Professionalism and Integrity in Aviation
We look at the characteristics of professionalism, some of the challenges and the relative value of training and leadership.
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When a Crew Intentionally Left Their Aircraft Running Knowing it Would Damage Itself…
An unusual event, rapid innovation & collaboration and a good example why culpability decision aids can be a distraction.
When a Crew Intentionally Left Their Aircraft Running Knowing it Would Damage Itself… Read Post »
Improvised Ice Road IMC Approaches – Twin Otter CFIT
A VFR flight continued in deteriorating weather, over reliant on EFB data and attempting ‘improvised’ instrument approaches in IMC.
Improvised Ice Road IMC Approaches – Twin Otter CFIT Read Post »
Cold Comfort Conference Call: USAF F-35A Alaska Accident
A $196.5 mn organisational accident: a conference call and a contaminated barrel.
Cold Comfort Conference Call: USAF F-35A Alaska Accident Read Post »
OceanGate Titan: Toxic Culture & Fatal Hubris
Deep dive: Toxic culture of a submersible company and their CEO’s hubris. Implosion on a dive to the wreck of the Titanic. Five fatalities.
OceanGate Titan: Toxic Culture & Fatal Hubris Read Post »
CHC Sikorsky S-92A Seat Slide Surprise(s)
Failure to learn? In 2010 an Aircraft Commander was left ‘hanging’ after seat components omitted during maintenance. It reoccurred just 3.5 years later.
CHC Sikorsky S-92A Seat Slide Surprise(s) Read Post »
S-76D Loss of Control on Approach to an Indian Drilling Rig
A low time on type crew lost control while distracted. Everyone escaped but 4 died in the water due to poor briefings and inadequate rescue capability.
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29 Seconds to Impact: A Fatal Night Offshore Approach in the Irish Sea
A loss of control on approach to a helideck at night that completes a trilogy of case studies where visual cueing at offshore platforms is believed to have been a significant factor.
29 Seconds to Impact: A Fatal Night Offshore Approach in the Irish Sea Read Post »
Night Deck Landing Accident While Training off Brazil
We look at the 2024 CENIPA report into a 2021 night deck training accident off Brazil.
Night Deck Landing Accident While Training off Brazil Read Post »
Fatal Offshore S-76C++ LOC-I & Water Impact Brazil 2022: CENIPA Investigation
The Aircraft Commander / Instructor died after a water impact during the first flight of a command course following a loss of control on approach to a NUI.
Fatal Offshore S-76C++ LOC-I & Water Impact Brazil 2022: CENIPA Investigation Read Post »
Deadly Delay: Catastrophic USAF CV-22B Osprey Gear Box Failure
We review the USAF AIB report, looking at the catastrophic gear box failure and decision making seemingly influence by low risk awareness and commitment to completing the flight.
Deadly Delay: Catastrophic USAF CV-22B Osprey Gear Box Failure Read Post »
“Sensation Seeking” Survey Fatal Accident
After completing a low level geophysical survey, a PA-31 was flown even lower back to base, hitting a powerline just 70 ft AGL.
“Sensation Seeking” Survey Fatal Accident Read Post »
HEMS Downwash Injuries: Two More Case Studies
A third party injury at a UK HEMS site and a medical personnel head injury during training in Canada.
HEMS Downwash Injuries: Two More Case Studies Read Post »
Drift into Danger: AW109SP Night HLS Accident
Helicopter landing site suitability, flight planning and Threat & Error Management are all topics discussed in this AAIB report where an AW109 contacted trees during a night take off.
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Night Offshore Helicopter Approach Water Impact
A night visual approach resulted in illusions that resulted in a water impact. Everyone on board was rescued but not before highlighting many survivability & SAR enhancements, as well as triggering improved helideck lighting and TAWS improvements.
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Multi-Tasking Managers & Deficient Operational Control: Low Viz AS350B3 Take-Off Accident
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.
Helicopter Water Impact Accident: Safety of Airborne Geophysical Survey Operations
An aerial survey accident highlights problems implementing flight following technology, the dangerous use of marine lifejackets and the value of considering competence.
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The Loss of RAF F-35B ZM152: An Organisational Accident
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
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’.
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EC135 Air Ambulance CFIT when Pilot Distracted Correcting Tech Log Errors
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
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 »
Twisted Firestarters
Two Australian occurrences were helicopters have triggered bushfires.
Twisted Firestarters Read Post »
Main Rotor Blade Certification Anomaly in Fatal Canadian Accident
TSB uncover a difference in interpreting certification requirements applied to retrofit composite blades resulting in an omitted test.
Main Rotor Blade Certification Anomaly in Fatal Canadian Accident Read Post »
Impatience Comes Before a Fatal Fall During HESLO
A refueller, who was a former HESLO loadmaster, becomes impatient with progress, steps in and is lifted to his death.
Impatience Comes Before a Fatal Fall During HESLO Read Post »
DC3-TP67 CFIT: Result-Oriented Subculture & SMS Shelfware
Operating VFR in IMC had become a norm and as workload increased the aircraft commander “adopted a single-pilot mindset”. TSB reveal a consultant’s self-licking shelfware SMS re-write.
DC3-TP67 CFIT: Result-Oriented Subculture & SMS Shelfware Read Post »