Botched engine maintenance trouble shooting preceded an engine failure on take off and aircraft mishandling that resulted in the loss of a C-130 and 9 personnel.
Inadequate Maintenance, An Engine Failure and Mishandling: Crash of a USAF WC-130H Read Post »
While the response to this incident did include a design change the operator couldn’t it seems resist ‘re-eduction’.
Fallacy of ‘Training Out’ Error: Japanese AS332L1 Dropped Load Read Post »
An AS350B2 impacted terrain after continuing visual flight into deteriorating IMC. The helicopter was configured with boxes to carry huskies, but their weight was not accounted for, so the aircraft was operating overweight.
Low Viz Helicopter CFIT Accident, Alaska Read Post »
The TSB report posses many questions on the management and oversight of aircraft maintenance, competency and maintenance standards & practices. We look at opportunities for forward thinking MROs to improve their maintenance standards and practices.
B1900D Emergency Landing: Maintenance Standards & Practices Read Post »
We report from the fourth HeliOffshore Conference and AGM on ‘Delivering Our Priorities’ for improved offshore helicopter safety.
“Delivering Our Priorities”: HeliOffshore 2018 Conference Report Read Post »
A heavy landing after a crew were put under considerable stress during a poorly planned VIP flight booking and a hurried overweight take off.
An AW109SP, Overweight VIPs and Crew Stress Read Post »
Do accident reports make the error of treating human error as a cause not a symptom?
NTSB Probable Causes and Bad Apples Read Post »
A Shorts 360 cargo aircraft contracted to FedEx crashed in the Caribbean after the crew likely suffered a Somatogravic Illusion raising the flaps on a dark night in 2014. The lack of an FAA SMS regulation for Part 135, the operator’s poor safety culture and implications for the wider industry culture stand out in a thoughtful accident report.
Investigators point to a shelfware SMS and low crew type experience / confidence in an automation related KA200 accident that killed 10.
Indian King Air Take Off Accident: Organisational & Training Weaknesses Read Post »
In a report released on 22 Feb 2018 the NTSB reveal shocking maintenance standards prior to an air tour accident in which a 16 year old boy died and his parents were seriously injured.
NTSB Reveal Lax Maintenance Standards in Honolulu Tour Helicopter Accident Read Post »
The investigation into a training accident identified a unit culture that instructor proficiency was not a high priority but student output was, and consequently flight commanders and schedulers acted within that culture.
RCAF Production Pressures Compromised Culture Read Post »
We look back on Enron and how their Code of Ethics was shelfware in a company described as having a ‘culture of arrogance’.
Enron and the Hubris of the “World’s Leading Energy Company” Read Post »
We look at lessons in a NTSB rail accident report on how a cult of compliance and routine over-emphasis on judging front line workers can lead to disaster, lessons relevant to all industries.
A Railroad’s Cult of Compliance Read Post »
A US airline shows a strange grasp of human factors principles and argues AGAINST a design change intended to address a long running series of maintenance errors.
United Airlines Suffers from ED (Error Dysfunction) Read Post »
In need of inspiration for your maintenance human factor continuation training? Why not use this free CASA HF video?: ‘Crossed Wires’
Crossed Wires: Online Maintenance Human Factors Training Video Read Post »
The absence of a policy of landing with a specific minimum fuel quantity was a key factor in a survey helicopter’s loss of power and collision with trees near Whitecourt, AB in 2016.
Running on Fumes: Fatal Canadian Helicopter Accident Read Post »
TSB explain how an airline risk assessed operations into icing, had not implemented all the mitigations but had started routinely operating into forecast icing, with fatal consequences.
How a Cultural Norm Lead to a Fatal C208B Icing Accident Read Post »
A collision during apron works at Stavanger. A skipped risk assessment by airport/contractors, misleading concrete barriers and confirmation bias. Highlights the fallacy of over reliance on safety reporting.
S-92A Collision with Obstacle while Taxying Read Post »
Aerossurance is pleased to support this Chartered Institute of Ergonomics & Human Factors (CIEHF) conference at Gatwick 13-14 November 2017.
How do we Improve Human Performance in Today’s Aviation Business? Read Post »
Accident investigators comment on human factors that influenced a KA200 flypast, caught on video, which turned disastrously wrong in Iceland. Amazingly one person survived the impact.
Impromptu Flypast Leads to Disaster Read Post »
A case study of a pathological safety culture. Management and peer pressure, compounded by poor contracting and scheduling by a cruise line resulted in high risk flights in poor weather.
All Aboard CFIT: Alaskan Sightseeing Fatal Flight and Safety Culture Read Post »
We report from the third HeliOffshore Conference and AGM on deepening commitment and collaboration to improve offshore helicopter safety.
Deepening Delivery: HeliOffshore 2017 Conference Report Read Post »
Good leaders inspire trust but there is a Dutch proverb: “Trust comes on foot, but leaves on horseback.” We discuss why trust is important in developing an organisation’s culture to overcome blame and fear and how behaviour is key.
Leadership and Trust Read Post »
We look at the background to this guilty plea and the associated maintenance related accident.
Director of Maintenance Pleads Guilty To Obstructing an NTSB Air Accident Investigation Read Post »
Continuing an unstable approach after a loss of visual reference led to a Jazz Dash 8 contacting the ground 450ft short of the runway, causing significant damage.
Unstable Approach Dash 8 Touches Down 450ft Before Threshold Read Post »
