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 »
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 »
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 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 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 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 »
This dual engine incident highlights maintenance fatigue and Management of Change at both a macro level (corporate restructuring) and the micro level (a new task).
The Missing Igniters: Fatigue & Management of Change Shortcomings Read Post »
Fatal G-IV runway excursion: take off with gust lock engaged. Contributing: habitual noncompliance and inadequate certification.
Gulfstream G-IV Take Off Accident & Human Factors Read Post »
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 »
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 »
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 »
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 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 »
A military accident investigation has paradoxically determined that a $62.4mn fire was due to a maintenance error but that no human factors were involved.
USAF RC-135V Rivet Joint Oxygen Fire Read Post »
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 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 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’ 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 (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 »
An unstabilised approach and a late change of control were critical in an accident that resulted in a SWA B737 nose gear collapse at La Guardia say NTSB.
Southwest Unstabilised Approach Accident Read Post »
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 »
