ValuJet Flight 592: 11 May 1996
This accident had major lessons on the management of maintenance/maintenance errors, dangerous goods handling and regulatory behaviour.
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Bell 412 Cross Tube Failure Case Study
Bell 412 Cross Tube Failure Case Study Earlier this year the German accident investigation agency, the BFU, published their report into Helicopter Emergency Medical Service (HEMS) Bell 412HP that suffered a rear cross tube failure during start up at a hospital in Berlin on 6 September 2010. The helicopter was fitted with ‘high’ skids manufactured by Aeronautical Accessories Inc
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EC225 Main Rotor Head and Main Gear Box Design
EC225/H225 Main Rotor Head and Main Gear Box Design (CHC LN-OJF Fatal Accident 2016) Following the recent tragic accident at Turøy near Bergen, Norway involving CHC Airbus EC225/H225 LN-OJF there is a lot of interest in the Main Rotor (MR) and Main Gear Box (MGB) design of the EC225. Here we provide some background information on the
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Night Offshore Windfarm HEMS Winch Training CFIT (BK117C1 D-HDRJ)
During night winch training a German HEMS BK117 suffered a fatal CFIT in the Baltic, highlighting readiness, equipment, procedural and training issues.
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Chernobyl: 30 Years On – Lessons in Safety Culture
Chernobyl: 30 Years On – Lessons in Safety Culture Late at night on 26 April 1986 in the then USSR, a team of nuclear workers prepared to conduct a test on Reactor 4 of the Chernobyl nuclear power plant as part of an otherwise routine shutdown. The exercise was to test a modified safety system
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Dim, Negative Transfer Double Flameout
Inadvertently leaving lights dimmed, a compromised NVG mod, no aural low fuel warning and negligible recent experience on type all feature in this NZ HEMS incident.
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NASA ASRS at 40 and the Continued Challenge of Timeliness for Safety Reporting
NASA Aviation Safety Reporting System at 40 and the Continued Challenge of Timeliness for Safety Reporting On 16 April 16 2016 the National Aeronautics and Space Administration (NASA) Aviation Safety Reporting System (ASRS) celebrated 40 years of operation. Its origins highlights one major challenge of safety reporting, learning and action: timeliness. The Purpose and Administration of
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C-130J Control Restriction Accident, Jalalabad
C-130J Control Restriction Accident, Jalalabad The US Air Force (USAF) Air Mobility Command (AMC) has released its accident report into the fatal loss of control (LOC-I) accident involving of Lockheed Martin C-130J 08-3174 during a night-time take-off from Jalalabad Airfield, Afghanistan on 2 October 2015. The accident was caused by the failure to remove a loose article that had been deliberately placed
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Crew Bag FOD Shatters Hawk Canopy
A Canadian Hawk pilot got a big surprise when rolling inverted: his flight crew bag contacted the firing unit of the canopy explosive fragmentation system with shattering results…
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A319 Double Cowling Loss and Fire – AAIB Safety Recommendation Update
A319 Double Cowling Loss and Fire – AAIB Safety Recommendation Update The UK Air Accidents Investigation Branch (AAIB) has issued an update on responses to their safety recommendations from their investigation into British Airways Airbus A319 G-EUOE. G-EUOE, powered by IAE V2500s, lost both engine fan cowlings and suffered an associated fire on take-off from London Heathrow
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C-130 Fireball Due to Modification Error
C-130 Fireball Due to Modification Error A botched modification program unnecessarily changed the original design for a hydraulic system modification when a drawing was misread. A longer hydraulic hose was necessary after that change but an inappropriate design process short-cut meant the shorter hose remained listed as an alternative. The shorter hose was fitted to the modified fleet
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Fatigued Flight Test Crew Superjet 100 Crosswind Accident
Fatigued Flight Test Crew Crosswind Accident The Icelandic Transportation Safety Board (ITSB), the RNSA, recently issued their report into a wheels up runway excursion accident that occurred on 21 July 2013 to Sukhoi RRJ-95B ‘Superjet 100’ 97005 during flight tests by Sukhoi at Keflavik airport. The Flight Test Objective and the Accident Flight The purpose of
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US Police Helicopter Night CFIT: Is Your Journey Really Necessary?
US Police Helicopter Night CFIT: Is Your Journey Really Necessary? On 27 March 2014, at 0147 local time, ex-military Bell OH-58A, N497E, operated by, the Kern County Sheriff’s Office (KCSO) collided with terrain near Tehachapi, California. The three occupants were uninjured, although the helicopter was substantially damaged. The Accident and Investigation The US National Transportation Safety Board (NTSB)
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Metro 23 MLG Corrosion Causes Runway Excursion
On touch down a corroded MLG torque link lug fractures, the wheels turn 90 degrees and the aircraft veers off the runway. Continuing a/w changes followed,
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Solent Hoegh Osaka Car Carrier Accident
Solent Hoegh Osaka Car Carrier Accident The Singapore registered 180m, 51,770 gross tonnage ‘pure car and truck carrier’ (PCTC) MV Hoegh Osaka, managed by Wallem Shipmanagement Pte Ltd, developed a significant starboard list when turning to port while departing Southampton on 3 January 2015. The Marine Accident Investigation Branch (MAIB) say in their recent report: As the list increased
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Marine Pilot Transfer Winching Accident
Marine Pilot Transfer Winching Accident (Brim Aviation AW109SP N361CR) During a night Marine Pilot Transfer (MPT) helicopter winching / hoist operation on 21 April 2014, the marine pilot being transferred, was injured. The marine pilot was being transferred from an outgoing ship to a container vessel, inbound to Astoria, Oregon, the 222 m, 27,437 gross ton MV Northern
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AAIB Report on 2013 Sumburgh Helicopter Accident (CHC Scotia AS332L2 G-WNSB)
AAIB Report on 2013 Sumburgh Helicopter Accident (CHC Scotia AS332L2 G-WNSB) The UK Air Accidents Investigation Branch (AAIB) has published its report into the 23 August 2013 accident were CHC Scotia Airbus Helicopters AS332L2 Super Puma G-WNSB impacted the sea on approach to Sumburgh Airport in the Shetland Islands. The AAIB report is 266 pages long. This article is
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Germanwings: Psychiatry, Suicide and Safety
Germanwings: Psychiatry, Suicide and Safety The French Bureau d’Enquêtes et d’Analyses (BEA) has issued their report into the loss of Germanwings Airbus A320 D-AIPX and 150 lives in the French Alps on 24 March 2015, which was due to the actions of the Co-Pilot. Below we focus on the highlights from the 110 page report. The Co-Pilot
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2009 Newfoundland S-92A C-GZCH Accident: A Failure of Design and Certification
On 12 Mar 2009 17 people lost their lives in a preventable accident when the failure of an oil filter stud highlighted a known fatal flaw in the type’s design.
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Step Change in Safety: Helicopter Safety Update 2016
Step Change in Safety: Helicopter Safety Update 2016 Step Change in Safety held a webinar on North Sea helicopter safety (covering CA-EBS, emergency egress, FCOMs and airworthiness matters) on 9 March 2016 (following on from a March 2015 event we have previously covered). Introduction Step Change is a tripartite UK offshore health and safety organisation combining companies,
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Shell Pernis 11.2t Ethylene Oxide Leak
Shell Pernis 11.2t Ethylene Oxide Leak The Dutch Safety Board has reported (in Dutch) on the leak of 11.2 tonnes of ethylene oxide from a overhead pipe at the 550 hectare Shell Pernis oil refinery on 30 December 2013. The leak was detected by a site worker at what is Europe’s largest refinery, surrounded by 500,000 inhabitants. Ethylene oxide is
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Forgotten Fasteners – Serious Incidents
Forgotten Fasteners – Serious Incidents We examine three incidents where fasteners were forgotten during maintenance. It two cases these maintenance errors resulted in parts falling from the aircraft. In a third, a massive fuel leak occurred. Incident 1 – Twin Otter Mission Pod The Irish Air Accident Investigation Unit (AAIU) has recently reported on a
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Heli-Expo 2016 Photo Report
Heli-Expo 2016 Photo Report News from HAI Heli-Expo 2016 in Louisville, Kentucky (1-3 March 2016): Airbus Helicopters H215 Airbus Helicopters had on show the newly designated H215, formerly the AS332C1e (i.e. an enhanced, short fuselage Super Puma) and AS332L1e (the long fuselage version), to be built in Romania and aimed at aerial work, disaster relief and other
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Misrouted Engine Fuel Control Cable Hawker 800XP
Misrouted Engine Fuel Control Cable Hawker 800XP In Issue 4/2015 of TP 6980 – Canadian Aviation Service Difficulty Reports – Feedback an maintenance error involving a Hawker 800XP fuel control cable is reported: During a planned major structural inspection, the technician noticed that the no.1 engine high-pressure fuel lever cable was trapped under the cover of the electrical junction
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Pitot Punctures Floats in Icelandic SAR Ditching
Pitot Punctures Floats in Icelandic SAR Ditching The ditching of Icelandic Coast Guard Aérospatiale SA365N Dauphin TF-SIF in the Atlantic off Reykjavik on 16 July 2007 highlights the importance of avoiding protuberances that can puncture emergency flotation systems, careful configuration management and establishing emergency drills. The Icelandic Transportation Safety Board (ITSB), the RNF, issued their report in
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