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 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
HEMS S-76C+ Night Approach LOC-I Incident Read Post »
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
CAP1145 Helicopter Water Impact Survivability Statistics – A Critique Read Post »
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
Maintenance Personnel Fatigue and Alertness Read Post »
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
Aerossurance Marks RAeS 150th Anniversary by Sponsoring Rotorcraft Automation Conference Read Post »
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.
G-III Attempted Takeoff Using Runway Edge Lights as Centerline Read Post »
An inappropriate, undocumented practice, coupled with a failure to follow the checklist contributed to writing off an SF340 while taxying.
Procedural Drift at Saab 340 Operator Leads to Taxiway Excursion Read Post »
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
Our Top 20 Articles of 2015 Read Post »
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
Dangers of Aircraft Tyre Inflation Read Post »
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
UK BOSIET/FOET Cat-A CA-EBS HUET Update Read Post »
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
B1900C PSM+ICR Accident in Pakistan 2010 Read Post »
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 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 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 »
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.
Back to the Future: Error Management Read Post »
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 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
S-92A Emergency Landing: MGB Oil Checklist Recommendation Read Post »
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
Misassembled Anti-Torque Pedals Cause EC135P1 Accident Read Post »
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
When Down Is Up: 747 Actuator Installation Incident Read Post »
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 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 »
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.
Coaching and the 70:20:10 Learning Model – Beyond Training Read Post »
HeliOffshore Progress One Year On We first reported on the plan to create HeliOffshore in June 2014. HeliOffshore was formally launched on 21 October 2014 in London and held its first AGM and conference in Lisbon in May 2015. When membership was opened up beyond helicopter operators in January 2015, Aerossurance is pleased to have been one
HeliOffshore Progress One Year On Read Post »
AAIB: The helicopter was operated for a “sustained period” with the fuel transfer pumps off despite low fuel warnings being triggered and acknowledged.
AAIB Report on Glasgow Police EC135T2+ Clutha Helicopter Accident Read Post »
Aircraft Maintenance: Going for Gold? We pose the question: Can aviation maintenance learn lessons from championship athletes? Aerossurance is pleased to have sponsored the Royal Aeronautical Society (RAeS) conference Human Factors in Engineering – the Next Generation at Cranfield University on 12 May 2015. In his opening address Cranfield University’s Professor Dave King (a former Chief Inspector of Air Accidents with
Aircraft Maintenance: Going for Gold? Read Post »
