1950’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...
read moreFOD Damages 737 Flying Controls
Foreign Object Debris (FOD) Damages 737 Flying Controls Accident investigators in New Zealand report on damage to the flying controls of a 737 due to a trapped cleaning cloth. The Incident During routine maintenance of a Boeing 737-838, engineers found metal filings next to the stabilizer trim cable drum in the forward electronics and equipment compartment (located underneath the flight deck). While investigating further they found what they described as a cleaning ‘rag’ had been trapped in the windings on the forward cable drum. This foreign object had caused the stainless steel cable to bulge outward, contact the softer aluminium cable guides and the resulting wear had created the metal filings. In places the cables had worn right through the tubular aluminium spacer and had started to wear through the harder steel bolts that run through the spacers. The rag also resulted in increased cable tension, damaging a number of the cable pulleys between the front and rear drums. This occurrence was detected on 7 June 2013 on a B737 operated by New Zealand airline Jetconnect, a Qantas subsidiary, at Auckland International Airport. It was investigated by New Zealand’s Transport Accident Investigation Commission (TAIC). The Investigation In their investigation report, issued in March 2015, TAIC state, based on lab tests of the material, that it was “highly likely” the debris originated from the Qantas Sydney maintenance hangar. The ‘rag’ was actually a cellulosic or paper-based fibre and polypropylene material, consistent with one of the disposable tear-off paper roll products used at Sydney. TAIC concluded that: The integrity of the aeroplane’s stabiliser trim system manual control was compromised. Whilst considered unlikely, there was the potential for the stabiliser trim system manual control to become jammed or at worst disabled if a cable severed. Another Incident Interestingly Melbourne and Auckland sites use fabric rags which, due to their greater robustness, have a far greater potential to cause FOD events, such as jamming bell cranks, or jamming landing gear uplocks. The later was demonstrated by a subsequent incident involving a Jetconnect aircraft that had undergone maintenance at the Qantas Melbourne maintenance hangar in September 2013. TAIC did not investigate this incident but do comment on it: On 11 September 2013 a Jetconnect B737-838, registration ZK-ZQC, was involved in an incident that occurred during a flight to Wellington. The aeroplane had departed from Melbourne, where it had recently had maintenance carried out on the landing gear. After departing Melbourne the flight crew had difficulty raising the right main landing gear. The right main landing gear initially retracted but did not stay up, falling back down once the gear selector was moved to the off position. When the crew reselected the gear lever to the up position, the right main gear retracted and stayed up. After the aeroplane landed at Wellington the ground engineers inspected the landing gear and found a rag wrapped around the right main landing gear uplock assembly. Qantas… conducted a safety investigation into the second incident, which found that the rag had been used by an engineer to protect against an accidental head strike on the uplock during a maintenance task in the right main wheel well area. The rag was subsequently left on the uplock assembly after the maintenance task was completed, and it interfered with the retraction of the right main landing gear during the next flight. Safety Lessons TAIC make no recommendations but state, fairly self-evidently that the key lesson is that:...
read moreA320 Unstabilised Approaches: Descent Below MSA and a Runway Excursion at Lyon
A320 Unstabilised Approaches: A Descent Below Minimum Safe Altitude (MSA) and a Runway Excursion at Lyon An airline introducing a new type suffers a serious incident while training a new captain, highlighting the importance of Management of Change, Risk Assessment and good Training. UPDATE: Then within a year they have a runway excursion after an unstabilised approach at the same airfield. Descent Below MSA 2012 The French accident investigation agency, the Bureau d’Enquêtes et d’Analyses (BEA), has recently issued an English translation of a report into a Serious Incident involving a Greek Airbus A320 SX-BHV of Hermes Airlines, operated on behalf of charter carrier Air Mediterranee, on a night approach into Lyon on 11 April 2012. The Flight The flight had departed from Ajaccio, with the Captain as Pilot Non Flying (PNF) and instructor in the right-hand-side seat and a pilot-in-command under supervision as Pilot Flying (PF) in the left seat. The BEA comment: The failure to carry out checks of the RADIO NAV page on the FMGS [Flight Management Guidance System], which are normally carried out when passing FL100 in a climb and during approach preparation, did not allow the crew to detect that the FMGS had not automatically selected the ILS for runway 36L at Lyons Saint-Exupéry and that the Ajaccio AC ILS was still active on arrival. The crew had been expecting an ILS approach to runway 18L, however as they neared Lyon the approach controller reported low winds and suggested an ILS approach to runway 36L instead, which was accepted by the crew. The BEA go on: About one minute after the beginning of radar vectoring, the controller, who realized that the aeroplane was high on the glide, asked “…forty nautical […] is that OK for you, four zero?”. The crew, while programming the FMGS for an ILS approach to runway 36L, answered “Actually we… we’ll need to make a thirty six”. The controller, who interpreted the response of the crew as a confirmation of a landing on runway 36, did not understand that the crew wanted to make a late turn onto heading 360. He provided a heading of 315° to the localiser axis for runway 36L. As the Ajaccio AC ILS had not been deselected, the FMGS did not automatically select the ILS for runway 36L at Lyons. About three minutes later (at the point marked 1 on the graphic below), the controller gave a heading of 270° to extend the flight path conscious the aircraft was high. The crew tuned 30 seconds later. They were distracted by solving the inconsistency in the ILS frequency display (actually a symptom that the FMGS was set to the wrong frequency and was picking up a DME at Marseille, which shared the same frequency as Ajaccio) and by another crew’s read back error. The aircraft crossed the ILS axis twice (between points 2 and 4) with the ILS frequency being correctly set at point 3 on the graphic. Then at point 4: While the Capture mode engaged for a selected altitude of 3,000 ft at a speed of 240 kt, the crew decided to select an altitude of 400 ft on the control panel (FCU), which caused a mode reversion of the autopilot from ALT* to VS 1200 ft/min, the current vertical speed of the aeroplane at that time. They set the approach mode and engaged the...
read moreNorth Sea Helicopter Safety – Step Change in Safety Event
North Sea Helicopter Safety – Step Change in Safety Event The offshore industry safety initiative, Step Change in Safety, held a workforce engagement seminar on Helicopter Safety in Aberdeen in early March. The presentations are all available to download (click on the presenter’s name below): HSSG Update – Mark Abbey This presentation on behalf of the Helicopter Safety Steering Group highlights that 80,000 people have been had dry training to use the Category A Compressed Air – Emergency Breathing System integrated with the Survitec Mk 50 Lifejacket. Over 300,000 journeys have been made with the kit since it was introduced, with around 1 in a thousand resulting in a ‘snag’ being raised with the equipment. Five improvement actions have been identified for the lifejacket / CA-EBS. The presentation also discussed passenger sizing issued (previously discussed by Aerossurance last year). CAP1145 Update – Rick Newson This UK Civil Aviation Authority (CAA) presentation focused more on the flight operations than the wider issues discussed in the CAP1145 report published 20 February 2014 and the recent CAP1243, the Offshore Helicopter Review Progress Report. It does seem to feature more on automation than CAP1145 did (a subject discussed at the RAeS last year). HeliOffshore – Gretchen Haskins HeliOffshore, formed last year, is taking an explicitly collaborative approach to improving helicopter safety, calling for alignment amongst stakeholders. Aerossurance is a member of HeliOffshore. HeliOffshore have 6 safety priority areas. The presentation features draft material from the Flight Safety Foundation (FSF) Basic Aviation Risk Standards Offshore Helicopter Operations (BARSOHO), in the form of a bow-tie. UPDATE 27 May 2015: BARSOHO is launched. UPDATE 1 February 2017: BARSOHO Version 3, fully aligned with the HeliOffshore Safety Performance Model released in 2016, is now available. Airbus Safety Partnership – Andrew Dettl Airbus Helicopters have 11,727 helicopters in service, the highest time being an AS332L at 42,000 flying hours (almost certainly the historically significant G-TIGE, the first helicopter to fly with the pioneering IHUMS and with TCAS2). In total the company has 87 million flying hours of service experience (3.2 million in 2014). In particular Dettl discussed five safety initiatives: The preparation of an offshore Flight Crew Operations Manual for the EC225 (now the H225). The FCOM, a first for the helicopter industry was produced in cooperation with Avincis (now Babcock), Bristow and CHC. The FCOM has just been updated too. It remains to be seen if other manufacturers follow this lead. Training Standardisation across the various training organisations in relation to essential training. Maintenance Mentors: this initiative recognises that helicopter rotor, transmission and flight control systems can be more prone to undetected error and so provides greater expert support. Vision 1000, which Aerossurance has previously discussed in That Others May Live – Inadvertent IMC & The Value of Flight Data Monitoring Rig ‘n Fly automated approaches (similar to a the Rig Approach system developed by Sikorsky). Plus operator’s representatives covered background on three critical topics: Helicopter Maintenance – Lee James Pilot Training – Rob Dyas Flight Operations – Tim Glasspool Aerossurance has extensive helicopter safety, airworthiness, operations, survivability, safety analysis 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 moreIHST Update – March 2015
International Helicopter Safety Team (IHST) Update – March 2015 At the HAI Heli-Exp0 2015 in Orlando, Aerossurance attended the IHST Regional Partners Panel as one of the European representatives. The session featured presentations from different national and regional teams supporting the IHST: Introduction IHST Regional Partner Panel Introductory Slides India Rotary Wing Society of India: The RWSI presented the results of a highly successful 2014, with zero helicopter accidents in India, compared to 5 per annum in each of the previous 3 years. The key initiative was Directorate General of Civil Aviation (DGAC) Air Safety Circular 09 of 2013 that prohibited punitive action against pilots who made precautionary landings (see also this article). This concept was echoed in HAI’s 2014 Live and Land initiative. New Zealand New Zealand Helicopter Industry: Safety Update: There are 512 commercial helicopters in New Zealand, mostly light singles. The New Zealand Civil Aviation Authority (NZCAA) do, rather uniquely, require operators not only to report flying hours annually but also hours broken down into about 20 usage categories, so they do have very good rate data. According to the NZCAA, 47% of local operators have only 1 or 2 aircraft. This creates challenge for effective SMS implementation and safety promotion. The NZ CAA described their solution of analysing accidents and creating informative safety bulletins in conjunction with the New Zealand Helicopter Association. South America Safety Road Show: Airbus Helicopters‘ presentation highlighted that the accident rate in the region has been 2-4 times higher than in other areas (something sadly underscored by a mid air collision in Argentina a few days later). AH described a 2 day road show approach that they have been supporting in the region, culminating in a workshop to identify actions. Helicopter Safety Team – Brazil: In Brazil 55% of helicopters belong to owners/operators with just one helicopter. In their review of accidents, safety management and regulatory issues were even more significant than in US and European studies. North America USHST Update: Among the interesting items of data is study on night accidents. Pilots with less than 500 hours of night experience make were involved in 61% of night accidents and pilots with less than 100 hours 30% of all night accidents. The presentation also discussed the USHST’s Reel Safety audio visual safety initiative. US General Aviation & Part 135 Activity Survey: FAA contractor Tetra Tech describe the process for gathering flying hours data in the US. Canadian Update: The Helicopter Association of Canada noted that in their analysis, they noted a disproportionate number of piston-engine helicopter accidents. The HAC has been busy developing best practice guides for various specialist operations. Encouragingly they noted that in 2-14 they had no fatal helicopter accidents in Canada. Europe European Helicopter Safety Team (EHEST): Highlighted a number of engagement activities and a series of publications. The EHEST web site, with access to all EHEST publications, can be found at: www.ehest.org EHEST also has a LinkedIn Discussion Group. EHEST is part of the European Strategic Safety Initiative (ESSI), an aviation safety partnership between the European Aviation Safety Agency (EASA), other regulators and the industry. Aerossurance is a specialist aviation consultancy. For expert advice on helicopter safety, accident analysis, operations, airworthiness and contracting matters, contact us at enquiries@aerossurance.com Follow us on LinkedIn for our latest updates....
read moreOperator & FAA Shortcomings in Alaskan B1900 Accident
Operator & FAA Shortcomings in Alaskan B1900 Accident UPDATE 10 April 2018: with details below of further NTSB recommendations after a 2016 C208B accident The US National Transportation Safety Board (NTSB) has reported on a Beechcraft 1900C accident on the North Slope of Alaska on 23 Nov 2013. The B1900C was being operated by Hageland Aviation Services (doing business as [dba] ERA Alaska) on a passenger shuttle for an oil and gas company to a remote production site. The aircraft, N575X, sustained substantial damage during the landing accident, but neither crew or the single passenger were injured. The NTSB investigation identified shortcoming in procedures, training and oversight (both by the company and the Federal Aviation Administration [FAA]). This accident highlights the importance of contractual safety requirements and effective assurance when contracting in air services and operating remote airfields. The NTSB Investigation Before departure from Deadhorse on the short flight to Badami, the weather at the destination airport was reported to be wind from the northeast at 27 mph, scattered clouds with blue skies above, and 1.5 statute miles visibility with blowing snow. As the Alaska Dispatch News reported, during the short flight the airport weather observer informed told the NTSB that he notified the pilots he could “…occasionally see the cold storage camp, which was located ‘1.25 miles away,’ but he did not consistently have 1 mile visibility.” The observer further described the weather as “bad” and that he could sometimes not see the runway. He apparently he advised the pilots to “use their own judgment”. The NTSB comment that “At the time of the accident the Badami METAR reported in part: wind 120 degrees, variable 060 degrees thru 210 degrees, at 30 knots, visibility 0.5 sm in heavy blowing snow, broken clouds at 1,000 feet, and temperature -16 degrees F”. The captain told the NTSB his visibility “…was unrestricted and that he had the runway environment in sight 20 miles from the airport.” After a brief hold, apparently believing visibility was 1 statute mile, he asked the FO to load the instrument approach into the GPS and the approach commenced. The Captain described the approach as normal until he realized he “was too low.” However, the FO told the NTSB he voiced concerns multiple times while on approach, finally saying “watch out,” just prior to impact. The aircraft touched down short, the right main landing gear separated and the aircraft slid along the runway. The investigation does not appear to have reconciled the differences in Captain, FO and weather observer’s statements. This was hampered by the CVR data being overwritten by post-incident engine runs. The ADN reported that the company explained: This particular CVR issue had to do with the configuration of our BE1900C aircraft, some of which have both a CVR and an FDR and some of which only have a CVR. When the mechanic was dispatched out to retrieve the CVR, he accidentally retrieved the FDR only thinking that he had sent in the CVR. Weeks later, when it was discovered that we had pulled the FDR, the engine runs had already been completed after the replacement of the propeller. The CVR and FDR are both in similar orange boxes and everyone thought the CVR was secured. When examined, the FDR did show the accident sequence and was consistent with the reports provided by the flight crew. The company had a pre-flight risk assessment process. According...
read moreNew Airbus Helicopters Designations: A Guide
New Airbus Helicopters Designations: A Guide At the same time as revealing their new X4 medium was to be called the H160, Airbus Helicopters unveiled new marketing designations for most of their models at the HAI Heli-Expo in Orlando, March 2015. The rebranding primarily affects the more modern production aircraft (with the exception of military only production types). Aerossurance is an Aberdeen based aviation consultancy. For expert advice you can trust on helicopter design, acquisition, airworthiness, operations and safety, contact: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest...
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