Fatal Helicopter / Crane Collision – London Jan 2013
Fatal Helicopter / Crane Collision – London Jan 2013 While manoeuvring over the River Thames, an AgustaWestland A109E helicopter, G-CRST, operated by charter company Rotormotion, collided at 700ft amsl with a crane in Vauxhall, Central London. The crane was atop the 50 storey St George Wharf Tower. The helicopter pilot and a passer-by died. The UK Air Accident Investigation Branch (AAIB) have now issued their report into the accident, which occurred in poor visibility on 16 January 2013. Circumstances of the Accident The pilot is reported to have commented that morning he felt ‘under pressure’ into doing the flight to collect a prominent businessman, and appears to have reversed an initial intent to cancel the flight. Despite a poor forecast, the aircraft departed Redhill (South of London) at 07:35 to see what conditions were like at the planned pick-up location (Elstree, North West of London). The pilot received and sent text messages during the flight, including one at 07:55 regarding a possible diversion to London Heliport (Battersea) to rendezvous with the client. Its not clear if the pilot had seen current NOTAMs. The helicopter had been fitted with a Garmin 430 which could display obstacles, though was no certified as a terrain awareness and warning system (TAWS). AAIB report that it was not included in the helicopter’s Maintenance Programme as it was a ‘customer option’ and the operator only updated such databases annually. While awaiting a request for feedback of the availability of London Heliport made at 07:56, the helicopter was holding near the H4 helicopter route that follows the River Thames. The construction of buildings on either side of the river created what the AAIB called a “challenging positional separation requirement for pilots if they plan to achieve the required 500 ft separation when the cloud base is low”. At 07:59:13 ATC cleared the pilot to proceed to London Heliport. AAIB conclude: “The pilot turned onto a collision course with the crane attached to the building and was probably unaware of the helicopter’s proximity to the building at the beginning of the turn. The pilot did not see the crane or saw it too late to take effective avoiding action.” The collision occurred at about 07:59:24. AAIB Safety Recommendations AAIB have made 10 safety recommendations. Six relate to obstacles. Julian Firth, a principal inspector from the AAIB, told the BBC: The AAIB has recommended improvements in the way obstacles are notified to the regulator so that their effect on aviation factors can be considered and before the planning permission is granted on the case of new developments. Two more relate to pre-flight risk assessment processes and the last two to Helicopter TAWS. These are matched pairs to the European Aviation Safety Agency (EASA) and the Civil Aviation Authority (CAA). The CAA currently are responsible for rule-making for civil ‘state’ aircraft operations, perhaps an acknowledgement of the regulatory differences no doubt to feature in the awaited Glasgow Clutha Vaults police helicopter accident report. Helicopter Safety Observations AAIB highlight the European Helicopter Safety Team (EHEST) Pre-flight Planning Checklist as one potential tool to increase awareness of risk and improve decision making pre-flight. However it is still vital to appreciate how changes in-flight affect risk. In many ways this accident neatly highlights how circumstances and changes once a flight is underway can magnify risk in a matter of minutes. In-flight texting, while it may not have distracted the pilot during the final manoeuvre, was a mechanism that...
read moreGM Ignition Switch Debacle – Safety Lessons
GM Ignition Switch Debacle – Safety Lessons General Motors has faced intense criticism, large fines, on-going court cases and big rectification costs after mishandling a dangerous design fault in millions of vehicles. So are there safety lessons for other organisations? Aerossurance thinks so. Some have commented that this is a case of corporate complacency while others, similar to Edward Tufte after the NASA Columbia Space Shuttle accident have commented on the perils of PowerPoint presentations. Aerossurance thinks there are a raft of design assurance, safety investigation, safety management system, leadership and cultural lessons. Background GM’s Board directed lawyer Anton Valukas of law firm Jenner & Block, the lawyer who investigated the demise of Lehman Brothers, to investigate the circumstances that led up to the recall of the Chevrolet Cobalt and various other models due to the flawed detent plunger in the ignition switch. The Valukas Report gives a detailed insight into the case. The fundamental problem was that the ignition switch could turn off when running, due to something as trivial as vibration of other keys on the key fob, resulting in a dangerous moving stall and the automatic disabling of the front airbags. Valukas Report In the Valukas Report it is stated that: In the fall of 2002, General Motors (“GM”) personnel made a decision that would lead to catastrophic results – a GM engineer chose to use an ignition switch in certain cars that was so far below GM’s own specifications that it failed to keep the car powered on in circumstances that drivers could encounter, resulting in moving stalls on the highway as well as loss of power on rough terrain a driver might confront moments before a crash. [see report page 1] That defective switch made its way into a variety of vehicles, including the Chevrolet Cobalt. However, those individuals tasked with fixing the problem… did not understand one of the most fundamental consequences of the switch failing and the car stalling: the airbags would not deploy. The failure of the switch meant that drivers were without airbag protection at the time they needed it most. [1] So due to inadequate system safety assessment, this was not recognised as a genuine safety issue but misclassified as customer inconvenience. This failure, combined with others… led to devastating consequences: GM has identified at least 54 frontal-impact crashes, involving the deaths of more than a dozen individuals, in which the airbags did not deploy as a possible result of the faulty ignition switch. [1] Other sources suggest the death toll could be far higher and press reports have highlighted that the method of identifying related fatalities may have been too narrow. The Valukas Report claims that: Throughout the entire 11 year odyssey there was not demonstrated sense of urgency. [4] When an engineer was tasked with studying the problem in 2007, he: ..was given directions neither about a deliverable nor a time frame, highlighting several themes that permeated GM personnel’s failed efforts to understand or solve the problem: lack of urgency, lack of ownership of the issue, lack of oversight, and lack of understanding of the consequences of the problem. [9] As the database grew it was initially not understood why the problem did not occur on 2008 models on. This lack of understanding appears to have defused any urgency to resolve the issue. The engineer monitoring the problem...
read moreOffshore Helicopter Safety Action Group & OGUK Helicopter Briefing
Offshore Helicopter Safety Action Group (OHSAG) The UK Civil Aviation Authority (CAA) has published the minutes of the latest, 14 August 2014, meeting of the Offshore Helicopter Safety Action Group (OHSAG). The OHSAG was formed as a result of the ‘Civil Aviation Authority Safety Review of Offshore Public Transport Helicopter Operations in Support of the Exploitation of Oil and Gas’ (known more conveniently by its report number: CAP1145). Among the issues discussed was a list of the top 10 risks identified in a recent risk workshop (listed in no particular order): Aircraft Design + OEM Support Automation (the subject of a recent RAeS conference) Bow Deck Operations Fatigue Helideck Standards (obstacle collision/Fuel/HLO) Night Operations to Helidecks Oil + Gas Intrusion (Inc. Commercial Pressure) Ops to NUIs Training + Experience Weather (Inc. Lightning, Weather Information, Visibility) In a discussion on customer audits the CAA mentioned their move to Performance Based Regulation. The minutes of the previous meetings: 20 March 2014 29 April 2014 28 May 2014 23 June 2014 Oil & Gas UK North Sea Helicopter Safety Breakfast Briefing Oil & Gas UK will have a Breakfast Briefing “Safety in the North Sea – What is the future for our Helicopters?” in Aberdeen on 2 October 2014 with speakers from the CAA and the offshore helicopter operators. The webcast videos are below: Mark Swan, CAA Panel 1 Panel 2 For advice on offshore helicopter safety and contracting matters, contact us at enquiries@aerossurance.com Follow us on LinkedIn for our latest updates....
read moreBusiness Jet Collides With ‘Uncharted’ Obstacle During Go-Around
Business Jet Collides With ‘Uncharted’ Obstacle During Go-Around Five people died when a business jet collided with what the NTSB originally stated was an un-charted 72 ft concrete powerline pole, built 0.25 miles from the departure end of the runway, during a nighttime go-around. The US National Transportation Safety Board (NTSB) have issued a factual update on this accident to Beechcraft Corporation 390 Premier (Premier 1A), N777VG, on 20 February 2013. The aircraft collided with the utility pole and crashed following a go around initiated after touch down at Thomson-McDuffie County Airport in Georgia. The crew of two were seriously injured and all five passengers, all employees of a surgical service company, were fatally injured. Note: In mid 2015 the NTSB made revisions to their factual report after representations, including acknowledging that the pole was charted. The Go-Around It is not clear why the go-around / touch-and-go was initiated. The Commander has no recollection of the flight after turning on the landing light on approach. The co-pilot did not recall anything unusual about the approach but commented that the “ANTI SKID FAIL” annunciator light illuminated before touch down. After touch-down the co-pilot recalls the Commander announcing a go-around but did not know why, though concern about the anti-skid failure is a possibility. The NTSB report the co-pilot then: …began to monitor the airspeed indicator, saw that they were at 105 knots approaching the end of the runway, and thought “it was going to be close.” Crewing Although there was a co-pilot on board, the NTSB note that “both co-pilots who flew with the [Commander], including the accident co-pilot, stated that they did not have a specific role on the flights they flew with him…” perhaps because “his role in the cockpit is not required by federal regulations”, the Premier 1A being certified for single pilot operation. So while there was benefit in having two crew, this potential was subverted because the aircraft was not apparently being flown in a true ‘multi crew concept’ with duties formally split between a ‘Pilot Flying and a ‘Pilot Monitoring’. Training A training issue is identified in the NTSB report: FlightSafety instructors and evaluators…stated that they discouraged students from executing a balked landing after touchdown. The Commander: …stated that the only balked landings he conducted in training were while airborne. When asked by investigators if he recalled anyone at FlightSafety telling him not to conduct a go-around or balked landing after touching down, the pilot said “no.” and …did not remember ever doing a touch and-go in the simulator and had never done one in a Premier. However: Beechcraft Premier IA manuals and FlightSafety training guidance for the Premier IA do not contain language prohibiting a balked landing procedure after touchdown. The Obstacle The NTSB report that the aircraft stuck ‘Pole 48’: Pole 48 was 72 ft high, and the airplane struck the pole about 58 ft agl. The pole was not equipped with lights, but orange visibility balls were on the adjacent wires. The pole was owned and maintained by Georgia Power…. Pole 48 was erected in 1989, along with similar poles and electrical utility lines, to provide electrical power to the Milliken and Company textile plant adjacent to HQU [the airport]. Georgia Power did not notify the FAA before constructing the utility poles in 1989; However, as noted previously, the 2012 [Georgia Dept of Transportation] GDOT report did note that an...
read moreKeep Your Eyes on the Hook! Underslung External Load Safety
Keep Your Eyes on the Hook! Underslung External Load (HESLO) Safety This video was commissioned by Transport Canada and highlights key lessons for working safely around helicopters and longline loads. Video: https://www.youtube.com/watch?v=eESeTQVjOTY Canadian Coast Guard Ground Crewman Michel Raymond’s story of an incident he was involved in is particular worth hearing. UPDATE 7 September 2016: A worker got caught in Australia during a helirig operation for a mining company (ATSB database entry and WA Department of Mines and Petroleum report). As the helicopter lifted the rig, [a worker’s] leg became entangled in a tag line. He was lifted some distance before the helicopter pilot became aware of the situation. The worker fell 5 to 10 metres to the ground, injuring his back. UPDATE 25 November 2016: The Australian Transport Safety Bureau (ATSB) have issued their report: On 23 May 2016 at about 0700 Western Standard Time, a team of ground and flight crew commenced sling operations to move a drill rig and associated platform and equipment by helicopter to a new location on a salt lake at Lake Disappointment, Western Australia. The ground team for the removal of the equipment consisted of a load master and a driller’s offsider. The driller’s offsider involved in the operation was new to the role. For the operation, the offisider’s role included ground support and to sling equipment under the guidance of the load master. The load master was to guide the helicopter using hand signals and a two way radio to communicate with the helicopter pilot. The pilot of an Aerospatiale Industries [sic] AS350 helicopter, registered VH-BII, worked with the ground crew to move three mats and a power pack to a new site, before returning to move the rig. The load master and offsider attached the rig to the hook under the helicopter and attached two tag lines – 6 m loop slings, to the load on separate corners. At about 1040, in readiness to lift the rig, the load master advised the pilot using hand signals that the load was attached and that they were clear and ready for the lift. The helicopter climbed and the rig lifted a few centimetres above the ground. The load swivelled as it lifted off the ground, and pushed against a PVC pipe protruding from a bore hole. The load master and offsider stepped in closer to manoeuvre the rig clear of the pipe. The pilot observed the ground crew then step away from the rig. As they stepped back, the offsider had inadvertently stepped into the loop of the tag line. As the helicopter lifted the rig, the tag line went taught, and the offsider’s leg was ensnared in the loop. The offsider was lifted off the ground by the leg and the helicopter began lifting the load. The load master radioed the pilot, and advised that the offsider was hanging in the loop. The helicopter was then about 50–60 ft above the salt lake. The pilot turned the helicopter around to return to the pad and descended to about 15–20 ft above the ground. The pilot also slowed the helicopter as much as possible given the load and the tailwind, to a groundspeed of about 25 kt. The offsider then freed their leg and was about to jump off, but the helicopter then started to climb and accelerate....
read moreNTSB Recommendations on Offshore Methane Gas Venting
NTSB Recommendations on Offshore Methane Gas Venting The US National Transportation Safety Board (NTSB) have issued a series of recommendations following two accidents were single engined offshore helicopters ditched after the suspected ingestion of vented methane gas caused a full or partial engine power loss near an offshore platform. Vented combustible gas can cause surging, a compressor stall, or flameout of a helicopter engine. The NTSB quote the UK Civil Aviation Authority (CAA), who state in Chapter 2.3.5 of CAP437 that concentrations above 10% lower flammable limit (LFL) pose a risk. LFL is the lower end of the concentration range over which a flammable mixture of gas or vapour in air can ignite at a given temperature and pressure. While some safety alerts had been issued in 2011, the NTSB is acting because the second accident occurred after these measures. The NTSB: …believes this occurrence highlights the need for the identification and development of comprehensive systems and procedures for oil platform operators to mitigate the risk of vented gas ingestion. The majority of offshore installations in the Gulf of Mexico tend to be small and serviced by small single engined helicopters that are particularly vulnerable to a power loss on take off. Accidents 24 March 2011 Bell 206-L3 N32041, operated by PHI (ASN Database Entry / NTSB Database Entry) 13 August 2013 Bell 407 helicopter N53LP, operated by Panther Helicopters (ASN Database Entry / NTSB Database Entry) Both types are powered by a Rolls-Royce 250 turboshaft engine. The six people on the two helicopters all received minor injuries. Recommendations To the US Department of the Interior, Bureau of Safety and Environmental Enforcement (BSEE): In collaboration with the US Coast Guard, identify and develop comprehensive systems and procedures to mitigate the risk of ingestion of raw gas discharges, such as methane, by helicopters operating in the vicinity of offshore oil platforms. (A-14-67) After appropriate mitigations are developed as recommended in Safety Recommendation A-14-67, require fixed offshore oil platform operators to implement these systems and procedures. (A-14-68) To the US Coast Guard (USCG): Work with the US Department of the Interior, Bureau of Safety and Environmental Enforcement to identify and develop comprehensive systems and procedures to mitigate the risk of ingestion of raw gas discharges, such as methane, by helicopters operating in the vicinity of offshore oil platforms. (A-14-69) After appropriate mitigations are developed as recommended in Safety Recommendation A-14-69, require mobile offshore oil platform operators to implement these systems and procedures. (A-14-70) To the American Petroleum Institute (API): Finalize revisions to API Recommended Practice 2L, Recommended Practice for Planning, Designing, and Constructing Heliports for Fixed Offshore Platforms, to address the venting of raw gases, such as methane, as a risk to turbine-powered helicopters operating in the vicinity of fixed offshore oil platforms. (A-14-71) Interestingly, no recommendations are directed at the Federal Aviation Administration (FAA). The Bureau of Safety and Environmental Enforcement (BSEE) issued Safety Alert No. 311 in 1 April 2014. UPDATE 24 September 2014: The BSEE issued an Advance Notice Of Proposed Rulemaking on Helideck and Aviation Fuel Safety for Fixed Offshore Facilities. 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. Aerossurance expand on this and another helideck accident here. UPDATE 8 September 2015:...
read moreUK Airborne Anti-Pollution Assets
UK Airborne Anti-Pollution Assets The UK Maritime and Coastguard Agency issued this video in 2011 on their anti-pollution airborne dispersant spraying and surveillance assets. The video describes their two sesnor equipped surveillance aircraft. It goes onto show their airborne dispersant spray capability being demonstrated in Lyme Bay, using both a small Cessna Caravan II and a Lockheed Electra, doing runs at 300ft and then 50ft. The MCA’s fixed wing contract is held by RVL Group. The elderly Electras were withdrawn in 2013. UK company Oil Spill Response Limited (OSRL) provide a global aviation aerial dispersant service. UPDATE 26 April 2016: OSRL has commissioned its first UK based 727 dispersant aircraft with a TERSUS dispersant system. UPDATE 12 July 2016: OSRL’s first 727, G-OSRA, operated by 2Excel, was displayed at Farnborough International Airshow in July 2016. It has since been joined by G-OSRB. UPDATE 14 September 2016: Both OSRL 727s were in action for an exercise off the Isle of Wight today. 2Excel explain: In 2014, EASA ruled that for an aircraft spraying system, oil spill dispersant liquids are to be classified as ‘flammable fluids’. The FAA soon aligned with EASA, and as a result any system entering service now has to meet the stringent regulation set out by these agencies. TERSUS, the system on the B727, was designed and built from scratch by 2Excel’s EASA Part21J & G design and production organization Leading Edge. Awarded an EASA STC in 2016, TERSUS is the only aerial dispersant system in the world that complies with the new EASA and FAA regulations. Spraying is done at 150ft. UPDATE 17 August 2020: OSRL and 2Excel sign a contract with the MCA. UPDATE 18 August 2020: 2Excel have modified the 727s to enable flight in known icing conditions with spray booms fitted. For expert advice you can trust on contracting for, design & conversion of and operation of special mission aircraft, contact us at enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest updates. ...
read moreBristow Invests £3.2mn in Tool Control
Bristow Invests £3.2mn in Tool Control Energy Voice reports that Bristow Group has introduced the latest Snap-on Industrial Automated Tool Control (ATC) system to its maintenance operations as part of the company’s commitment to safety by reducing the risk of Foreign Object Debris (FOD) being introduced during maintenance. Jeremy Cresswell reports: The ATC Box is fitted with hi-tech camera technology which captures images of its contents, allowing the system to identify whether tools are present or not. This information is then displayed on a screen on top of the tool kit so that a maintenance engineer is constantly aware of the location of each tool. Tools are automatically issued and returned without user input and the activity from each toolbox is streamed across the company network giving administrators real time visibility of all tooling activity. At a cost of £3.2million Bristow has introduced the technology to the company’s bases in Europe and the US Gulf of Mexico and is in the process of rolling it out across all of its bases across the globe. This builds on an initiative pioneered at their Aberdeen base in 2009. All three Aberdeen based helicopter operators have introduced ‘company tools’ and some form of enhanced tool control. However in the UK it is still common for aircraft maintenance personnel to supply their own tool kits and to rely only on company issued specialist tools. This makes it far harder to identify when tools are lost. In one famous example, during a hangar tour a senior manager at an airline picked a tool box at random and asked to see the owner to verify that all the tools were accounted for. To everyone’s general embarrassment it was found the engineer who owned the tool box had passed away several years earlier… UPDATE 28 May 2016: From Australia Rotor Blade Tool Control FOD Incident UPDATE 12 February 2017: Flying Control FOD: Screwdriver Found in C208 Controls Aerossurance has extensive air safety, airworthiness, maintenance human factors and safety analysis 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 updates. ...
read moreLeonardo Helicopter Obstacle Proximity LIDAR System (OPLS)
AgustaWestland Helicopter Obstacle Proximity LIDAR System (OPLS) Earlier in 2014 AgustaWestland (now Leonardo Helicopters) gained EASA certification of a new laser based obstacle warning safety system to help protect helicopters from main and tail rotor strikes when operating in confined areas and close to obstacles (e.g. around a helideck). Initially available as an option for the AW139, it will be made available for AW169, AW189 and AW101. Such a warning system was one of the proposals in a 2003 UK Civil Aviation Authority (CAA) research paper on managing the risk of tail rotor failures. The Obstacle Proximity LIDAR System (OPLS) uses three independent fixed Laser Imaging Detection and Ranging (LIDAR) sensors, a central computer (a GE MAGIC 1) and a dedicated control panel. It can present a 360º representation of adjacent obstacles (closer than 25m) on the aircraft’s existing Multi-Functional Displays with a two level aural tone as the clearance distance reduces. A detailed presentation given to the Helicopter Safety Research Management Committee (HSRMC) can be found here. UPDATE: the link has been amended after changes to the CAA website. The OPLS system is expected to be of particular value for military, offshore, Search and Rescue (SAR) and Emergency Medical Service (EMS) helicopters. UPDATE 1 June 2016: The AW101s being purchased as part of the NAWSARH SAR project by Norway will be equipped with OPLS. Aerossurance has extensive helicopter safety, design, airworthiness, operations and special mission aircraft experience. For aviation advice you can trust, contact us at: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest...
read moreHouse of Lords Inquiry into Civil RPAS
RPAS (or Unmanned Air Vehicle / Systems [UAV/UAS]) are a hot topic internationally at the moment. The House of Lords, the upper house of the British Parliament, is to hold an inquiry into the civil use of remotely piloted aircraft systems (RPAS) in the European Union. Written evidence is sought by Friday 19 September 2014. Public evidence sessions will be held in October and November 2014. The hearings will be held by the un-snazzily titled “Internal Market, Infrastructure and Employment Sub-Committee of the House of Lords European Union Committee”, which for once makes the unmanned community’s acronyms look simplistic. They explain: The European Commission has been discussing since 2012 how to regulate the operations of RPAS in the EU. It published a Communication on 8 April 2014 setting out its ideas on how European industry can become a global leader in the market for this emerging technology. At the same time, it acknowledged that the integration of RPAS into the EU’s airspace must be accompanied by adequate public debate on societal concerns… The Committee will consider whether the Commission has identified the key issues in this debate, and how the EU’s actions can benefit the RPAS industry in Europe in a way that is acceptable to all stakeholders. In its deliberation the Committee will look at wider questions such as the advantages and disadvantages of regulating RPAS at national, EU or international level and the new and innovative ways in which RPAS are likely to be used in the future. Currently, regulation of UAS in the UK is described in the UK Civil Aviation Authority (CAA) CAP722 document. Aerossurance is also aware of progress of work by the UK Military Aviation Authority (MAA), announced last year, to overhaul the regulatory framework military UAS/RPAS, with an Notice of Proposed Amendment (NPA) to the MAA Regulatory Publications (MRPs) likely by year end. Aerossurance has experience in UAS/RPAS going back to the mid 1990s. If you want to discuss their safety, technical, operational and regulatory issues, contact Aerossurance at: enquiries@aerossurance.com Follow us on LinkedIn for our latest updates....
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