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 […]
Shell Pernis 11.2t Ethylene Oxide Leak Read Post »
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
Forgotten Fasteners – Serious Incidents Read Post »
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
Heli-Expo 2016 Photo Report Read Post »
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
Misrouted Engine Fuel Control Cable Hawker 800XP Read Post »
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
Pitot Punctures Floats in Icelandic SAR Ditching Read Post »
Falcon 7X LOC-I Due To Solder Defect On 25 May 2011, Dassault Falcon 7X business jet, HB-JFN, operated by Jet-Link, suffered a pitch trim runaway that caused a 40° pitch up, rapid climb and temporary Loss of Control Inflight (LOC-I) over Malaysia. First flown in 2005 and certified in April 2007, after a 590 flight, 1600 flying hour test programme,
Falcon 7X LOC-I Due To Solder Defect Read Post »
UK CAA CAP1145 North Sea Helicopter Safety Two Years On Not long after the fatal loss of Eurocopter AS332L2 G-WNSB of Sumburgh Airport, Shetland Islands on 23 August 2013 with 4 fatalities (AAIB Special Bulletin), the UK Civil Aviation Authority (CAA) launched an rapid review on offshore helicopter safety. That CAA Review resulted in the CAP1145 report (‘Safety review of
UK CAA CAP1145 North Sea Helicopter Safety Two Years On Read Post »
US Helicopter Accident Rate Analysis Aerossurance recently looked at US Helicopter Emergency Medical Service (HEMS) accident data for the last 10 years and has also examined accident rates in Gulf of Mexico (GOM) oil and gas operations. We thought we would also look at published accident rates for all US helicopters and demonstrate the effects of choosing different start
US Helicopter Accident Rate Analysis Read Post »
There is a danger that data that can give insight into safety is not combined because it is in multiple databases but there is a great potential opportunity.
Safety Data Silo Danger – Data Analytics Opportunity Read Post »
A maintenance error installing a TRDS bearing resulted in an EC130B4 LOC-I. An excellent AIBN report highlights the value of Independent Inspections.
EC130B4 Accident: Incorrect TRDS Bearing Installation Read Post »
Troublesome Tiedowns The US National Transportation Safety Board (NTSB) has recently reported on two cases in October 2015 were helicopters offshore suffered accidents after the tie-downs were not fully removed: Fish Spotting Helicopter, Pacific Ocean (B206, N1060C) On 21 October 2015 Bell 206B N1060C was being prepared for take-off from the 74m Fishing Vessel Majestic Sun off Christmas Island,
Troublesome Tiedowns Read Post »
Takata have been the centre of fatal air bag failures and millions of vehicle recalls. We look at the recommendations of a US panel reviewing their quality.
Airbag Explosions: Independent Takata Corp QA Panel (‘Skinner Panel’) Reports Read Post »
Inadequate preflight inspection of an un-refuelled aircraft resulted in a total loss of engine power due to fuel exhaustion and a dramatic emergency landing.
Fuel Exhaustion Causes EMB-110 Emergency Landing Read Post »
US HEMS Accident Rates 2006-2015 The safety of US Helicopter Emergency Medical Service (HEMS) operations has been a topic we have discussed previously. With HeliExpo approaching, when 10 years of the International Helicopter Safety Team (IHST) will be marked and with US NTSB Board Member Robert Sumwalt just publishing a HEMS article in Professional Pilot,
US HEMS Accident Rates 2006-2015 Read Post »
An ATSB report on a fatal man overboard incident questions if blindly valuing compliance may create a culture that actually undermines safety.
Culpable Culture of Compliance? Read Post »
Machining Defect Cause of V2500 Failure On 18 September 2014 JetBlue Airways Airbus A320-232 N656JB experienced a Number 2 IAE V2527-A5 engine failure and under-cowl fire during initial climb out from Long Beach, California. The US National Transportation Safety Board (NTSB) say in their report: The flightcrew shutdown the No. 2 engine, discharged both fire bottles, and
Machining Defect Cause of V2500 Failure Read Post »
Ignoring Corrosive Environment Brings Down B206 Helicopter An operator that ignored the Rolls-Royce M250-C20 Series Engine Operation and Maintenance Manual classification of their entire island operating location as a “severe corrosion operating environment” and failed to do the associated maintenance requirements suffered the loss of the their Bell 206B3. Emerald Pacific Airlines B206B3 B-31019 was hovering at
Ignoring Corrosive Environment Brings Down B206 Helicopter Read Post »
The ASC Taiwan has issued their investigation report into the CFIT of a TransAsia ATR 72-500 on 23 July 2014 during an attempted landing in bad weather.
Safety Lessons from TransAsia ATR-72 Flight GE222 CFIT Read Post »
On the evening of 27 Jan 1986 a group were preparing for what we now know as one of the most infamous telecons in history. We look at lessons for all complex, high hazard industries.
NASA Challenger Launch Decision Read Post »
HEMS S-76C Night Approach Loss of Control – In-flight (LOC-I) Incident A Helicopter Emergency Medical Service (HEMS) Sikorsky S-76C+ C-GHHJ operated by Helijet on behalf of the BC Ambulance Service was on a VFR approach to the coastal Tofino/Long Beach Airport (CYAZ), British Columbia, Canada at 02:39 Local Time on the dark, moonless night of 15 November 2015. It suffered a Loss of Control
HEMS S-76C+ Night Approach LOC-I Incident Read Post »
CAP1145 Helicopter Water Impact Survivability Statistics – A Critique Eurocopter AS332L2 G-WNSB impacted the sea 1.5 nm west of Sumburgh Airport, Shetland Islands on 23 August 2013 (see the last AAIB Special Bulletin) with the loss of 4 lives. https://youtu.be/C_3xlunGUk0 Within weeks the UK Civil Aviation Authority (CAA) ordered a hurried safety review. This resulted in the CAP1145 report (‘Safety review of offshore public transport
CAP1145 Helicopter Water Impact Survivability Statistics – A Critique Read Post »
Maintenance Personnel Fatigue and Alertness Maintenance personnel fatigue and a consequential lack of alertness is regularly being identified as contributory, or potentially contributory, to maintenance related air accidents and serious incidents. We have covered three examples previously: Some involve poor shift patterns: Missing Igniters: Fatigue & Management of Change Shortcomings: The UAE GCAA investigation report explains most of the
Maintenance Personnel Fatigue and Alertness Read Post »
HUMS Vibration Health Monitoring Success Australia’s Civil Aviation Safety Authority (CASA) has published a Service Difficulty Report (SDR), dated 1 November 2015, that highlights a Health & Usage Monitoring System (HUMS) Vibration Health Monitoring (VHM) success. During investigation of a HUMS vibration alert, the main rotor head of an Airbus Helicopters EC225/H225 offshore helicopter was examined and wear was identified beyond the limits
HUMS Vibration Health Monitoring Success Read Post »
CSB: ‘Multiple Safety Deficiencies’ Led to ExxonMobil Refinery Explosion The US Chemical Safety Board (CSB) report that they have “uncovered multiple process safety management deficiencies” that led to the 18 February 2015, explosion at the ExxonMobil Torrance refinery, California and an associated serious near miss. The CSB explain: …two workers were injured when an explosion occurred in the
CSB: ‘Multiple Safety Deficiencies’ Led to ExxonMobil Refinery Explosion Read Post »
The Passengers Who ‘Caused’ a 737 Tail Strike On 12 January 2003 a serious incident occurred involving Transavia Boeing 737-800 PH-HZB at Rotterdam. The Dutch Safety Board (DSB) report says the aircraft: …pitched nose-up just after take -off thrust had been selected. The pitch up movement stopped when the aft fuselage and the tailskid assembly contacted the
The Passengers Who ‘Caused’ a 737 Tail Strike: Ground Handling Lessons Read Post »
