Human Factors / Performance

HF / Human Performance

Multi-Tasking Managers & Deficient Operational Control: Low Viz AS350B3 Take-Off Accident

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

Two people died after a loss of visual references shortly after take-off in the transition from vertical to horizontal flight. NSIA point to organisational and systemic factors.

Multi-Tasking Managers & Deficient Operational Control: Low Viz AS350B3 Take-Off Accident Read Post »

In-Flight Break-up of King Air C90 After Wing Spar Repaired Against Manufacturer’s Advice

Accidents & Incidents, Design & Certification, Fixed Wing, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Regulation, Safety Management, Special Mission Aircraft

The wing spar failed from fatigue cracking elsewhere in the wing that was missed during the same inspection.

In-Flight Break-up of King Air C90 After Wing Spar Repaired Against Manufacturer’s Advice Read Post »

South Korean Night Black Hole Spatial Disorientation Fatal Helicopter Accident

Accidents & Incidents, Airfields / Heliports / Helidecks, Crises / Emergency Response / SAR, Helicopters, Human Factors / Performance, Safety Management, Special Mission Aircraft

We translate a South Korean report into an emergency service helicopter accident investigation. Spatial disorientation, use of automation and heliport management issues.

South Korean Night Black Hole Spatial Disorientation Fatal Helicopter Accident Read Post »

Helicopter Water Impact Accident: Safety of Airborne Geophysical Survey Operations

Accidents & Incidents, Crises / Emergency Response / SAR, Helicopters, Human Factors / Performance, Mining / Resource Sector, Safety Culture, Safety Management, Special Mission Aircraft, Survivability / Ditching

An aerial survey accident highlights problems implementing flight following technology, the dangerous use of marine lifejackets and the value of considering competence.

Helicopter Water Impact Accident: Safety of Airborne Geophysical Survey Operations Read Post »

The Loss of RAF F-35B ZM152: An Organisational Accident

Accidents & Incidents, Crises / Emergency Response / SAR, Design & Certification, Fixed Wing, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Military / Defence, Regulation, Safety Culture, Safety Management, Survivability / Ditching

An £81 mn fighter is downed by FOD, one of its own intake blanks.
This case study illustrates James Reason’s concept of Organisational Accidents and how just asking “who left the intake blank ?” misses the real reasons behind this accident.

The Loss of RAF F-35B ZM152: An Organisational Accident Read Post »

BK117 Offshore Medevac CFIT & Survivability Issues

Accidents & Incidents, Crises / Emergency Response / SAR, Design & Certification, Helicopters, Human Factors / Performance, Offshore, Safety Culture, Safety Management, Special Mission Aircraft, Survivability / Ditching

An offshore medevac accident that highlights considering the changing risk of an individual flight, flight path management in degrading conditions and offshore survivability in a ‘regulatory void’.

BK117 Offshore Medevac CFIT & Survivability Issues Read Post »

EC135 Air Ambulance CFIT when Pilot Distracted Correcting Tech Log Errors

Accidents & Incidents, Helicopters, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Safety Culture, Safety Management, Special Mission Aircraft, Survivability / Ditching

The single pilot was head down as the sun set correcting tech log entries. The helicopter struck trees on a mountain top then force landed in woodland.

EC135 Air Ambulance CFIT when Pilot Distracted Correcting Tech Log Errors Read Post »

Poor Contracting Practices and a Canadian Helicopter HESLO Accident

Accidents & Incidents, Helicopters, Human Factors / Performance, Mining / Resource Sector, Oil & Gas / IOGP / Energy, Regulation, Safety Culture, Safety Management, Special Mission Aircraft

An underslung load strikes a tail boom and when jettisoned damages a tail rotor. But this case study really highlights how poor contracting practices drive up risk and how to avoid that.

Poor Contracting Practices and a Canadian Helicopter HESLO Accident Read Post »

Blinded by Light, Spanish Customs AS365 Crashed During Night-time Hot Pursuit

Accidents & Incidents, Crises / Emergency Response / SAR, Helicopters, Human Factors / Performance, Offshore, Regulation, Safety Management, Special Mission Aircraft, Survivability / Ditching

A helicopter contracted by Spanish customs hit the sea at night when descending to intercept smugglers. The sensor operator in the cabin died.

Blinded by Light, Spanish Customs AS365 Crashed During Night-time Hot Pursuit Read Post »

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