321/2014 “as regards alignment of rules for continuing airworthiness with the ‘Basic Regulation’ Regulation (EC) No 216/2008“. Critical Maintenance Tasks (CMTs) One of the most important parts of the amendment relates to CMTs, which are defined as: …a maintenance task that involves the assembly or any disturbance of a system or any part on an aircraft, engine or propeller that, if an error occurred during its performance, could directly endanger the flight safety. The European Aviation Safety Agency (EASA) has said that this change: …addresses a safety issue related to the risk of errors made during the performance of critical maintenance tasks and the need for maintenance organisations to implement methods to capture those errors before the certificate of release to service is issued. The change primarily enhances M.A.402 for Continuing Airworthiness Management Organisations (CAMOs). It also introduces 145.A.48 on the Performance of Maintenance for maintenance organisations (with 145.A.65(b) adjusted to be consistent with 145.A.48), which include tool control. Previously the expectation would be that the CAMO would ensure that M.A.402 defined standards were achieved by the maintenance organisation. Now effectively they are both accountable, the Part-145 to ensure the requirements are met and the Part-M to assure they are. Note: M.A.402 (a) previously referred to ‘flight safety sensitive maintenance tasks’ and 145.A.65 (b)(3) to ‘critical systems’. For background and the history of the rule making see: Terms of Reference for the Rule Making Team: Review Group ToR RMT.0222 (MDM.020) – Issue 1 Notice of Proposed Amendment: NPA 2012-04 Comment Response Document: CRD 2012-04 (193 comments were received) Opinion 06/2013 – Explanatory Note Draft amendment to Commission Regulation (EC) No 2042/2003 The NPA was in part prompted by following three safety recommendations addressed to the Agency: AIBN recommendation 12/2006, Report on the aircraft accident at Bergen Airport Flesland, Norway, on 31 January 2005 involving ATR 42-320, OY-JRJ, operated by Danish Air Transport, when control problems were experienced an elevator bolts loosened and fell out. The self-locking nuts were not tightened with the required torque. UK AAIB Safety Recommendation 2005-123 in Report 3/2005 on the serious incident to Boeing 757-236 G-CPER, operated by British Airways, on 7 September 2003. Maintenance errors that had culminated in the failure to reinstall two access panels on the right-hand outboard flap and incorrect engine oil top up. UK AAIB Safety Recommendation 2006-030 AAIB Bulletin: 11/2006 EW/C 2004/10/03 on the fatal accident to a privately operated Mooney Aircraft Corporation M20J, G-EKMW. A defect was discovered within the engine’s dual magneto, which had recently been refitted following a 500 hour inspection, affecting both ignition systems. This led to a loss of power shortly after take off and the aircraft impacting the ground while attempting to return to the airfield When discussed at the EASA Management Board, issue of whether the Type Certificate Holder was better placed to identify critical tasks. EASA clarified that this text is dealing with errors that occur during performance of maintenance, hence the responsibility is a continuing airworthiness one. The associated AMC and GM is expected to be published this autumn. However CRD 2012-04 indicates what can be expected. In particular the AMC and GM to 145.A.48 will cover implementing maintenance error capturing methods, that may include Independent Inspections and other techniques such as functional checks. Other Changes Although we...
read moreThe Missing Igniters: Fatigue & Management of Change Shortcomings
The Missing Igniters: Fatigue & Management of Change Shortcomings On 15 September 2015 the UAE General Civil Aviation Authority (GCAA) issued their investigation report into a Serious Incident that affected both engines of a Dash 8. Their report highlights the importance of Management of Change both at a macro level, when undertaking corporate restructuring (highly topical for air operators in the oil and gas sector with $50 / barrel oil) and at the micro level, when introducing new tasks. It is also the latest of a series of investigations to discuss maintenance personnel fatigue and alertness. The Incident Flight On 9 September 2012, Bombardier Dash 8 / DHC-8-315Q A6-ADB, operated by Abu Dhabi Aviation and chartered by a local oil and gas company, departed Abu Dhabi International Airport on a scheduled 35 minute passenger flight to Das Island, about 100 nm away and home to multiple oil and gas facilities. A crew of 3 and 46 oil and gas workers on board. Several minutes intro the flight, a concerned passenger informed the cabin crew member about paint blisters forming on the right hand engine inboard cowling. Although no fire warnings were generate the crew decided to return to the international airport and landed 10 minutes after take off. It was only after a safe landing that it was discovered that similar damaged had occurred on the left hand engine outboard cowling too. The engine cowlings were damaged because of: …of hot engine gases escaping through an open igniter boss on the engine casing. The hot gas was impinging on the nacelle, engine case drain line and engine support strut. The Maintenance History – Management of Change at the Micro Level The operator has suffered from unscheduled engine removals due to environmentally induced performance deterioration. Several engine wash options are available for the Pratt & Whitney Canada PW123. The operator had been conducting turbine washes since May 2009. Until December 2011, these were conducted using a task card, that contained technical instructions and was used to record the sign-off by both mechanic and certifying engineer. However to “reduce paperwork” and “improve process efficiency” these were replaced by a procedure that described the task and required a technical log entry, signed just by the certifying engineer. In July 2012 supervisors locally, without reference to management, decided to trial doing a compressor wash at the same time as a turbine wash on one engine. As the investigators note, unfortunately the trial was briefed verbally and inconsistently and conducted in an even less controlled manner than the compressor washes as: …the work was being performed based on experience alone, and without any referral documentation from the AMM [Aircraft Maintenance Manual] to perform the physical task. In addition, the work was being conducted without any sign-off by the mechanic, or the engineer, and without any updates being entered into the electronic data system of the Operator. They go on to report that: On the night prior to the Incident flight, the duty Engineer in charge of the shift had physically prepared both engines for turbine washes… He removed engine access panels 415AL and 425AL, the igniter leads and the left igniter from each engine. The removed igniters were left inside the recess of the engine compartment without placing them in protective bags. The duty Engineer returned to the ‘control office’ where he proceeded to update the electronic data system for work done inside the hangar. He allocated two mechanics to perform...
read moreB787 GEnx Fan Shaft Failure
B787 GEnx Fan Shaft Failure The very day a British Airways Boeing 777-200 G-VIIO suffered an uncontained GE GE90 engine failure and fire at Las Vegas, Nevada, the US National Transportation Safety Board (NTSB) coincidentally published the probable cause of another GE engine failure. The 2012 Failure On 28 July 2012 Boeing 787-8 Dreamliner VT-ANJ, ultimately destined for Air India, experienced a GE GEnx-1B67 contained engine failure (i.e. no debris penetrated the engine casing radially) during a taxi test by Boeing at Charleston International Airport (CHS), South Carolina. There were no injuries, the airframe received extensive minor damage (from axially ejected debris) and the airfield was temporarily shut after the failure caused a grass fire. The ~8 feet (2.4 m) Fan Mid Shaft (FMS), made in Japan by IHI, which connects the fan and Low Pressure Compressor booster stages to the Low Pressure Turbine (LPT), had failed aft of the forward retaining nut. Consequently the LPT had migrated aft resulting in extensive secondary damage, by design, as the blades contacted the stationary guide vanes (thus preventing a overpseed of the unloaded LPT). The Investigation The NTSB investigation determined that: Examination confirmed separation of the FMS adjacent to the lock nut face located at the aft most full thread root. The fracture exhibited features indicative of multiple failure modes: one progressive, and one instantaneous. About 85 percent of the fracture surface exhibited features consistent with progressive fracture. The remaining fracture surface showed signs consistent with instantaneous failure by overstress. Further examination revealed features consistent with environmentally assisted cracking (EAC) specific to GE 1014 ultrahigh strength steel. The FMS threads and the retaining nut were coated with a dry film lubricant, and grease or engine oil was used as an assembly aid. Although a lead based dry film lubricant was previously used on GE engine fan mid shafts, during development of the GEnx engine, the design was changed to incorporate a lead free dry film lubricant [Everlube 9002], and graphite grease [MolyDag 254] instead of the previously used engine oil as an assembly aid. Testing of specimens taken from the FMS, and comparison to other dry film lubricants used previously on GE 1014 ultrahigh strength steel indicated that the dry film lubricant used on the incident FMS absorbed moisture at a higher rate. Additionally, the combination of dry film lubricant and graphite assembly grease was shown to increase the corrosion rate of GE 1014. The Continued Airworthiness / Safety Action GE expeditiously introduced an Ultrasonic Inspection (UI) to scan the forward end of the FMS in the area of the threads where the fracture had occurred. A second cracked fan mid-shaft was discovered in mid-August 2012 on another GEnx-1B. The NTSB issued Safety Recommendations A-12-052 and A-12-053 to the Federal Aviation Administration (FAA) on 14 September 2012. The NTSB Recommendation Letter suggested that AirBridgeCargo 747-8 Freighter VQ-BLR might have experienced a similar FMS failure on one of its GEnx-2B67 engines, resulting in a rejected take-off in Shanghai, China on 11 September 2012. However within two weeks they had determined that a different LPT failure mode had occurred. Coincidentally Air India took delivery of their second 787 on 19 September 2012. On 21 September 2012, the FAA published Airworthiness Directive (AD) 2012-19-08. This AD required an initial ultrasonic inspection (UI) of the FMS before further flight and then a repetitive UI every 90 days. The AD applied to all GEnx- l B and GEnx-2B engines with particular part numbers of FMS...
read moreGulfstream G-IV Take Off Accident & Human Factors
Gulfstream G-IV Take Off Accident & Human Factors (N121JM) The US National Transportation Safety Board (NTSB) has highlighted a number of important human performance issues in a recent Board Meeting held to discuss a Gulfstream G-IV business aircraft accident. UPDATE 24 September 2015: The full final report is now published. The Accident On 31 May 2014, 3 crew and 4 passengers died when G-IV N121JM, registered to SK Travel LLC, and operated by Arizin Ventures LLC under Part 91 rules, was destroyed at the joint civil/military Hanscom Field (BED) in Bedford, Massachusetts, after a night-time high speed rejected takeoff and runway excursion. Aerossurance discussed the preliminary findings of the investigation in July 2014: Focus on Gust Locks After US GIV accident. The gust lock system is used to lock the elevator, ailerons and rudder when parked to protect against damage in gusting wind. Indeed, the failure to unlock the gust locks prior to commencing take off was a critical failure. This NTSB video illustrates the take off: The aircraft overran the 2,137 m (7,011 feet) runway, collided with approach lights and a localizer antenna, went through the perimeter fence and ended up in a small ravine 564 m (1,850 feet) from the end of the runway, where the post crash fire took hold. Among the dead was Lewis Katz, co-owner of the US’s third-oldest daily newspaper. the Philadelphia Inquirer. Katz died just days after agreeing a $88 million deal, with partner Jerry Lenfesto, be sole owners of the newspaper’s parent company. The flight crew were experienced. The aircraft commander had >11,000 total flight hours (with > 1,600 hours on the G-IV) and the first officer >18,000 total flight hours (with >3,000 hours on the G-IV). They had flown together for about 12 years, a fact which is worth noting when we discuss human performance matters below. The NTSB abstract on that accident is here. The NTSB determined that the probable cause of this accident was: … the flight crewmembers’ failure to perform the flight control check before takeoff, their attempt to take off with the gust lock system engaged, and their delayed execution of a rejected takeoff after they became aware that the controls were locked. Contributing to the accident were the flight crew’s habitual noncompliance with checklists, Gulfstream Aerospace Corporation’s failure to ensure that the G-IV gust lock/throttle lever interlock system would prevent an attempted takeoff with the gust lock engaged, and the Federal Aviation Administration’s failure to detect this inadequacy during the G-IV’s certification. From the NTSB abstract and presentations we observe five human performance aspects to this accident: Human Performance Aspect 1 – Omitting to Disengage Gust Locks During the engine start process, the flight crew didn’t disengage the aircraft’s gust lock sustem. This omission should not on its own be fatal as there where at other safeguards (one procedural, a status indication and a physical design feature) that should act as further risk controls. Human Performance Aspect 2 – Omitting a Flying Control Check The flight crew failed to perform a flight control check. This procedural control would have alerted them that the controls remained locked. It is noteworthy that when the NTSB reviewed flight data from the aircraft’s Quick Access Recorder (QAR), they discovered that this flight crew had failed to perform complete flight control checks before 98% of their previous 175 take offs. To the NTSB this indicated that this omission was “habitual”. The NTSB comment that: SK Travel [sic – note not Arizin Ventures] flight operations manual required...
read moreLoss of MV Derbyshire 9th September 1980
Loss of MV Derbyshire 9th September 1980 On 9th September 1980 the Bibby Line OBO (oil/bulk/ore) carrier MV Derbyshire sank during Typhoon Orchid in the South China Sea. All 44 people on board died. The Derbyshire, at 90,000 gross registered tons, remains the largest UK registered ship ever to be lost at sea. Until 1994 the location of the wreckage was not know and so the initial 1980 inquiry was relatively inconclusive. Following a survey of the wreck using the latest underwater search technology, a re-opened inquiry concluded in 2000 that a structural failure had occurred. This removed unfounded accusations of error by the Captain and crew. It also highlighted that vessels that only complied with the minimum requirements of the International Load Line Convention of 1966 posed an unacceptable risk to safety. This video describes the failure mechanism: UPDATE 9 August 2025: OceanGate Titan: Toxic Culture & Fatal Hubris Aerossurance has extensive safety management and accident analysis experience. Contact us at: enquiries@aerossurance.com Follow us on LinkedIn and Twitter @Aerossurance for our latest...
read moreHTAWS Technology: Friend or Foe?
HTAWS Technology: Friend or Foe? Technology has great potential to reduce aviation risk. The European Helicopter Safety Team (EHEST) issued a study in October 2014 on the safety value of technology. Terrain Avoidance and Warning Systems (TAWS) have proved highly effective at fixed wing Approach and Landing Accident Reduction (ALAR). On 20 February 2014, the Federal Aviation Administration (FAA) issued an extensive package of changes to Parts 91, 120 and 135 to improve Helicopter Emergency Medical Service (HEMS) safety that includes a requirement for Helicopter TAWS (HTAWS). While the adoption of HTAWS offers great potential safety benefit, its introduction, like any new technology, needs to be carefully considered. It may be tempting to simply see the introduction of such equipment as an incremental improvement in safety and simply base introductory training, for example, on the avionic manufactures’ technical publications for the equipment. However, there are wider potential impacts that need to be addressed when risk assessing the unintended consequences of introducing new technology. For example reducing the risk of one accident type may heighten the risk of another unless additional mitigations are in place. One example of this phenomena has been the introduction of flight deck automation, the subject of a July 2014 the Royal Aeronautical Society Rotorcraft Group conference, Technology: Friend or Foe? which we discussed in a previous article. A US HEMS accident in 2013 highlights an unintended consequence of HTAWS introduction. The Hospital Wing Accident On 22 October 2013, Airbus Helicopters AS350B3e (H125) helicopter N353HW, operated by the Memphis Medical Center Air Ambulance Service (doing business as Hospital Wing) was 18 minutes into positioning flight to collect a patient for an inter-hospital transfer, when it crashed near Somerville, Tennessee at 06:05 local time. There was a post crash fire (a subject Aerossurance has discussed recently). All three persons on board died. Two calls had been turned down during the night due to poor weather. At an airport about 2 miles from the accident site, a few clouds were observed at 800 feet agl, and a broken ceiling existed at 1,200 feet agl. As well as Garmin GNS530W TAWS the helicopter was equipped with Night Vision Goggles (NVGs) but was not equipped for operation under Instrument Flight Rules (IFR). In there final report the US National Transportation Safety Board (NTSB) state: …the helicopter was observed in a climb and in a right turn away from the observed course. The last data point indicated that the helicopter was on a course of 146 degrees and at 98 knots ground speed and at an altitude of 1,560 feet above mean sea level (msl) or about 1,116 feet above ground level (agl). A review of the helicopter’s ground track revealed two obstacles in the immediate vicinity, an unlit, nonoperational cellular tower, 140-feet tall, and a water tower, about 115-feet tall. Although recorded HTAWS data was not available, research and flight testing revealed that the pilot may have received an in-flight obstacle alert, prompting a climb. Considering the low clouds and night conditions that probably existed along the last segment of the flight’s track, it is likely that the pilot initiated a climb and inadvertently entered instrument meteorological conditions, where a loss of helicopter control occurred. The NTSB probable cause was: The pilot’s inadvertent encounter with night, instrument meteorological conditions while responding to an obstacle alert, resulting in an in-flight loss of helicopter control. The pilot was described by colleagues as “good pilot”, “well-liked” and “conscientious”. He flew...
read moreThe Contrarian Director
The Contrarian Director Public companies should appoint a “Contrarian Director” to systematically challenge management recommendations, says Australian corporate lawyer Siobhan Sweeney. Sweeney won the 2015 Cambridge-McKinsey Risk Prize at the Centre for Risk Studies at University of Cambridge Judge Business School for her paper on the subject: In the current economic climate marked by volatility and uncertainty, risk oversight by boards is increasingly important. The function of boards to ensure a healthy balance between risk-taking and risk avoidance is critical to the success of the company and the stability of the economy. This paper notes the significant failings of boards in this regard. The changes suggested by this paper go directly to improving this position. The paper examines the economic, social and psychological forces propelling directors on boards towards collegial consensus and deterring real independence from each other. The paper offers a highly innovative yet simple solution. It develops the concept of a ‘Contrarian Director’, inspired by the Advocatus Diaboli (‘devil’s advocate’) of 1587 but modelled more closely to the Advocate General of the European Court of Justice. The paper provides a structure and process to appoint and support this director. The result of these proposed changes would be a change to culture on boards and a radical improvement in the risk oversight function by boards. The name derives from the Greek for someone who “habitually opposes or rejects prevailing opinion or established practice”. The aim of the proposal is to prevent groupthink and rubber-stamping of management decisions by overly-collegial boards by ‘independent’ non-executive directors who are independent in title only. The Contrarian Director’s role would be to review every recommendation to the board of substance, giving careful consideration to any possible case, if any, against the recommendation. Observations There have been a wide range of scandals in recent years were boards have agreed to flawed proposals without adequate challenge or failed to stop risky or illegal practices, for example the classic tales of: Bearings Bank: Rogue Trader, Enron: The Smartest Guys in the Room, HBOS: Hubris, RBS: Making it Happen, BP: Failure to Learn / Spills and Spin and Olympus: Exposure as well as GM Ignition Switch Debacle and the faked Koito airline seat safety data). So any proposal that enhances corporate governance and engenders a more questioning culture (as recommended by Charles Haddon-Cave QC in the Nimrod Review) is worth attention. It is perhaps not surprising that a quasi-adversarial solution has been proposed by a lawyer. Taking a contrarian view of this proposal, an unintended consequence may be that some directors could chose to just compare the proposal with the Contrarian Director’s analysis and simply decide which case is stronger, rather than probe the proposal directly. It also may mean that every non-objection by the Contrarian Director may expose them to greater personal liability as a director for not identifying a weakness that emerges later. A single Contrarian Director will also probably be at a disadvantage in being significantly less well resourced than the management team preparing the proposal. Perhaps it would be better to appoint multiple non-executive directors who have the right knowledge to ask challenging questions, identify weaknesses in proposals and opportunities to reduce risk, perhaps supported by a small staff to gather data independently for them. UPDATE 11 September 2015: This article offers a complementary perspective Why Getting Directors on Board with Risk Management Matters. It also emphasises sharing...
read moreMid Air Collision Typhoon & Learjet 35
Mid Air Collision Typhoon & Learjet 35 During ‘Renegade’ air interception training a civilian Learjet 35, D-CGFI, collided with a Luftwaffe Eurofighter Typhoon. The German Federal Bureau of Aircraft Accidents Investigation (BFU) have issued their final report and we attended an excellent briefing by the BFU at the ISASI 2015 conference. In Germany, as in the UK, air accidents involving both civil and military aircraft are investigated by the civilian accident investigation body. The mid-air collision occurred on 23 June 2014, over Olsberg, North Rhine-Westphalia. The civilian aircraft crashed and both crew members died. The damaged Typhoon performed an emergency landing at Nörvenich Air Base. The Operator The Learjet was operated by GFD, a German defence contractor that provides target towing and other training services. The company, founded in 1966, operated 13 civil registered Learjets for military training support. They gained a German Air Operators Certificate (AOC) in 1989, but that AOC covered passenger and cargo operations (commercial air transport), not their actual training support activity (aerial work). The Flight The Learjet and two Typhoons were involved in an ‘Renegade’ interception exercise (with the Learjet simulating a potentially uncooperative airliner) when the collision occurred between the Learjet and the lead Typhoon. The collision occurred shortly after the intercepted target began to comply with the instructions given (as part of the exercise it initially ‘failed’ to obey). The Learjet Captain was Pilot Monitoring and the Co-Pilot, Pilot Flying. Both were ex Luftwaffe fighter pilots. The Captain was using a portable computer, effectively an unapproved Type B Electronic Flight Bag, for navigation purposes throughout the flight. Having started to ‘obey’ the intercepting fighters commands, about 15 seconds prior to the collision the autopilot was disengaged and the Co-Pilot flew the airplane manually to follow the Typhoon into a left-hand turn. The BFU concluded the slant range of the two aircraft was initially approximately 30 m. The turn continued, but the Co-Pilot was unable to maintain visual contact with fighter once the Learjet reached a 4° bank angle. The Learjet was turning more sharply than the fighter and was accelerating. Control was passed to the Learjet Captain but at this critical moment he had to pass the laptop to the Co-Pilot. The two aircraft came into contract, 2 seconds later, with the Learjet being catastrophically damaged. Analysis The BFU say: The operator’s safety management had not sufficiently analysed the use of the computer, and the cross cockpit procedure in regard to flight safety risks. The company had issued an Safety Management Handbook on 1 June 2012. However, at the time of he accident, just over 2 years later, “a concrete hazard and risk analysis had not been conducted in the company”, even though a functioning SMS as required of AOC holders by 28 October 2014. In this case it appears the SMS was still in development. In other organisations it has been apparent after accidents that the documented SMS was not an effective, living system but in practice was just ‘shelfware’ (as we recently discussed in the case of Metro-North). Equally the German military procedures for Renegade interceptions “were neither described in detail nor assessed by way of risk analysis”. The BFU concluded that the ‘Immediate Causes’ were: During positioning for the intervention the collision risk due to unexpected manoeuvres of the intercepted airplane was not sufficiently taken into consideration. The Learjet crew did not take into account the risks due to possible limitations of the field of vision and the distraction by using the computer...
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