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 »
What Lies Beneath: The Scope of Safety Investigations
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 »
Review of “The impact of human factors on pilots’ safety behavior in offshore aviation – Brazil”
Research indicates intense commercial pressures, intolerable stress and fatigue, ‘schizophrenic’ simulator sessions and weaponizing of FDM, SMS and ‘fair culture boards’ in a “big brother reality show.” We review a recent paper published in Safety Science.
HeliOffshore 2022 Conference Review
We discuss the key points from this year’s HeliOffshore conference in Portugal. HeliOffshore is the global collaborative safety association for the offshore helicopter industry.
HeliOffshore 2022 Conference Review Read Post »
HEMS Pilot Seizure While Rotor-Running
The HEMS pilot, who had been cleared to fly after a previous head injury, suffered a seizure say investigators. The helicopter yawed into a snow bank, ejecting a casualty who was being loaded.
HEMS Pilot Seizure While Rotor-Running Read Post »
SAR AW101 Roll-Over: Entry Into Service Involved “Persistently Elevated and Confusing Operational Risk”
Accident investigators say a SAR AW101 rolled over “during a period of persistently elevated and confusing operational risk” as the aircraft type was being introduced to military service in Norway.
Loss of Control, Twice, by Offshore Helicopter off Nova Scotia
During the second go-around the crew started an impromptu visual approach when the ExxonMobil installation suddenly came into view. A high ROD at low airspeed developed in low-visibility. The helicopter avoided the sea by just 13 ft. A second loss of control occurred during the ascent.
Loss of Control, Twice, by Offshore Helicopter off Nova Scotia Read Post »
A Second from Disaster: RNoAF C-130J Near CFIT
The investigation showed that the RNoAF should intensify its safety management, including on risk, competency and safety culture. It also identified a need for an independent and comprehensive supervisory body for military aviation in Norway.
A Second from Disaster: RNoAF C-130J Near CFIT Read Post »
ATR 72 Rudder Travel Limitation Unit Incident: Latent Potential for Misassembly Meets Commercial Pressure
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.
B206B Hit by Truck in Forced Landing after 16 Months of Operation with Unairworthy Engine
An engine overdue for overhaul was refitted and 16 months later failed. The operator was not approved for passenger transport but the company was in financial distress so the pilot and part-owner accepted this charter.
Loss of Control During HESLO Construction Task: BEA Highlight Wellbeing / Personal Readiness
BEA were unable to establish the reason for Loss of Control in the hover. The pilot was suffering from an unreported back condition and the HESLO technique required an awkward body position. BEA make recommendations about wellbeing and personal readiness.
Latent Engine Defect Downs R44: NR Dropped to Zero During Autorotation
A confused response to an engine issue earlier in the day, a sudden power loss and a failed autorotation…but crashing into trees was decisive in the two occupants’ survival say NSIA.
Latent Engine Defect Downs R44: NR Dropped to Zero During Autorotation Read Post »
Investigators Suggest Cultural Indifference to Checklist Use a Factor in TAROM ATR42 Runway Excursion
Failure to perform the Descent Check during the approach was a key factor for a loss of direction control after landing. This had “become a fairly common practice among crews”.
Fatal Falcon 50 Accident: Unairworthy with Unqualified Crew
A US business jet was operating Part 135 flights with known unresolved maintenance discrepancies and an unqualified flight crew. Due to a brake failure and improper configuration it went off a 50 ft embankment killing the flight crew.
Fatal Falcon 50 Accident: Unairworthy with Unqualified Crew Read Post »
Survival Flight Fatal Accident: Air Ambulance Operator’s Poor Safety Culture
A poor safety culture normalised rushed departure with inadequate preparation to do an air ambulance flight two other operators had turned down. The helicopter encountered snow and struck the ground during an Inadvertent IMC escape manoeuvre. Poor FAA oversight was contributory say NTSB.
Survival Flight Fatal Accident: Air Ambulance Operator’s Poor Safety Culture Read Post »
Culture and CFIT in Côte d’Ivoire
French investigators point to wider cultural issues in an overseas military accident.
Culture and CFIT in Côte d’Ivoire Read Post »
Fatal MD600 Collision With Powerline During Construction
The pilot was seriously injured and two linesmen were fatally injured when this helicopter stuck a powerline during its construction.
Fatal MD600 Collision With Powerline During Construction Read Post »
Saab 340 Runway Excursion Exposes Safety Management Issues
Highlights the risk of awarding to the lowest bidder and relying only on an AOC being in place. Investigators call for regulators to focus on the practical application and performance of SMS (not shelfware documents).
Saab 340 Runway Excursion Exposes Safety Management Issues Read Post »
ATR72 Missed Damage: Maintenance Lessons
Unclear communications, shift handover & roles and responsibilities, complacency about fatigue and failure to use access equipment all feature in this serious incident.
ATR72 Missed Damage: Maintenance Lessons Read Post »
Regulator Missed the Chance to Intervene Before Fatal Tour Accident say TAIC
The operator’s training system did not adequately prepare the pilot. The regulator claims they were mislead by an operator about who was really in charge of training. TAIC say this was evident in advance.
Regulator Missed the Chance to Intervene Before Fatal Tour Accident say TAIC Read Post »
Survey Aircraft Fatal Accident: Fatigue, Fuel Mismanagement and Prior Concerns
Concerns had been raised about the pilot and the operation just days before this fatal accident. It highlights the importance of doing a proper due diligence and having independent aviation expertise available when contracting for special mission support.
Survey Aircraft Fatal Accident: Fatigue, Fuel Mismanagement and Prior Concerns Read Post »
Meeting Your Waterloo: Competence Assessment and Remembering the Lessons of Past Accidents
No one was injured in this low speed derailment after signal maintenance errors but investigators expressed concern that the lessons from the fatal triple collision at Clapham in 1988 may have been forgotten.
Inadequate Maintenance at a USAF Depot Featured in Fatal USMC KC-130T Accident
An inadequate USAF propeller overhaul preceded an in-flight failure that resulted on loss of a USMC C-130 and 16 personnel.
Inadequate Maintenance at a USAF Depot Featured in Fatal USMC KC-130T Accident Read Post »
Investigation into F-22A Take Off Accident Highlights a Cultural Issue
Take off performance was seen as unconcerning in the powerful F-22A, so calculations were skipped and under-speed rotation had become common across the F-22 community.
Investigation into F-22A Take Off Accident Highlights a Cultural Issue Read Post »