Air 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...
read moreAerossurance Wins MAA HUMS Maintenance Credit Contract
HUMS Maintenance Credit Contract Awarded to Aerossurance by the Military Aviation Authority Aberdeen based aviation consultancy Aerossurance has won a competitively tendered contract for a Health and Usage Monitoring System (HUMS) maintenance credit project from the UK Military Aviation Authority (MAA). Part of the Ministry of Defence (MOD), the MAA is an independent and autonomous organization responsible for the regulation, surveillance, inspection and assurance of the Defence Air operating and technical domains. Aerossurance has extensive experience in the certification, Controlled Service Introduction (CSI) and operational management of helicopter HUMS / Vibration Health Monitoring (VHM) systems. Aerossurance also has deep understanding of helicopter rotor and transmission design, safety, certification and continuing airworthiness matters. We also have wide expertise in civil and military aviation regulations. UPDATE 7 January 2015: We have more on European Aviation Safety Agency (EASA) and Federal Aviation Administration (FAA) HUMS / VHM activity, including maintenance credits, here. HUMS is also a priority area of attention for HeliOffshore, whose formation Aerossurance has previously reported on. Aerossurance is an Aberdeen based aviation consultancy. For practical advice and support on HUMS, VHM or regulation development you can trust, contact us at: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest updates....
read moreDC-10 Air Tanker Retardant Drop
DC-10 Air Tanker Retardant Drop A short but spectacular video of a DC-10-10 air tanker dropping fire fighting retardant. The aircraft are operated by US company 10 Tanker. The company has had three DC-10s converted to date, two of which are in service. Each carries nearly 12,000 US gallons (45,000 litres) of water or fire retardant in an exterior belly-mounted tank, the contents of which can be released in eight seconds. UPDATE An even more impressive video of a mountain drop on the 1500 acre Silverado Fire. This neatly underlines the importance of detailed structural stress assessment and usage monitoring. The National Transportation Safety Board (NTSB) made recommendations on the need for rigorous maintenance programmes after accidents in 2002. For detailed coverage see the excellent Fire Aviation site. For information on a smaller fire fighting conversion see also our article: BAe 146 & Avro RJ85 Fire Bombers UPDATE 24 September 2014: An illustration of the dangers of aerial fire fighting can be found in this NTSB report issued today. UPDATE 18 November 2014: FireAviation report that the first DC-10 to be converted for 10 Tanker has been retired, after 10 years service and 1,250 missions. The company is converting a fourth DC-10 which will take on the same fire fighting callsign ‘Tanker 910’. UPDATE 14 September 2016: The new Tanker 910 on the Soberanes Fire: UPDATE 14 September 2016: For details of another special mission conversion see our article: Oil Spill Response Boeing 727s UPDATE 6 February 2020: The Californian airman flying the DC-10 waterbomber in Canberra’s skies For expert advice 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...
read moreMastering the Message: Transform Your Safety Communication
Mastering the Message: Transform Your Safety Communication Effective safety promotion is an essential part of a Safety Management System (SMS) and a critical tool to influence an organisation’s safety culture. However safety promotion is an often neglected and misunderstood skill. Your Safety Communication: How to Craft Targeted and Inspiring Safety Messages for a Productive Workplace Australian communications and marketing specialist Marie-Claire Ross aims to correct that with her book Transform Your Safety Communication: How to Craft Targeted and Inspiring Safety Messages for a Productive Workplace. Ross wrote this book “to help all the passionate safety professionals who realise how important it is to influence and engage on safety and risk”. In the preface, Ross, drawing on her experience working with a public health department on a health promotion campaign, observes that advertisers extensively market test their campaigns to determine their effect. In contrast she observes, workplace communication is often delivered with a blind assumption of effectiveness, with effective marketing techniques being ignored as ‘manipulative’ rather than a positive way to create a persuasive message. The failure to apply these techniques perhaps explains why so much safety communication is overly-complex, legalistic and patronising. Chapter 1 emphasises the “Four Commandments of Safety Campaigns”: Promote the message in multiple places, multiple times to break through the general noise of other messages Understand and actually focus on your target audience Deliver a consistent core message Stick to a recognisable look and feel (one example used is the Yarra Trams Beware the Rhino campaign) Chapter 2 focuses on capturing the audience’s attention by using surprise, fear (but only when you offer a way to avoid the danger), being interesting (sad that needs to be said!) and being trustworthy. Chapter 3 give tips on making your message memorable through mnemonics, promoting the ‘lead’ of your message (as in a good newspaper story), using comparisons and metaphors and posing questions. Chapter 4 focuses on persuasion and the 8 element SELLSAFE formula to change safety behaviour. Chapters 5 and 6 look at compelling graphics and engaging copywriting respectively. Chapter 7 introduces some supporting online templates. This book is valuable whether you are communicating on a small scale locally with self-created material or you plan to commission a large global safety campaign across a multi-national. In the former case you will pick up practical skills to apply and develop. In the later case, you will become an intelligent customer, with a clearer idea of your requirements and what good safety communication looks like. Either way this book is an excellent investment. Buy the book: Amazon.com or Amazon.co.uk Other Recommended Reading for Safety Promotion Readers who want to further delve into this subject are recommended to consider these two books: Made to Stick: Why Some Ideas Take Hold and Others Come Unstuck by Chip & Dan Heath. Referenced in Chapter 3 of Ross’ book, Made to Stick explores what makes some ideas and messages ‘stick’. Buy the book: Amazon.com or Amazon.co.uk Words That Work: It’s Not What You Say, It’s What People Hear by Frank Luntz. Luntz, a pollster, describes how careful choice of words can enhance the audience’s reception. Buy the book: Amazon.com or Amazon.co.uk Plus, Marie-Claire Ross publishes the Workplace Communicator Blog. UPDATE 3 May 2016: Also see our article: 5000-1 Safety Lesson: Communication UPDATE 3 August 2016: We also recommend this article on the importance of dialogue: People value dialogue and conversation. It takes much longer…but is infinitely more effective....
read moreNorth Sea Offshore Standardised Clothing Policy
North Sea Offshore Standardised Clothing Policy As anticipated previously by Aerossurance, a new standardised clothing policy is being introduced for helicopter travel to offshore installations in UK waters. It defines what should and should not be worn under survival suits. The policy is effective from Wednesday, 1st October 2014, in-line with the changeover to the winter season. UPDATE 1 October: The BBC has taken an odd and rather irrelevant angle on this story (“Skirts and dresses banned from offshore helicopter flights“)! Aberdeen based aviation consultancy Aerossurance has a proven track record in helicopter safety, air logistics, airworthiness, survivability and accident analysis. For aviation expertise you can trust, contact us at: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest...
read moreFatal 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...
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