Safety Culture

UK CAA CAP1145 North Sea Helicopter Safety Two Years On

Accidents & Incidents, Design & Certification, Helicopters, Human Factors / Performance, HUMS / VHM / UMS / IVHM, Offshore, Oil & Gas / IOGP / Energy, Regulation, Safety Culture, Safety Management, Survivability / Ditching

UK CAA CAP1145 North Sea Helicopter Safety Two Years On Not long after the fatal loss of Eurocopter AS332L2 G-WNSB of Sumburgh Airport, Shetland Islands on 23 August 2013 with 4 fatalities (AAIB Special Bulletin), the UK Civil Aviation Authority (CAA) launched an rapid review on offshore helicopter safety. That CAA Review resulted in the CAP1145 report (‘Safety review of […]

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US HEMS Accident Rates 2006-2015

Accidents & Incidents, Helicopters, Regulation, Safety Culture, Safety Management, Special Mission Aircraft, Survivability / Ditching

US HEMS Accident Rates 2006-2015 The safety of US Helicopter Emergency Medical Service (HEMS) operations has been a topic we have discussed previously.  With HeliExpo approaching, when 10 years of the International Helicopter Safety Team (IHST) will be marked and with US NTSB Board Member Robert Sumwalt just publishing a HEMS article in Professional Pilot,

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HEMS S-76C+ Night Approach LOC-I Incident

Accidents & Incidents, FDM / Data Recorders, Helicopters, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Safety Culture, Safety Management, Special Mission Aircraft

HEMS S-76C Night Approach Loss of Control – In-flight (LOC-I) Incident A Helicopter Emergency Medical Service (HEMS) Sikorsky S-76C+ C-GHHJ operated by Helijet on behalf of the BC Ambulance Service was on a VFR approach to the coastal Tofino/Long Beach Airport (CYAZ), British Columbia, Canada at 02:39 Local Time on the dark, moonless night of 15 November 2015.  It suffered a Loss of Control

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CSB: ‘Multiple Safety Deficiencies’ Led to ExxonMobil Refinery Explosion

Accidents & Incidents, Oil & Gas / IOGP / Energy, Safety Culture, Safety Management

CSB: ‘Multiple Safety Deficiencies’ Led to ExxonMobil Refinery Explosion The US Chemical Safety Board (CSB) report that they have “uncovered multiple process safety management deficiencies” that led to the 18 February 2015, explosion at the ExxonMobil Torrance refinery, California and an associated serious near miss. The CSB explain: …two workers were injured when an explosion occurred in the

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Our Top 20 Articles of 2015

Accidents & Incidents, Business Aviation, Crises / Emergency Response / SAR, Design & Certification, Fixed Wing, Helicopters, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Military / Defence, News, Offshore, Oil & Gas / IOGP / Energy, Regulation, Safety Culture, Safety Management, Special Mission Aircraft, Survivability / Ditching

Aerossurance: Our Top 20 Articles of 2015 As we start the new year we look back on the 20 articles that proved most popular with our readers in 2015.  In reverse order: Number 20: Building St Helena Airport – An Industrial Scale ‘Grand Design’ This started with the building of the first airport on the volcanic

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Canadian Coast Guard Helicopter Accident: CFIT, Survivability and More

Accidents & Incidents, Crises / Emergency Response / SAR, Helicopters, Human Factors / Performance, Offshore, Safety Culture, Safety Management, Special Mission Aircraft, Survivability / Ditching

Fatal Arctic Bo105 CFIT gives lessons on low level ops, compliance with mx data, cold water survivability, alerting, data recorders and regulatory oversight.

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Back to the Future: Error Management

Accidents & Incidents, Air Traffic Management / Airspace, Airfields / Heliports / Helidecks, Business Aviation, Crises / Emergency Response / SAR, Design & Certification, Fixed Wing, Helicopters, Human Factors / Performance, HUMS / VHM / UMS / IVHM, Logistics, Maintenance / Continuing Airworthiness / CAMOs, Military / Defence, Mining / Resource Sector, Offshore, Oil & Gas / IOGP / Energy, Resilience, Safety Culture, Safety Management

We look at some of the problems of error management and ask if we are still making the error management mistakes James Reason warned of in 1997 (spoiler: some organisations are). We also look at drift and how some have failed to grasp its more than poor compliance.

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EC155 of a European Operator

CHIRP Critical of an Oil Company’s Commercial Practices

Helicopters, Human Factors / Performance, Logistics, Offshore, Oil & Gas / IOGP / Energy, Regulation, Safety Culture, Safety Management

CHIRP Critical of an Oil Company’s Commercial Practices The CHIRP Charitable Trust, who run the UK’s Confidential Human Factors Incident Reporting Programme (CHIRP), has highlighted two “of the many” reports received relating to an oil company changing its North Sea helicopter operator for the second time in three years. CHIRP do not name the oil company.

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Aircraft Maintenance: Going for Gold?

Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Resilience, Safety Culture, Safety Management

Aircraft Maintenance: Going for Gold? We pose the question: Can aviation maintenance learn lessons from championship athletes?   Aerossurance is pleased to have sponsored the Royal Aeronautical Society (RAeS) conference Human Factors in Engineering – the Next Generation at Cranfield University on 12 May 2015. In his opening address Cranfield University’s Professor Dave King (a former Chief Inspector of Air Accidents with

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Fatal Night-time UK AW139 Accident Highlights Business Aviation Safety Lessons

Accidents & Incidents, Business Aviation, Helicopters, Human Factors / Performance, Regulation, Safety Culture, Safety Management

Fatal Night-time UK AW139 Accident Highlights Business Aviation Safety Lessons The UK Air Accidents Investigation Branch (AAIB) has published their report into the fatal accident to AgustaWestland AW139 G-LBAL on 13 March 2014.  This accident reinforces many important past lessons on business aviation safety, managing clients, training, human factors and learning from previous accidents. The helicopter, owned by Haughey Air, departed from a

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Aerossurance Sponsors HF in Aviation Safety Conference

Human Factors / Performance, Resilience, Safety Culture, Safety Management

Aerossurance Sponsors Human Factors in Aviation Safety Conference Aerossurance is pleased to sponsor the Chartered Institute of Ergonomics & Human Factors’ (CIEHF) Human Factors in Aviation Safety Conference that takes place at the Radison Blu Hotel, East Midlands Airport, 9-10 November 2015. Aerossurance was keen to sponsor this event as it is such an excellent independent professional

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City of London (Credit: Andy Evans)

The Contrarian Director

Human Factors / Performance, Resilience, Safety Culture, Safety Management

The Contrarian Director Public companies should appoint a “Contrarian Director” to systematically challenge management recommendations, says Australian corporate lawyer Siobhan Sweeney.  Sweeney won the 2015 Cambridge-McKinsey Risk Prize at the Centre for Risk Studies at University of Cambridge Judge Business School for her paper on the subject: In the current economic climate marked by volatility and uncertainty, risk oversight

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Moerdijk Explosion: “Failure to Learn”

Accidents & Incidents, Human Factors / Performance, Oil & Gas / IOGP / Energy, Safety Culture, Safety Management

Shell Moerdijk Explosion: “Failure to Learn” On 3 June 2014 two major explosions and a fire occurred at a Shell petrochemical plant in Moerdijk, Netherlands. Two employees were injured in the explosions that were heard 20 km away.  Debris was found 800 metres away. The Dutch Safety Board has investigated this incident.  Currently only the investigation summary

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Loose B-Nut: Accident During Helicopter Maintenance Check Flight

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

Loose B-Nut: Accident During Helicopter Maintenance Check Flight Another investigation by the US National Transportation Safety Board (NTSB), published on 13 July 2015, has highlighted poor maintenance standards and continuing airworthiness management in a US helicopter operator. The NTSB report that on 1 January 2014, Airbus Helicopters EC130B4, N133GC, operated by Papillon Airways Inc (PAI), was

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‘Procedural Drift’: Lynx CFIT in Afghanistan

Accidents & Incidents, FDM / Data Recorders, Helicopters, Human Factors / Performance, Military / Defence, Safety Culture, Safety Management

‘Procedural drift’ in the operating detachment was noted by the Service Inquiry into a British military helicopter accident in Afghanistan that killed 5 service personnel. This drift is said to have allowed standards to dilute during sustained operations in theatre.

‘Procedural Drift’: Lynx CFIT in Afghanistan Read Post »

Performance Based Regulation and Detecting the Pathogens

Accidents & Incidents, Human Factors / Performance, Regulation, Resilience, Safety Culture, Safety Management

Performance Based Regulation (PBR) and Detecting the Pathogens At a time when Performance Based Regulation (PBR) is a hot topic in the aviation industry, a series of rail accidents in North America help demonstrate the type of poor performance that PBR must successfully detect.  These accidents were what James Reason, Professor Emeritus, University of Manchester described as ‘organisational accidents’ in his

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Metro-North: Organisational Accidents and Shelfware

Accidents & Incidents, Human Factors / Performance, Regulation, Safety Culture, Safety Management

Metro-North: Organisational Accidents and Shelfware An NTSB study into five accidents on US railway (‘railroad’) Metro-North gives a unique perspective on organisational accidents.  Metro-North was described as having an “invisible safety department”, that kept its SMS on the shelf until external audits and assumed on-time performance would give them safe operations. Organisational Accidents James Reason, Professor Emeritus, University of Manchester popularised the

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A319 Double Cowling Loss and Fire – AAIB Report

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

A319 Double Cowling Loss and Fire – AAIB Report The UK Air Accidents Investigation Branch (AAIB) has published their report into an Airbus A319 that lost both engine fan cowlings and suffered an associated fire on take-off from London Heathrow in 2013. We look at the circumstances of the previous evening’s maintenance on this aircraft,

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DuPont Reputational Explosion

Accidents & Incidents, Human Factors / Performance, News, Safety Culture, Safety Management

DuPont Reputational Explosion Chemical company DuPont (E.I. DuPont de Nemours & Co Inc.) has been feted for its safety performance for many years (for example winning the National Safety Council‘s 2013 Robert W. Campbell Award).  Its reputation in the field of safety stretches back to the founding of the company as a gunpowder manufacturer in

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