Life Flight 6 – US HEMS Accident
In 2003 a HEMS A109K2 helicopter was lost in a fatal accident in Salt Lake City, UT in poor weather.
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Flight Crew Incapacitation – Oxygen System Failure
Flight Crew Incapacitation – Oxygen System Failure The Australian Transport Safety Bureau (ATSB) has published their investigation report on a case of hypoxia in an unpressurised twin turboprop survey aircraft: On 1 August 2014, at about 0935 EST, a Reims Aviation F406 aircraft, registered VH-EYQ, departed Emerald, Queensland, on an aerial survey task with a pilot
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Breaking the Chain: X-31 Lessons Learned
An experimental X-31 was making a routine test flight when disaster struck. NASA produced a unique documentary insight into this accident and its lessons.
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Wait to Weight & Balance – Lessons from a Loss of Control
Wait to Weight & Balance – Lessons from a PC-12 Loss of Control On take off, pitch control of a Pilatus PC-12 was lost resulting in a series of pitch oscillations and stall warnings. Fortuitously the pilot was able to abort the take off with only damage to one main wheel. The incident could have been
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Inadvertent Fire Bottle Discharge During Maintenance
Inadvertent Fire Bottle Discharge During Maintenance The CHIRP Charitable Trust, who run the UK’s Confidential Human Factors Incident Reporting Programme, has reported on an inadvertent fire bottle discharge incident during maintenance in their Air Transport FEEDBACK Issue 113. The Aircraft was on a heavy maintenance input and several teams were busy working in the flight
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UK CAA CAP1145: Update on North Sea Helicopter Safety (CAP1243)
UK CAA CAP1145: Update on North Sea Helicopter Safety (CAP1243) Not long after the fatal loss of Eurocopter AS332L2 G-WNSB 1.5 nm west of Sumburgh Airport, Shetland Islands on 23 August 2013 with 4 fatalities (AAIB Special Bulletin), the UK Civil Aviation Authority (CAA) launched an rapid review on offshore helicopter safety. CAP1145 This CAA Review resulted in the CAP1145 report
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The ‘Automation Problem’ – A Discussion
The ‘Automation Problem’ – A Discussion Automation, or perhaps more correctly the use of automated systems, has become a hot topic in the aviation industry, particularly since the issue of the accident report into the loss of AF447 (issued in July 2012). We review one analysis of the underlying cause and discuss a warning about an emerging
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When Habits Kill – Canadian MD500 Accident
When Habits Kill – Canadian Hughes 500 Helicopter Accident Establishing habits can be effective ways to achieve safe outcomes, by sub-consciously completing routine actions. Examples include automatically fastening harnesses and seat belts or routinely scanning for other traffic. However, sometimes habits can be dangerous, for example when circumstances or equipment change. Just such a case occurred in Canada to
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The Power of Safety Leadership: Paul O’Neill, Safety and Alcoa
The Power of Safety Leadership: Paul O’Neill, Safety and Alcoa In his book The Power of Habit: Why We Do What We Do, and How to Change, Charles Duhigg, described the reaction to Paul O’Neill’s first presentation as the new CEO of the Aluminum Company of America (Alcoa) in 1987: A few minutes before noon, the new
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NTSB Report on Bizarre 2012 US S-76B Ditching
An overweight helicopter, flown with a known defect, ditched during a poorly executed approach to a GOM drilling rig, then water taxying was attempted…
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Bell 525 Fly-By-Wire Update
Bell 525 Fly-By-Wire Update Bell Helicopter gave an update this month on the Fly-By-Wire (FBW) system being developed for their new super-medium helicopter, the 525 Relentless, at the 8th Rotorcraft Symposium in Cologne. This event was organised by the European Aviation Safety Agency (EASA). The paper by Mike Bothwell and Awais Razais is downloadable as part of a large zip file for the whole symposium
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Elbit Enhanced Flight Vision Systems
Elbit Enhanced Flight Vision Systems (EFVS) for Helicopters and regional Aircraft Elbit Systems presented to the European Aviation Safety Agency (EASA) 8th Rotorcraft Symposium today. The paper is downloadable and a prior video is available to view: https://www.youtube.com/watch?feature=player_embedded&v=XMm-AAdo5zc UPDATE 5 July 2016: Certification of the SkyLens system on the ATR turboprop family is expected in 2017: EASA
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James Reason’s 12 Principles of Error Management
James Reason’s 12 Principles of Error Management James Reason, Professor Emeritus, University of Manchester, set out 12 systemic human factors centric principles of error management in his book Managing Maintenance Error: A Practical Guide (co-written with Alan Hobbs and published in 2003). These principles are valid beyond aviation maintenance and are well worth re-visiting: Human error is both universal
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UK OHSAG Oct 2014 Minutes
UK Offshore Helicopter Safety Action Group (OHSAG) Oct 2014 Minutes The UK Civil Aviation Authority (CAA) has published the minutes of the latest, 28 Oct 2014, meeting of the Offshore Helicopter Safety Action Group (OHSAG). The OHSAG was formed as a result of the ‘Civil Aviation Authority Safety Review of Offshore Public Transport Helicopter Operations in Support of
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Accident Report: Fatal Police Helicopter Double Engine Flameout Over City Centre
Both engines flamed out on a police helicopter over a crowded city with multiple fatalities. We examine the accident report. But its not where you think.
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Psychology of Blame
Research shows that rushing to blame your own employees might not only increase the risk you’ll fail to prevent future accidents but tends to turn public opinion against you too.
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UK CAA Release CRM Videos
UK CAA Release Crew Resource Management Videos In an initiative to improve Crew Resource Management (CRM) in the industry the UK Civil Aviation Authority (CAA) has released a series of open-access training videos. The CAA comment that: The three case-study videos have been developed to highlight some of the main human factors concerns currently facing the aviation industry,
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NTSB Update on SpaceShip Two Accident
NTSB Update on SpaceShip Two Accident Today the National Transportation Safety Board (NTSB) issued a press release on progress with the investigation into the Virgin Galactic Scaled Composites Model 339 SpaceShip Two N339SS accident on 31 Oct 2014: November 12, 2014 WASHINGTON — The National Transportation Safety Board issued an investigative update today into the
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Dash 8 Runway Excursion after Unstable Crosswind Approach – Danish AIB Report
We look at a Dash 8 runway excursion in Greenland, after an unstable approach above the crosswind limit.
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Go Around Flap Overspeed and Altitude Exceedance – ATSB Report
The ATSB has reported on an occurrence during a go around with an A321 where the aircraft exceeded the flap limit speed and climbed above cleared altitude.
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UK MAA NPA for RPAS
UK Military Aviation Authority Notice of Proposed Amendment on Remotely Piloted Air Systems The UK MAA has issued an NPA as part of the consultation on a change to the MAA Regulatory Publications (MRPs) to cover the better integration of RPAS. The MAA introduce the NPA as follows: The aim of the review of RPAS regulations
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Boeing 737 Automation Related Descent Below Cleared Altitude – ATSB Report
Boeing 737 Automation Related Descent Below Cleared Altitude – ATSB Report The Australian Transport Safety Bureau (ATSB) has issued a report on an automation related occurrence: On 17 October 2012, a Boeing 737-838 aircraft, registered VH-VXB and operated by Qantas Airways Limited (Qantas), was conducting a flight from Adelaide, South Australia to Canberra, Australian Capital Territory…
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HeliOffshore Launch
HeliOffshore Launch HeliOffshore, whose foundation we discussed in June, was launched today in London. HeliOffshore have issued the following press release: Oct. 21, 2014 – London – Five major helicopter operators today officially announced a new industry association – HeliOffshore – for The new association was introduced at a launch event at its offices in London.
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Maintenance Check Flights: Safety Lessons
We look at the safety lessons from three AAIB reports into serious incidents during maintenance check flights.
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How To Develop Your Organisation’s Safety Culture
Safety culture is increasingly recognised as critical to safety performance. But how do you develop your organisation’s safety culture? Safety Leadership.
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