ATP Serious Incident – Temporary LOC In Icing Conditions
ATP Serious Incident – Temporary LOC In Icing Conditions The Accident Investigation Board Norway (AIBN) has issued their report into a serious incident where West Air Sweden BAE Systems ATP cargo aircraft SE-MAF suffered control problems while en route on 25 September 2014. Coincidentally, their report was issued on the eve of the 21st Anniversary of the Roselawn ATR 72 accident (we covered the 20th Anniversary of that 1984 accident last October). The AIBN say: A cargo aircraft flying from Oslo to Trondheim gradually lost speed after reaching cruising altitude. The crew observed ice forming on the aircraft and activated the de-icing system. However, the speed continued to drop. The commander decided to descend to a lower altitude. Before the descent could be initiated, severe buffeting occurred. The nose pitched up and the aircraft banked in an uncontrolled manner. The first officer, who was at the controls, stated that he had to push the nose down by force. The ailerons did not respond properly, and the buffeting was so violent that he could hardly read the instruments. He was able to disconnect the autopilot, and the speed increased as the nose was lowered. Control was regained after about 30 seconds. The loss of altitude was not critical in relation to the terrain. The aircraft continued to its destination and landed safely. The AIBN go on to say: Findings made during the investigation indicate that the loss of speed was a result of a combination of icing and mountain waves. A simultaneously occurring technical malfunction in the de-icing system had a minor impact only. The investigation has also shown that the vibrations and the loss of control most likely were caused by a stall or incipient stall. When control was lost, the speed had dropped to 22 kt below the manufacturer’s recommended minimum speed for flying in icing conditions. The crew was not aware that minimum speed in icing conditions existed other than for the approach phase, and believed they had sufficient margin in relation to a stall. The senior operational personnel with the operator seem to have suffered from the same lack of knowledge. The investigation also revealed that the operator’s training program did not touch upon minimum speed in relation to icing during the cruising phase. A potential for improvement in documentation from the type certificate holder was also identified. The AIBN comment that the BAE Systems’ subsequent communications and clarifications in the AFM are significant improvements. However they make two recommendations regarding making minimum speeds in icing conditions easily available for reference in the cockpit. Other Resources Icing conditions (ground and in flight) was the topic for a European Aviation Safety Agency (EASA) conference in 2013. Aerossurance has also published other icing articles: De-Iced Drama: a Norwegian Air Shuttle Boeing 737-800 came close to stalling as a result of a blocked elevator. Canadian Mining Air Accident (Cessna 208B Caravan): where a cold soaked aircraft took off over gross weight due to accumulated ice from a previous flight. Breaking the Chain: X-31 Lessons Learned: where an experimental NASA aircraft was lost after pitot tube icing. Cessna Citation Excel Controls Freeze UPDATE 3 December 2016: ATR72 Control Problems in Severe Icing, Norway, 14 November 2016 UPDATE 29 December 2016: CRJ-200 LOC-I Sweden 6 Jan 2016: SHK Investigation Results, another West Air accident. UPDATE 29 November 2018: Iced C208 Loses Airspeed During Circling Approach and Strikes Ground...
read moreHeliOffshore Progress One Year On
HeliOffshore Progress One Year On We first reported on the plan to create HeliOffshore in June 2014. HeliOffshore was formally launched on 21 October 2014 in London and held its first AGM and conference in Lisbon in May 2015. When membership was opened up beyond helicopter operators in January 2015, Aerossurance is pleased to have been one of the first Alliance Members to join. The organisation has recently issued a news bulletin on progress. Articles include an update from CEO Gretchen Haskins, updates on HeliOffshore’s six priority workstreams, a welcome message for newly appointed Operations Director Francois Lassale and a report from Capt. John Black on Helitech 2015, which included supporting European Helicopter Association (EHA) and European Helicopter Safety Team (EHEST) events. In a spirit if transparency, the audio from two all members conference calls held of 28 October 2015 has also been made publically available. This session included briefings on three of the six current workstreams underway: Automation Health & Usage Monitoring with a HUMS Best Practice Guide, which Aerossurance has had the privilege of being invited to contribute to, due to be launched in November 2015 Information Exchange HeliOffshore CEO Gretchen Haskins has also recently been elected as a Board Member of the Flight Safety Foundation (FSF). Haskins was recently interviewed by Energy Voice commenting: The blame culture doesn’t work as well as the lesson learning culture. HeliOffshore will do everything it can to ensure the lessons do get learned. People are willing to talk about the difficult stuff, act on it and improve safety. What becomes crucial is the adoption of best practice so that we can standardise and improve the safety of global offshore operations. The interest has been great from all sectors, operators big and small from all over the world, manufacturers, oil companies. Everyone is getting together, I’m very excited about how it is progressing. UPDATE 22 May 2016: Offshore Helicopter Safety Performance: 2016 HeliOffshore Conference Report UPDATE 21 May 2017: Deepening Delivery: HeliOffshore 2017 Conference Report UPDATE 13 May 2018: Delivering Our Priorities: HeliOffshore 2018 Conference Report UPDATE 8 May 2022: HeliOffshore 2022 Conference Review Aerossurance is an Aberdeen based aviation consultancy with extensive helicopter safety, operations and contracting experience. For helicopter advice you can trust, contact us at: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest updates....
read moreUK CAA PBR Stakeholder Engagement (CAP1345)
UK CAA Performance Based Regulation (PBR) Stakeholder Engagement (CAP1345) We have previously written about the emerging concept of performance based regulation (PBR) and discussed some of the challenges to overcome. This week the UK Civil Aviation Authority (CAA) have issued a consultation document on PBR: CAP1345: Performance Based Regulation: Business Engagement Assessment In the document the CAA illustrate their PBR process: The CAA identify 5 areas of change: Consistently gathering and analysing safety risk information about all parts of an organisation’s operations. Assessing the performance of each regulated entity to manage its safety risks effectively and agreeing with the entity’s Accountable Manager the actions that are needed to uphold standards and further enhance safety. Grouping safety risk information about entities into sectors of the industry with similar types of operation to create a better understanding of the top risks posed by the total aviation system and good practice approaches to managing them. Making more informed decisions about the safety outcomes to better manage the top risks and setting out the actions required. Directing regulatory resources proportionately to entities and sectors where standards are not being upheld or there is the significant potential to enhance safety. The CAA say they expect that the benefits of PBR to be in three main areas: 1. Improvements in the performance of industry and the CAA to manage and oversee safety risks, and the ability to demonstrate on-going improvements in safety. 2. Improvements in the CAA’s ability to allocate resources to areas with the greatest potential to enhance safety (i.e. better management of resource capacity, competencies and workload against a prioritised set of safety risks). 3. Increased efficiency and effectiveness of the CAA’s core oversight processes, generating the potential for the reallocation of capacity to higher priority areas of safety risk or reducing the amount of people needed to carry out tasks associated with traditional compliance activity. CAP1345 reveals CAA have previously committed to external change management / programme management support and software costs estimated at £740,000 between April 2014 and March 2016 for PBR. The consultation is open until the end of the year (see CAP1345 for full details). For more on the general topic of PBR see this 2002 paper from the Harvard John F Kennedy School of Government: Performance-Based Regulation Prospects and Limitations in Health, Safety and Environmental Protection UPDATE 21 December 2015: The UK CAA have published a report (CAP1365) on a conference held in London in October 2015 on PBR. It also described the CAA’s new Regulatory Safety Management System (RSMS) that sits above its Performance Based Oversight (PBO) process. UPDATE 17 January 2017: We discuss new UK CAA guidance: Performance Based Oversight: Accountable Manager Meetings (CAP1508) UPDATE 19 March 2017: The Rule Illusion: Organisations should beware of a ‘rules bias’, a tendency to give in to risk aversion by establishing ever more rules: Just like in the real world, stricter rules in an organization are rarely effective in stopping the most egregious transgressions. In practice, those who make the rules are often insulated from the true consequences. The lack of a good feedback mechanism to adjust the rules would be bad enough if the rules were based on evidence and logic. But it’s often even worse, because rules often originate from received (but dubious) wisdom, unproven ‘common sense’, or reactions to one-off events. Rules that are based on beliefs rather than evidence, and never tested, are unlikely to produce net benefits. Yet...
read moreFatal G-IV Runway Excursion Accident in France – Lessons
Fatal G-IV Runway Excursion Accident in France – Lessons The French accident investigation agency, the Bureau d’Enquêtes et d’Analyses (BEA), has issued their report (warning 12Mb) on the 13 July 2012 accident to Gulfstream G-IV business jet N823GA. The US registered aircraft was operated by Universal Jet Aviation (UJT) under 14 CFR Part 135. It suffered a runway excursion while landing during a short ferry flight from Nice, France to Le Castellet Airport. All three occupants were killed. The Accident The BEA comment (emphasis added): Between Nice airport and Le Castellet aerodrome which was not familiar to the crew, the flight was short. The cruise, which lasted only five minutes, left the crew little time to prepare for their arrival. The flight was the last of the day and it was made without any passengers, with the co-pilot in the right seat as PF. This context may have been conducive to lax pre-flight planning and management of the flight by the crew with a heavy workload during the cruise and the approach. Despite having been warned the day before of the need to park the aeroplane at Le Castellet, the copilot learnt the characteristics of the aerodrome during the flight. Few checklists and briefings were heard throughout the flight. During the flight, the crew referred to the proximity of the terrain, the need to reduce speed and anticipate the configuration, and the short runway length. The crew nevertheless understated the impact of a short flight on the preparation of the arrival. The BEA say that: During a visual approach to land on runway 13 at Le Castellet aerodrome, the crew omitted to arm the ground spoilers. During touchdown, the latter did not deploy. The crew applied a nose-down input which resulted, for a short period of less than one second, in unusually heavy loading of the nose gear. The aeroplane exited the runway to the left, hit some trees and caught fire. The Investigator’s Conclusions The BEA concluded: The runway excursion was the result of an orientation to the left of the nose gear and the inability of the crew to recover from a situation for which it had not been trained. The investigation revealed inadequate pre-flight preparation, checklists that were not carried out fully and in an appropriate manner. A possible link between the high load on the nose gear and its orientation to the left was not demonstrated. In particular they explain: Forgetting to arm the ground spoilers delayed the deployment of the thrust reversers despite their selection. Several MASTER WARNING alarms were triggered and the deceleration was low. The crew then responded by applying a strong nose-down input in order to make sure that the aeroplane stayed in contact with the ground, resulting in unusually high load for a brief moment on the nose gear. After that, the nose gear wheels deviated to the left as a result of a left input on the tiller or a failure in the steering system. It was not possible to establish a formal link between the high load on the nose gear and this possible failure. The crew was then unable to avoid the runway excursion at high speed and the collision with trees. The aerodrome fire-fighter, alone at the time of the intervention, was unable to bring the fire under control after the impact. Although...
read moreAAIB Report on Glasgow Police EC135T2+ Clutha Helicopter Accident
AAIB Report on Glasgow Police Scotland Airbus EC135T2+ Helicopter Clutha Accident (Bond [now Babcock] G-SPAO) The UK Air Accidents Investigation Branch (AAIB) has published their report (which has since been subject to minor corrections) into the fatal accident involving a Airbus Helicopters (formerly Eurocopter) EC135T2+ G-SPAO. It crashed onto the Clutha Vaults Bar in Glasgow, Scotland on the night of Saturday 29 November 2013. The helicopter was operated under a UK CAA issued Police Air Operator’s Certificate by Bond Air Services for Police Scotland. In addition to the pilot and two police observers, seven people in the packed bar died. The Flight The AAIB report: The helicopter departed Glasgow City Heliport (GCH [then located at Stobcross Quay alongside the River Clyde]) at 2044 hrs on 29 November 2013, in support of Police Scotland operations. On board were the pilot and two Police Observers. After their initial task, south of Glasgow City Centre [at Oatlands, 2 nm from GCH], they completed four more tasks; one in Dalkeith, Midlothian [south of Edinburgh], and three others to the east of Glasgow, before routing back towards the heliport. When the helicopter was about 2.7 nm from GCH, the right engine flamed out [at around 22:21:40]. They note that the single engine emergency shutdown checklist was not completed. Shortly [~32s] afterwards, the left engine also flamed out. An autorotation, flare recovery and landing were not achieved and the helicopter descended at a high rate onto the roof of the Clutha Vaults Bar, which collapsed. The three occupants in the helicopter and seven people in the bar were fatally injured. Eleven others in the bar were seriously injured. Organisational Matters, Police Observers & Operational Tasking Police Scotland is the UK’s second largest police service. It was formed in 1 April 2013, from the merger of 8 regional forces and several specialist agencies, but has not been without controversy and the Chief Constable has recently resigned. Originally the Glasgow based helicopter had been a Strathclyde Police asset, Strathclyde being the region of Scotland around Glasgow. The helicopter is tasked by the Police Scotland control room with, typically short-notice, ‘non-routine’ tasks. An inventory of ‘routine’ tasks is contained in a folder available to the crew. The AAIB report that: The primary duties of the front seat observer [FSO] are the operation of the FLIR Television/IR camera, to assist the pilot and rear seat observer [RSO] with navigation, using visual references and maps, and to assist the pilot as and when directed. The primary duties of the rear seat observer are the navigation to and from each task, utilising police role equipment and navigational aids, and Police radio communications. The front seat observer normally assumes ‘operational command’ of the tasking of the aircraft. However, when two experienced observers fly together, the more experienced observer will normally assume operational command in relation to the tasking of the helicopter. Given that both observers were experienced it is likely that they would alternate operational command. However, it is not known who had operational command on the accident flight. In addition to their other training, police observers undergo recurrent Crew Resource Management (CRM) training. The specific CRM training is not identified but BAS do market such training. While part of the crew, as they have specific in-flight tasks, the UK CAA treat police observers as passengers. Police tactical communication is by the emergency services Airwave secure radio, which is recorded. The...
read moreMisloading Caused Fatal 2013 DHC-3 Otter Accident
Misloading Caused Fatal 2013 DHC-3 Otter Accident The US National Transportation Safety Board (NTSB) investigation into a fatal accident to Rediske Air de Havilland DHC-3T Otter N93PC in Soldotna, Alaska on 7 July 2013, has determined it was caused by misloading. A passenger iPhone video of the aircraft’s take-off was recovered from the wreckage and analysed. The full report can be found here. Shortly after take-off: …the airplane’s angle of attack continually increased as the airplane’s airspeed decreased from about 68 mph to about 44 mph over a period of about 8.5 seconds. About 11 seconds after takeoff, airspeed and angle of attack reached values consistent with an aerodynamic stall. The airplane rolled right-wing-down and impacted the ground several seconds later. (a) Camera Orientation Estimation – A/c Reference Points Aligned with Image (b) A/c Location and Orientation Estimation – Ground Reference Points Aligned with Image (Credit: NTSB) Estimated Speed, Altitude and Pitch Angle (Credit: NTSB) The cabin was destroyed by the impact and a post-crash fire. The pilot and nine passengers aboard the 16 seat aircraft were fatally injured. The NTSB say (emphasis added): Before picking up the nine passengers, the pilot loaded the accident airplane at the operator’s base in Nikiski with cargo (food and supplies for the lodge). The operator of the lodge where the passengers were headed estimated the cargo weighed about 300 pounds (lbs) and that the passengers’ baggage weighed about 80 lbs. Estimates of the passengers’ weights were provided to the lodge operator in preparation for the trip, which totalled 1,350 lbs. The load manifest listed each of these weight estimates for a total weight of 1,730 lbs and did not contain any balance data. The cargo was not weighed, and the pilot did not document any weight and balance calculations nor was he required to do so. The weight of the cargo recovered from the crash site, and determination of the weight of cargo destroyed in the impact and post-crash fire, showed the cargo weight was about 418 pounds higher than the cargo weight stated on the load manifest, resulting in a center of gravity aft of the limits for the airplane. Neither 14 CFR Part 135 (as 14 CFR 135.63(c) does not apply to single engined aircraft) nor the operator’s operations specifications required that aircraft weight and balance actually be documented. The NTSB determined the probable cause to be: The operator’s failure to determine the actual cargo weight, leading to the loading and operation of the airplane outside of the weight and center of gravity limits contained in the airplane flight manual, which resulted in an aerodynamic stall. Contributing to the accident was the Federal Aviation Administration’s failure to require weight and balance documentation for each flight in 14 Code of Federal Regulations Part 135 single-engine operations. This accident again demonstrated the investigative value of video footage and that small consumer devices can survive impacts and fires. Comment It also demonstrates the vital importance of correct loading and weight & balance. Aerossurance has previously written about a misloaded Pilatus PC-12 were pitch control lost on take off resulting in a series of pitch oscillations and stall warnings, but fortuitously only damage to one wheel: Wait to Weight & Balance – Lessons from a Loss of Control. Loading issues also featured in this Canadian accident: Culture + Non Compliance +...
read moreEASA Annual Safety Review 2014 Published
EASA Annual Safety Review 2014 Published The European Aviation Safety Agency (EASA) Annual Safety Review for 2014 is now available at: https://www.easa.europa.eu/newsroom-and-events/general-publications/annual-safety-review-2014 Worldwide in 2014, 16 fatal accidents involved Commercial Air Transport (CAT) aeroplanes (excluding MH17, that was considered to be a hostile act). This was two more than 2014, but still significantly below the average number of fatal accidents for the previous 10 years (2004-2013). The number of fatalities however rose from 185 in 2013 to 648 in 2014. In the foreword EASA Executive Director Patrick Ky comments: 2014 has been a very challenging year for the European Aviation Safety Agency (EASA) and for aviation safety in general. The disappearance of Malaysia Airlines MH370, the dramatic loss of MH17, the crash of Air Asia [Indonesia] QZ8501 and the radar interferences over central Europe have reminded us that the safety of passengers can never be taken for granted. Commercial Air Transport Aeroplane Performance In the 32 EASA Member States (the 28 European Union Member States plus Iceland, Liechtenstein, Norway and Switzerland) there was one fatal CAT Aeroplane accident (MD-83 EC-LTV operated by Spanish airline Swiftair in Mali on 24 July 2014, resulting in 116 fatalities). There were 26 non-fatal accidents (up from 22 the previous year) and 66 serious incidents (down from 74). In the EASA Member States, no more than one fatal accident CAT Aeroplane accident has occurred per annum since 2005 (with none in 2010 and 2013). EASA has identified the 5 top risk areas for CAT Aeroplanes as: Loss of Control – Inflight (LOC-I in the CAST/ICAO Common Taxonomy Team [CICTT] taxonomy) System Component Failure (SCF = SCF-PP + SCF-NP) Airprox / Mid air Collision (MAC) Abnormal Runway Contact / Runway Excursions (ARC/RE) Ground Collisions / Ground Handling (GCOL/RAMP) Interestingly Controlled Flight into Terrain CFIT does not make the list. Commercial Air Transport Helicopter Performance EASA say 2014 was a better year for CAT Helicopter safety: There was 1 fatal accident in 2014 resulting in 2 fatalities. This is compared with 3 fatal accidents in 2013,resulting in 11 fatalities. There was also a 34% reduction in the number of non-fatal accidents and a 71% reduction in serious incidents compared with the 10 year average. Based on the past fatal accident history the top 5 helicopter risk areas, in descending order, are SCF, LOC-I, CTOL, CFIT and ARC (although Low Altitude Operation, LALT and ARC are very close). General Aviation Performance 2014 has also been a positive year for General Aviation safety, with a 20% reduction in the number of fatal accidents and an 18% reduction in the number of fatalities when compared with the 10 year average. However, there were still 173 fatalities in General Aviation, highlighting the importance of the continued safety improvement efforts. Strategic Safety Matters Patrick Ky also noted the agency is moving to a “more proportionate and performance-based approach to safety” with an reorganisation that creates : A new Strategy and Safety Management Directorate…to develop a single, more transparent, evidence-based and data-driven strategy, which will drive the Agency’s work programme. The rulemaking activities were incorporated into ‘operational’ directorates, in order to increase synergies and to benefit from a better and direct operational feedback. This year’s review includes more detailed analyses of the causes of safety occurrences. It also starts to include Sector Safety Risk Portfolios. These will directly support the European Aviation Safety Plan (EASp) which is being...
read moreAircraft Maintenance: Going for Gold?
Aircraft Maintenance: Going for Gold? We pose the question: Can aviation maintenance learn lessons from championship athletes? Aerossurance is pleased to have sponsored the Royal Aeronautical Society (RAeS) conference Human Factors in Engineering – the Next Generation at Cranfield University on 12 May 2015. In his opening address Cranfield University’s Professor Dave King (a former Chief Inspector of Air Accidents with the UK Air Accidents Investigation Branch [AAIB]) made the point that after a generation of attention on maintenance errors, similar occurrences were still repeating. Professor King challenged the audience to think about a next generation approach to human factors in engineering. Over the last 10-15 years, much attention has been focused on maintenance human factors training, reporting errors, investigating errors (for example using Boeing’s MEDA) and taking corrective actions. While we could concentrate on simply doing more of these and certainly can find ways to do these things better, perhaps the next generation approach needs to include a wider range of activities. For example, the UK Civil Aviation Authority (CAA) has commented that: Human Factors training alone is not considered sufficient to minimise maintenance error. Most of the [contributing factors] can be attributed to the safety culture and associated behaviours of the organisation. Perhaps we should we start treating maintenance personnel more like athletes who need to achieve peak performance every day? During a similar time frame British Cycling has gone from a historically rather lacklustre performance, for example wining two bronze medals in the 1996 Olympics, to producing spectacular performances. By the London 2012 Olympics, Britain was ranked number one in the world and British riders won 12 medals, including 8 of the available 14 gold medals, with Sir Chris Hoy winning a UK record 6th gold medal. The same year Sir Bradley Wiggins became the first Briton to win the Tour de France, a feat repeated in 2013 and 2015 by Chris Froome. There have been many reasons for this, not least the availability of funding from the National Lottery to support deserving British sports. However, this success is not just due to investment, but to talent, individual commitment and a highly effective strategy for improving performance. Much of the latter has been credited to Sir Dave Brailsford, first performance director of British Cycling (until 2014) and since 2010 general manager of Team Sky. Brailsford, who describes himself as a conductor not a manager, says: Sport is about continuous improvement, it’s about getting better. It’s about being better next year than you are this year. It’s a bit like Formula One. You have a car and the designers might say ‘we can’t think how we’re going to make this any better’. But ultimately you can. And that’s what we’ve got to do. We’ve got to keep looking, researching and working – trying things. And that’s what it’s all about. One of the more quotable examples is his concept of ‘marginal gains’ (very much akin to a Japanese kaizen philosophy). Brailsford advocates a near obsessive attention to detail, to focus on every element that can affect human performance, seeking out opportunities to make small improvements, that collectively lead to noticeable performance improvement. This includes the ‘secret squirrel club’ dedicated to technological advances to enhance human performance (even hi-tech socks). UPDATE 15 August 2016: To understand just how far the obsession with marginal gains went for Rio 2016 read: How scientific rigour helped Team GB’s saddle sore cyclists on their...
read moreFatal Night-time UK AW139 Accident Highlights Business Aviation Safety Lessons
Fatal Night-time UK AW139 Accident Highlights Business Aviation Safety Lessons The UK Air Accidents Investigation Branch (AAIB) has published their report into the fatal accident to AgustaWestland AW139 G-LBAL on 13 March 2014. This accident reinforces many important past lessons on business aviation safety, managing clients, training, human factors and learning from previous accidents. The helicopter, owned by Haughey Air, departed from a private site near Gillingham Hall, Norfolk, UK with little nearby cultural lighting, at night and in fog, impacting the ground shortly after. The four occupants, including millionaire Northern Irish peer Edward Haughey, Baron Ballyedmond (Chairman and CEO of Norbrook), were all fatally injured. Pre-Flight Preparation and the Take-off The AAIB note that the crew had been monitoring the deteriorating weather that afternoon and that while departure had been planned for 18:30, the passengers had not been ready until 19:20. At least one of the crew was concerned according to the Cockpit Voice Recorder (CVR) transcript: One said: “[unintelligible] i don’t mind telling you i’m not **** very happy about lifting out of here”. The other replied: “it should be ok it’s… i don’t think it is because you can still see the moon”. The Commander (the Pilot Flying) had briefed for a vertical departure, but shortly after the helicopter pitched progressively nose-down. The Co-Pilot twice said ‘Nose Low’. The AAIB could not determine if these were to highlight the nose-down pitch attitude or prompt for more nose-down pitch. In both cases they were however followed by a further nose-down pitch. The last nose-down pitch attitude recorded by the combined voice and flight data recorder (CVFDR) was 25° with the helicopter 82 ft above the ground, descending at 2,400 ft/min, with a ground speed of 90 kt. The aircraft was destroyed in the impact with the ground. The AAIB discuss Somatogravic Illusions and possibly misidentify headlights on a car as as static lights. Organisational Factors, a Past Accident and Safety Management Haughey Air (a subsidiary of Norbrook Laboratories) had been formed in 1993 and had held an Air Operators Certificate (AOC) until 2008. During this period Norbrook had suffered another accident, while privately using Sikorsky S-76B G-HAUG in Ireland on 12 December 1996. Having examined the Irish Air Accident Investigation Unit (AAIU) report on that accident, the UK AAIB comment: Similarities exist between the causal factors determined in that case and those around the loss of G-LBAL. The AAIU found that the primary cause of the accident to G-HAUG was ‘loss of situational awareness’ on the part of the pilot flying, and it is apparent that the pilot or pilots of G-LBAL experienced a similar condition. This suggests a failure to learn (a topic Aerossurance has discussed recently). Regulations The AAIB note that: In the absence of an AOC, there was no regulatory requirement for an operations manual or safety management system for private flying. Some evidence suggested that an operations manual, including type-specific matters, procedures to be employed by pilots flying together, such as briefings and standard calls, and a safety management system had existed, at least in draft form, in recent years, but none was in use at the time of the accident. Although in this case it appears the draft material had not progressed to publishing, we have previously written about ‘safety shelfware’, where policies and procedures are documented but in practice either ignored or ineffective. The European Aviation Safety Agency (EASA) has published Part NCC, covering...
read moreBA Changes Briefings, Simulator Training and Chart Provider After B747 Accident
BA Changes Briefings, Simulator Training and Chart Provider After B747 Accident According to a recently released UK Civil Aviation Authority (UK CAA) FACTOR (Follow-up ACTion on Occurrence Report), British Airways (BA) have enhanced their simulator training and changed chart provider in response to a ground accident in South Africa. The Accident On 22 December 2013, BA G-BNLL sustained substantial damage when its right wing hit a building while taxying at Johannesburg-O.R. Tambo International Airport (JNB). Four people in the building were injured by flying debris. The crew had originally expected that they would be using a different route after pushback (another example of the risks of late changes in plan which we have recently written about). The South African Civil Aviation Authority (SA CAA) summarise the Captain’s statement in their report (South Africa does not have a separate air accident investigation body but does have an separate department within the CAA): The aircraft remained on what was perceived to be still taxiway Bravo. The taxiway edge lights illuminated in a continuous straight line with no signage indicating the change of the two taxiways Bravo & Mike. Also, some of the green centreline lights on taxiway Bravo were not illuminated in sequence thus leading to a false perception that the aircraft is still on taxiway Bravo. …while going through the before take-off procedure and checklist, after we entered the taxiway Mike, the Co-pilot voiced a concern about the width of the taxiway Mike and proximity of the building on the right side of the taxiway. The Co-pilot could not judge the proximity of the aircraft from the building because of the strong apron background glare. The SACAA concluded that the cause was: The loss of situational awareness caused the crew to taxi straight ahead on the wrong path, crossing the intersection/junction of Bravo and Mike instead of following Bravo where it turns off to the right and leads to the Category 2 holding point. Following aircraft stand taxilane Mike; they collided with a building on the righthand side of Mike. They identified the following contributory factors: The crew did not conduct a briefing to discuss the cleared route, nor did they refer to the correct taxiway information in chart 10-6. In combination with the ground movement visual aids, this created confusion and loss of situational awareness when taxiing on taxiway Bravo. The SA CAA Safety Recommendations The SA CAA raised 10 recommendations, which did include important recommendations on airport markings/lighting and their inspection by the SA CAA. Two recommendations were directed to the UK Air Accidents Investigation Branch (AAIB). These however were picked up by UK CAA and the subject of FACTOR F4/2015: Briefings / Simulator Training SA CAA recommended: …AAIB enter into consultations with the operator (British Airways) about the crew’s non-adherence to applicable briefing and taxi policies, procedures and requirements. The AAIB to communicate to AIID what the appropriate corrective action shall be to prevent recurrence. The UK CAA report that a new training package, including simulator exercises, has been designed and delivered to all BA crews. The package, designed by the Human Factors Standards Group (HSFG) in conjunction with fleet Training Standards Captains (TSCs) from a variety of BA fleets, consists of a non type specific human factors briefing that discusses decision-making and change identification. This is followed by Full Flight Simulator exercises to put into practice the human factors briefing....
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