We look at lessons in a NTSB rail accident report on how a cult of compliance and routine over-emphasis on judging front line workers can lead to disaster, lessons relevant to all industries.
A Railroad’s Cult of Compliance Read Post »
A helicopter was left spinning on the ramp after a tail strike when control was lost landing on a towed dolly, incapacitating both occupants in a horrific accident caught on video.
Dramatic Loss of Control During AS350 Landing Practice Read Post »
A US airline shows a strange grasp of human factors principles and argues AGAINST a design change intended to address a long running series of maintenance errors.
United Airlines Suffers from ED (Error Dysfunction) Read Post »
In need of inspiration for your maintenance human factor continuation training? Why not use this free CASA HF video?: ‘Crossed Wires’
Crossed Wires: Online Maintenance Human Factors Training Video Read Post »
A crew with low experience on type had a lucky escape when they inadvertently descended and struck a frozen lake during an exercise in Norway.
Swedish NH90 CFIT: Pilot Experience and Skating on Frozen Lake Read Post »
Miscommunication and poor ground crew briefing resulted in a long-line and load snagging on a B407 at take off causing a crash.
Unexpected Load: B407 USL / External Cargo Accident in PNG Read Post »
The absence of a policy of landing with a specific minimum fuel quantity was a key factor in a survey helicopter’s loss of power and collision with trees near Whitecourt, AB in 2016.
Running on Fumes: Fatal Canadian Helicopter Accident Read Post »
Cockpit confusion, a rushed approach, procedural deviations and a design flaw featured in a fatal turboprop LOC-I accident in Luxembourg in 2002.
Luxair F50 LOC-I Accident 6 November 2002 Read Post »
TSB explain how an airline risk assessed operations into icing, had not implemented all the mitigations but had started routinely operating into forecast icing, with fatal consequences.
How a Cultural Norm Lead to a Fatal C208B Icing Accident Read Post »
The pilot of a CF-188 Hornet pulled out at 270ft above the ground after a partial loss of consciousness during a 6.8g overhead break.
High G Drama at Cold Lake Read Post »
A runway arrestor gear system using green lights for both UP and DOWN has been involved in two incidents in Australia that highlight the risks of expectation bias.
When Green is for Stop: Poor Design HF Read Post »
A catastrophic accident was prevented by the electrical harness. A series of quality issues were found in the FIPS. In particular screws intended for another part of the unit had been fitted and bottomed out leading to a fatigue failure.
Production Errors on a SAR AW139 Helicopter Full Ice Protection System Read Post »
False stick shaker and stick pusher activation occurred after an airflow sensor with a dormant failure was fitted and a key functional test omitted.
Swedish Stick Shake: Dormant Sensor Defect not Detected on Installation Read Post »
This accident and the loss of 12 lives off the coast of Norway in 1997 had far reaching consequences for the use and regulation of helicopter HUMS.
Loss of AS332L1 LN-OPG off Brønnøysund, Norway, 8 September 1997 Read Post »
An offshore helicopter incident highlighted a new hazard as offshore industry practices change. We look at the lessons for companies using both helicopters and walk-to-work vessels to their NUIs.
Mind the Handrail! – Walk-to-Work Helideck Hazard Read Post »
319 seconds to disaster: a high speed impact on approach to a drilling rig off Mumbai. Night offshore ops are 6 times higher risk than daytime ops. We look at the lessons.
Night Offshore Training AS365N3 Accident in India 2015 Read Post »
The Singapore TSIB report on yet another A320 fan cowl loss. We look at the human factors that influenced missing the unlatched cowls.
Tiger A320 Fan Cowl Door Loss & Human Factors: Singapore TSIB Report Read Post »
An airliner on a night approach at Dublin lined-up not on the runway but on the lights of a tower block. We look at the investigation, the lessons and the prompt safety action taken.
The Jet that Almost ‘Landed’ on a Tower Block Read Post »
Night departure of a Otter in Alaska into a ‘back hole’ when outside of the weight and CG limits resulted in spatial disorientation, a stall and LOC-I.
Deadly Combination of Misloading and a Somatogravic Illusion: Alaskan Otter Read Post »
The brakes had been set OFF during maintenance trouble shooting and the chocks removed prematurely, so the aircraft rolled when a tug with a u/s radio was being swapped out.
An A320 was flown with pax back to Germany after a 3.32G heavy landing due to insufficient maintenance resource and lack of understanding of fault codes say CIAIAC.
A320 Flown on After Damaging Heavy Landing Read Post »
An air ambulance King Air 200 was substantially damaged during a single engined landing in Australia with HF, training, SMS and CAMO lessons.
False Fire Warning and Unfeathered Propeller KA200 Accident Read Post »
A critical flying control component was unnecessarily removed during an inspection say the NTSB and when refitted, the fasteners were not lock-wired with fatal consequences.
Incomplete Maintenance Leads to Fatal Collective Control Loss on B407 Read Post »
A collision during apron works at Stavanger. A skipped risk assessment by airport/contractors, misleading concrete barriers and confirmation bias. Highlights the fallacy of over reliance on safety reporting.
S-92A Collision with Obstacle while Taxying Read Post »
David Marquet describes a technique developed while CO of the nuclear submarine USS Santa Fe, to reduce errors and increase mindfulness during critical tasks.
Deliberate Action: A Mindful Method from the Nuclear Navy Read Post »
