ValuJet Flight 592: 11 May 1996
This accident had major lessons on the management of maintenance/maintenance errors, dangerous goods handling and regulatory behaviour.
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Night Offshore Windfarm HEMS Winch Training CFIT (BK117C1 D-HDRJ)
During night winch training a German HEMS BK117 suffered a fatal CFIT in the Baltic, highlighting readiness, equipment, procedural and training issues.
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5000-1 Safety Lesson: Communication
5000-1 Safety Lesson: Communication After their spectacular season, starting as 5000-1 underdogs but ultimately winning the English Football Premiership, a number of commentators have been discussing the success of Leicester City FC and their manager, Claudio Ranieri. In one article, the Guardian observes (emphasis added): They use technology that is more commonplace at the highest level…, regularly
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Chernobyl: 30 Years On – Lessons in Safety Culture
Chernobyl: 30 Years On – Lessons in Safety Culture Late at night on 26 April 1986 in the then USSR, a team of nuclear workers prepared to conduct a test on Reactor 4 of the Chernobyl nuclear power plant as part of an otherwise routine shutdown. The exercise was to test a modified safety system
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Dim, Negative Transfer Double Flameout
Inadvertently leaving lights dimmed, a compromised NVG mod, no aural low fuel warning and negligible recent experience on type all feature in this NZ HEMS incident.
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NASA ASRS at 40 and the Continued Challenge of Timeliness for Safety Reporting
NASA Aviation Safety Reporting System at 40 and the Continued Challenge of Timeliness for Safety Reporting On 16 April 16 2016 the National Aeronautics and Space Administration (NASA) Aviation Safety Reporting System (ASRS) celebrated 40 years of operation. Its origins highlights one major challenge of safety reporting, learning and action: timeliness. The Purpose and Administration of
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C-130J Control Restriction Accident, Jalalabad
C-130J Control Restriction Accident, Jalalabad The US Air Force (USAF) Air Mobility Command (AMC) has released its accident report into the fatal loss of control (LOC-I) accident involving of Lockheed Martin C-130J 08-3174 during a night-time take-off from Jalalabad Airfield, Afghanistan on 2 October 2015. The accident was caused by the failure to remove a loose article that had been deliberately placed
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Crew Bag FOD Shatters Hawk Canopy
A Canadian Hawk pilot got a big surprise when rolling inverted: his flight crew bag contacted the firing unit of the canopy explosive fragmentation system with shattering results…
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A319 Double Cowling Loss and Fire – AAIB Safety Recommendation Update
A319 Double Cowling Loss and Fire – AAIB Safety Recommendation Update The UK Air Accidents Investigation Branch (AAIB) has issued an update on responses to their safety recommendations from their investigation into British Airways Airbus A319 G-EUOE. G-EUOE, powered by IAE V2500s, lost both engine fan cowlings and suffered an associated fire on take-off from London Heathrow
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Fatigued Flight Test Crew Superjet 100 Crosswind Accident
Fatigued Flight Test Crew Crosswind Accident The Icelandic Transportation Safety Board (ITSB), the RNSA, recently issued their report into a wheels up runway excursion accident that occurred on 21 July 2013 to Sukhoi RRJ-95B ‘Superjet 100’ 97005 during flight tests by Sukhoi at Keflavik airport. The Flight Test Objective and the Accident Flight The purpose of
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US Police Helicopter Night CFIT: Is Your Journey Really Necessary?
US Police Helicopter Night CFIT: Is Your Journey Really Necessary? On 27 March 2014, at 0147 local time, ex-military Bell OH-58A, N497E, operated by, the Kern County Sheriff’s Office (KCSO) collided with terrain near Tehachapi, California. The three occupants were uninjured, although the helicopter was substantially damaged. The Accident and Investigation The US National Transportation Safety Board (NTSB)
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Solent Hoegh Osaka Car Carrier Accident
Solent Hoegh Osaka Car Carrier Accident The Singapore registered 180m, 51,770 gross tonnage ‘pure car and truck carrier’ (PCTC) MV Hoegh Osaka, managed by Wallem Shipmanagement Pte Ltd, developed a significant starboard list when turning to port while departing Southampton on 3 January 2015. The Marine Accident Investigation Branch (MAIB) say in their recent report: As the list increased
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AAIB Report on 2013 Sumburgh Helicopter Accident (CHC Scotia AS332L2 G-WNSB)
AAIB Report on 2013 Sumburgh Helicopter Accident (CHC Scotia AS332L2 G-WNSB) The UK Air Accidents Investigation Branch (AAIB) has published its report into the 23 August 2013 accident were CHC Scotia Airbus Helicopters AS332L2 Super Puma G-WNSB impacted the sea on approach to Sumburgh Airport in the Shetland Islands. The AAIB report is 266 pages long. This article is
AAIB Report on 2013 Sumburgh Helicopter Accident (CHC Scotia AS332L2 G-WNSB) Read Post »
Germanwings: Psychiatry, Suicide and Safety
Germanwings: Psychiatry, Suicide and Safety The French Bureau d’Enquêtes et d’Analyses (BEA) has issued their report into the loss of Germanwings Airbus A320 D-AIPX and 150 lives in the French Alps on 24 March 2015, which was due to the actions of the Co-Pilot. Below we focus on the highlights from the 110 page report. The Co-Pilot
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Step Change in Safety: Helicopter Safety Update 2016
Step Change in Safety: Helicopter Safety Update 2016 Step Change in Safety held a webinar on North Sea helicopter safety (covering CA-EBS, emergency egress, FCOMs and airworthiness matters) on 9 March 2016 (following on from a March 2015 event we have previously covered). Introduction Step Change is a tripartite UK offshore health and safety organisation combining companies,
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Forgotten Fasteners – Serious Incidents
Forgotten Fasteners – Serious Incidents We examine three incidents where fasteners were forgotten during maintenance. It two cases these maintenance errors resulted in parts falling from the aircraft. In a third, a massive fuel leak occurred. Incident 1 – Twin Otter Mission Pod The Irish Air Accident Investigation Unit (AAIU) has recently reported on a
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Misrouted Engine Fuel Control Cable Hawker 800XP
Misrouted Engine Fuel Control Cable Hawker 800XP In Issue 4/2015 of TP 6980 – Canadian Aviation Service Difficulty Reports – Feedback an maintenance error involving a Hawker 800XP fuel control cable is reported: During a planned major structural inspection, the technician noticed that the no.1 engine high-pressure fuel lever cable was trapped under the cover of the electrical junction
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UK CAA CAP1145 North Sea Helicopter Safety Two Years On
UK CAA CAP1145 North Sea Helicopter Safety Two Years On Not long after the fatal loss of Eurocopter AS332L2 G-WNSB of Sumburgh Airport, Shetland Islands on 23 August 2013 with 4 fatalities (AAIB Special Bulletin), the UK Civil Aviation Authority (CAA) launched an rapid review on offshore helicopter safety. That CAA Review resulted in the CAP1145 report (‘Safety review of
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First Eleven: Guidance for Designers on Maintenance Human Performance
First Eleven: RAeS Guidance for Design Organisations on Maintenance Human Performance The Royal Aeronautical Society (RAeS) Human Factors Group: Engineering (HFG:E) has published a short guidance document on 11 steps an aviation Design Organisation (DO) can take to “deliver safer, more effective and reliable aircraft through improved design for maintenance”. The RAeS say: Aircraft safety
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EC130B4 Accident: Incorrect TRDS Bearing Installation
A maintenance error installing a TRDS bearing resulted in an EC130B4 LOC-I. An excellent AIBN report highlights the value of Independent Inspections.
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Troublesome Tiedowns
Troublesome Tiedowns The US National Transportation Safety Board (NTSB) has recently reported on two cases in October 2015 were helicopters offshore suffered accidents after the tie-downs were not fully removed: Fish Spotting Helicopter, Pacific Ocean (B206, N1060C) On 21 October 2015 Bell 206B N1060C was being prepared for take-off from the 74m Fishing Vessel Majestic Sun off Christmas Island,
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Fuel Exhaustion Causes EMB-110 Emergency Landing
Inadequate preflight inspection of an un-refuelled aircraft resulted in a total loss of engine power due to fuel exhaustion and a dramatic emergency landing.
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Culpable Culture of Compliance?
An ATSB report on a fatal man overboard incident questions if blindly valuing compliance may create a culture that actually undermines safety.
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Ignoring Corrosive Environment Brings Down B206 Helicopter
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
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Safety Lessons from TransAsia ATR-72 Flight GE222 CFIT
The ASC Taiwan has issued their investigation report into the CFIT of a TransAsia ATR 72-500 on 23 July 2014 during an attempted landing in bad weather.
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