Human Factors / Performance

HF / Human Performance

BK117B2 Air Ambulance Flameout: Fuel Transfer Pumps OFF, Caution Lights Invisible in NVG Modified Cockpit

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

Dimming the NVG compatible cockpit lighting for a flight at dusk meant the fuel transfer pump caution lights were invisible. The failure to turn these pumps on was only evident after flameout. We wrote of this problem 14 months earlier after a NZ HEMS accident.

BK117B2 Air Ambulance Flameout: Fuel Transfer Pumps OFF, Caution Lights Invisible in NVG Modified Cockpit Read Post »

‘Crazy’ KC-10 Boom Loss: Informal Maintenance Shift Handovers and Skipped Tasks

Accidents & Incidents, Fixed Wing, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Military / Defence, Safety Management, Special Mission Aircraft

Informal verbal handovers over 4 shifts and skipping a key functional check had a hand in an air refuelling boom that went ‘crazy’ in flight and detached.

‘Crazy’ KC-10 Boom Loss: Informal Maintenance Shift Handovers and Skipped Tasks Read Post »

King Air 100 Stalls on Take Off After Exposed to 14 Minutes of Snowfall: No De-Icing Applied

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

The operator had “wide-ranging deficiencies” said a Transport Canada audit but was allowed to continue to operate before a scheduled suspension came into force.

King Air 100 Stalls on Take Off After Exposed to 14 Minutes of Snowfall: No De-Icing Applied Read Post »

Loose Engine B-Nut Triggers Fatal Forced Landing

Accidents & Incidents, Helicopters, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Mining / Resource Sector, Safety Management, Special Mission Aircraft

Loose Engine B-Nut Triggers Fatal Forced Landing On 26 September 2017 Hughes (later MD) 369D SE-JVI was being used for power line inspection on behalf of energy company Vattenfall, by the First European Aviation Company when it suffered a sudden power loss and impact with the ground that killed one occupant History of the Accident Flight The Swedish Accident Investigation Authority, the

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Survey Aircraft Fatal Accident: Fatigue, Fuel Mismanagement and Prior Concerns

Accidents & Incidents, Crises / Emergency Response / SAR, Fixed Wing, Human Factors / Performance, Safety Culture, Safety Management, Special Mission Aircraft, Survivability / Ditching

Concerns had been raised about the pilot and the operation just days before this fatal accident. It highlights the importance of doing a proper due diligence and having independent aviation expertise available when contracting for special mission support.

Survey Aircraft Fatal Accident: Fatigue, Fuel Mismanagement and Prior Concerns Read Post »

Alaskan Mid Air Collision at Non-Tower Controlled Airfield

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

Both pilots failed to see and avoid each other while landing at a non-tower-controlled airport. Contributing to the accident was the absence of radio calls from the Cessna during the traffic pattern preceding the accident.

Alaskan Mid Air Collision at Non-Tower Controlled Airfield Read Post »

Near B777 CFIT Departing LAX (0.3 mi H / 0 ft V)

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

Near B777 CFIT Departing LAX (0.3 mi H / 0 ft V) According to the US National Transportation Safety Board (NTSB) investigation report issued 7 May 2019 a “near controlled flight into terrain (CFIT) incident occurred near Mt. Wilson, California, when a Boeing 777-300 departing Los Angeles International Airport (LAX) was instructed to turn left toward

Near B777 CFIT Departing LAX (0.3 mi H / 0 ft V) Read Post »

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