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 […]
Inadvertent Fire Bottle Discharge During Maintenance Read Post »
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
UK CAA CAP1145: Update on North Sea Helicopter Safety (CAP1243) Read Post »
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
The ‘Automation Problem’ – A Discussion Read Post »
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
When Habits Kill – Canadian MD500 Accident Read Post »
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
The Power of Safety Leadership: Paul O’Neill, Safety and Alcoa Read Post »
An overweight helicopter, flown with a known defect, ditched during a poorly executed approach to a GOM drilling rig, then water taxying was attempted…
NTSB Report on Bizarre 2012 US S-76B Ditching Read Post »
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
Bell 525 Fly-By-Wire Update Read Post »
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
Elbit Enhanced Flight Vision Systems Read Post »
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 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
UK OHSAG Oct 2014 Minutes Read Post »
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.
Accident Report: Fatal Police Helicopter Double Engine Flameout Over City Centre Read Post »
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.
Psychology of Blame Read Post »
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 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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We look at a Dash 8 runway excursion in Greenland, after an unstable approach above the crosswind limit.
Dash 8 Runway Excursion after Unstable Crosswind Approach – Danish AIB Report Read Post »
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.
Go Around Flap Overspeed and Altitude Exceedance – ATSB Report Read Post »
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
UK MAA NPA for RPAS Read Post »
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…
Boeing 737 Automation Related Descent Below Cleared Altitude – ATSB Report Read Post »
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.
HeliOffshore Launch Read Post »
We look at the safety lessons from three AAIB reports into serious incidents during maintenance check flights.
Maintenance Check Flights: Safety Lessons Read Post »
Safety culture is increasingly recognised as critical to safety performance. But how do you develop your organisation’s safety culture? Safety Leadership.
How To Develop Your Organisation’s Safety Culture Read Post »
European Helicopter Safety Team (EHEST) Issues New Publications on Technology & SMS EHEST have released two new publications, one on accident reducing technologies and the other on SMS for non-complex operators: The Potential of Technologies to Mitigate Helicopter Accident Factors – An EHEST Study EHEST created a Specialist Team Technology (ST Technology) to assess the potential of
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How To Destroy Your Organisation’s Safety Culture The term ‘safety culture’ was initially used in the report on the 1986 Chernobyl nuclear accident. Building a strong, positive safety culture takes deliberate, concerted and continual effort. Destroying a safety culture is a lot easier… Bad Safety Leadership The following is the text of a real e-mail, spotted pinned to the wall of the
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Fatal $16 Million Maintenance Errors (Sundance Helicopters AS350B2 N37SH) A jury in Las Vegas awarded $16 million to the families of 4 passengers killed in a December 2011 helicopter sightseeing accident, caused by a series of maintenance errors. The National Transportation Safety Board (NTSB) made safety recommendations on maintenance human factors and fatigue after this accident. The
Fatal $16 Million Maintenance Errors Read Post »
US BSEE Helideck A-NPR / Bell 430 Tail Strike The Bureau of Safety and Environmental Enforcement (BSEE) issued an Advance Notice Of Proposed Rulemaking on Helideck and Aviation Fuel Safety for Fixed Offshore Facilities on 24 September 2014. BSEE explain: Although the Federal Aviation Administration (FAA) has broad authority regarding helicopter-related safety issues and onshore and offshore
US BSEE Helideck A-NPR / Bell 430 Tail Strike Read Post »
