A maintenance error installing a TRDS bearing resulted in an EC130B4 LOC-I. An excellent AIBN report highlights the value of Independent Inspections.
EC130B4 Accident: Incorrect TRDS Bearing Installation Read Post »
Ignoring Corrosive Environment Brings Down B206 Helicopter An operator that ignored the Rolls-Royce M250-C20 Series Engine Operation and Maintenance Manual classification of their entire island operating location as a “severe corrosion operating environment” and failed to do the associated maintenance requirements suffered the loss of the their Bell 206B3. Emerald Pacific Airlines B206B3 B-31019 was hovering at
Ignoring Corrosive Environment Brings Down B206 Helicopter Read Post »
UK Military Flying Training System Fixed Wing (UKMFTS) Aircraft Service Provision Contract Awarded The contract to provide Elementary, Basic and Multi-Engined training aircraft to the UK Military Flying Training System (UKMFTS) through to 2033 has been awarded. The contract was placed by Babcock / Lockheed Martin joint venture Ascent Flight Training. Ascent, selected as the UK MOD’s
UKMFTS Fixed Wing Aircraft Service Provision Contract Awarded Read Post »
HEMS S-76C Night Approach Loss of Control – In-flight (LOC-I) Incident A Helicopter Emergency Medical Service (HEMS) Sikorsky S-76C+ C-GHHJ operated by Helijet on behalf of the BC Ambulance Service was on a VFR approach to the coastal Tofino/Long Beach Airport (CYAZ), British Columbia, Canada at 02:39 Local Time on the dark, moonless night of 15 November 2015. It suffered a Loss of Control
HEMS S-76C+ Night Approach LOC-I Incident Read Post »
Maintenance Personnel Fatigue and Alertness Maintenance personnel fatigue and a consequential lack of alertness is regularly being identified as contributory, or potentially contributory, to maintenance related air accidents and serious incidents. We have covered three examples previously: Some involve poor shift patterns: Missing Igniters: Fatigue & Management of Change Shortcomings: The UAE GCAA investigation report explains most of the
Maintenance Personnel Fatigue and Alertness Read Post »
Aerossurance: Our Top 20 Articles of 2015 As we start the new year we look back on the 20 articles that proved most popular with our readers in 2015. In reverse order: Number 20: Building St Helena Airport – An Industrial Scale ‘Grand Design’ This started with the building of the first airport on the volcanic
Our Top 20 Articles of 2015 Read Post »
Dangers of Aircraft Tyre (US: Tire) Inflation The Royal Canadian Air Force are investigating two recent tyre inflation burst accidents. Both involve visiting aircraft using borrowed equipment: 25 August 2015 CT-114 Tutor CT114058 A Snowbird aircraft was diverted from the rest of the deployed team due to an in-flight emergency. The aircraft was repaired, including a successful
Dangers of Aircraft Tyre Inflation 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 »
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 »
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
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 »
Aircraft Maintenance: Going for Gold? We pose the question: Can aviation maintenance learn lessons from championship athletes? Aerossurance is pleased to have sponsored the Royal Aeronautical Society (RAeS) conference Human Factors in Engineering – the Next Generation at Cranfield University on 12 May 2015. In his opening address Cranfield University’s Professor Dave King (a former Chief Inspector of Air Accidents with
Aircraft Maintenance: Going for Gold? Read Post »
Critical Maintenance Tasks: EASA Part -M & -145 Change Commission Regulation (EU) 2015/1536 was issued on of 16 September 2015. Technically it amends Regulation (EU) No 1321/2014 “as regards alignment of rules for continuing airworthiness with the ‘Basic Regulation’ Regulation (EC) No 216/2008“. Critical Maintenance Tasks (CMTs) One of the most important parts of the amendment relates to CMTs, which
Critical Maintenance Tasks: EASA Part-M & -145 Change Read Post »
CHIRP – Independent Review The results of an independent review on the work of CHIRP (the Confidential Human Factors Incident Report Programme) have just been published by the British charitable trust. CHIRP Chief Executive Ian Dugmore commented that the review: …reaffirmed the requirement for an independent and confidential reporting system for the UK and recommended that
CHIRP – Independent Review Read Post »
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.
USAF RC-135V Rivet Joint Oxygen Fire Read Post »
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
Fuel System Maintenance Error: Tuniter ATR72 TS-LBB Ditching 6 August 2005 Read Post »
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
Loose B-Nut: Accident During Helicopter Maintenance Check Flight Read Post »
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
Crashworthiness and a Fiery Frisco US HEMS Accident Read Post »
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,
A319 Double Cowling Loss and Fire – AAIB Report Read Post »
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)
B767 Engine Fire – Ignition from Misrouted / Chaffed Cables Read Post »
Cessna Citation Excel Controls Freeze On final approach to Traverse City, MI on 26 March 2014 the Pilot Flying of a Cessna Citation Excel N580QS discovered that the aircraft rudder pedals were ‘hard or frozen’. The results of the subsequent investigation published by the National Transportation Safety Board (NTSB) revealed an unusual dormant failure. History of the Flight
Cessna Citation Excel Controls Freeze Read Post »
Maintenance Human Factors: The Next Generation On 12 May 2015 at Cranfield University, the Royal Aeronautical Society (RAeS) discussed Human Factors in Engineering – the Next Generation. Aerossurance is pleased to have sponsored this thought provoking RAeS Human Factors Group: Engineering event. While the seminar was intended to connect the new generation of aerospace professionals and experienced HF practitioners, it posed
Maintenance Human Factors: The Next Generation Read Post »
Virgin Atlantic Engineers Trial Sony SmartWear (AR & VR in Aviation & Aerospace) Virgin Atlantic engineers at London Heathrow have come to the scheduled end of a 2 month trial of Sony SmartWear equipment. The aim of this wearable technology is to aid communications between line maintenance engineers working remotely on aircraft and engineering support teams. The line engineers were
Virgin Atlantic Engineers Trial Sony SmartWear Read Post »
Culture + Non Compliance + Mechanical Failures = DC-3 Accident (Buffalo Airways C-GWIR) The Transportation Safety Board of Canada (TSB) recently issued a report on the forced landing of a 1942 Douglas DC-3 C-GWIR after an engine failure on 19 August 2013. The Buffalo Airways aircraft was operating a scheduled passenger flight between Yellowknife and Hay River
Culture + Non Compliance + Mechanical Failures = DC3 Accident Read Post »
