Beware Last Minute Changes in Plan
An NTSB report on an EC130 helicopter wirestrike accident that illustrates the need fully plan and risk assess last minute changes in plan.
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Misfuelling Accidents
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
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The Missing Igniters: Fatigue & Management of Change Shortcomings
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).
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B787 GEnx Fan Shaft Failure
The failure of a GE GEnx engine shaft on an Air India Boeing 787 during engine runs at the factory in 2012.
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Gulfstream G-IV Take Off Accident & Human Factors
Fatal G-IV runway excursion: take off with gust lock engaged. Contributing: habitual noncompliance and inadequate certification.
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Loss of MV Derbyshire 9th September 1980
Loss of MV Derbyshire 9th September 1980 On 9th September 1980 the Bibby Line OBO (oil/bulk/ore) carrier MV Derbyshire sank during Typhoon Orchid in the South China Sea. All 44 people on board died. The Derbyshire, at 90,000 gross registered tons, remains the largest UK registered ship ever to be lost at sea. Until 1994 the location of
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HTAWS Technology: Friend or Foe?
HTAWS Technology: Friend or Foe? Technology has great potential to reduce aviation risk. The European Helicopter Safety Team (EHEST) issued a study in October 2014 on the safety value of technology. Terrain Avoidance and Warning Systems (TAWS) have proved highly effective at fixed wing Approach and Landing Accident Reduction (ALAR). On 20 February 2014, the Federal Aviation
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Mid Air Collision Typhoon & Learjet 35
Mid Air Collision Typhoon & Learjet 35 During ‘Renegade’ air interception training a civilian Learjet 35, D-CGFI, collided with a Luftwaffe Eurofighter Typhoon. The German Federal Bureau of Aircraft Accidents Investigation (BFU) have issued their final report and we attended an excellent briefing by the BFU at the ISASI 2015 conference. In Germany, as in the UK, air
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Moerdijk Explosion: “Failure to Learn”
Shell Moerdijk Explosion: “Failure to Learn” On 3 June 2014 two major explosions and a fire occurred at a Shell petrochemical plant in Moerdijk, Netherlands. Two employees were injured in the explosions that were heard 20 km away. Debris was found 800 metres away. The Dutch Safety Board has investigated this incident. Currently only the investigation summary
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ISASI Seminar 2015 – ‘Independence does not mean Isolation’
International Society of Air Safety Investigators Seminar 2015 Aerossurance will be attending the 46th annual seminar of the International Society of Air Safety Investigators (ISASI) 24-28 August 2015, in Augsburg, Germany. Organised by the society’s European chapter, the European Society of Air Safety Investigators (ESASI), this year’s theme is ‘Independence does not mean Isolation’. Programme Aerossurance has
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USAF RC-135V Rivet Joint Oxygen Fire
A military accident investigation has paradoxically determined that a $62.4mn fire was due to a maintenance error but that no human factors were involved.
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Fuel System Maintenance Error: Tuniter ATR72 TS-LBB Ditching 6 August 2005
Fuel System Maintenance Error: Tuniter ATR72 TS-LBB Ditching 6 August 2005 On the 6 August 2005 a Tuninter ATR72 turboprop aircraft, TS-LBB, flying from Bari, Italy to Tunis, Tunisia, ran out of fuel and ditched off the northern coast of Sicily. Of the 39 people on board, 16 died. The aircraft had been erroneously fitted during maintenance with
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Loose B-Nut: Accident During Helicopter Maintenance Check Flight
Loose B-Nut: Accident During Helicopter Maintenance Check Flight Another investigation by the US National Transportation Safety Board (NTSB), published on 13 July 2015, has highlighted poor maintenance standards and continuing airworthiness management in a US helicopter operator. The NTSB report that on 1 January 2014, Airbus Helicopters EC130B4, N133GC, operated by Papillon Airways Inc (PAI), was
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‘Procedural Drift’: Lynx CFIT in Afghanistan
‘Procedural drift’ in the operating detachment was noted by the Service Inquiry into a British military helicopter accident in Afghanistan that killed 5 service personnel. This drift is said to have allowed standards to dilute during sustained operations in theatre.
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Performance Based Regulation and Detecting the Pathogens
Performance Based Regulation (PBR) and Detecting the Pathogens At a time when Performance Based Regulation (PBR) is a hot topic in the aviation industry, a series of rail accidents in North America help demonstrate the type of poor performance that PBR must successfully detect. These accidents were what James Reason, Professor Emeritus, University of Manchester described as ‘organisational accidents’ in his
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Southwest Unstabilised Approach Accident
An unstabilised approach and a late change of control were critical in an accident that resulted in a SWA B737 nose gear collapse at La Guardia say NTSB.
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Crashworthiness and a Fiery Frisco US HEMS Accident
Crashworthiness and a Fiery Frisco US HEMS Accident (Airbus Helicopters AS350B3e, N390LG of Air Methods) Shortly after take-off from a hospital in Frisco, Colorado, on 2 July 2015, Airbus Helicopters AS350B3e helicopter, N390LG, operated by Air Methods as ‘Flight for Life’, crashed in a parking lot 120m away. This was a daytime, Visual Meteorological Condition (VMC), Part 135
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Metro-North: Organisational Accidents and Shelfware
Metro-North: Organisational Accidents and Shelfware An NTSB study into five accidents on US railway (‘railroad’) Metro-North gives a unique perspective on organisational accidents. Metro-North was described as having an “invisible safety department”, that kept its SMS on the shelf until external audits and assumed on-time performance would give them safe operations. Organisational Accidents James Reason, Professor Emeritus, University of Manchester popularised the
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Inadequately Secured Cargo Caused B747F Crash at Bagram, Afghanistan
Inadequately Secured Cargo Caused B747F Crash at Bagram, Afghanistan The US National Transportation Safety Board (NTSB) has determined that a National Airlines Boeing 747 Freighter N949CA that crashed on take-off on 29 April 2013 did so because the five armoured military vehicles (2x12t and 3x18t) on-board were inadequately restrained. As the NTSB explain: These vehicles were considered a special
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A319 Double Cowling Loss and Fire – AAIB Report
A319 Double Cowling Loss and Fire – AAIB Report The UK Air Accidents Investigation Branch (AAIB) has published their report into an Airbus A319 that lost both engine fan cowlings and suffered an associated fire on take-off from London Heathrow in 2013. We look at the circumstances of the previous evening’s maintenance on this aircraft,
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DuPont Reputational Explosion
DuPont Reputational Explosion Chemical company DuPont (E.I. DuPont de Nemours & Co Inc.) has been feted for its safety performance for many years (for example winning the National Safety Council‘s 2013 Robert W. Campbell Award). Its reputation in the field of safety stretches back to the founding of the company as a gunpowder manufacturer in
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Metro III Low-energy Rejected Landing and CFIT
Metro III Low-energy Rejected Landing and CFIT The Transportation Safety Board of Canada (TSB) has issued a report on a fatal accident to Fairchild SA227-AC Metro III, C-GFWX, operated by Perimeter Aviation at Sanikiluaq, Nunavut, on the coast of Hudson Bay on 22 December 2012. The route from Winnipeg is normally operated by sister company Keewatin Air, but
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Helicopter Ops and Safety – Gulf Of Mexico 2014
Helicopter Ops and Safety – Gulf of Mexico 2014 The Helicopter Safety Advisory Conference (HSAC) has been publishing data on the Gulf of Mexico (‘GOM’) offshore helicopter fleet and its safety since 1995. Helicopter Operations: GOM Fleet Data They report that flying activity has remained “relatively constant” for the last several years, with just under 300k flying
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B767 Engine Fire – Ignition from Misrouted / Chaffed Cables
B767 Engine Fire – Ignition from Misrouted / Chaffed Cables The National Transportation Safety Board (NTSB) have reported on an engine fire that occurred on 11 July 2014 when: …Boeing B-767-332, registration number N139DL, operated by Delta Air Lines (DAL)… powered by two General Electric (GE) CF6-80A2 turbofan engines, experienced a left engine (No. 1)
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Scottish Court Orders Release of Sumburgh Helicopter CVFDR
Scottish Court Orders Release of Sumburgh Helicopter CVFDR A Scottish Court has ordered that the UK Air Accidents Investigation Branch (AAIB) release the combined Cockpit Voice and Flight Data Recorder (CVFDR) from a fatal 2013 AS332L2 Super Puma offshore helicopter accident at Sumburgh to prosecutors, who will use the Civil Aviation Authority (CAA) to “provide an expert opinion on
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