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.
Safety Lessons from TransAsia ATR-72 Flight GE222 CFIT Read Post »
NASA Challenger Launch Decision
On the evening of 27 Jan 1986 a group were preparing for what we now know as one of the most infamous telecons in history. We look at lessons for all complex, high hazard industries.
NASA Challenger Launch Decision Read Post »
HEMS S-76C+ Night Approach LOC-I Incident
HEMS S-76C Night Approach Loss of Control – In-flight (LOC-I) Incident A Helicopter Emergency Medical Service (HEMS) Sikorsky S-76C+ C-GHHJ operated by Helijet on behalf of the BC Ambulance Service was on a VFR approach to the coastal Tofino/Long Beach Airport (CYAZ), British Columbia, Canada at 02:39 Local Time on the dark, moonless night of 15 November 2015. It suffered a Loss of Control
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CAP1145 Helicopter Water Impact Survivability Statistics – A Critique
CAP1145 Helicopter Water Impact Survivability Statistics – A Critique Eurocopter AS332L2 G-WNSB impacted the sea 1.5 nm west of Sumburgh Airport, Shetland Islands on 23 August 2013 (see the last AAIB Special Bulletin) with the loss of 4 lives. https://youtu.be/C_3xlunGUk0 Within weeks the UK Civil Aviation Authority (CAA) ordered a hurried safety review. This resulted in the CAP1145 report (‘Safety review of offshore public transport
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Maintenance Personnel Fatigue and Alertness
Maintenance Personnel Fatigue and Alertness Maintenance personnel fatigue and a consequential lack of alertness is regularly being identified as contributory, or potentially contributory, to maintenance related air accidents and serious incidents. We have covered three examples previously: Some involve poor shift patterns: Missing Igniters: Fatigue & Management of Change Shortcomings: The UAE GCAA investigation report explains most of the
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Aerossurance Marks RAeS 150th Anniversary by Sponsoring Rotorcraft Automation Conference
Aerossurance Marks RAeS 150th Anniversary by Sponsoring Rotorcraft Automation Conference The Royal Aeronautical Society (RAeS) was founded on 12 January 1866, so is today celebrating its 150th anniversary (or sesquicentennial). To mark this significant milestone Aerossurance is pleased to be sponsoring the Society’s 2016 Rotorcraft Conference. This conference, to be held 6-7 July 2016 at the
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G-III Attempted Takeoff Using Runway Edge Lights as Centerline
We look at the lessons on aerodrome lighting and charts from a UK bizjet take off accident. Mistaking edge lights for the centreline is not uncommon.
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Procedural Drift at Saab 340 Operator Leads to Taxiway Excursion
An inappropriate, undocumented practice, coupled with a failure to follow the checklist contributed to writing off an SF340 while taxying.
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Our Top 20 Articles of 2015
Aerossurance: Our Top 20 Articles of 2015 As we start the new year we look back on the 20 articles that proved most popular with our readers in 2015. In reverse order: Number 20: Building St Helena Airport – An Industrial Scale ‘Grand Design’ This started with the building of the first airport on the volcanic
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Dangers of Aircraft Tyre Inflation
Dangers of Aircraft Tyre (US: Tire) Inflation The Royal Canadian Air Force are investigating two recent tyre inflation burst accidents. Both involve visiting aircraft using borrowed equipment: 25 August 2015 CT-114 Tutor CT114058 A Snowbird aircraft was diverted from the rest of the deployed team due to an in-flight emergency. The aircraft was repaired, including a successful
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UK BOSIET/FOET Cat-A CA-EBS HUET Update
UK BOSIET/FOET Cat-A CA-EBS HUET Update Category A Compressed Air Emergency Breathing Systems (CA-EBS) were introduced for helicopter passengers flying offshore over the UK Continental Shelf in September 2014. This followed the UK Civil Aviation Authority (CAA) North Sea Review, which resulted in the CAP1145 report. Oil and Gas UK, Step Change in Safety, OPITO, the International Association of Drilling Contractors
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B1900C PSM+ICR Accident in Pakistan 2010
B1900C PSM+ICR Accident in Pakistan 2010 The Pakistan Civil Aviation Authority (CAA) has recently published the report into the loss of a Beechcraft B1900C in 2010. The aircraft, AP-BJD, was being operated by JS Air (as subsidiary of the JS Group) when it crashed on 5 November 2010, killing 21 people. The accident featured what a
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Canadian Coast Guard Helicopter Accident: CFIT, Survivability and More
Fatal Arctic Bo105 CFIT gives lessons on low level ops, compliance with mx data, cold water survivability, alerting, data recorders and regulatory oversight.
Canadian Coast Guard Helicopter Accident: CFIT, Survivability and More Read Post »
UK OHSAG Oct 2015 Minutes
UK Offshore Helicopter Safety Action Group (OHSAG) October 2015 Minutes The UK Civil Aviation Authority (CAA) has just published the minutes of the 16 October 2015 meeting of the Offshore Helicopter Safety Action Group (OHSAG). This is the third and last of the year (compared to six in 2014), postponed from July 2015. The OHSAG was formed as a result of the ‘Civil
UK OHSAG Oct 2015 Minutes Read Post »
So You Think The GOM is Non-Hostile?
So You Think The Gulf of Mexico (GOM) is Non-Hostile? The Gulf of Mexico (GOM), off the coast of Mississippi, Louisiana and Texas in particular, remains a busy area for offshore helicopter operations with over 2 million passengers carried and nearly 300,000 flying hours last year (see our article: Helicopter Ops and Safety – Gulf Of
So You Think The GOM is Non-Hostile? Read Post »
Back to the Future: Error Management
We look at some of the problems of error management and ask if we are still making the error management mistakes James Reason warned of in 1997 (spoiler: some organisations are). We also look at drift and how some have failed to grasp its more than poor compliance.
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ANSV Highlight Procedures & HF After ATR72 Landing Accident
Landing briefing missed. ANSV claim Vapp too high (CIAS disagree). No go around after first bounce. NLG & MLG collapse.
ANSV Highlight Procedures & HF After ATR72 Landing Accident Read Post »
S-92A Emergency Landing: MGB Oil Checklist Recommendation
S-92A Emergency Landing: MGB Oil Checklist Recommendation Earlier this month the Norwegian Accident Investigation Board (AIBN) issued their report into an emergency landing of Sikorsky S-92A LN-ONW, operated by Bristow Norway on 4 October 2013. The crew almost ditched due to false warnings created by a single tripped circuit breaker. The Incident The S-92A was returning from the
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Misassembled Anti-Torque Pedals Cause EC135P1 Accident
Misassembled Anti-Torque Pedals Cause EC135P1 Accident The US National Transportation Safety Board (NTSB) has recently determined that misassembled anti-torque pedals caused an accident to Airbus Helicopters (formerly Eurocopter) EC135P1 N911KB, during a post-maintenance check flight by Metro Aviation at Shreveport, Louisiana on 9 November 2013. The Accident The pilot and two mechanics sustained minor injuries and the helicopter was substantially damaged
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When Down Is Up: 747 Actuator Installation Incident
When Down Is Up: 747 Actuator Installation Incident The UK Air Accidents Investigation Branch (AAIB) has published their report into a serious incident involving Boeing 747-443 G-VROM on 29 December 2014. History of the Flight The AAIB report that: The aircraft departed from London Gatwick Airport for a scheduled flight to Las Vegas. Following retraction of the
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Regulation (EU) 376/2014: Reporting, Analysis and Follow-up of Occurrences in Civil Aviation
Regulation (EU) 376/2014: Reporting, Analysis and Follow-up of Occurrences in Civil Aviation On 15 November 2015, a new European Union wide aviation reporting regulation came into force. The European Commission has created a safety reporting portal. Previously Mandatory Occurrence Reporting (MOR) was effectively regulated by a Directive 2003/42/EC to each nation to create compatible national regulation. That directive is
CHIRP Critical of an Oil Company’s Commercial Practices
CHIRP Critical of an Oil Company’s Commercial Practices The CHIRP Charitable Trust, who run the UK’s Confidential Human Factors Incident Reporting Programme (CHIRP), has highlighted two “of the many” reports received relating to an oil company changing its North Sea helicopter operator for the second time in three years. CHIRP do not name the oil company.
CHIRP Critical of an Oil Company’s Commercial Practices Read Post »
Coaching and the 70:20:10 Learning Model – Beyond Training
We look at how people really learn. Formal pre-fab classroom training is the least effective method. So why do we do waste so much time and money on the ‘Great Training Robbery’? We show there is a better way: 70:20:10.
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