Human Factors / Performance

HF / Human Performance

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 »

29 Seconds to Impact: A Fatal Night Offshore Approach in the Irish Sea

Accidents & Incidents, Airfields / Heliports / Helidecks, Crises / Emergency Response / SAR, FDM / Data Recorders, Helicopters, Human Factors / Performance, Offshore, Oil & Gas / IOGP / Energy, Regulation, Safety Culture, Safety Management

A loss of control on approach to a helideck at night that completes a trilogy of case studies where visual cueing at offshore platforms is believed to have been a significant factor.

29 Seconds to Impact: A Fatal Night Offshore Approach in the Irish Sea Read Post »

An Air Traffic Control Assisted H-60 Collision

Accidents & Incidents, Air Traffic Management / Airspace, Airfields / Heliports / Helidecks, Helicopters, Human Factors / Performance, Military / Defence, Oil & Gas / IOGP / Energy, Safety Management, Special Mission Aircraft

Brown Field ATC cleared two H-60s to land on a runway underrun despite them being over the paving weight limit, then asked one to go around and it collided with the other. Everyone survived.

An Air Traffic Control Assisted H-60 Collision 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 »

CHC Scotia AS332L Rollover on West Navion Helideck After Loss of Dynamic Positioning

Accidents & Incidents, Airfields / Heliports / Helidecks, Helicopters, Human Factors / Performance, Offshore, Oil & Gas / IOGP / Energy, Safety Management

A loss of drillship DP and poor bridge display ergonomics. Two more CHC serious helideck ‘sudden departure’ incidents follow within 38 months.

CHC Scotia AS332L Rollover on West Navion Helideck After Loss of Dynamic Positioning 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 »

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