How To Destroy Your Organisation’s Safety Culture
How To Destroy Your Organisation’s Safety Culture The term ‘safety culture’ was initially used in the report on the 1986 Chernobyl nuclear accident. Building a strong, positive safety culture takes deliberate, concerted and continual effort. Destroying a safety culture is a lot easier… Bad Safety Leadership The following is the text of a real e-mail, spotted pinned to the wall of the flight planning room of an onshore helicopter operator (but with expletives deleted!): Gentlemen, I have been flying multiengine airplanes and helicopters for over 40 years and 20,000+ hours, and have yet to see two gauges match perfectly!!!!!! Please don’t waste your time and my email space reporting this $&*@!!! It’s not even worth writing about!!! The Captain of the aircraft makes the decision if he wants something looked at, at which time he will tell the crew chief and it will get fixed. If the Co-pilot sees something that he is concerned about, he tells the captain. Only the Captain!!! His job is to do what the Captain asks him to do. If the Captain has concerns, he is to ask me. SIGNED – Director of Ops Dated: December 2008 As well as discouraging safety reporting and communication, there is an underlying tone of ‘you will be blamed if you don’t conform to previously undisclosed expectations’ and ‘I know best’ contrary to the principles of a just culture or that of a questioning/learning culture. This was a powerful sign that this operator had a pathological safety culture. Prof Patrick Hudson proposed the following model, developed from earlier work by Ron Westrum: When discussing this model, Hudson wittily explains why brown was chosen as the colour for the pathological to whom bad things just happen… Operational Control However in this case, the situation is even worse as the very existence of the memo also subverted the management of the operator. The context is that the Director of Operations worked for a North American operator who leased aircraft and support services (including captains), to a South American operator. The aircraft were actually legally being flown under the AOC of the South American operators (who provided co-pilots). Just a few months earlier a Bell 412EP, operated under a similar basis, supporting a remote copper mine was, lost in a fatal accident. The Peruvian Comisión de Investigación de Accidentes de Aviación (CIAA) commented in that case on the effect on operational control of having a ‘Field Manager’ from a US organisation with a satellite link back to his US HQ, controlling operations at the forward operating base, rather than the actual operator. UPDATE 14 October 2014: A legal action after this accident is still on-going and the case will be heard in the US. Downeast Airlines In another example of a pathological culture, the US National Transportation Safety Board (NTSB) reported on the 30 May 1979 Downeast Airlines DHC-6-200 Twin Otter N68DE Controlled Flight Into Terrain (CFIT) accident in which 17 people died. The NTSB report stated: The Safety Board’s investigation determined that past and present company personnel perceived the company president as a particularly strong-wilted individual who dominated the course of lay-to-day operations of the company and who was the final authority in all matters. These same company personnel stated that employees who did not unquestioningly accept the president’s decisions were often subjected to various types of coercion ranging from ridicule and verbal abuse to films, seasonal layoffs, and, In some cases,...
read morePDG Helicopters Win UK & Eire Lighthouse Support Contract
PDG Helicopters Win UK & Eire Lighthouse Support Contract The three lighthouse authorities in the UK and Eire have joined together to award a contract for helicopter support. The three General Lighthouse Authorities (GLAs) awarded the £13mn contract to Inverness, Scotland based, PDG Helicopters. PDG will use two new Airbus Helicopters EC135s on the contract which runs from 1 December 2015 for 7 years with three optional one year extensions. This contract supports maritime navigation aids, mostly in remote locations, includes considerable HESLO / underslung load work (the requirement was for an aircraft that could move individual loads >500kg over 50nm to support construction projects), operation with GLA’s fleet of ships (four are ‘helicopter capable’), as well as passenger movements. The contract is expected to involve around 1000 flying hours per annum. The three contracting GLAs are: The Commissioners of Northern Lighthouses, known as the Northern Lighthouse Board (Scotland and the Isle of Man) whose history goes back to 1768 The Corporation of Trinity House, known as Trinity House (England, Wales, Channel Islands and Gibraltar), the oldest of the three, granted a royal charter in 1514 The Commissioners of Irish Lights, known as Irish Lights (the Republic of Ireland and Northern Ireland) dating to only(!) 1786 This contract is a good example of three customers, with common specialist requirements, working together to place a cost effective long term contract. Some reports suggest this arrangement could save nearly £8mn. Its is explained that: Deployment of the helicopter will be co-ordinated by the three lighthouse authorities, working in collaboration. The GLAs will consult on PDG Helicopters work plans and align the helicopter services in the most efficient and effective manner to meet their operational requirements. However, by the very nature of the safety critical work of the GLAs, an agreed contingency procedure will be put in place to allow the Authorities to deal with any immediate or short-notice high priority tasking. PDG was formed in 1995 by the amalgamation of PLM Helicopters and Dollar Helicopters. In recent years it was owned by venture capitalists but the management team and the Scottish Laing family and bought out Glasgow-based Maven Capital Partners in 2012 for £1.8mn. The company currently has 17 helicopters in its fleet, which fly a total of 11,000 hours per annum and employs 85 people. PDG subsidiary Irish Helicopters has been operating EC135T2+ EI-ILS for the Irish Lights. This aircraft is float equipped, with an HR Smith ADELT mounted under the tailboom and the usual mirrors for use monitoring external loads. The company started supporting that GLA in 1986. A GLA is an agency tasked with the provision and maintenance of lighthouses, lightvessels, navigational aids and thus has some analogies with the infrastructure service provide by an air navigation service provider (ANSP) in the aviation sector. An example of the remote locations is the Skerryvore, a pillar rock lighthouse marking a extensive and treacherous reef of rocks 11 miles south west of Tiree. Access is only really feasible by helicopter at certain weather/tidal windows to a 1970s helipad. Up to 30 November 2015 the contracts were as follows: Trinity House: MD902 – Specialist Aviation Services NLB: EC135 – Bond Air Services (part of Babcock International) Irish Lights: EC135 – Irish Helicopters (which is owned by PDG Helicopters) UPDATE 6 October 2015: PDG took delivery of a new EC135T2+ G-GLAA, configured for lighthouse support, at Helitech in London. UPDATE 30 November 2015: The UK Civil Aviation Authority...
read morePassive Fire-Retarding Helideck Designs
Passive Fire-Retarding Helideck Designs A number of helideck manufacturers offer aluminium helideck designs with a passive fire-retarding capability. Typically this is achieved by draining fuel through holes in the deck surface, into cavities filled with aluminium mesh. This starves the fire of oxygen and dissipates heat, extinguishing the flames and draining away unburnt fuel for collection. To show the range of providers, and the capabilities of such deck designs compared to steel decks, we highlight videos from three below. Dutch company Bayards, market their self-extinguishing Safedeck design: Aluminium Offshore, the Singapore based manufacturer of helidecks, has release a video that illustrates their XE Enhanced Safety helideck design: UK company NCMP market their Firesafe design: Spanish helideck manufacturer Helitecnica offer the Safe Aludeck design. Each company is keen to point out that the UK Civil Aviation Authority (CAA) Standards for Offshore Helicopter Landing Areas (CAP437) allow passive fire-retarding decks to use seawater instead of foam in any Deck Integrated Fire Fighting System (DIFFS) fitted (see Chapter 5 para 2.11). This gives a reduction in complexity, maintenance and cost (capital and recurring). This combination of a passive fire-retarding deck and DIFFS is particularly effective on Normally Unattended Installations (NUIs). NUI fire-fighting capabilities were the subject of Chapter 10 of CAP1145, which resulted from the CAA Review. The Risk of Helideck Fires One of the helideck manufacturers includes footage of a 2002 helicopter accident resulting in a fire on the helideck of a US Navy destroyer. It is worth noting that this involved an old generation military helicopter (a Sikorsky H-3, a type that entered service in 1959) suffering a loss of tail rotor drive while landing on a naval vessel in the Arabian Gulf. This aircraft type was designed before the advent of crash resistant fuel systems (CRFS), triggered by military experience during the Vietnam War. It is also worth noting that in that case all personnel survived. Historically, the number of post crash fires on helidecks is small. In CAP1145 the CAA had to use a photograph a non-fatal accident that occurred in the South China Sea off Malaysia in 1985 as an illustration as no such fire has occurred on the UK Continental Shelf (UKCS). Aerossurance is aware of a 2009 helideck fire in Saudi Arabia and again there were no fatalities in that fire. There was also a fire on a drilling rig in 2008 after a helicopter collided with one of the jack-up legs, but this look place away from the helideck. In November 1994 a series of CRFS requirements were introduced into FAR-27 Amendment 27-30 for future civil helicopter certifications (and adopted into the next revision of the European JAR-29 [Change 1]). The FAA explained that: The fuel containment and hazard elimination provisions contained in these proposals would, in the majority of cases, give occupants the time necessary to escape a survivable crash before a [Post Crash Fire] PCF could become critical. A crash resistant fuel system, CRFS, would not be expected to prevent all fires; however, a CRFS would, in the majority of impact survivable cases, either prevent a PCF or delay the sudden massive fire, or fireball, long enough to allow the occupants to escape. These proposed standards have been validated by military safety statistics and their adoption would significantly minimize the PCF hazard and its associated fatalities and injuries. Service experience suggests the probability of a fatal helideck accident is relatively low, however passive fire-retarding decks remain a very...
read moreFatal $16 Million Maintenance Errors
Fatal $16 Million Maintenance Errors (Sundance Helicopters AS350B2 N37SH) A jury in Las Vegas awarded $16 million to the families of 4 passengers killed in a December 2011 helicopter sightseeing accident, caused by a series of maintenance errors. The National Transportation Safety Board (NTSB) made safety recommendations on maintenance human factors and fatigue after this accident. The Accident Airbus Helicopters AS350B2 N37SH, operated by Sundance Helicopters, suffered a Loss of Control (LOC) accident in mountainous terrain east of Las Vegas on 7 December 2011. The helicopter, en route to overfly the Hoover Dam, was destroyed by the impact forces and post-crash fire. The pilot and four passengers were killed. The day before the accident a team of three mechanics and one inspector had completed a 100 hour inspection on the aircraft, along with replacement of the engine, the tail rotor servo and the main rotor fore/aft servo. In their report the NTSB state: During examination of the wreckage, the main rotor fore/aft servo, one of the three hydraulic servos that provide inputs to the main rotor, was found with its flight control input rod not connected. The bolt, washer, self-locking nut, and split pin (sometimes referred to as a “cotter pin” or “cotter key”) that normally secure the input rod to the main rotor fore/aft servo were not found. The investigation revealed that the hardware was improperly secured during maintenance that had been conducted the day before the accident. Probable Cause The NTSB determines that the probable cause of this accident was Sundance Helicopters’ inadequate maintenance of the helicopter, including: (1) the improper reuse of a degraded self-locking nut, (2) the improper or lack of installation of a split pin, and (3) inadequate post-maintenance inspections, which resulted in the in-flight separation of the servo control input rod from the fore/aft servo and rendered the helicopter uncontrollable. Contributing to the improper or lack of installation of the split pin was the mechanic’s fatigue and the lack of clearly delineated maintenance task steps to follow. Contributing to the inadequate post-maintenance inspection was the inspector’s fatigue and the lack of clearly delineated inspection steps to follow. Maintenance Safety Issues The NSTB specifically highlighted four maintenance safety issues. Issue 1: Improper reuse of degraded self-locking nuts Certification requirements FAR 27.607 and CS-27.607 state that “Each removable bolt, screw, nut, pin, or other fastener whose loss could jeopardize the safe operation of the rotorcraft must incorporate two separate locking devices”. This requirement is designed to give redundancy. In this case the first locking feature is provided by using a self-locking nut and the second by use of the split pin. The NTSB found during their interviews and inspection of a sample of the operator’s aircraft that during maintenance nuts were being routinely re-used that did not meet the published criteria for re-use. That meant the nuts were no longer self-locking and one line of defence was eliminated. Issue 2: Maintenance personnel fatigue / alertness The NTSB concluded that both the mechanic and the inspector, who worked on the helicopter the day before the accident, were likely fatigued, with a consequential reduction in alertness. This was in part, because they had insufficient time to adjust to returning to work earlier than normal. Both were on a 4 days-on, 3 days-off shift pattern, from 12:00 to 23:00. They were due to be off 4-6 December, but were both called on the afternoon of 5 December and asked to...
read moreVVIP AW101
Very Very Important Person (VVIP) AW101 There are a number of nations introducing the AgustaWestland AW101 into VVIP service. https://www.youtube.com/watch?v=qfm3XM82SuQ&feature=player_detailpage In the VVIP role the large AW101 cabin has the flexibility to be fitted out in a wide range of configurations. One easy way to visualise potential cabin layout options is now offered by 3D printing techniques. The images below shows a range of single VVIP seats, double staff seats, a medical station (in place of the 4 side facing seats above), galley, toilet and even a shower. The shower though is limited to ground use only! UPDATE November 2014: Aerossurance has also discussed the booming aircraft interiors sector and its challenges. The type entered service in the VVIP role in 2013 in the oil and gas rich Central Asian republic of Turkmenistan. They received the first of two in March 2013. The first flight has recently taken place at Yeovil of the first of two VVIP AW101’s to be operated by the Nigerian Air Force (with a Defensive Aids suite visible and national marking covered). Meanwhile, one of the aircraft originally intended for India, AW101 Mk641 ZR343, shown here with British Prime Minister David Cameron, was conducting VVIP movements for the NATO Summit in Cardiff in September 2014. Other VVIP customers for the AW101 are reported to include Algeria and Saudi Arabia (each with a pair of VVIP aircraft) and, although earlier EH101 variants have been civil certified, the company is reported to be seeking civil certification for a more current variant. AW101 Background The Agusta Westland AW101 (nee EH101 and known in UK military service as Merlin) first flew as a prototype 0n 9 October 1987 and entered service in 1999. There are however a wide range of developments underway at the moment: The Royal Navy (RN) are taking delivery of the upgraded Merlin HM2 at RNAS Culdrose, being declared operational four months ahead of schedule in July 2014. This followed the largest-ever deployment of Merlins in Exercise Deep Blue in the Eastern Atlantic Ocean. UPDATE: December 2014 Lockheed Martin released this video on Exercise Deep Blue: Nine aircraft flew 480 hours. during the deployment on HMS Illustrious in June 2014 (shortly before her retirement). These aircraft have been equipped with a new mission system and avionics suite as part of the Merlin Capability Sustainment Programme (MCSP). In the longer term the Royal Navy will be taking over the Royal Air Force (RAF) Merlin HC3, after a programme of ‘marinsation’ (ultimately to create the Merlin HC4), to replace the Sea King HC4s of the Commando Helicopter Force. UPDATE 30 September 2014 The transition has started with 78 Squadron RAF standing down at RAF Benson. Flight trials will soon be underway of both the Thales and Lockheed Martin Merlin based solutions to the RN’s Cowsnest requirement to replace the Airborne Surveillance and Control (ASaC) Sea Kings Mk7s. A video of the Royal Danish Air Force Merlins operating in the medevac role in Afghanistan has recently been released: The Royal Norwegian Air Force will receive the first of 16 AW101s for the Norwegian All Weather Search & Rescue Helicopter (NAWSARH) requirement in 2017. The AW101 has been in SAR service with the Royal Canadian Air Force as the CH-149 Cormorant for over 12 years. The Portuguese Air Force Esquadra 751 has demonstrated the AW101’s SAR capability with missions to a radius as great as 380nm. In particular, in February 2013, they completed a challenging 360nm night-time rescue mission...
read moreUS BSEE Helideck A-NPR / Bell 430 Tail Strike
US BSEE Helideck A-NPR / Bell 430 Tail Strike The Bureau of Safety and Environmental Enforcement (BSEE) issued an Advance Notice Of Proposed Rulemaking on Helideck and Aviation Fuel Safety for Fixed Offshore Facilities on 24 September 2014. BSEE explain: Although the Federal Aviation Administration (FAA) has broad authority regarding helicopter-related safety issues and onshore and offshore flight safety, BSEE has the lead responsibility for safety of helidecks and aviation fuel storage and handling on fixed offshore facilities, while the USCG [US Coast Guard] has the lead responsibility for helidecks and aviation fuel handling on floating offshore facilities. BSEE’s regulations are in 30 CFR Part 250. BSEE is seeking comments on whether to incorporate in its regulations certain industry and international standards for the design, construction and maintenance of offshore helidecks, as well as standards for aviation fuel quality, storage and handling. BSEE cite studies by both the Helicopter Safety Advisory Conference (HSAC), who publish Gulf of Mexico (GOM) focused helicopter safety data annually on their website, and a Centers for Disease Control and Prevention (CDC) study in 2013. In their accompanying press release, BSEE state: We know that transportation accidents account for the majority of fatalities on the OCS [Offshore Continental Shelf], and that helicopter-related accidents are a significant concern” said BSEE Director Brian Salerno. “We are looking at our regulations to ensure that the aviation related areas over which we have jurisdiction have the benefit of rigorous safety standards.” The CDC found that helicopter accidents were responsible for 49 fatalities out of a total of 128 in the US offshore industry between 2003 and 2010. The significance of transport safety is also highlighted in the OGP safety data for 2013 (for global offshore and onshore oil and gas operations), where air transport formed the largest category of fatalities (all helicopter related). BSEE discuss some of the existing sources of standards and practices/regulations in other countries and want feedback on the following issues: (1) In addition to the statistical reports and summaries described in this notice, what other relevant, reliable data on accidents or other safety issues related to helicopters, helidecks, or aviation fuel systems on fixed offshore facilities should BSEE consider before deciding whether to propose any new regulations? (2) Which existing domestic or international standards or guidance documents, if any, related to planning, design, construction, inspection, maintenance and/or use of helidecks on fixed offshore facilities should BSEE consider incorporating by reference in its regulations? What would the potential cost impacts be if BSEE incorporated, and required compliance with, such documents? (3) Which domestic or international standards or guidance for aviation fuel quality, storage, or handling should BSEE consider incorporating in its regulations for fixed offshore facilities? What would the potential cost impacts be if BSEE incorporated, and required compliance with, such documents? (4) If you think that BSEE should consider incorporating any existing standards for helidecks or aviation fuel systems, please identify any specific provisions in those standards that BSEE should not incorporate, or that BSEE should modify or supplement before incorporation. (5) If you are a fixed offshore facility owner or operator, please describe how you currently address any existing industry or other standards regarding safety of helidecks and aviation fuel systems. (6) What differences between fixed and floating offshore facilities should BSEE consider with regard to whether any existing standards...
read moreMedevac Misadventure – Inquest in the Yukon
Medevac Misadventure – Inquest in the Yukon The Coroner for Canada’s Yukon Territory has recommended a review of procedures for medical evacuations (medevacs) following the death on board an air ambulance of a 31 year-old woman from Carmacks in November 2013, CBC has reported. In particular the wrong IV tubing was taken on the aircraft as different sizes tubes were stored in the same storage location. This is a classic human performance influencing factor that increases the risk of human error. The key medevac recommendations are below: The Coroner’s full judgement is here. Health Minister Doug Graham subsequently said: We believe that our systems are pretty good right now, but they need some improvement so we’ve agreed with the recommendations and we’ll be following through and dealing with them as quickly as we can. He also says there are now checklists for emergency equipment. Medevac Misadventure – Observations While these recommendations will be of interest to medevac providers they are also relevant to organisations, for example in the energy and resource sectors (e.g. mining, oil and gas companies), who contract for medevac support. At one end of the spectrum this can be done through a single turnkey contract for both aircrafts and medical provision using specially fitted out air ambulance aircraft or as part of a helicopter SAR contract (as discussed by Aerossurance earlier this year). These have the benefit that aircrew and medical crew are familiar with each others procedures and requirements plus medical carry-on equipment is usually ‘kitted’ specifically for air medevacs. In other cases the aviation and medical provision is contracted separately. At the other end of the spectrum, worst case, are scenarios where medevacs are conducted only very occasionally, on aircraft normally used for passenger duties, with medical staff who normally man normal site clinics, with minimal equipment, only gathered together at the time of the call out, that is not necessarily compatible with aircraft use, with limited medevac procedures or exercises. If this sounds like your current arrangements, perhaps it is time to look more closely. The hazards are not only related to patient safety. Among the highest risk scenarios are night-time call outs, where there is a long history of fatal air accidents. In offshore operations a study by the International Association of Oil and Gas Producers (OGP) Aviation Sub-Committee (ASC) Night Operations Working Group suggests the risk at night has been 5.25 times that of day operations. This is why the Night Operations Working Group introduced a specific control on a policy for emergency night flights into their bow-tie risk assessment: Control 1.6 Emergency Night Flight Policy: An Emergency Night Flight Policy should be established in all circumstances when night flights can reasonably be expected to be requested in response to medical, weather or other emergencies. OGP Members, in consultation with the air operator, should develop, using a risk assessment methodology, a documented night medevac/emergency policy. This should be issued to both parties and have a suitable level of authorisation to request such flights. In recognition of their higher risk, night offshore emergency flights should only be requested in genuinely life-threatening situations where the risk of waiting until first light is considered to outweigh the risk of an emergency night flight. Once the cause of the emergency is over, subsequent flights, such as for re-manning, should be conducted under the Non-Emergency Night...
read moreBuilding St Helena Airport – An Industrial Scale ‘Grand Design’
Building St Helena Airport – An Industrial Scale ‘Grand Design’ A remarkable construction project is underway to bring the remote South Atlantic island of St Helena closer to the outside world: VIDEO St Helena a 420 km² volcanic island, with a population of 4,300, is a British Overseas Territory 1200 miles off the coast of South West Africa. The island has neither had an airport or even a jetty in the past. The current life line has been landing by boat from RMS St Helena. St Helena Government and the UK Department for International Development are spending around £250 million on the development of the airport. They hopes the investment will promote tourism to the island and reduce the UK’s £25m annual subsidy. The runway location was identified by Atkins. A series of trial approaches had been conducted in 2006 with a Safair Lockheed Martin L100-30 Hercules and a study by the UK Met Office, on matters such as wind shear, followed. In November 2011 a contract was signed with South African construction company Basil Read. Due to the geography and lack of equipment and material on the island, the project is exceptionally demanding logistically. Around 70,000 tons of goods had to be shipped to the island, including 20 million litres of diesel, 20,000 tons of cement, 5,000 tons of explosives and more than 100 items of construction plant. VIDEO The projects, centred on Prosperous Bay Plain in the east of the island, entails: a 1850m concrete runway with taxiway and apron to cater for aircraft up to the size of an Airbus A320 or Boeing 737-800; approximately 8 million m³ rockfill embankment through which a 750m long reinforced concrete culvert will run; an airport terminal building of 35,00m² and support infrastructure; air traffic control infrastructure; bulk fuel installation for 6 million litres of diesel and aviation fuel; a 14km airport access road, and all related logistics. A key milestone has recently been achieved by the filling of Dry Gut valley with 450,000 lorry loads of material, moved over 22 months. The airport is scheduled to open early in 2016. The operational phase will be in partnership with Lanseria Airport for the first 10 years. Read more here and these project updates and here for the competition to provide air services. UPDATE 21 March 2015: See also this update from Think Defence and this BBC article. South African airline Comair has been named the preferred bidder for the air service. Comair is proposing a weekly flight between Johannesburg (JNB – O.R. Tambo International Airport, formerly known as Johannesburg International Airport) and St Helena using a Boeing 737-800 aircraft. UPDATE 11 August 2015: Erecting of the security fencing commences next week and will be in place by late October 2015, prior to the airport certification audits. The photos below show progress from earlier in the year. Navaid calibration flights are scheduled for mid-September 2015 with a Beechcraft King Air 200, subject to approval from Air Safety Support International (ASSI) for temporary use of the runway. ASSI’s Senior Aerodrome Inspector is expected to arrive on-Island on 29 August 2015 to carry out that assessment. ASSI is a not-for-profit, wholly-owned, subsidiary of the UK Civil Aviation Authority (CAA), established under directions from the UK Department for Transport (DfT) to help provide a “more cohesive system of civil aviation safety regulation” in the UK’s Overseas Territories. UPDATE 5 September 2015: Permission has...
read moreAir Accidents Investigation Branch Video
New AAIB Video The UK Air Accidents Investigation Branch (AAIB) has recently issued a short video on its role. The AAIB exists to determine the circumstances and causes of civil air accident with a view to the preservation of life and the avoidance of accidents in the future. The AAIB does not apportion blame or liability. The Chief Inspector of Air Accidents, Keith Conradi was a pilot with both the Royal Air Force and a UK airline before joining the AAIB in 2002. In the video he emphasises, as is fairly traditional in AAIB publications, that AAIB is independent of the regulators, such as the UK Civil Aviation Authority (CAA). Additionally it is emphasised that AAIB is independent from the Police. This emphasis is topical as in recent months there has been a court decision in England that AAIB reports can be admissible in evidence in court cases and an application in Scotland by the Crown Office for access to the Cockpit Voice Recorder from a recent helicopter accident. Details of the associated UK regulations can be found here. As well as participating on overseas investigations (for example when a British designed or registered aircraft is involved) the AAIB is also responsible for accident investigation in the UK’s overseas territories and the Crown Dependencies. The AAIB is administratively part of the Department for Transport (DfT), based alongside Farnborough Aerodrome in Hampshire. Their site is now shared with both the UK Military Air Accident Investigation Branch (MilAAIB) and the Rail Accident Investigation Branch (RAIB). AAIB History While the video focus on the present it is worth reflecting briefly on the Branch’s history. The AAIB has its origins in the Accidents Investigation Branch (AIB) of the Royal Flying Corps, established in 1915. However, the AIB’s first Inspect of Accidents, Capt G B Cockburn had been an active member of the Royal Aero Club’s Public Safety and Accidents Investigation Committee formed 27 February 1912. It was this group which is believed to have conducted the worlds first air accident investigation. This followed an accident on 13 May 1912 a Flanders monoplane crashed and was engulfed by fire at Brooklands, Surrey. In an early example of safety promotion the brief report was included the magazine, then simply known as Flight. The first civil Accidents Investigation Branch of the Air Ministry was formed in 1919. Peter Coombs an Inspector of Air Accidents since 1972, gave a presentation to the Royal Aeronautical Society’s Historical Specialist Group on 11 April 2013. Audio of that lecture is available in an RAeS podcast. Follow Aerossurance on LinkedIn for our latest updates. ...
read moreCatastrophe in the Congo – The Company That Lost its Board of Directors
Catastrophe in the Congo – The Company That Lost its Board of Directors When you charter aircraft for business purposes, any fatal air accident can leave a terrible scar on your company as well as on the friends and family of the people who die. In 2010 a small Australian mining company suffered a particularly catastrophic air accident, as among the fatalities were the company’s entire board of directors. We look at that accident and some associated lessons on managing aircraft charters and corporate travel. The Air Accident The six directors of Sundance Resources, three other staff and two crew were aboard the twin turboprop CASA C212 TN-AFA of Congolese operator Aero-Service on 19 June 2010. TN-AFA went missing while flying between Yaoundé in Cameroon, to Yangadou in Congo. The wreckage was located 2 days later in mountainous rain forest by Gabon based French troops. There were no survivors. The accident in the Congo occurred just 9 weeks after the Polish Government suffered a loss of many national figures in an well-publicised air accident en route to a memorial service in Russia. The Travel Policy It is reported that the company did have a policy that no more that two members of the board could travel on one aircraft. They did try to respect the intent of that policy by reportedly originally planning to use two aircraft. However before departure they discovered that the other aircraft, the business aircraft of one of the directors and major investors, billionaire Ken Talbot, was not able to land at the short strip in Yangadou. Crisis Management Sundance had to suspend trading in it shares for a period and immediately recalled a former chairman, George Jones. Aerossurance recently reported on another case this year (Focus on Gust Locks after US GIV Accident) were a multi-million dollar takeover deal had to be restructured at the last moment after one of the business partners was killed in an business aircraft accident. In 2013, the former owner and new billionaire owner of a French chateau died with two other people during a post contract signature helicopter flight over the property in a Robinson R44. Just hours after being re-appointed, and minutes after it was confirmed that all were dead, Jones recalls receiving a call from a US fund manager: “I’ve heard that you’ve found the plane and they’re all dead,” the fund manager said. “How on earth did you find that out? I’ve only just been told myself,” Mr Jones replied. “That’s how it works,” the fund manager shot back. At that point, just before midnight in Australia, the families of the victims had not even been informed: “We didn’t have the luxury of waiting until the next day to do something about it,” he said. “We had to organise counsellors, police and various representatives of the company heads to make sure the wives were informed before the media, because we knew it was coming.” Observations In this case it appears that the realisation that one aircraft would be unable to land at the destination came late in the day. A last minute change of plan dramatically increased the risk. Proper advanced planning, and the involvement of the right aviation expertise early may have made a critical difference. Many commentators have previously highlighted that this accident highlights the importance of travel policies. According to a survey of 101 firms conducted by the Association of Corporate Travel Executives (ACTE) in 2009, 16% had no policy restricting the...
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