UK CAA to Review IFR Ops Outside of Controlled Airspace
UK CAA to Review IFR Ops Outside of Controlled Airspace The UK Civil Aviation Authority (CAA) has announced it plans an enhanced review of Instrument Flight Rules (IFR) flying outside of controlled airspace. This is in response to a UK Air Accidents Investigation Branch (AAIB) recommendation in their final report on a serious incident involving a chartered executive Sikorsky S-76C++ G-WIWI in East Sussex on3 May 2012: Safety Recommendation 2014-35: It is recommended that the Civil Aviation Authority review the regulations that permit a helicopter engaged in public transport operations to descend below MSA for the purpose of landing, when flying in instrument meteorological conditions but not on a published approach procedure. The review will be “broader and deeper” than originally planned based on feedback from the British Helicopter Association and an unnamed on-going accident investigation (most likely AgustaWestland AW139 G-LBAL, which crashed on a night take off in Norfolk in March 2014 UPDATE 11 Oct 2015: We discuss the AAIB report on that accident here: Fatal Night-time UK AW139 Accident Highlights Business Aviation Safety Lessons). In the S-76C++ serious incident the helicopter descended towards tree tops after a discontinued night approach to a private landing site. The occurrence gained tabloid press attention because Sir Paul McCartney was aboard. In their report AAIB concluded: The descent from above the minimum safe altitude was conducted in reduced visibility and low cloud conditions into an area with limited visual references. The helicopter was therefore brought close to terrain in an environment in which situational awareness could become degraded easily. The decision to execute an orbit around the landing site, in the circumstances pertaining, further increased the chances of situational awareness becoming degraded, whilst the helicopter was at low height above unlit and undulating terrain. In the course of the orbit, the commander became spatially disorientated and the helicopter descended towards the tops of trees. Although the EGPWS issued warnings that the helicopter was approaching contact with the ground, the flight crew were not aware of these warnings. The CAA review will be ‘multi-disciplinary’ and currently only may involve industry. It is due to report in October 2015. Aerossurance recently covered two Night Time HEMS Accidents in the US in March 2013. For expert advice on helicopter safety, operations and accident analysis, contact: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest updates. ...
read moreWhat Leaks in Vegas Stays in Vegas – A320 Hydraulic Failure
What Leaks in Vegas Stays in Vegas – A320 Hydraulic Failure The National Transportation Safety Board (NTSB) has recently issued a report on a Airbus A320 hydraulic failure incident. On 17 June 2012, a JetBlue Airways A320-232, N552JB, experienced a loss of two of its three hydraulic systems after departure from Las Vegas McCarran International Airport. This incident is interesting because of the failure modes and effects, automation, crew workload and Service Bulletin assessment issues. The Flight Before departure an inoperative slat flap control system (SFCS) number 2 flap channel was legitimately deferred in accordance with the Federal Aviation Administration (FAA) approved Minimum Equipment List. The NTSB report that: During landing gear retraction after takeoff, the Green hydraulic system on the airplane lost pressure, and the flight warning computer detected a flight control flaps system fault followed by a reservoir overheat condition for the Yellow hydraulic system 2 minutes later. The Blue hydraulic system was unaffected. However: Normal inhibition of alerts and warnings from the flight warning computer prevented notification of the faults to the flight crew until the airplane was climbing out of 1,500 above ground level. The crew subsequently experienced a period of high workload as they received multiple aural and visual warnings on the flight deck. At this point: The captain, who was the pilot flying, transferred airplane control to the first officer and began to accomplish the abnormal procedures that were displayed on the electronic centralized aircraft monitor. These procedures included turning off the engine-driven pumps for both the Green and Yellow hydraulic systems and the power transfer unit (PTU) which can mechanically exchange power between the Green and Yellow systems. This resulted in: Low pressure in the Yellow hydraulic system (leaving only the Blue hydraulic system with useable pressure) Reversion to the alternate flight control law with reduced flight envelope protections (most critically, stall protection) Autopilot and autothrust disconnection. The NTSB report that: The crew attempted to raise the flaps from position 1 (the takeoff position) to 0, but the flaps remained at position 1 because the loss of the Green hydraulic system and subsequent loss of the remaining flap control computer channel resulted in the flaps being inoperable. The crew entered a holding pattern at 12,000 feet. With two inoperative hydraulic systems and the flap fault, the required landing distance was 11,000 feet. The captain recognized that the Yellow hydraulic system reservoir was no longer overheating and so was able to restore the Yellow system, which reduced the required landing distance to about 8,500 feet. Concerned about the high landing speed and the inability to raise the gear if they did need to go-around the crew remained in a holding pattern to burn fuel and made a safe landing 3 hours 35 minutes after takeoff. The Investigation A leak was found in the Green hydraulic system. The right main landing gear door retraction flexible pipe had failed due to a kink and collapsed sidewall. The NTSB note that: An article in the June 2007 issue of Safety First, Airbus’ safety magazine… described a scenario in which a leak in the Green hydraulic system results in that system’s loss of fluid, which can lead to the loss of the Yellow hydraulic system. As the hydraulic pressure decreases and reaches a 500 psi differential between the Green and Yellow system, the PTU, by design, automatically activates and operates at maximum speed in an effort...
read moreUS HEMS “Delays & Oversight Challenges” – IG Report
US Helicopter Emergency Medical Service (HEMS) “Delays & Oversight Challenges” – Inspector General Report We recently published an article on two March 2015 night-time US HEMS accidents. This month the US Department of Transportation’s Inspector General has released a report entitled: Delays in Meeting Statutory Requirements and Oversight Challenges Reduce FAA’s Opportunities To Enhance HEMS Safety The Office of Inspector General works within the DoT to “promote effectiveness and head off, or stop, waste, fraud and abuse in departmental programs”. They say: The Helicopter Emergency Medical Services (HEMS) industry safely transports over 400,000 patients in the United States each year, frequently in challenging conditions, including night flight, poor weather, low visibility, and landing at unfamiliar accident sites. The industry has grown significantly in the last few decades, with more than 1,500 specialized air medical helicopters used by 75 different companies in 2014. As the industry has grown, so has the number of accidents, and the Federal Aviation Administration (FAA) and Congress continue to seek ways to enhance safety in the HEMS industry. FAA issued a final HEMS rule in February 2014, and Congress passed the FAA Modernization and Reform Act of 2012 (FMRA). In light of these efforts, the Ranking Member of the House Aviation Subcommittee requested that we review FAA’s progress in improving air ambulance safety. They go on: While FAA’s recently issued HEMS rule is a good first step toward realizing FMRA goals, continued delays in finalizing the remaining congressional mandates affect FAA’s ability to focus its accident reduction efforts and limit the effectiveness of safety initiatives. Additionally, until FAA updates key oversight policies and obtains meaningful safety data to analyze for trends, it will not be well positioned to effectively oversee a rapidly expanding HEMS industry. In particular: FAA met or partially met three of the six major FMRA safety requirements for HEMS operators but has not completed the remaining three requirements involving safety data collection. Specifically, FAA completed a night vision goggle study, issued a HEMS rule implementing new operational procedures and additional equipment requirements, and initiated a second HEMS rule requiring improved training standards and additional safety equipment for crews and passengers. While FAA completed the requirements for both rules, the first rule was nearly 2 years late, and neither rule has been fully implemented. Therefore, the industry is not yet benefitting from the rules’ provisions. Additionally, FAA did not complete the remaining three requirements for collecting, storing, and reporting HEMS-specific operations data. FAA has issued a notice to the industry that it will require operators to report operational data; however it did not meet the February 2013 congressionally mandated deadline to start this action. Therefore, FAA is currently not in the position to report its data gathering efforts to Congress, though it was required to do so starting in February 2014. Continued delays in meeting statutory deadlines will postpone enhancements needed to improve safety in the HEMS industry. The IG has made five recommendations to the FAA: 1. Develop helicopter-specific accident reduction goals and communicate them in FAA planning documents and business plans. 2. Expand the criteria for dedicated certificate management teams and use of SEP [Surveillance and Evaluation Program] for HEMS operators with 20 to 24 aircraft [note – currently only used for operators with >25]. 3. Conduct a workforce assessment that includes a determination of whether:...
read moreHuman Factors in Engineering – the Next Generation (12 May 2015)
Human Factors in Engineering – the Next Generation Aerossurance is pleased to be one of the sponsors of a Royal Aeronautical Society (RAeS) Human Factors Group: Engineering conference on 12 May 2015 at Cranfield University entitled Human Factors in Engineering – the Next Generation: This one day conference aims to bring together industry professionals and a new generation of engineers and maintenance professionals to promote a common understanding of Human Factors. It will also highlight successful interventions in managing human factors related risks in engineering and maintenance. The conference aims to gain a closer connectivity between the new generation of aerospace professionals and experienced human factors practitioners, as well as a greater shared understanding of the impact of human factors The programme includes presentations from speakers from Cranfield University, the Civil Aviation Authority, the Royal Air Force, EasyJet and Rolls-Royce, plus two workshop sessions, each with a choice of 4 different topics. The event has been priced very reasonably with prices ranging from £100 for non-members to just £35 for students & apprentices (excluding VAT). With just 4 weeks to go book now to avoid missing out. Aerossurance has previously written about a number of engineering HF issues: Professor James Reason’s 12 Principles of Error Management How To Develop Your Organisation’s Safety Culture Fatal $16 Million Maintenance Errors Technical Records – Component Overrun Inadvertent Fire Bottle Discharge During Maintenance FOD Damages 737 Flying Controls For support on maintenance human factors, continuing airworthiness management and safety assurance, contact Aerossurance: enquiries@aerossurance.com Follow us on LinkedIn for our latest...
read morePsychological Screening of Flight Crew
Psychological Screening of Flight Crew The circumstances of the recent loss of Germanwings Airbus A320 D-AIPX in the French Alps on 24 March 2015 has thrown attention on how the mental health of pilots and others in safety critical positions is assessed. Tony Tyler, CEO of the airline trade body International Air Transport Association (IATA), said on Tuesday: The issue of psychological screening, psychological testing, the evaluation of the mental state of not only pilots but others in the safety value chain as it were, will no doubt be something that has to be considered.… There has been a lot of work done on health care requirements for the crew, but I think people will start looking at these issues now with fresh eyes. We need to draw all the knowledge that we currently have and consider what we need to do about it. Aviation Safety Network has recently published a list of commercial airline accidents and serious incidents where pilot suicide (intended or actual) is believed to have been a factor. While the probability of such an event remains low, they do have the potential to kill large numbers of people in the air and/or on the ground. The increase in the number of suspected cases involving airliners in the last three years is therefore particularly concerning. Of the 7,244 fatal aircraft accidents of all types in the United States from 1993 through 2012, 24 (all involving private aircraft) were the result of aircraft-assisted suicide, according to a study published in the journal Aviation, Space and Environmental Medicine in 2014. An earlier 2005 study examined US general aviation accidents between 1983-2003. During that time, 37 pilots either committed or attempted suicide by aircraft with 36 cases resulting in one or more fatality. In that study: 100% of the pilots were male and pretty equally balance between those aged <40 and >40 38% of the pilots had known psychiatric problems 40% of the suicides or attempts were linked to legal troubles 46%, were linked to domestic or social problems 24% of the cases involved alcohol 14% involved illicit drugs 24% involved aircraft taken illicitly. A 1998 study examined UK general aviation accidents between 1970 and 1996: A review was undertaken of 415 general aviation accidents. Three were definite cases of suicide and in another seven it seemed possible that the deceased had taken their own lives. Therefore, in the United Kingdom, suicide definitely accounts for 0.72% of general aviation accidents and possibly for more than 2.4%. The latter accords more closely with the findings from Germany than from the United States. Previous psychiatric or domestic problems and alcohol misuse are features of these cases. Aerobatics before the final impact is another frequent finding. A 1993 study in Germany concluded: Approximately 2-3% of all fatal air accidents may be attributed to suicide, and in many other accidents in aviation there are grounds for inferring that self-destructive or suicidal behaviour was involved. Narcissistic personality traits are of paramount importance for the choice of this suicide method. The lessons from private flying do not automatically read across to commercial aviation but Alpo Vuorio MD PhD, author of the 2014 study and an aviation specialist in occupational medicine at the Mehiläinen Airport Health Centre in Finland is quoted by Time magazine as saying: I really wish that we had some kind of deeper...
read moreAW169 Update
AW169 Update Launched at Farnborough International 2010, the 4.5t AgustaWestland AW169 is progressing towards certification and entry-into-service which AW describes as being “in a few months’ time”. Currently orders for nearly 150 AW169’s have been placed by customers for a range of applications including corporate transport, air ambulance and law enforcement. Flight Test The four AW169 prototypes performed their maiden flights in May 2012, July 2012, November 2012 and January 2013 respectively. Certification had been expected in late 2014. As inevitable with new designs changes have been made during development flying. According to Flight International in October 2013: …modifications to the flight-test aircraft include the addition of a pair of fairings atop the engine cover aft of the main rotor mast. One of them – dubbed the “horse’s collar” – runs along the edge of the cover, while the second, a comb-shaped component, sits immediately aft of the mast. The fairings are designed to prevent tail shake through changing the path of the rotor wash. The exhaust ports have additionally been turned outboard by 10˚ to prevent overheating of a section of the AW169’s composite tail boom. This temperature anomaly manifested itself on the port side of the tail during lateral flights or with crosswinds in hot conditions, says the manufacturer. The third prototype, I-AWCG, was on show at the HAI Heli-Expo in Orlando in March 2015. It had arrived from Alaska where it had been undergoing cold weather trials. I-AWCG was put on show still with extensive flight test instrumentation (FTI). For example the tail boom was heavily strain gauged. Family AW are marketing the AW169, powered by two Pratt & Whitney Canada PW210A 1100shp turboshafts, as the smallest of a ‘family’ of similar designs, alongside the popular AW139 (now certified at 7t and with over 700 in service) and the 8.6t AW189, certified in 2014. AW claim the trio “share the same common cockpit concept and design philosophy”. https://www.youtube.com/watch?feature=player_detailpage&v=Jmdq7Pvf_CE The AW169 features three 10×8 inch Rockwell Collins displays with touchscreen controls. AW selected Rockwell Collins’ Helisure system in 2013 for a number of their product lines. Production AW169s will be produced both at Vergiate, Italy and at Philadelphia, Pennsylvania. The company’s Yeovil, UK plant is manufacturing a number of critical sub-assemblies for the AW169. Training On 31 March 2015, AgustaWestland announced the first AW169 Flight Training Device (FTD) had been certified. The certification, by a joint European Aviation Safety Agency (EASA) and Italian Civil Aviation Authority (ENAC) team, is to FTD Level 2 as per CS-FSTD(H), the EASA certification specification for Helicopter Flight Simulation Training Devices. This AW169 FTD at AW’s Marchetti Training Academy in Sesto Calende, Italy, has been designed and built by AW and operated by Rotorsim, a joint venture between CAE and AW. AW say that: The AW169 FTD features an AgustaWestland developed flight dynamic model, avionics and aircraft software modelling, and a high performance visual system with 150 degree by 60 degree field-of-view 12 ft (3.66 m) dome display system. The FTD will provide effective training for pilots in the use of automated flight data systems and various flight procedures including situational awareness and decision making under normal, abnormal and emergency conditions. This device will allow for credits for IFR Training and for the majority of malfunctions and emergency scenarios. Roles In the offshore role the aircraft has a D-value of 14.7m, which puts it...
read more1950’s Aerial Firefighting and Smokey Bear
1950’s Aerial Firefighting and Smokey Bear A look at aerial firefighting 60+ years ago: However, as per the background poster: If you really feel the need to sing along to Smokey Bear we are happy to oblige: https://youtu.be/sfgWbhPYFGI But while in the song it is Smokey THE Bear (to scan better), the Smokey Bear Act of 1952 (16 U.S.C. 580 (p-2); 18 U.S.C. 711) is a federal law to protect Smokey Bear. We couldn’t make this up…! Seriously though Smokey Bear is the longest running public service advertising campaign in US Ad Council history: Safety Resources For more on carefully crafting safety messages see our article: Mastering the Message: Transform Your Safety Communication Plus more on the conversion of the latest fire-fighting aircraft: BAe 146 & Avro RJ85 Fire Bombers UPDATE 30 August 2016: As the US National Parks turn 100 Vintage films show risky (and hilarious) behaviour in US national parks UPDATE 28 July 2018: Wayward Window: Fatal Loss of a Fire-Fighting Helicopter in NZ UPDATE 1 December 2018: Helicopter Tail Rotor Strike from Firefighting Bucket For expert advice on both special mission aircraft and safety promotion, contact ever versatile Aerossurance at enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest...
read moreMore US Night HEMS Accidents
More US Night Helicopter Emergency Medical Service (HEMS) Accidents At the beginning of March 2015 we published an article on the aftermath of a 2003 fatal night-time US HEMS accident: Life Flight 6 – US HEMS Post Accident Review. During March 2015 there were two more fatal night-time medical helicopter accidents in the US. Air Methods EC130B4 6 March 2015 St Louis The first accident was during a night-time, post-fuelling, positioning flight, which killed the pilot, the sole person on-board. The US National Transportation Safety Board (NTSB) preliminary report states: On March 6, 2015, at 2310 central standard time, an Airbus Helicopters (Eurocopter) EC130-B4, N356AM, operated by Air Methods (doing business as ARCH), struck the edge of a hospital building and impacted its parking lot during a visual approach to the St Louis University Hospital elevated rooftop helipad (MO55), St Louis, Missouri. During the approach, the helicopter experienced a loss of directional control and entered an uncontrolled descent. The helicopter was destroyed by impact forces and a post-crash fire. The commercial pilot, who was the sole occupant, sustained fatal injuries. The helicopter was operated under Title 14 CFR Part 91 as an air medical positioning flight that was operating on a company flight plan. Night visual meteorological conditions prevailed at the time of the accident. The flight was returning to MO55 after it had been refueled at the operator’s base in St. Louis, Missouri. The flight’s first approach and landing at MO55 was to drop off a medic, nurse, and a patient. During the approach, the pilot reported to the flight nurse and medic that winds were gusting to 25 knots. The flight nurse stated that helicopter was yawing quite a bit and there was a noticeable roll side to side during landing. The helicopter landed without incident during the first approach and landing. The flight then departed to obtain fuel at the operator’s base and then departed to return to MO55, to pick up the medic and flight nurse. The accident occurred during the return’s approach for landing at MO55. Examination of the wreckage confirmed flight control continuity of the tail rotor drive system and there were indications consistent with engine power on the turbine wheel output shaft. There was a post crash fire. UPDATE 22 June 2016: The NTSB have now published their final report: A security video showed the helicopter on a northerly flightpath descending at about a 45-degree angle before impacting the ground and coming to rest on an approximate northerly heading. The pilot sustained fatal injuries due to the subsequent fuel tank fire/explosion, which otherwise would have been a survivable accident. A postaccident safety evaluation of the heliport showed that the final approach and takeoff area/safety area were obstructed by permanent and semi-permanent objects that pose a serious hazard to helicopter operations. These obstructions limited the available approach paths to the heliport, which precludes, at times, approaches and landings with a headwind. The helipad is privately owned; therefore, it is not subject to Federal Aviation Administration (FAA) certification or regulation. A review of the helicopter’s flight manual revealed that there were no wind speed/azimuth limitations or suggested information available to pilots to base the performance capabilities of the make and model helicopter in their flight planning/decision-making process. Examination of the helicopter revealed no anomalies that would have precluded normal operation...
read moreDe-Iced Drama: 737 in Scandinavia
De-Iced Drama : 737 in Scandinavia During the approach to the Finnish airport of Kittilä on 26 December 2012, Norwegian Air Shuttle‘s Boeing 737-800 LN-DYM came close to stalling as a result of a blocked elevator. The elevator system worked at only 1/250th of the expected effectiveness according to investigators. The Investigation The Accident Investigation Board Norway (AIBN – the Statens Havarikommisjon for Transport [SHT] in Norwegian) released their investigation report and three safety recommendation in March 2015. De-icing, with 3000l of fluid (unthickened Type I fluid) had been carried out prior to departure from Helsinki to remove about 25 cm of snow that had settled on the aircraft since it had last flown on 23 December 2012. The AIBN report that: As the aircraft was in the process of intercepting the glide slope, the elevator trim started to pitch the nose up. This trim continued for 12 seconds. At the same time, the aircraft started to unintentionally ascend while the autothrottle commanded full engine thrust. Both pilots eventually pushed the elevator control column with full force, but the aircraft’s nose continued to pitch up to an angle of +38.5° before slowly decreasing. The aircraft’s speed dropped to 118 kt (Calibrated Airspeed, CAS) and the Angle of Attack (AOA) reached a maximum of approximately 25°. The aircraft was thus close to stalling. The aircraft’s autopilot was disengaged just after the aircraft’s nose angle was at its highest. Control over the aircraft was slowly regained. A new approach was carried out without additional problems. The AIBN classified this occurrence as a Serious Incident noting: The aircraft was relatively low above the terrain and in clouds, and it would have been difficult for the pilots to regain control of the aircraft with an elevator system that did not function as intended. AIBN’s investigation determined that: …even after the introduction of new de-icing procedures from Boeing, considerable volumes of fluid and pertaining humidity are penetrating the Tail Cone Compartment during de-icing of the Boeing 737 aircraft type. The investigation shows fluid penetration toward the four Input cranks on the aircraft’s two Power Control Units. If this fluid freezes in the narrow gap between the Input cranks, this may result in blockage of the Power Control Units. This prevents operation of the elevator on Boeing 737 with potentially catastrophic outcome. The AIBN report features dramatic video of fluid pouring into the Tail Cone Compartment during trial de-icing of those revised procedures. AIBN also discuss Scandinavian experience with higher than normal elevator control loads and a case of Foreign Object Debris (FOD) that jammed a Power Control Unit (PCU) on a Turkish B737-400 in 2009. Safety Recommendations The AIBN have issued Recommendation SL 2015/01T to Boeing, /02T to the FAA and /03T to EASA. The last two relate to FAA and EASA ensuring Boeing conduct SL 2015/01T, namely: AIBN recommends that the aircraft manufacturer Boeing conduct a new safety assessment of the Boeing 737 aircraft type as regards blockage of the aircraft type’s elevator system, and establish measures in order to satisfy the requirements in FAR Part 25 § 25.671 and EASA CS-25 §25.671. Reporting and Assessment of Incidents The Commander did not make any entry in the Technical Log regarding the abnormality experience with the flying controls. The Commander said to AIBN that he had a telephone conversation with the airline’s...
read moreLoss of the Alexander Kielland
Loss of the Alexander Kielland The Norwegian semi-submersible floatel (floating hotel) Alexander L. Kielland capsized on 27 March 1980 when alongside Phillips Ekofisk Edda platform. The Kielland had lost one of its five legs in a severe, but not extreme, gale. At 18:30, a ‘sharp crack’ was heard followed by ‘some kind of trembling’. The floatel heeled over 30° but stabilised, held by one of the six anchor cables that did not break. The list continued to increase and at 18:53, the remaining anchor cable snapped and the rig capsized. Of the 212 people aboard, 123 were killed, making it the worst disaster in Norwegian maritime history since WWII and second only to Piper Alpha in North Sea oil disasters for loss of life. No-one was rescued by the standby vessel, which took an hour to reach the scene. One of the leg’s bracings had failed due to fatigue, thereby causing a succession of overload failures of the other bracings attached to that leg. During the resulting investigation it was determined that the weld of an hydrophone connection on the bracing had contained cracks since manufacture. The following factors contributed to the accident: Fabrication defect due to bad welding, inadequate inspection No fatigue design check carried out Codes did not require damage tolerance Damage stability rules did not cover loss of a column Failure to shut doors, ventilators etc. contributed to the rapid flooding and capsizing Evacuation not planned for an accident of this kind Lack of usable life boats & survival suits Long mobilizing time for rescue vessels/helicopters Following the accident command arrangements were dramatically improved and offshore based search and rescue (SAR) helicopters were introduced. Aerossurance has previously written on the: Increasing SAR Use by the Oil & Gas Industry On the 30th anniversary the Norwegian Petroleum Safety Authority (PSA) held a conference on the lessons. UPDATE 27 March 2020: Disaster led to important and lasting changes and Kielland at 40: new exhibition on the disaster UPDATE 9 August 2025: OceanGate Titan: Toxic Culture & Fatal Hubris Aerossurance is an Aberdeen based aviation consultancy. If you are considering introducing a SAR capability, Aerossurance can help you identify clear requirements, evaluate options, make informed decisions and navigate some of the pitfalls: enquiries@aerossurance.com Follow us on LinkedIn for our latest...
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