Design & Certification

Design Organisations / DOAs, Part 21, EMAR-21, DAOS, Aircraft Design, Aeronautical Engineering

Engine & Emergency Flotation Failures – Greenland B206L4 Ditching

Accidents & Incidents, Crises / Emergency Response / SAR, Design & Certification, Helicopters, Maintenance / Continuing Airworthiness / CAMOs, Offshore, Safety Management, Survivability / 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 »

UK CAA HOFO ACAS Rulemaking 2025 & a 2004 Tornado / AS332L Airprox

Accidents & Incidents, Air Traffic Management / Airspace, Design & Certification, Fixed Wing, Helicopters, Military / Defence, Offshore, Oil & Gas / IOGP / Energy, Regulation, Safety Management

UK CAA are proposing making ACAS II mandatory for offshore helicopters: we look back to the 2004 incident that prompted a demonstration that ACAS II was practical for helicopters.

UK CAA HOFO ACAS Rulemaking 2025 & a 2004 Tornado / AS332L Airprox Read Post »

S-76D Loss of Control on Approach to an Indian Drilling Rig

Accidents & Incidents, Crises / Emergency Response / SAR, Design & Certification, Helicopters, Human Factors / Performance, Offshore, Oil & Gas / IOGP / Energy, Regulation, Safety Culture, Safety Management, Survivability / Ditching

A low time on type crew lost control while distracted. Everyone escaped but 4 died in the water due to poor briefings and inadequate rescue capability.

S-76D Loss of Control on Approach to an Indian Drilling Rig Read Post »

Startled Shutdown: Fatal USAF E-11A Global Express PSM+ICR Accident

Accidents & Incidents, Design & Certification, FDM / Data Recorders, Fixed Wing, Human Factors / Performance, Military / Defence, Safety Management, Special Mission Aircraft

A fan blade off event leads to an engine automatic shutdown. The crew shut down the serviceable engine and choose to divert 200 NM further than necessary leading to a forced landing.

Startled Shutdown: Fatal USAF E-11A Global Express PSM+ICR Accident Read Post »

DA62 Forced Landing After Double Engine Shutdown Due to Multiple Electrical Issues

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

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 »

Dramatic AW139 Accident at Houma: Skillful Recovery from a Latent Production Defect

Accidents & Incidents, Crises / Emergency Response / SAR, Design & Certification, Helicopters, Human Factors / Performance, Offshore, Oil & Gas / IOGP / Energy, Safety Management

Exemplary airmanship after a production defect, dormant for 11 years emerged. We look at human centred design and a ‘scary version’ of current supply chain issues.

Dramatic AW139 Accident at Houma: Skillful Recovery from a Latent Production Defect Read Post »

Deadly Delay: Catastrophic USAF CV-22B Osprey Gear Box Failure

Accidents & Incidents, Design & Certification, Fixed Wing, Helicopters, Human Factors / Performance, HUMS / VHM / UMS / IVHM, Maintenance / Continuing Airworthiness / CAMOs, Military / Defence, Safety Culture, Safety Management, Special Mission Aircraft

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 »

Night Offshore Helicopter Approach Water Impact

Accidents & Incidents, Crises / Emergency Response / SAR, Design & Certification, Helicopters, Human Factors / Performance, Offshore, Oil & Gas / IOGP / Energy, Regulation, Safety Culture, Safety Management, Special Mission Aircraft, Survivability / Ditching

A night visual approach resulted in illusions that resulted in a water impact. Everyone on board was rescued but not before highlighting many survivability & SAR enhancements, as well as triggering improved helideck lighting and TAWS improvements.

Night Offshore Helicopter Approach Water Impact Read Post »

Undetected Cross Connection Maintenance Error Resulted in a DA42 Hard Landing During a Maintenance Check Flight

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

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.

Undetected Cross Connection Maintenance Error Resulted in a DA42 Hard Landing During a Maintenance Check Flight Read Post »

In-Flight Break-up of King Air C90 After Wing Spar Repaired Against Manufacturer’s Advice

Accidents & Incidents, Design & Certification, Fixed Wing, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Regulation, Safety Management, Special Mission Aircraft

The wing spar failed from fatigue cracking elsewhere in the wing that was missed during the same inspection.

In-Flight Break-up of King Air C90 After Wing Spar Repaired Against Manufacturer’s Advice Read Post »

The Loss of RAF F-35B ZM152: An Organisational Accident

Accidents & Incidents, Crises / Emergency Response / SAR, Design & Certification, Fixed Wing, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Military / Defence, Regulation, Safety Culture, Safety Management, Survivability / Ditching

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 »

BK117 Offshore Medevac CFIT & Survivability Issues

Accidents & Incidents, Crises / Emergency Response / SAR, Design & Certification, Helicopters, Human Factors / Performance, Offshore, Safety Culture, Safety Management, Special Mission Aircraft, Survivability / Ditching

An offshore medevac accident that highlights considering the changing risk of an individual flight, flight path management in degrading conditions and offshore survivability in a ‘regulatory void’.

BK117 Offshore Medevac CFIT & Survivability Issues Read Post »

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