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 »
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 »
A $196.5 mn organisational accident: a conference call and a contaminated barrel.
Cold Comfort Conference Call: USAF F-35A Alaska Accident Read Post »
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 »
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 »
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.
S-76D Loss of Control on Approach to an Indian Drilling Rig Read Post »
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 »
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 »
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 »
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 »
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 »
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 »
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.
Drift into Danger: AW109SP Night HLS Accident Read Post »
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.
Night Offshore Helicopter Approach Water Impact Read Post »
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.
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 »
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 »
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 »
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 »
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 »
Two Australian occurrences were helicopters have triggered bushfires.
Twisted Firestarters Read Post »
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 »
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 »
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 »
Narrowly focusing on the proximal means missing the full context. Beware of What-You-Look-For-Is-What-You-Find. “There is almost no human action or decision that cannot be made to look flawed and less sensible in the misleading light of hindsight.”
What Lies Beneath: The Scope of Safety Investigations Read Post »
