Accidents & Incidents

Investigations & Reports

Boeing 737 Automation Related Descent Below Cleared Altitude – ATSB Report

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

Boeing 737 Automation Related Descent Below Cleared Altitude – ATSB Report The Australian Transport Safety Bureau (ATSB) has issued a report on an automation related occurrence: On 17 October 2012, a Boeing 737-838 aircraft, registered VH-VXB and operated by Qantas Airways Limited (Qantas), was conducting a flight from Adelaide, South Australia to Canberra, Australian Capital Territory… […]

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EASA HUMS Research Developments

Accidents & Incidents, Design & Certification, Helicopters, HUMS / VHM / UMS / IVHM, Maintenance / Continuing Airworthiness / CAMOs, Offshore, Oil & Gas / IOGP / Energy, Resilience, Safety Management

EASA HUMS / VHM Research Developments The European Aviation Safety Agency (EASA) has been funding some innovative research into Health and Usage Monitoring Systems (HUMS) / Vibration Health Monitoring (VHM). EASA.2012.OP.13 VHM Recently, Cranfield University‘s Matt Greaves presented to the International Society of Air Safety Investigators (ISASI) annual conference on one EASA research project (EASA.2012.OP.13 VHM).  His paper

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US Vehicle Regulator in Firing Line

Accidents & Incidents, Design & Certification, Regulation, Safety Culture, Safety Management

US Vehicle Regulator in Firing Line The US National Highway Traffic Safety Administration (NHTSA) has been criticized by politicians and safety advocates this week for its handling of critical safety defects with the air bags on millions of vehicles.  It is reported that: The faulty air bags can explode with too much force and spray shrapnel at

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EHEST: New Publications on Technology & SMS

Accidents & Incidents, Design & Certification, Helicopters, Human Factors / Performance, Safety Management

European Helicopter Safety Team (EHEST) Issues New Publications on Technology & SMS EHEST have released two new publications, one on accident reducing technologies and the other on SMS for non-complex operators: The Potential of Technologies to Mitigate Helicopter Accident Factors – An EHEST Study EHEST created a Specialist Team Technology (ST Technology) to assess the potential of

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How To Destroy Your Organisation’s Safety Culture

Accidents & Incidents, Helicopters, Human Factors / Performance, Mining / Resource Sector, Safety Culture, Safety Management

How To Destroy Your Organisation’s Safety Culture The term ‘safety culture’ was initially used in the report on the 1986 Chernobyl nuclear accident.  Building a strong, positive safety culture takes deliberate, concerted and continual effort.  Destroying a safety culture is a lot easier… Bad Safety Leadership The following is the text of a real e-mail, spotted pinned to the wall of the

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Passive Fire-Retarding Helideck Designs

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

Passive Fire-Retarding Helideck Designs A number of helideck manufacturers offer aluminium helideck designs with a passive fire-retarding capability.  Typically this is achieved by draining fuel through holes in the deck surface, into cavities filled with aluminium mesh.  This starves the fire of oxygen and dissipates heat, extinguishing the flames and draining away unburnt fuel for

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Fatal $16 Million Maintenance Errors

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

Fatal $16 Million Maintenance Errors (Sundance Helicopters AS350B2 N37SH) A jury in Las Vegas awarded $16 million to the families of 4 passengers killed in a December 2011 helicopter sightseeing accident, caused by a series of maintenance errors.  The National Transportation Safety Board (NTSB) made safety recommendations on maintenance human factors and fatigue after this accident. The

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US BSEE Helideck A-NPR / Bell 430 Tail Strike

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

US BSEE Helideck A-NPR / Bell 430 Tail Strike The Bureau of Safety and Environmental Enforcement (BSEE) issued an Advance Notice Of Proposed Rulemaking on Helideck and Aviation Fuel Safety for Fixed Offshore Facilities on 24 September 2014.  BSEE explain: Although the Federal Aviation Administration (FAA) has broad authority regarding helicopter-related safety issues and onshore and offshore

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Medevac Misadventure – Inquest in the Yukon

Accidents & Incidents, Crises / Emergency Response / SAR, Fixed Wing, Helicopters, Human Factors / Performance, Logistics, Mining / Resource Sector, Offshore, Oil & Gas / IOGP / Energy, Safety Management, Special Mission Aircraft

Medevac Misadventure – Inquest in the Yukon The Coroner for Canada’s Yukon Territory has recommended a review of procedures for medical evacuations (medevacs) following the death on board an air ambulance of a 31 year-old woman from Carmacks in November 2013, CBC has reported. In particular the wrong IV tubing was taken on the aircraft as different

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Sundance chartered C212

Catastrophe in the Congo – The Company That Lost its Board of Directors

Accidents & Incidents, Business Aviation, Crises / Emergency Response / SAR, Fixed Wing, Logistics, Mining / Resource Sector, Oil & Gas / IOGP / Energy, Resilience, Safety Culture, Safety Management

Catastrophe in the Congo – The Company That Lost its Board of Directors When you charter aircraft for business purposes, any fatal air accident can leave a terrible scar on your company as well as on the friends and family of the people who die.  In 2010 a small Australian mining company suffered a particularly catastrophic air accident,

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Site of the G-CRST helicopter accident

Fatal Helicopter / Crane Collision – London Jan 2013

Accidents & Incidents, Air Traffic Management / Airspace, Airfields / Heliports / Helidecks, Business Aviation, Helicopters, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Regulation, Safety Culture, Safety Management

Fatal Helicopter / Crane Collision – London Jan 2013 While manoeuvring over the River Thames, an AgustaWestland A109E helicopter, G-CRST, operated by charter company Rotormotion, collided at 700ft amsl with a crane in Vauxhall, Central London.  The crane was atop the 50 storey St George Wharf Tower.  The helicopter pilot and a passer-by died.  The UK Air Accident Investigation Branch (AAIB)

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GM Ignition Switch Debacle – Safety Lessons

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

GM Ignition Switch Debacle – Safety Lessons General Motors has faced intense criticism, large fines, on-going court cases and big rectification costs after mishandling a dangerous design fault in millions of vehicles.  So are there safety lessons for other organisations? Aerossurance thinks so. Some have commented that this is a case of corporate complacency while others, similar to Edward

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Offshore Helicopter Safety Action Group & OGUK Helicopter Briefing

Accidents & Incidents, Airfields / Heliports / Helidecks, Crises / Emergency Response / SAR, Design & Certification, Helicopters, Human Factors / Performance, HUMS / VHM / UMS / IVHM, Maintenance / Continuing Airworthiness / CAMOs, Offshore, Oil & Gas / IOGP / Energy, Regulation, Safety Culture, Safety Management, Survivability / Ditching

Offshore Helicopter Safety Action Group (OHSAG) The UK Civil Aviation Authority (CAA) has published the minutes of the latest, 14 August 2014, meeting of the Offshore Helicopter Safety Action Group (OHSAG).  The OHSAG was formed as a result of the ‘Civil Aviation Authority Safety Review of Offshore Public Transport Helicopter Operations in Support of the Exploitation of Oil

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Business Jet Collides With ‘Uncharted’ Obstacle During Go-Around

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

Business Jet Collides With ‘Uncharted’ Obstacle During Go-Around Five people died when a business jet collided with what the NTSB originally stated was an un-charted 72 ft concrete powerline pole, built 0.25 miles from the departure end of the runway, during a nighttime go-around. The US National Transportation Safety Board (NTSB) have issued a factual update

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NTSB Recommendations on Offshore Methane Gas Venting

Accidents & Incidents, Airfields / Heliports / Helidecks, Helicopters, Offshore, Oil & Gas / IOGP / Energy, Safety Management

NTSB Recommendations on Offshore Methane Gas Venting The US National Transportation Safety Board (NTSB) have issued a series of recommendations following two accidents were single engined offshore helicopters ditched after the suspected ingestion of vented methane gas caused a full or partial engine power loss near an offshore platform. Vented combustible gas can cause surging, a compressor

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Wrong Deck Landings

Accidents & Incidents, Airfields / Heliports / Helidecks, Helicopters, Human Factors / Performance, News, Offshore, Oil & Gas / IOGP / Energy, Safety Culture, Safety Management

Wrong Deck Landings Occasionally, offshore helicopters do land on the wrong offshore installation.  On 26 August 2014 the media picked up an such an event that occurred a few days earlier involving a Sikorsky S-92A. So is it a big deal?  Well, yes and no! There are good reasons to avoid landing on a deck that is

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Commanders: Flying or Monitoring?

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

Commanders: Flying or Monitoring? At a recent Royal Aeronautical Society Conference, one of the speakers, Colin Milne of BALPA, highlighted that in a number of past UK large helicopter accidents involving Controlled Flight Into Terrain (CFIT) or Loss of Control (LOC) the Commander was the Pilot Flying rather than the Pilot Monitoring. While there are circumstances where this

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Alaska B1900C Accident – Contributory ATC Errors

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

Alaska B1900C Accident – Contributory ATC Errors The US National Transportation Safety Board (NTSB) identified contributory ATC errors when they issued their probable cause of a fatal Beechcraft B1900C Controlled Flight Into Terrain (CFIT) accident in instrument meteorological conditions at Aleknagik, Alaska on 8 March 2013.  The aircraft, N116AX, was operated by Alaska Central Express (Ace) Air Cargo.

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FAA

FAA Impose Fines After Maintenance Errors – Just Culture?

Accidents & Incidents, Helicopters, Maintenance / Continuing Airworthiness / CAMOs, News, Regulation, Safety Management

FAA Impose Fines After Maintenance Errors – Just Culture? The Federal Aviation Administration (FAA) have proposed fining two helicopter emergency medical service (HEMS) operators and one airline a total of $12.4 million for allegedly operating non-compliant aircraft after various maintenance errors.  However does this encourage a just, open reporting culture? The Cases In each case it should be

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EASA Launch Helicopter Gearbox Lubrication Rule Making

Accidents & Incidents, Design & Certification, Helicopters, Offshore, Oil & Gas / IOGP / Energy, Regulation, Safety Culture, Safety Management

 EASA Launch Helicopter Gearbox Lubrication Rule Making The first meeting was held last week of a new European Aviation Safety Agency (EASA) Rule Making Team (RMT.0608) on helicopter gearbox lubrication.  The Terms of Reference (ToR) and Group Composition (GC) are here. This activity follows European/US/Canadian dialogue after the loss of Cougar Sikorsky S-92A C-GZCH Flight 491 off Newfoundland,

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