Human Factors / Performance

HF / Human Performance

Fatal Night-time UK AW139 Accident Highlights Business Aviation Safety Lessons

Accidents & Incidents, Business Aviation, Helicopters, Human Factors / Performance, Regulation, Safety Culture, Safety Management

Fatal Night-time UK AW139 Accident Highlights Business Aviation Safety Lessons The UK Air Accidents Investigation Branch (AAIB) has published their report into the fatal accident to AgustaWestland AW139 G-LBAL on 13 March 2014.  This accident reinforces many important past lessons on business aviation safety, managing clients, training, human factors and learning from previous accidents. The helicopter, owned by Haughey Air, departed from a […]

Fatal Night-time UK AW139 Accident Highlights Business Aviation Safety Lessons Read Post »

B747 JNB

BA Changes Briefings, Simulator Training and Chart Provider After B747 Accident

Accidents & Incidents, Airfields / Heliports / Helidecks, Fixed Wing, Human Factors / Performance, Safety Management

BA Changes Briefings, Simulator Training and Chart Provider After B747 Accident According to a recently released UK Civil Aviation Authority (UK CAA) FACTOR (Follow-up ACTion on Occurrence Report), British Airways (BA) have enhanced their simulator training and changed chart provider in response to a ground accident in South Africa. The Accident On 22 December 2013, BA  G-BNLL sustained substantial

BA Changes Briefings, Simulator Training and Chart Provider After B747 Accident Read Post »

Misfuelling Accidents

Accidents & Incidents, Airfields / Heliports / Helidecks, Business Aviation, Fixed Wing, Human Factors / Performance, Safety Management

Misfuelling Accidents Misfuelling aircraft with kerosene based Jet A-1 rather than Aviation Gasoline (AVGAS) continues to be a source of accidents. PA31 15 Sept 2015 Manitoba The Canadian Transportation Safety Board (TSB) has recently released an update on the 15 September 2015 accident involving twin engined Keystone Air Service Piper PA31-350 Navajo C-FXLO at Thompson, Manitoba.  Shortly after takeoff the aircraft experienced a

Misfuelling Accidents Read Post »

Aerossurance Sponsors HF in Aviation Safety Conference

Human Factors / Performance, Resilience, Safety Culture, Safety Management

Aerossurance Sponsors Human Factors in Aviation Safety Conference Aerossurance is pleased to sponsor the Chartered Institute of Ergonomics & Human Factors’ (CIEHF) Human Factors in Aviation Safety Conference that takes place at the Radison Blu Hotel, East Midlands Airport, 9-10 November 2015. Aerossurance was keen to sponsor this event as it is such an excellent independent professional

Aerossurance Sponsors HF in Aviation Safety Conference Read Post »

Critical Maintenance Tasks: EASA Part-M & -145 Change

Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Regulation, Safety Management

Critical Maintenance Tasks: EASA Part -M & -145 Change Commission Regulation (EU)  2015/1536 was issued on of 16 September 2015.  Technically it amends Regulation (EU) No 1321/2014 “as regards alignment of rules for continuing airworthiness with the ‘Basic Regulation’ Regulation (EC) No 216/2008“. Critical Maintenance Tasks (CMTs) One of the most important parts of the amendment relates to CMTs, which

Critical Maintenance Tasks: EASA Part-M & -145 Change Read Post »

HTAWS Technology: Friend or Foe?

Accidents & Incidents, Design & Certification, Helicopters, Human Factors / Performance, Regulation, Safety Management, Special Mission Aircraft

HTAWS Technology: Friend or Foe? Technology has great potential to reduce aviation risk.  The European Helicopter Safety Team (EHEST) issued a study in October 2014 on the safety value of technology. Terrain Avoidance and Warning Systems (TAWS) have proved highly effective at fixed wing Approach and Landing Accident Reduction (ALAR). On 20 February 2014, the Federal Aviation

HTAWS Technology: Friend or Foe? Read Post »

City of London (Credit: Andy Evans)

The Contrarian Director

Human Factors / Performance, Resilience, Safety Culture, Safety Management

The Contrarian Director Public companies should appoint a “Contrarian Director” to systematically challenge management recommendations, says Australian corporate lawyer Siobhan Sweeney.  Sweeney won the 2015 Cambridge-McKinsey Risk Prize at the Centre for Risk Studies at University of Cambridge Judge Business School for her paper on the subject: In the current economic climate marked by volatility and uncertainty, risk oversight

The Contrarian Director Read Post »

Learrjet Typhoon Mid Air Collision Germany

Mid Air Collision Typhoon & Learjet 35

Accidents & Incidents, Fixed Wing, Human Factors / Performance, Military / Defence, Regulation, Safety Management, Special Mission Aircraft

Mid Air Collision Typhoon & Learjet 35 During ‘Renegade’ air interception training a civilian Learjet 35, D-CGFI, collided with a Luftwaffe Eurofighter Typhoon.  The German Federal Bureau of Aircraft Accidents Investigation (BFU) have issued their final report and we attended an excellent briefing by the BFU at the ISASI 2015 conference.  In Germany, as in the UK, air

Mid Air Collision Typhoon & Learjet 35 Read Post »

Moerdijk Explosion: “Failure to Learn”

Accidents & Incidents, Human Factors / Performance, Oil & Gas / IOGP / Energy, Safety Culture, Safety Management

Shell Moerdijk Explosion: “Failure to Learn” On 3 June 2014 two major explosions and a fire occurred at a Shell petrochemical plant in Moerdijk, Netherlands. Two employees were injured in the explosions that were heard 20 km away.  Debris was found 800 metres away. The Dutch Safety Board has investigated this incident.  Currently only the investigation summary

Moerdijk Explosion: “Failure to Learn” Read Post »

CHIRP – Independent Review

Fixed Wing, Helicopters, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, News, Safety Management

CHIRP – Independent Review The results of an independent review on the work of CHIRP (the Confidential Human Factors Incident Report Programme) have just been published by the British charitable trust. CHIRP Chief Executive Ian Dugmore commented that the review: …reaffirmed the requirement for an independent and confidential reporting system for the UK and recommended that

CHIRP – Independent Review Read Post »

Rockets Sleds, Steamships and Human Factors: Murphy’s Law or Holt’s Law?

Human Factors / Performance, Safety Management

Rockets Sleds, Steamships and Human Factors: Murphy’s Law or Holt’s Law? Murphy’s Law: Whatever can go wrong, will go wrong. To some a pessimistic inevitability, to others a call to arms for defensive design to prevent opportunities for failure.  We look at how that ‘law’ was named and how the origins of the ‘law’ actually stretch back to a Liverpool ship-owner

Rockets Sleds, Steamships and Human Factors: Murphy’s Law or Holt’s Law? Read Post »

Fuel System Maintenance Error: Tuniter ATR72 TS-LBB Ditching 6 August 2005

Accidents & Incidents, Fixed Wing, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Safety Management, Survivability / Ditching

Fuel System Maintenance Error: Tuniter ATR72 TS-LBB Ditching 6 August 2005 On the 6 August 2005 a Tuninter ATR72 turboprop aircraft, TS-LBB, flying from Bari, Italy to Tunis, Tunisia, ran out of fuel and ditched off the northern coast of Sicily.  Of the 39 people on board, 16 died. The aircraft had been erroneously fitted during maintenance with

Fuel System Maintenance Error: Tuniter ATR72 TS-LBB Ditching 6 August 2005 Read Post »

Loose B-Nut: Accident During Helicopter Maintenance Check Flight

Accidents & Incidents, Helicopters, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Safety Culture, Safety Management

Loose B-Nut: Accident During Helicopter Maintenance Check Flight Another investigation by the US National Transportation Safety Board (NTSB), published on 13 July 2015, has highlighted poor maintenance standards and continuing airworthiness management in a US helicopter operator. The NTSB report that on 1 January 2014, Airbus Helicopters EC130B4, N133GC, operated by Papillon Airways Inc (PAI), was

Loose B-Nut: Accident During Helicopter Maintenance Check Flight Read Post »

‘Procedural Drift’: Lynx CFIT in Afghanistan

Accidents & Incidents, FDM / Data Recorders, Helicopters, Human Factors / Performance, Military / Defence, Safety Culture, Safety Management

‘Procedural drift’ in the operating detachment was noted by the Service Inquiry into a British military helicopter accident in Afghanistan that killed 5 service personnel. This drift is said to have allowed standards to dilute during sustained operations in theatre.

‘Procedural Drift’: Lynx CFIT in Afghanistan Read Post »

Performance Based Regulation and Detecting the Pathogens

Accidents & Incidents, Human Factors / Performance, Regulation, Resilience, Safety Culture, Safety Management

Performance Based Regulation (PBR) and Detecting the Pathogens At a time when Performance Based Regulation (PBR) is a hot topic in the aviation industry, a series of rail accidents in North America help demonstrate the type of poor performance that PBR must successfully detect.  These accidents were what James Reason, Professor Emeritus, University of Manchester described as ‘organisational accidents’ in his

Performance Based Regulation and Detecting the Pathogens Read Post »

Metro-North: Organisational Accidents and Shelfware

Accidents & Incidents, Human Factors / Performance, Regulation, Safety Culture, Safety Management

Metro-North: Organisational Accidents and Shelfware An NTSB study into five accidents on US railway (‘railroad’) Metro-North gives a unique perspective on organisational accidents.  Metro-North was described as having an “invisible safety department”, that kept its SMS on the shelf until external audits and assumed on-time performance would give them safe operations. Organisational Accidents James Reason, Professor Emeritus, University of Manchester popularised the

Metro-North: Organisational Accidents and Shelfware Read Post »

Inadequately Secured Cargo Caused B747F Crash at Bagram, Afghanistan

Accidents & Incidents, Fixed Wing, Human Factors / Performance, Logistics, Regulation, Safety Management

Inadequately Secured Cargo Caused B747F Crash at Bagram, Afghanistan The US National Transportation Safety Board (NTSB) has determined that a National Airlines Boeing 747 Freighter N949CA that crashed on take-off on 29 April 2013 did so because the five armoured military vehicles (2x12t and 3x18t) on-board were inadequately restrained. As the NTSB explain: These vehicles were considered a special

Inadequately Secured Cargo Caused B747F Crash at Bagram, Afghanistan Read Post »

A319 Double Cowling Loss and Fire – AAIB Report

Accidents & Incidents, Design & Certification, Fixed Wing, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Safety Culture, Safety Management

A319 Double Cowling Loss and Fire – AAIB Report The UK Air Accidents Investigation Branch (AAIB) has published their report into an Airbus A319 that lost both engine fan cowlings and suffered an associated fire on take-off from London Heathrow in 2013. We look at the circumstances of the previous evening’s maintenance on this aircraft,

A319 Double Cowling Loss and Fire – AAIB Report Read Post »

DuPont Reputational Explosion

Accidents & Incidents, Human Factors / Performance, News, Safety Culture, Safety Management

DuPont Reputational Explosion Chemical company DuPont (E.I. DuPont de Nemours & Co Inc.) has been feted for its safety performance for many years (for example winning the National Safety Council‘s 2013 Robert W. Campbell Award).  Its reputation in the field of safety stretches back to the founding of the company as a gunpowder manufacturer in

DuPont Reputational Explosion Read Post »

Metro III Low-energy Rejected Landing and CFIT

Accidents & Incidents, Fixed Wing, Human Factors / Performance, Regulation, Safety Management, Survivability / Ditching

Metro III Low-energy Rejected Landing and CFIT The Transportation Safety Board of Canada (TSB) has issued a report on a fatal accident to Fairchild SA227-AC Metro III, C-GFWX, operated by Perimeter Aviation at Sanikiluaq, Nunavut, on the coast of Hudson Bay on 22 December 2012. The route from Winnipeg is normally operated by sister company Keewatin Air, but

Metro III Low-energy Rejected Landing and CFIT Read Post »

B767 Engine Fire – Ignition from Misrouted / Chaffed Cables

Accidents & Incidents, Fixed Wing, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Safety Management

B767 Engine Fire – Ignition from Misrouted / Chaffed Cables The National Transportation Safety Board (NTSB) have reported on an engine fire that occurred on 11 July 2014 when: …Boeing B-767-332, registration number N139DL, operated by Delta Air Lines (DAL)… powered by two General Electric (GE) CF6-80A2 turbofan engines, experienced a left engine (No. 1)

B767 Engine Fire – Ignition from Misrouted / Chaffed Cables Read Post »

Scroll to Top