Fatal Arctic Bo105 CFIT gives lessons on low level ops, compliance with mx data, cold water survivability, alerting, data recorders and regulatory oversight.
Canadian Coast Guard Helicopter Accident: CFIT, Survivability and More Read Post »
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
UK OHSAG Oct 2015 Minutes Read Post »
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
So You Think The GOM is Non-Hostile? Read Post »
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.
Back to the Future: Error Management Read Post »
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
Bell 407 Power Loss GOM Ditching: NTSB Read Post »
Landing briefing missed. ANSV claim Vapp too high (CIAS disagree). No go around after first bounce. NLG & MLG collapse.
ANSV Highlight Procedures & HF After ATR72 Landing Accident Read Post »
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
S-92A Emergency Landing: MGB Oil Checklist Recommendation Read Post »
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
Misassembled Anti-Torque Pedals Cause EC135P1 Accident Read Post »
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
Norwegian Survival Suits: Suited for Safety Read Post »
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
When Down Is Up: 747 Actuator Installation Incident Read Post »
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
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
AC-130J Prototype Written-Off After Flight Test LOC-I Overstress Read Post »
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
Micro FOD: Cessna 208B Grand Caravan Engine Failure & Forced Landing Read Post »
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
ATP Serious Incident – Temporary LOC In Icing Conditions Read Post »
Another US business jet accident highlights poor checklist use and SMS ‘shelfware’ according to the BEA report into the 2012 accident.
Fatal G-IV Runway Excursion Accident in France – Lessons Read Post »
AAIB: The helicopter was operated for a “sustained period” with the fuel transfer pumps off despite low fuel warnings being triggered and acknowledged.
AAIB Report on Glasgow Police EC135T2+ Clutha Helicopter Accident Read Post »
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
Misloading Caused Fatal 2013 DHC-3 Otter Accident Read Post »
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
EASA Annual Safety Review 2014 Published Read Post »
Fatal Night-time UK AW139 Accident Highlights Business Aviation Safety Lessons The UK Air Accidents Investigation Branch (AAIB) has published their report into the fatal accident to AgustaWestland AW139 G-LBAL on 13 March 2014. This accident reinforces many important past lessons on business aviation safety, managing clients, training, human factors and learning from previous accidents. The helicopter, owned by Haughey Air, departed from a
Fatal Night-time UK AW139 Accident Highlights Business Aviation Safety Lessons Read Post »
BA Changes Briefings, Simulator Training and Chart Provider After B747 Accident According to a recently released UK Civil Aviation Authority (UK CAA) FACTOR (Follow-up ACTion on Occurrence Report), British Airways (BA) have enhanced their simulator training and changed chart provider in response to a ground accident in South Africa. The Accident On 22 December 2013, BA G-BNLL sustained substantial
BA Changes Briefings, Simulator Training and Chart Provider After B747 Accident Read Post »
An NTSB report on an EC130 helicopter wirestrike accident that illustrates the need fully plan and risk assess last minute changes in plan.
Beware Last Minute Changes in Plan Read Post »
Misfuelling Accidents Misfuelling aircraft with kerosene based Jet A-1 rather than Aviation Gasoline (AVGAS) continues to be a source of accidents. PA31 15 Sept 2015 Manitoba The Canadian Transportation Safety Board (TSB) has recently released an update on the 15 September 2015 accident involving twin engined Keystone Air Service Piper PA31-350 Navajo C-FXLO at Thompson, Manitoba. Shortly after takeoff the aircraft experienced a
Misfuelling Accidents Read Post »
This dual engine incident highlights maintenance fatigue and Management of Change at both a macro level (corporate restructuring) and the micro level (a new task).
The Missing Igniters: Fatigue & Management of Change Shortcomings Read Post »
The failure of a GE GEnx engine shaft on an Air India Boeing 787 during engine runs at the factory in 2012.
B787 GEnx Fan Shaft Failure Read Post »
Fatal G-IV runway excursion: take off with gust lock engaged. Contributing: habitual noncompliance and inadequate certification.
Gulfstream G-IV Take Off Accident & Human Factors Read Post »
