Accidents & Incidents

Investigations & Reports

CSB: ‘Multiple Safety Deficiencies’ Led to ExxonMobil Refinery Explosion

Accidents & Incidents, Oil & Gas / IOGP / Energy, Safety Culture, Safety Management

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 […]

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Credit: Boeing

The Passengers Who ‘Caused’ a 737 Tail Strike: Ground Handling Lessons

Accidents & Incidents, Fixed Wing, Safety Management

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

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Our Top 20 Articles of 2015

Accidents & Incidents, Business Aviation, Crises / Emergency Response / SAR, Design & Certification, Fixed Wing, Helicopters, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Military / Defence, News, Offshore, Oil & Gas / IOGP / Energy, Regulation, Safety Culture, Safety Management, Special Mission Aircraft, Survivability / Ditching

Aerossurance: Our Top 20 Articles of 2015 As we start the new year we look back on the 20 articles that proved most popular with our readers in 2015.  In reverse order: Number 20: Building St Helena Airport – An Industrial Scale ‘Grand Design’ This started with the building of the first airport on the volcanic

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Dangers of Aircraft Tyre Inflation

Accidents & Incidents, Fixed Wing, Helicopters, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Military / Defence, Safety Management

Dangers of Aircraft Tyre (US: Tire) Inflation The Royal Canadian Air Force  are investigating two recent tyre inflation burst accidents.  Both involve visiting aircraft using borrowed equipment: 25 August 2015 CT-114 Tutor CT114058 A Snowbird aircraft was diverted from the rest of the deployed team due to an in-flight emergency.  The aircraft was repaired, including a successful

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B1900C PSM+ICR Accident in Pakistan 2010

Accidents & Incidents, Fixed Wing, Human Factors / Performance, Oil & Gas / IOGP / Energy, Safety Management

B1900C PSM+ICR Accident in Pakistan 2010 The Pakistan Civil Aviation Authority (CAA) has recently published the report into the loss of a Beechcraft B1900C in 2010. The aircraft, AP-BJD, was being operated by JS Air (as subsidiary of the JS Group) when it crashed on 5 November 2010, killing 21 people.  The accident featured what a

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Canadian Coast Guard Helicopter Accident: CFIT, Survivability and More

Accidents & Incidents, Crises / Emergency Response / SAR, Helicopters, Human Factors / Performance, Offshore, Safety Culture, Safety Management, Special Mission Aircraft, Survivability / Ditching

Fatal Arctic Bo105 CFIT gives lessons on low level ops, compliance with mx data, cold water survivability, alerting, data recorders and regulatory oversight.

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UK OHSAG Oct 2015 Minutes

Accidents & Incidents, Airfields / Heliports / Helidecks, Crises / Emergency Response / SAR, Helicopters, Human Factors / Performance, HUMS / VHM / UMS / IVHM, Logistics, Offshore, Oil & Gas / IOGP / Energy, Regulation, Resilience, Safety Management, Survivability / Ditching

UK Offshore Helicopter Safety Action Group (OHSAG) October 2015 Minutes The UK Civil Aviation Authority (CAA) has just published the minutes of the 16 October 2015 meeting of the Offshore Helicopter Safety Action Group (OHSAG).  This is the third and last of the year (compared to six in 2014), postponed from July 2015. The OHSAG was formed as a result of the ‘Civil

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So You Think The GOM is Non-Hostile?

Accidents & Incidents, Helicopters, Human Factors / Performance, Offshore, Oil & Gas / IOGP / Energy, Safety Management, Survivability / Ditching

So You Think The Gulf of Mexico (GOM) is Non-Hostile? The Gulf of Mexico (GOM), off the coast of Mississippi, Louisiana and Texas in particular, remains a busy area for offshore helicopter operations with over 2 million passengers carried and nearly 300,000 flying hours last year (see our article: Helicopter Ops and Safety – Gulf Of

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Back to the Future: Error Management

Accidents & Incidents, Air Traffic Management / Airspace, Airfields / Heliports / Helidecks, Business Aviation, Crises / Emergency Response / SAR, Design & Certification, Fixed Wing, Helicopters, Human Factors / Performance, HUMS / VHM / UMS / IVHM, Logistics, Maintenance / Continuing Airworthiness / CAMOs, Military / Defence, Mining / Resource Sector, Offshore, Oil & Gas / IOGP / Energy, Resilience, Safety Culture, Safety Management

We look at some of the problems of error management and ask if we are still making the error management mistakes James Reason warned of in 1997 (spoiler: some organisations are). We also look at drift and how some have failed to grasp its more than poor compliance.

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Bell 407 Power Loss GOM Ditching: NTSB

Accidents & Incidents, Helicopters, Offshore, Oil & Gas / IOGP / Energy, Safety Management, Survivability / Ditching

Bell 407 Power Loss GOM Ditching: NTSB (RLC B407 N373RL) The US National Transportation Safety Board (NTSB) has reported on the ditching of a Bell 407 offshore helicopter in the Gulf Of Mexico (GOM) on 11 November 2014.   The aircraft, N373RL operated by Rotorcraft Leasing Company (RLC), ditched following a partial power loss shortly after take off from an installation

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Bristow Sikorsky S-92A

S-92A Emergency Landing: MGB Oil Checklist Recommendation

Accidents & Incidents, Helicopters, Human Factors / Performance, Offshore, Oil & Gas / IOGP / Energy, Safety Management

S-92A Emergency Landing: MGB Oil Checklist Recommendation Earlier this month the Norwegian Accident Investigation Board (AIBN) issued their report into an emergency landing of Sikorsky S-92A LN-ONW, operated by Bristow Norway on 4 October 2013.  The crew almost ditched due to false warnings created by a single tripped circuit breaker. The Incident The S-92A was returning from the

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Misassembled Anti-Torque Pedals Cause EC135P1 Accident

Accidents & Incidents, Helicopters, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Safety Management

Misassembled Anti-Torque Pedals Cause EC135P1 Accident The US National Transportation Safety Board (NTSB) has recently determined that misassembled anti-torque pedals caused an accident to Airbus Helicopters (formerly Eurocopter) EC135P1 N911KB, during a post-maintenance check flight by Metro Aviation at Shreveport, Louisiana on 9 November 2013. The Accident The pilot and two mechanics sustained minor injuries and the helicopter was substantially damaged

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Norwegian Survival Suits: Suited for Safety

Accidents & Incidents, Crises / Emergency Response / SAR, Helicopters, Offshore, Oil & Gas / IOGP / Energy, Safety Management, Survivability / Ditching

Norwegian Survival Suits: Suited for Safety The Norwegian Petroleum Safety Agency (PSA), has published a piece on the history of survival suits in Norway in their latest Dialogue magazine. Amusingly their first illustration highlights a hazard unique to early survival suits that we discussed after the 2014 Oil & Gas UK annual aviation seminar, namely cigarette

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When Down Is Up: 747 Actuator Installation Incident

Accidents & Incidents, Design & Certification, Fixed Wing, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Safety Management

When Down Is Up: 747 Actuator Installation Incident The UK Air Accidents Investigation Branch (AAIB) has published their report into a serious incident involving Boeing 747-443 G-VROM on 29 December 2014. History of the Flight The AAIB report that: The aircraft departed from London Gatwick Airport for a scheduled flight to Las Vegas. Following retraction of the

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Regulation (EU) 376/2014: Reporting, Analysis and Follow-up of Occurrences in Civil Aviation

Accidents & Incidents, Air Traffic Management / Airspace, Airfields / Heliports / Helidecks, Design & Certification, Fixed Wing, Helicopters, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, News, Safety Management

Regulation (EU) 376/2014: Reporting, Analysis and Follow-up of Occurrences in Civil Aviation On 15 November 2015, a new European Union wide aviation reporting regulation came into force.  The European Commission has created a safety reporting portal. Previously Mandatory Occurrence Reporting (MOR) was effectively regulated by a Directive 2003/42/EC to each nation to create compatible national regulation. That directive is

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AC-130J Prototype Written-Off After Flight Test LOC-I Overstress

Accidents & Incidents, Fixed Wing, Safety Management, Special Mission Aircraft

AC-130J Prototype Written-Off After Flight Test LOC-I Overstress The prototype US Air Force (USAF) AC-130J Ghostrider, 09-5710, has been declared a total loss after the airframe was “severely overstressed” after a Loss of Control – Inflight (LOC-I) during a flight test from Eglin AFB, Florida on 21 April 2015.  Loss of the aircraft is estimated at $115.6 million. The Occurrence The

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Micro FOD: Cessna 208B Grand Caravan Engine Failure & Forced Landing

Accidents & Incidents, Fixed Wing, Maintenance / Continuing Airworthiness / CAMOs, Safety Management

Micro FOD: Cessna 208B Grand Caravan Engine Failure & Forced Landing We often think of FOD, Foreign Object Damage, as something caused by a carelessly discarded piece of waste or forgotten nut or bolt.  The recently issued US National Transportation Safety Board (NTSB) report on a Cessna 208B Grand Caravan accident in Hawaii however describes a ‘micro FOD’ accident

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ATP Serious Incident – Temporary LOC In Icing Conditions

Accidents & Incidents, Fixed Wing, Safety Management

ATP Serious Incident – Temporary LOC In Icing Conditions The Accident Investigation Board Norway (AIBN) has issued their report into a serious incident where West Air Sweden BAE Systems ATP cargo aircraft SE-MAF suffered control problems while en route on 25 September 2014.  Coincidentally, their report was issued on the eve of the 21st Anniversary of the Roselawn ATR

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Misloading Caused Fatal 2013 DHC-3 Otter Accident

Accidents & Incidents, FDM / Data Recorders, Fixed Wing, Safety Management

Misloading Caused Fatal 2013 DHC-3 Otter Accident The US National Transportation Safety Board (NTSB) investigation into a fatal accident to Rediske Air de Havilland DHC-3T Otter N93PC in Soldotna, Alaska on 7 July 2013, has determined it was caused by misloading. A passenger iPhone video of the aircraft’s take-off was recovered from the wreckage and analysed.  The full report can be

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EASA annual safety review 2014

EASA Annual Safety Review 2014 Published

Accidents & Incidents, Fixed Wing, Helicopters, Regulation, Safety Management

EASA Annual Safety Review 2014 Published The European Aviation Safety Agency (EASA) Annual Safety Review for 2014 is now available at: https://www.easa.europa.eu/newsroom-and-events/general-publications/annual-safety-review-2014 Worldwide in 2014, 16 fatal accidents involved Commercial Air Transport (CAT) aeroplanes (excluding MH17, that was considered to be a hostile act).  This was two more than 2014, but still significantly below the average number of fatal accidents

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