Human Factors / Performance

HF / Human Performance

The Curious Case of the Missing Shear Pin that Didn’t Shear: A Fatal Powerline Stringing Accident

Accidents & Incidents, Design & Certification, Helicopters, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Oil & Gas / IOGP / Energy, Safety Management, Special Mission Aircraft

A key component was never recovered, investigators seem to have misunderstood their own laboratory’s report on another and the NTSB conclusions omit to identify the evident failure of a shear pin to correctly perform its safety function as a factor.

The Curious Case of the Missing Shear Pin that Didn’t Shear: A Fatal Powerline Stringing Accident Read Post »

Fatal 2019 DC-3 Turbo Prop Accident, Positioning for FAA Flight Test: Power Loss Plus Failure to Feather

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

NTSB suggest an air lock in the fuel system plus an auto-feather system failure which may have occurred if the power lever was manually retarded during the auto-feather sequence. The DC-3 was below the airspeed required to maintain lateral control after an engine failure with an unfeathered propeller.

Fatal 2019 DC-3 Turbo Prop Accident, Positioning for FAA Flight Test: Power Loss Plus Failure to Feather Read Post »

ATR 72 Rudder Travel Limitation Unit Incident: Latent Potential for Misassembly Meets Commercial Pressure

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

An ATR72 suffered an uncommanded yaw and roll as it accelerated through 185 knots. The cause was traced to misassembly during a prior maintenance check. A cam in the rudder Travel Limitation Unit could be reversed, and pressures during the check triggered that misassembly.

ATR 72 Rudder Travel Limitation Unit Incident: Latent Potential for Misassembly Meets Commercial Pressure Read Post »

RCAF Investigate Defect on Newly Delivered CH-148 Cyclone (S-92)

Accidents & Incidents, Design & Certification, Helicopters, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Military / Defence, Safety Management

Terminal wire lugs T1, T2 & T3 were found unsecured. T1 was missing its securing nut, washer and lockwasher but was still contacting its terminal stud. T2 & T3 were found hand tight.

RCAF Investigate Defect on Newly Delivered CH-148 Cyclone (S-92) Read Post »

Fatal US Helicopter Air Ambulance Accident: One Engine was Failing but Serviceable Engine Shutdown

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

PSM+ICR: A propulsion system malfunction (a failing No 2 engine) was followed by an inappropriate crew response (shutting down the No 1 engine). The NTSB show how the pilot may not have been familiar with how the helicopter’s displays respond in emergencies.

Fatal US Helicopter Air Ambulance Accident: One Engine was Failing but Serviceable Engine Shutdown Read Post »

US Air Ambulance Near Miss with Zip Wire and High ROD Impact at High Density Altitude

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

NTSB points to a failure to consider the Density Altitude in this spectacular air ambulance accident caught on video. But there are wider lessons about planning and landing site hazards.

US Air Ambulance Near Miss with Zip Wire and High ROD Impact at High Density Altitude Read Post »

Grand Canyon Air Tour Tragic Tailwind Landing Accident

Airfields / Heliports / Helidecks, Crises / Emergency Response / SAR, Design & Certification, Helicopters, Human Factors / Performance, Safety Management, Survivability / Ditching

A Loss of Control – Inflight during a downwind approach to a busy remote landing site. The helicopter crashed in a difficult to access gully and caught fire. It took almost 10 hours for survivors to reach hospital. Five of the 7 occupants died.

Grand Canyon Air Tour Tragic Tailwind Landing Accident Read Post »

Korean Kamov Ka-32T Fire-Fighting Water Impact and Underwater Egress Fatal Accident

Accidents & Incidents, Helicopters, Human Factors / Performance, Safety Management, Special Mission Aircraft, Survivability / Ditching

Distracted by radio calls and with a poor split of duties the fire-fighting flight crew missed their high descent rate during their third attempt to uplift water. After the water impact there were survivability issues and one of the crew was unable to escape underwater.

Korean Kamov Ka-32T Fire-Fighting Water Impact and Underwater Egress Fatal Accident Read Post »

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