On 12 Mar 2009 17 people lost their lives in a preventable accident when the failure of an oil filter stud highlighted a known fatal flaw in the type’s design.
2009 Newfoundland S-92A C-GZCH Accident: A Failure of Design and Certification Read Post »
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
UK CAA CAP1145 North Sea Helicopter Safety Two Years On Read Post »
Takata have been the centre of fatal air bag failures and millions of vehicle recalls. We look at the recommendations of a US panel reviewing their quality.
Airbag Explosions: Independent Takata Corp QA Panel (‘Skinner Panel’) Reports Read Post »
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,
US HEMS Accident Rates 2006-2015 Read Post »
An ATSB report on a fatal man overboard incident questions if blindly valuing compliance may create a culture that actually undermines safety.
Culpable Culture of Compliance? Read Post »
On the evening of 27 Jan 1986 a group were preparing for what we now know as one of the most infamous telecons in history. We look at lessons for all complex, high hazard industries.
NASA Challenger Launch Decision Read Post »
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
HEMS S-76C+ Night Approach LOC-I Incident Read Post »
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
CSB: ‘Multiple Safety Deficiencies’ Led to ExxonMobil Refinery Explosion Read Post »
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
Our Top 20 Articles of 2015 Read Post »
Fatal Arctic Bo105 CFIT gives lessons on low level ops, compliance with mx data, cold water survivability, alerting, data recorders and regulatory oversight.
Canadian Coast Guard Helicopter Accident: CFIT, Survivability and More Read Post »
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.
Back to the Future: Error Management Read Post »
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.
CHIRP Critical of an Oil Company’s Commercial Practices Read Post »
We look at how people really learn. Formal pre-fab classroom training is the least effective method. So why do we do waste so much time and money on the ‘Great Training Robbery’? We show there is a better way: 70:20:10.
Coaching and the 70:20:10 Learning Model – Beyond Training Read Post »
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
Aircraft Maintenance: Going for Gold? Read Post »
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
Fatal Night-time UK AW139 Accident Highlights Business Aviation Safety Lessons Read Post »
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
Aerossurance Sponsors HF in Aviation Safety Conference Read Post »
This dual engine incident highlights maintenance fatigue and Management of Change at both a macro level (corporate restructuring) and the micro level (a new task).
The Missing Igniters: Fatigue & Management of Change Shortcomings Read Post »
Fatal G-IV runway excursion: take off with gust lock engaged. Contributing: habitual noncompliance and inadequate certification.
Gulfstream G-IV Take Off Accident & Human Factors Read Post »
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
The Contrarian Director Read Post »
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
Moerdijk Explosion: “Failure to Learn” Read Post »
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
Loose B-Nut: Accident During Helicopter Maintenance Check Flight Read Post »
‘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 (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
Performance Based Regulation and Detecting the Pathogens Read Post »
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
Metro-North: Organisational Accidents and Shelfware Read Post »
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,
A319 Double Cowling Loss and Fire – AAIB Report Read Post »
