Accidents & Incidents

Investigations & Reports

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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Fatal Night-time UK AW139 Accident Highlights Business Aviation Safety Lessons

Accidents & Incidents, Business Aviation, Helicopters, Human Factors / Performance, Regulation, Safety Culture, Safety Management

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

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B747 JNB

BA Changes Briefings, Simulator Training and Chart Provider After B747 Accident

Accidents & Incidents, Airfields / Heliports / Helidecks, Fixed Wing, Human Factors / Performance, Safety Management

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

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Misfuelling Accidents

Accidents & Incidents, Airfields / Heliports / Helidecks, Business Aviation, Fixed Wing, Human Factors / Performance, Safety Management

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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Loss of MV Derbyshire 9th September 1980

Accidents & Incidents, Design & Certification, Safety Management

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?

Accidents & Incidents, Design & Certification, Helicopters, Human Factors / Performance, Regulation, Safety Management, Special Mission Aircraft

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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Learrjet Typhoon Mid Air Collision Germany

Mid Air Collision Typhoon & Learjet 35

Accidents & Incidents, Fixed Wing, Human Factors / Performance, Military / Defence, Regulation, Safety Management, Special Mission Aircraft

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”

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

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’

Accidents & Incidents, FDM / Data Recorders, Safety Management

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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Fuel System Maintenance Error: Tuniter ATR72 TS-LBB Ditching 6 August 2005

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

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

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

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

Accidents & Incidents, FDM / Data Recorders, Helicopters, Human Factors / Performance, Military / Defence, Safety Culture, Safety Management

‘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

Accidents & Incidents, Human Factors / Performance, Regulation, Resilience, Safety Culture, Safety Management

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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Crashworthiness and a Fiery Frisco US HEMS Accident

Accidents & Incidents, Airfields / Heliports / Helidecks, Crises / Emergency Response / SAR, Design & Certification, Helicopters, Maintenance / Continuing Airworthiness / CAMOs, Safety Management, Special Mission Aircraft, Survivability / Ditching

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

Accidents & Incidents, Human Factors / Performance, Regulation, Safety Culture, Safety Management

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

Accidents & Incidents, Fixed Wing, Human Factors / Performance, Logistics, Regulation, Safety Management

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

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

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

Accidents & Incidents, Human Factors / Performance, News, Safety Culture, Safety Management

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

Accidents & Incidents, Fixed Wing, Human Factors / Performance, Regulation, Safety Management, Survivability / Ditching

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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