News & Comment

House of Commons Transport Committee Offshore Helicopter Safety Report

Posted by on 12:21 am in Accidents & Incidents, Helicopters, Human Factors / Performance, HUMS / VHM / UMS / IVHM, Logistics, News, Offshore, Oil & Gas / IOGP / Energy, Regulation, Safety Culture, Safety Management, Survivability / Ditching

The published at 00.01 am on Tuesday 8 July 2014. In its conclusions the committee say: Helicopter transfer across the North Sea has inherent risks but remains the most practical mode of transport for the offshore oil and gas industry. Five accidents since 2009 have led to a loss of confidence from the offshore work force in helicopter transport that will be difficult to remedy. Industry safety groups and operators have worked to rebuild confidence but more needs to be done. We were disheartened to learn of instances that reflect a “macho bullying culture” in the industry and wish to be reassured that the flawed EBS [Emergency Breathing Systems] safety briefing in not indicative of complacency toward safety. Oil and Gas UK‘s aviation seminar this year specifically looked at rebuilding confidence.  The Air Accident Investigation Branch (AAIB) had previously made recommendations on improving the passenger briefing after August 2013 accident off Sumburgh (on 10 April 2014, six survivors from that accident met with Members of the Transport Committee [see Appendix A]).  The introduction of new Category A Emergency Breathing Systems , as well as introducing enhanced capacity, will also give the entire workforce a refresher in EBS use. The committee dismissed any concerns with the Super Puma family (which make up some 60% of the UK offshore helicopter fleet). In relation to the UK Civil Aviation Authority (CAA) Review, which resulted in the CAP1145 report, the committee highlight: ….areas of the review that we think require additional work, particularly concerning occurrence reporting, the standardisation of customer requirements and the implementation of seating restrictions.  The CAA now needs the co-operation of the oil and gas industry, helicopter operators and EASA to ensure its recommendations are carried through to conclusion. We have called on the DfT to use its influence to ensure EASA has prioritised that important work. There is some slightly unfair criticism of EASA, especially as a considerable number of the recommendations and actions in CAP1145 are based on the work of EASA‘s existing helicopter ditching Rule Making Task RMT.0120 working group and EASA’s Management Board is actually chaired by CAA’s Director Of European And International Strategy. They also comment that the AAIB should keep survivors better informed on the progress of investigations in future. The committee go on to say, heavily influenced by evidence from union BALPA its seems: The CAA review did not look in sufficient detail at two key areas of offshore helicopter operations. The first was the offshore industry’s highly competitive environment. Commercial sensitivities ensure that it is difficult for external reviews to examine the contractual obligations set by industry. The second was the role and effectiveness of the CAA itself. Those who work in the hazardous conditions of the North Sea deserve to know those issues have been properly evaluated. We believe only a full, independent public inquiry would have the resources, remit and power to do this. A flaw in CAP1145, based on a study that CAA have recently publically admitted at two industry seminars was rushed (one might assume in order to be complete before the Transport Committee reported), was always its lack of self reflection on the CAA‘s own performance, organisation and resources. The BBC report that a DfT spokesman said: It is vital that offshore workers are able to operate in a safe environment. We are working closely with the CAA, as the independent regulator, on this critical issue. UPDATE...

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Increasing SAR Use by the Oil & Gas Industry

Posted by on 9:16 pm in Crises / Emergency Response / SAR, Helicopters, Offshore, Oil & Gas / IOGP / Energy, Resilience, Safety Management

Increasing SAR Use by the Oil & Gas Industry The oil and gas industry is increasingly contracting commercial Search & Rescue (SAR) helicopters to support offshore exploration work and support offshore safety cases. For example, commercial operator Bristow has provided a SAR service in the UK since 1971 (for both government and oil and gas customers) that has flown more than 44,000 SAR operational hours and over 15,000 SAR missions.  They currently also deliver oil and gas SAR operations in Australia, Brazil, Canada (via Cougar – video), Norway (video), Russia, Tanzania and Trinidad. Bond Offshore Helicopters (part of Avincis) operates the so called JIGSAW service for BP in the North Sea (video). CHC meanwhile provide SAR in a number of locations including UK, Ireland and Norway (video 1, and UPDATE Sept 2014 video 2).  Meanwhile NHV (video) now provide SAR cover to the Dutch oil and gas association (NOGEPA).  There are of course other operators… One of the latest operations to start up is Shell‘s contract with CHC in Broome, Australia with an Airbus Helicopters EC225, announced today. This service is on standby 24-hours a day and is able to respond within 15 minutes during daylight hours and 30 minutes at night. Initially the service will be daytime SAR, with a medevac capability only at night.  Medical Rescue Air Ambulance is providing the paramedic SAR crew for the service.  As has become common in these circumstances, when the capability is not required for oil and gas activities, it may be tasked by the local authorities to assist with other medevac and SAR needs. CHC Asia Pacific’s Regional Director Nick Mair explained: Early next year, a new, state-of –the- art, all-weather SAR helicopter will enable full, 24-hour search and rescue coverage. This, and the earlier videos, neatly highlight the distinction between a LIMSAR (Limited SAR) capability that is daylight (and fair weather only) and a full AWSAR (All Weather SAR) capability that can also operate at night.  Even LIMSAR, is a step beyond simply using a winch equipped helicopter in an emergency. Key aircraft upgrades essential for AWSAR is the addition of a 4-axis autopilot with auto-hover (and ideally a means for the winch operator to ‘trim’ the aircraft position) and a means to aid search such as FLIR (Forward Looking Infa Red) turret with a suitable operator interface and a Night Vision Imaging System (see a recent example certified here).  Clearly even for LIMSAR, the helicopter needs to be winch (or ‘hoist’) equipped.  For a permanent standby capability of the AWSAR a dual winch is essential to give redundancy.  However, to provide a SAR service you need an offshore equipped helicopter with those features and: Extensive SAR, winching & medical equipment A carefully planned SAR cabin fit, with a sea tray (to protect the floor from sea water and bodily fluids), equipment stowage etc External winch lighting (including a Nitesun type search light) Direction finders (and ideally the ability to decode the <50 millisecond periodic burst transmissions from 406MHz beacons) Extra radios including satellite communications when operating at long ranges including, SAR crew intercoms / radios etc Automatic Identification System (AIS) to detect shipping (important when hovering in low visibility at low altitude – a Royal Navy Westland Lynx helicopter was knocked into the sea by an Omani ship in 2001!) Suitable stand-by accommodation and an ops room close to the aircraft with...

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New EASA Structure

Posted by on 12:11 pm in Regulation, Safety Management

A new organisational structure for the European Aviation Safety Agency (EASA) has been announced and can be found here. This reorganisation follows a decision of the Management Board in May 2014, and follows an extensive consultation, known as the Article 62 review. In the introduction to the paper to the Management Board, a governance body chaired by Mike Smethers (the UK CAA’s Director Of European And International Strategy), EASA states: After 10 years of existence, the Agency completed the foundation of its regulatory system covering its initial scope and the so-called 1st and 2nd extensions…. This being now in place… more attention needs to be paid to supporting Member States and Industry with implementation and to maintaining the regulatory framework, also considering the challenges faced by Member States themselves, in particular as concerns oversight capabilities. Furthermore, the objective to continuously improve safety in economically challenging times implies revising the way the Agency defines its strategic priorities: a more consistent, data-centred, risk based approach should be implemented. Finally, the Agency’s relationship with the Commission, Member States and Industry has always been pivotal to the establishment of a robust and internationally recognised EU aviation system. To further consolidate this relationship, clearer interfaces should be established, by ensuring single points of contact for dedicated domains. The high level structure is below: There are effectively 5 directorates: The Executive Directorate (ED), including Quality/Internal Audit, Legal, and Communications, reporting to EASA Executive Director Patrick Ky. A new Strategy and Safety Management Directorate (SM), to leverage a risk- and performance based, data-centred approach (as previously discussed by Aerossurance here). It will also be responsible for International Cooperation, Technical Training and Safety Promotion  (such as the European Strategic Safety Initiative). The Certification Directorate (CT) will be organised in departments in charge of each product category . It will be responsible for all activities related to the Initial and Continuing Airworthiness of type design, Environmental Certification, Operational Suitability, and Design Organisation Approvals (DOA). A Flight Standards Directorate (FS) will be organised in departments in charge of technical domains, such as Production and Maintenance, Air Operations, Aircrew, ATM/ANS and Aerodromes. A Resources and Support Directorate (RS), responsible for finance, IT, HR, etc. Rulemaking, Approvals and pan-European Standardisation activity is now absorbed into the CT & FS directorates. Aerossurance has extensive experience in safety management, with aviation regulations, regulators and the activity of regulation.  For advice, contact us at enquiries@aerossurance.com Follow us on LinkedIn for our latest...

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737s in Montana Rail Ravine Plunge

Posted by on 8:41 am in Accidents & Incidents, Logistics, News, Resilience

737s in Montana Rail Ravine Plunge In a bizarre rail accident, three Boeing 737 fuselages, being transported from the Spirit AeroSystems Wichita factory to the Boeing assembly line in Seattle, were left at the bottom of a ravine in Montana on 4 July 2014.  None of the train’s crew were injured. Of the 90 cars of the BNSF Railway train, 19 derailed, 18 miles east of Superior, Montana.  Thirteen of the cars that derailed were carrying freight, mostly aircraft parts with some soybeans and denatured alcohol. Six were empty. The train was carrying six complete 737 fuselages, fuselage panels for the 777 and wing parts for a 747.   All six cars with the 737s were derailed, two fuselages were partly submerged in the Clark Fork River. A Boeing spokesman stated they have: …deployed experts to the scene to begin a thorough assessment of the situation. Once we determine the extent of damage we will assess what, if any, impact there will be to production. Spirit has been delivering Next-Generation 737s from Wichita since 1998. The company builds the 737 fuselage, engine struts and nacelles in Wichita and wing components in its Tulsa, Oklahoma facility. Earlier this year, Boeing accelerated 737 production to 42 aircraft each month.  Spirit recently delivered their 5,000th 737 Next Generation fuselage. This is not the first time that business continuity and Boeing’s supply chain has been threatened.  In June 2011, a BNSF train derailed in Nebraska after being hit by a tornado, damaging 737 fuselages on board (video 1m 40s onwards).  On 14 April 2012 an EF-3 tornado struck Spirit’s main factory in Wichita, resulting in 9 days lost production.  In that case, Boeing were able to recover, without delaying a delivery. Spirit released the following statement: Spirit AeroSystems has been working closely with our customer since we learned of the incident and continue supporting as needed. The Spirit team’s resolve was tested with an even greater challenge as recently as the 2012 Wichita tornado. We are confident that, working together, we will overcome whatever challenges may be presented. UPDATE 1 In the Puget Sound Business Journal there were two helpful articles on 7 July 2014: Are these Boeing fuselages totaled? That’s a complicated question That 737 train wreck could derail Boeing’s production line in Renton Aerospace eBusiness published this item that will help you consider Aerossurance‘s response time!: When Aerospace News Happens on the Weekend… Flight International comment on 10 July 2014: Boeing studying impact of 737 fuselage derailment UPDATE 2 During week commencing 21 July 2014 personnel from Pacific Steel and Recycling have been breaking up the 737s on site.  While other parts appear to have been salvaged )or at least relocated for evaluation) all six 737 fuselages it appears have been scrapped. UPDATE 3 Flight International report that 737 derailment probe ‘suggests’ track alignment issue based on an investigation by Montana Rail Link. Aerossurance has extensive air safety, operations, airworthiness, human factors, aviation regulation 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...

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Offshore Passenger Fatality 2 July 2014: CHC Medevac Norway

Posted by on 6:09 am in Accidents & Incidents, Helicopters, Human Factors / Performance, Logistics, News, Offshore, Oil & Gas / IOGP / Energy

Offshore Passenger Fatality 2 July 2014: CHC Medevac Norway In an unusual and tragic occurrence, the Norwegian press have reported that an ill offshore worker being medevaced to shore on 2 July 2014 died after apparently being able to exit the CHC H225 helicopter in flight. The patient was being transferred form the Statoil Troll A platform to Bergen, when it is reported that: …the man was reportedly able to come out of the helicopter at an altitude of about 600 metres and fell into the sea, only a few kilometres from land, at about 8:45am. Details are limited and investigations are underway. UPDATE 25 April 2015: The Petroleum Safety Authority reported: In 2014, there was one fatal incident in connection with transporting a mentally unstable person. The patient was medically cleared for transport ashore by SAR helicopter by a doctor and nurse, but jumped out of an emergency exit/window at a height of 2,000 feet roughly 10 minutes before landing. Aerossurance has extensive offshore helicopter safety, flight operations, SAR and accident analysis experience.  For aviation advice you can trust, contact us at: enquiries@aerossurance.com Follow us on LinkedIn and on Twitter @Aerossurance for our latest...

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Military Mid Air Collisions

Posted by on 9:14 pm in Accidents & Incidents, Air Traffic Management / Airspace, Fixed Wing, Military / Defence, News, Safety Management, Survivability / Ditching

Military Mid Air Collisions One recent accident in Germany and the release of a Service Inquiry into a UK Mid Air Collision (MAC) highlight the importance of managing MAC risk. The UK Military Aviation Authority (MAA) consider MAC to be one of the highest risk hazards in military aviation (as discussed in para 5a of their 2012-2013 Annual Report and highlighted in their first annual report, for 2010-2011).  In fact, of the five 2* Operating Duty Holders in the UK military (three RAF, one RN and one Army), four consider it to be their ‘top risk’.  Between 2008 and 2012, the MAA report that 48% of all Airproxes in the UK, examined by the UK Airprox Board, involved military aircraft. Definition of an Airprox (ICAO Doc 4444: PANS-ATM): An Airprox is a situation in which, in the opinion of a pilot or air traffic services personnel, the distance between aircraft as well as their relative positions and speed have been such that the safety of the aircraft involved may have been compromised. Tornadoes, Moray Firth, Scotland  –  July 2012 One sad illustration of the devastating consequences of MAC, can be found in the Service Inquiry (SI) published on 30 June 2014 into the MAC involving Panavia Tornado GR4s ZD743 and ZD812 over the Moray Firth in Scotland on 3 July 2012.  The two aircraft, both from Operational Conversion Unit XV(R) Squadron based at nearby RAF Lossiemouth, were operating independently as ABBOT 2 and ASTON 1 and collided at 920ft above the sea in Class G airspace. Three of the four crew perished.  The survivor, injured during ejection, was recovered by RAF 202 Squadron Westland Sea King HAR3  after 75 minutes in 12ºC water, wearing flying coveralls (but not an immersion suit).  While the associated text is relatively heavily redacted it is clear that his core temperature had dropped to a critical level. The report highlights that UK military sea survival regulation and RAF survival policy were out of date.  The continued lack of automatically activating 406MHz beacons for fast jet aircrew is another point raised (even though the international agreement to only monitor for 406MHz using the COSPAS-SARSAT satellite system was made in 2000 with 8 years 4 months notice of the 2009 implementation).  A number of other observations relate to the Search and Rescue activity. On the eve of the report’s release, the press were focusing on the procurement of a Collision Warning System (CWS) for the Tornado fleet.  The BBC observing: The 300-page report is particularly critical of the processes within the MoD, which meant that procurement of a collision warning system for the Tornado fleet was repeatedly delayed, deferred and at one point deleted. This is no great surprise as it has been a matter of long running interest in parliament and the subject of discussion in past MAA Annual Reports.  The report does however examine this saga in critical detail. However, a CWS such as ACAS2 (already fitted to the BAE Systems Hawk T2), is only a final line of defence.  Other hardware defences were found wanting. The local military Secondary Surveillance Radar (SSR) was unavailable due to scheduled maintenance and one aircraft had an unserviceable Radar Homing & Warning Receiver (RHWR). While unrelated, the SI also highlighted short comings in the safeguarding of the SSR and navaids. The SI identifies ‘procedural drift’ in the air weapons range procedures and practices as another contributory factor...

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OPITO Compressed Air Emergency Breathing System (CA-EBS) Initial Deployment Training Standard

Posted by on 5:49 pm in Helicopters, Logistics, Offshore, Oil & Gas / IOGP / Energy, Safety Management, Survivability / Ditching

OPITO Compressed Air Emergency Breathing System (CA-EBS) Initial Deployment Training Standard OPITO has issued a standard for Compressed Air Emergency Breathing System (CA-EBS) Initial Deployment Training, to support the initial introduction of Category A Emergency Breathing System (EBS) following the a UK Civil Aviation Authority (CAA) Review, which resulted in the CAP1145 report. To successfully complete this 1.5 hour ‘dry’ training, delegates must able to: Explain the fundamental differences between re-breather and compressed air systems (technology and use) Explain the rationale and use of CA-EBS in helicopter emergencies Explain the hazards associated with CA-EBS Demonstrate a pre-flight inspection of the life jacket and CA-EBS Demonstrate donning the life jacket with CA-EBS correctly, including ‘buddy check’ Demonstrate an emergency deployment of the CA-EBS in a dry environment UPDATE 1 July 2014 Step Change in Safety issued a further update: The approval and certification of the new CAT A EBS and the MK 50 Lifejacket is progressing and expected within the next few days.   This is a credit to the great work that the HSSG EBS Workgroup has done in collaboration with Survitec Group.  OPITO have pulled out all the stops and developed and issued the training standard in record time.  Their approach has been one of pragmatic support and as a result has offered considerable flexibility in how we, as an industry, can meet the challenge of training everyone to use the new EBS equipment.  In the next few days we will issue support material to member companies to provide them the necessary information as we move into the next critical phase of training and deployment. The new dual chamber Mk 50 lifejacket, from UK company Survitec, is to be approved by the European Aviation Safety Agency (EASA) and the EBS is to be approved by CAA in accordance with the Category A specification in CAP1034. Aerossurance has discussed the Category A EBS previously here and the recent Oil & Gas UK’s annual aviation seminar here. UPDATE July 2014 Step Change in Safety issued a further update that detailed the system’s performance and further roll-out plans. UPDATE 1 September 2014 Energy Voice interviews Step Change in Safety team leader Les Linklater. UPDATE 1 November 2014 OPITO has commenced their periodic review of the 3 day Basic Offshore Safety Induction and Emergency Training (BOSIET) and the 1 day Further Offshore Emergency Training (FOET) courses.  Its within these that most HUET training is delivered. Among the issues being considered are: These are international standard but the CA-EBS is mandatory in the UK only, how to keep the standard generic worldwide? In-water CA-EBS training has potential health risks, how to prevent accidents from happening during training? In-water CA-EBS training might conflict with local laws and regulations, how to make sure that the training stays within local legislation? UPDATE 14 December 2014: Further CA-EBS options have now been approved. UPDATE 24 December 2015: UK BOSIET/FOET Cat-A EBS HUET Update UPDATE 24 January 2016: CAP1145 Helicopter Water Impact Survivability Statistics – A Critique UPDATE 25 January 2016: OPITO has issued an update that the ‘interim’ standard will be introduced across the UK on 15 February 2016.  They have provided two sets of FAQs: Oil and gas workforce – BOSIET FAQs Training Providers – BOSIET FAQs UPDATE 20 September 2016: The UK CAA today briefed the Oil and Gas UK Aviation Seminar the following: UPDATE 26 September 2017: ASD-STAN prEN 4856 for Rotorcraft — Emergency Breathing Systems (EBS) — Requirements, testing and marking has been issued.  This will then become a full European Standard (EN) via CEN and be incorporated in...

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EC120 Underslung Load Accident 26 September 2013 – Report

Posted by on 11:07 pm in Accidents & Incidents, Helicopters, Human Factors / Performance

EC120 Underslung Load Accident 26 September 2013 – Report Airbus Helicopters EC120B, SE-JHH, operated by Kallax Flyg, was engaged in a reindeer herding approximately 85 km north of Kiruna, in Northern Sweden on 26 September 2013. The customer requested a broken 350kg quad bike be moved to a nearby village. This was left to the end of the flying programme to when the aircraft had burnt off fuel.  The helicopter took off with the quad attached to a 12-metre cable and 4-metre straps. The functioning of the cargo hook was checked. Following take-off the helicopter turned downwind to avoid terrain but started to settle, resulting in the load hitting the ground. The load was dragged as the pilot flared to cushion the landing and the helicopter hit the ground, rolling over.  The three people on board escaped without any serious injuries. The Swedish Accident Investigation Board (Statens Haverikommission [SHK]) published their final report on 11 June 2014. The SHK concludes that the complexity of the task was underestimated. The Board further concludes that a misinterpretation of the wind direction and angle of the terrain may have contributed.  The Board also postulated that the pilot may not have ‘pickled’ (released) the load because of a focus on flying the helicopters as it settled. SHK recommends the Swedish Transport Agency (STA) ensures that: Operators engaging in flight with sling loads conduct practical exercises of simulated emergency release in their training. Aerossurance observes that impromptu tasking is an immediate warning sign of a potential increase in risk and that risk is often highest at the start and at the finish of a series of tasks. Aviation Safety Network entry is here. Aerossurance has recently reported an underslung load accident in Australia here. UPDATE 4 February 2017: Unexpected Load: AS350B3 USL / External Cargo Accident in Norway UPDATE 12 November 2017: Unexpected Load: B407 USL / External Cargo Accident in PNG UPDATE 3 June 2018: Helicopter Wildlife Netting Accidents In May 2018 the NTSB published two reports into accidents involving helicopters attempting to carry out wildlife net captures. UPDATE 28 July 2018: Wayward Window: Fatal Loss of a Fire-Fighting Helicopter in NZ UPDATE 21 October 2018: Fallacy of ‘Training Out’ Error: Japanese AS332L1 Dropped Load UPDATE 1 December 2018: Helicopter Tail Rotor Strike from Firefighting Bucket UPDATE 20 December 2019: Helicopter External Sling Load Operation Occurrences in New Zealand UPDATE 11 April 2020: Bear Paws Claw Reindeer Herding Bell 206 UPDATE 28 June 2020: Maintenance Issues in Fire-Fighting S-61A Accident UPDATE 26 July 2020: Impromptu Landing – Unseen Cable UPDATE 7 September 2020: Shocking Accident: Two Workers Electrocuted During HESLO UPDATE 31 October 2020: Loss of Control During HESLO Construction Task: BEA Highlight Wellbeing / Personal Readiness UPDATE 2 April 2021: Windscreen Rain Refraction: Mountain Mine Site HESLO CFIT UPDATE 12 June 2021: HESLO Dynamic Rollover in Alaska UPDATE 28 August 2021: Ditching after Blade Strike During HESLO from a Ship UPDATE 4 September 2021: Dynamic Rollover During HESLO at Gusty Mountain Site UPDATE 25 September 2021: Fuel Starvation During Powerline HESLO UPDATE 1 January 2022: Snagged Sling Line Pulled into Main Rotor During HESLO Shutdown UPDATE 18 March 2023: HESLO AS350 Fatal Accident Positioning with an Unloaded Long Line UPDATE 5 August 2023: A Concrete Case of Commercial Pressure: Fatal Swiss HESLO Accident Aerossurance has extensive HESLO, helicopter flight operations, safety 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...

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‘Freedom to speak up?’ in the NHS: independent review

Posted by on 5:41 pm in Accidents & Incidents, Human Factors / Performance, News, Safety Culture, Safety Management

Sir Robert Francis QC is to chair an independent review into creating an open and honest reporting culture in the National Health Service (NHS). It has been announced that the review will: …provide independent advice and recommendations to ensure that: NHS workers can raise concerns in the public interest with confidence that they will not suffer detriment as a result appropriate action is taken when concerns are raised by NHS workers where NHS whistleblowers are mistreated, those mistreating them will be held to account. It will also consider independent mediation and appeal mechanisms. Aerossurance welcomes the initiative, but does think it is perhaps unfortunate that the emphasis is on whistleblowing, the most extreme form of safety reporting, rather than routine, open and cooperative reporting. Francis, a barrister specialising in medical negligence, previously chaired the Mid Staffordshire Inquiry into what have been described as ‘appalling’ standard of patient care at one the 260 NHS Trusts between 2005 and 2009 that is thought to be responsible for hundreds of deaths.  Francis has been described as ‘formidable’ and ‘forensically exceptional’ by solicitors who have hired him. The Guardian has commented that Francis’ new report: …needs to be short and punchy. It will only help change culture if everyone in the NHS can read and understand it; plain English, not lawyerly circumlocution, is required. The NHS not only works in an a sector where there are large risk of human error resulting in fatalities but it is also the world’s fifth largest employer. UPDATE 11 Feb 2015: The report is published.  It recommends: A “Freedom to Speak Up Guardian” to be appointed in every NHS trust to support staff, particularly junior members. A national independent officer to help guardians when cases are going wrong. A new support scheme to help NHS staff who have found themselves out of a job as a result of raising concerns. Processes established at all trusts to make sure concerns are heard and investigated properly The Chief Executive of the NHS responded: As a nation we can rightly be proud of the fact that NHS care is now the safest it has ever been. But as I’ve sat down and listened hard to whistleblowers over the past year, it’s blindingly obvious that the NHS has been missing a huge opportunity to learn and improve the care we offer to patients and the way we treat our staff. These important proposals – particularly for a new national office of the whistleblower – will provide clear new safeguards and signal a decisive change in culture in every part of the health service. UPDATE 16 July 2015: The Secretary of State for Health Jeremy Hunt announced that the recommendations will be taken forward as part of a package of patient safety improvements, releasing the report Learning not Blaming. For expert advice on safety reporting and safety culture development, contact Aerossurance at enquiries@aerossurance.com Follow us on LinkedIn for our latest updates and on Twitter...

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Four 2014 Helicopter Accidents (Australia, Norway & Alaska)

Posted by on 6:50 am in Accidents & Incidents, Helicopters, News

Four 2014 Helicopter Accidents (Australia, Norway & Alaska) Alaska (1): R44 N392GP On 28 May 2014, piston engined Robinson R44 helicopter N392GP, operated by survey company Global Positioning Services Inc, crashed while conducting underslung (HESLO) load training at Chugiak, Alaska.  The pilot was the sole person on-board and died in the accident.  The National Transportation Safety Board (NTSB) have issued a preliminary report.  After impact, there was a post crash fire. The R44 has a history of post impact fires.  Robinson introduced a Service Bulletin in 2012 to replace the original aluminium fuel tanks with more impact‑resistant bladder‑type fuel tanks.  Although Robinson recommend that this SB is embodied, in most countries it only has legal force when an Airworthiness Directive (AD) is adopted.  In the US, the NTSB have recommended this (SB) be made mandatory.  As yet the US regulator, the Federal Aviation Administration (FAA) has chosen not to issue an AD, but simply ‘recommend’ this SB.  The Australian accident investigation agency, the Australia Transport Safety Bureau (ATSB), who have investigated several R44 accidents with catastrophic post-crash fires has also recommended that operators embody the SB.  The regulator in Europe, the European Aviation Safety Agency (EASA), disagrees with the FAA and does believe that the original tanks result in an ‘unsafe condition’ and issued an Airworthiness Directive earlier this year, applicable in all EASA Member States. UPDATE: the probable cause was added 9 August 2017: The pilot’s loss of control of the helicopter due to impairment or incapacitation from a sudden, acute cardiac event. Alaska (2): R44 N74713 Another R44 helicopter, N74713, operated by Quicksilver, crashed in northern Alaska near Coldfoot (population 10 and a truck stop on the Dalton Highway from Fairbanks to Prudhoe Bay), on 18 June 2014, as described subsequently in local press reports and a very brief NTSB database entry.  The helicopter rolled on landing and there were no injuries. The helicopter was carrying a team of geologists from the Alaska Division of Geological and Geophysical Surveys (DGGS) that was making the trip to examine frozen debris lobes, slow moving landslides occurring in permafrost, that are threatening the Dalton Highway, the North Slope Haul Road. UPDATE: the probable cause was added 14 August 2014: The pilot’s failure to maintain adequate main rotor rpm while maneuvering at a low altitude, which resulted in an emergency landing on uneven terrain. The pilot included very reflective recommendations in the accident report form: Coincidentally the DGGS’s parent department, Alaska Department of Natural Resources, has just put out a notice for helicopter contractor to provide heli-borne geophysical surveys for two areas in interior and southern Alaska, with tenders due by 2 July 2014.  Coldfoot has a small private airstrip, at which there was an accident to a DHC-3T Turbine Otter in 2011, that landed on soft ground. Australia: Bell 206L3 VH-NKW The Australian Transport Safety Bureau (ATSB) has commenced an investigation into a collision with terrain involving Bell 206L3, VH-NKW, at the Scotia 3D Seismic Camp, near Taroom, Queensland, on 20 June 2014.  The helicopter was operated by MI Helicopters. While conducting sling load (HESLO) operations, the load became tangled. The pilot reportedly attempted to land, but at about 10 ft above ground level, the line pulled tight. The pilot was unable to release the line (aka ‘pickle the load’) and the helicopter collided with the terrain.  The pilot received minor injuries and the aircraft was substantially damaged....

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