Schiebel Camcopter S-100 Water Impact
French Navy S-100 accident: A previously identified failure mode occured prior to the completion of a roll-out of a product improvement.
Schiebel Camcopter S-100 Water Impact Read Post »
A Maintenance Error Preceded a Fiery Fatal AS350B3 Accident
A high base maintenance workload and disruptions resulted in a forced landing. A boundary fence post punctured the fuel tank and a post crash fire followed.
A Maintenance Error Preceded a Fiery Fatal AS350B3 Accident Read Post »
When a Crew Intentionally Left Their Aircraft Running Knowing it Would Damage Itself…
An unusual event, rapid innovation & collaboration and a good example why culpability decision aids can be a distraction.
When a Crew Intentionally Left Their Aircraft Running Knowing it Would Damage Itself… Read Post »
Attention on Engine Shop Assembly of a S-92A CT7-8 after North Sea IFSD
A CT7-8 IFSD: 12 T-bolts fractured, disconnecting the compressor from the GGT. Investigators examined the engine’s last shop visit in Spain.
Attention on Engine Shop Assembly of a S-92A CT7-8 after North Sea IFSD Read Post »
A Screw in the Wrong Place…A Loss of Hoist Cable
An error of just a few millimetres resulted in a Breeze-Eastern hoist cable being dropped by an AW139…
A Screw in the Wrong Place…A Loss of Hoist Cable Read Post »
Cold Comfort Conference Call: USAF F-35A Alaska Accident
A $196.5 mn organisational accident: a conference call and a contaminated barrel.
Cold Comfort Conference Call: USAF F-35A Alaska Accident Read Post »
Air India B787 GEnx-1B In Flight Shut Down After Maintenance Error 5 Years Earlier
A latent failure introduced during maintenance was dormant for 5 years.
Air India B787 GEnx-1B In Flight Shut Down After Maintenance Error 5 Years Earlier Read Post »
B214ST Tail Rotor Drive Shaft Coupling Misassembly
A maintenance error resulted in a loss of TR drive on a firefighting B214ST. We look at three airworthiness related incidents with the same airframe in UKCS offshore operations.
B214ST Tail Rotor Drive Shaft Coupling Misassembly Read Post »
CHC Sikorsky S-92A Seat Slide Surprise(s)
Failure to learn? In 2010 an Aircraft Commander was left ‘hanging’ after seat components omitted during maintenance. It reoccurred just 3.5 years later.
CHC Sikorsky S-92A Seat Slide Surprise(s) Read Post »
T-Bolt Trouble: Unrecorded Maintenance on US HEMS BK117C2/H145 and Loss of TR Pitch Control
Components disconnected without paperwork being raised, temporarily refitted finger tight and the absence of lockwire being missed….and not for the first time.
Engine & Emergency Flotation Failures – Greenland B206L4 Ditching
A tiny loose turbine bearing tang triggers an autorotation but frozen water in a hose caused the EFS to malfunction. SB/ICA changes for engine and EFS.
Engine & Emergency Flotation Failures – Greenland B206L4 Ditching Read Post »
DA62 Forced Landing After Double Engine Shutdown Due to Multiple Electrical Issues
NTSB were unable to identify the cause of the initiating electrical failure but did identify two battery issues, one connected to a maintenance error & inadequate functional test requirement.
DA62 Forced Landing After Double Engine Shutdown Due to Multiple Electrical Issues Read Post »
B407 Worn Throttle Detent Power Loss Accident
A latent defect is found to have occurred on other aircraft. Could throttle detent inspections be improved?
B407 Worn Throttle Detent Power Loss Accident Read Post »
Deadly Delay: Catastrophic USAF CV-22B Osprey Gear Box Failure
We review the USAF AIB report, looking at the catastrophic gear box failure and decision making seemingly influence by low risk awareness and commitment to completing the flight.
Deadly Delay: Catastrophic USAF CV-22B Osprey Gear Box Failure Read Post »
Undetected Cross Connection Maintenance Error Resulted in a DA42 Hard Landing During a Maintenance Check Flight
Wear is found during a check that results in a rare flying control maintenance task, poorly described in the AMM. Its unrecorded and delegated to an apprentice with insufficient supervision. We examine the maintenance human factors involved.
Multi-Tasking Managers & Deficient Operational Control: Low Viz AS350B3 Take-Off Accident
Two people died after a loss of visual references shortly after take-off in the transition from vertical to horizontal flight. NSIA point to organisational and systemic factors.
In-Flight Break-up of King Air C90 After Wing Spar Repaired Against Manufacturer’s Advice
The wing spar failed from fatigue cracking elsewhere in the wing that was missed during the same inspection.
Maintenance Distraction in Bell 407 Accident
After this accident the operator introduced an RII / Independent Inspection program.
Maintenance Distraction in Bell 407 Accident Read Post »
The Loss of RAF F-35B ZM152: An Organisational Accident
An £81 mn fighter is downed by FOD, one of its own intake blanks.
This case study illustrates James Reason’s concept of Organisational Accidents and how just asking “who left the intake blank ?” misses the real reasons behind this accident.
The Loss of RAF F-35B ZM152: An Organisational Accident Read Post »
Engine Maintenance Introduced FOD that Caused an EC120 Power Loss
FOD, likely introduced during fuel system maintenance, caused a power loss and necessitated a backyard forced landing.
Engine Maintenance Introduced FOD that Caused an EC120 Power Loss Read Post »
Missing Cotter Pin Causes Fatal S-61N Accident
A missing flying control cotter pin was identified by the NTSB investigation into a fatal S-61N accident in Hawaii. Interview evidence raises SMS effectiveness concerns.
Missing Cotter Pin Causes Fatal S-61N Accident Read Post »
EC135 Air Ambulance CFIT when Pilot Distracted Correcting Tech Log Errors
The single pilot was head down as the sun set correcting tech log entries. The helicopter struck trees on a mountain top then force landed in woodland.
EC135 Air Ambulance CFIT when Pilot Distracted Correcting Tech Log Errors Read Post »
Double Trouble: Offshore Surveillance P68 Forced to Glide
An offshore border surveillance P68C suffered two engine power loss failure modes in quick succession. One may have been sabotage.
Double Trouble: Offshore Surveillance P68 Forced to Glide Read Post »
Dornier 328-100 Crossed Apron During Runway Excursion
Fortuitously no aircraft were struck as this Do328 TP left the runway, crossed the airport apron and stopped 3 m from the boundary fence by a hangar. The AIB report identifies a PCU failure but focuses on the crew response rather than the PCU defect.
Dornier 328-100 Crossed Apron During Runway Excursion Read Post »
S-61N Accident in Afghanistan: Investigators Focus on Auxiliary Servocylinder
An S-61N contracted by the DoD crashed after a loss of control due to a fatigue failure of a flying control system component.
S-61N Accident in Afghanistan: Investigators Focus on Auxiliary Servocylinder Read Post »