Safety Culture

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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Scottish Court Orders Release of Sumburgh Helicopter CVFDR

Accidents & Incidents, FDM / Data Recorders, Helicopters, Human Factors / Performance, News, Offshore, Oil & Gas / IOGP / Energy, Regulation, Safety Culture, Safety Management

Scottish Court Orders Release of Sumburgh Helicopter CVFDR A Scottish Court has ordered that the UK Air Accidents Investigation Branch (AAIB) release the combined Cockpit Voice and Flight Data Recorder (CVFDR) from a fatal 2013 AS332L2 Super Puma offshore helicopter accident at Sumburgh to prosecutors, who will use the Civil Aviation Authority (CAA) to “provide an expert opinion on

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EASA North Sea Offshore Helicopter Operations Review

Helicopters, News, Offshore, Oil & Gas / IOGP / Energy, Safety Culture, Safety Management

EASA North Sea Offshore Helicopter Operations Review Today the European Aviation Safety Agency (EASA) open the sealed bids for a new research study, EASA.2015.HVP.01, entitled: Helicopter North Sea Operations Management Current Practices Safety Review EASA say: Apart from analysis of past accidents and incidents, the need of more detailed and systematic analysis of the practices

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Culture + Non Compliance + Mechanical Failures = DC3 Accident

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

Culture + Non Compliance + Mechanical Failures = DC-3 Accident (Buffalo Airways C-GWIR) The Transportation Safety Board of Canada (TSB) recently issued a report on the forced landing of a 1942 Douglas DC-3 C-GWIR after an engine failure on 19 August 2013. The Buffalo Airways aircraft was operating a scheduled passenger flight between Yellowknife and Hay River

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1950’s Aerial Firefighting and Smokey Bear

Crises / Emergency Response / SAR, Fixed Wing, Helicopters, Safety Culture, Special Mission Aircraft

1950’s Aerial Firefighting and Smokey Bear A look at aerial firefighting 60+ years ago: However, as per the background poster: If you really feel the need to sing along to Smokey Bear we are happy to oblige: https://youtu.be/sfgWbhPYFGI But while in the song it is Smokey THE Bear (to scan better), the Smokey Bear Act of 1952 (16 U.S.C.

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More US Night HEMS Accidents

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

More US Night Helicopter Emergency Medical Service (HEMS) Accidents At the beginning of March 2015 we published an article on the aftermath of a 2003 fatal night-time US HEMS accident: Life Flight 6 – US HEMS Post Accident Review.  During March 2015 there were two more fatal night-time medical helicopter accidents in the US. Air Methods EC130B4 6

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A320 Unstabilised Approaches: Descent Below MSA and a Runway Excursion at Lyon

Accidents & Incidents, Air Traffic Management / Airspace, Fixed Wing, Human Factors / Performance, Regulation, Safety Culture, Safety Management

A320 Unstabilised Approaches: A Descent Below Minimum Safe Altitude (MSA) and a Runway Excursion at Lyon An airline introducing a new type suffers a serious incident while training a new captain, highlighting the importance of Management of Change, Risk Assessment and good Training.  UPDATE: Then within a year they have a runway excursion after an unstabilised approach at

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North Sea Helicopter Safety – Step Change in Safety Event

Accidents & Incidents, Design & Certification, Helicopters, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Offshore, Oil & Gas / IOGP / Energy, Regulation, Safety Culture, Safety Management, Survivability / Ditching

North Sea Helicopter Safety – Step Change in Safety Event The offshore industry safety initiative, Step Change in Safety, held a workforce engagement seminar on Helicopter Safety in Aberdeen in early March. The presentations are all available to download (click on the presenter’s name below): HSSG Update – Mark Abbey This presentation on behalf of

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Operator & FAA Shortcomings in Alaskan B1900 Accident

Airfields / Heliports / Helidecks, Fixed Wing, Human Factors / Performance, Oil & Gas / IOGP / Energy, Safety Culture, Safety Management

Operator & FAA Shortcomings in Alaskan B1900 Accident UPDATE 10 April 2018: with details below of further NTSB recommendations after a 2016 C208B accident The US National Transportation Safety Board (NTSB) has reported on a Beechcraft 1900C accident on the North Slope of Alaska on 23 Nov 2013. The B1900C was being operated by Hageland Aviation Services (doing

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Aerossurance Joins HeliOffshore

Helicopters, News, Offshore, Oil & Gas / IOGP / Energy, Safety Culture, Safety Management

Aerossurance Joins HeliOffshore   HeliOffshore is a global safety-focused organisation formed by major offshore helicopter operators. They state: We enable helicopter operators to develop, share and apply best practices, create and use advanced technology, and advocate for harmonised flight standards. HeliOffshore is dedicated to achieving the highest levels of safety, in the air and on the

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UK CAA CAP1145: Update on North Sea Helicopter Safety (CAP1243)

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: Update on North Sea Helicopter Safety (CAP1243) Not long after the fatal loss of Eurocopter AS332L2 G-WNSB 1.5 nm west 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. CAP1145 This CAA Review resulted in the CAP1145 report

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The Power of Safety Leadership: Paul O’Neill, Safety and Alcoa

Business Aviation, Fixed Wing, Helicopters, Human Factors / Performance, Military / Defence, Mining / Resource Sector, Offshore, Oil & Gas / IOGP / Energy, Safety Culture, Safety Management

The Power of Safety Leadership: Paul O’Neill, Safety and Alcoa In his book The Power of Habit: Why We Do What We Do, and How to Change, Charles Duhigg, described the reaction to Paul O’Neill’s first presentation as the new CEO of the Aluminum Company of America (Alcoa) in 1987: A few minutes before noon, the new

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NTSB Report on Bizarre 2012 US S-76B Ditching

Accidents & Incidents, Airfields / Heliports / Helidecks, Business Aviation, Helicopters, Human Factors / Performance, Maintenance / Continuing Airworthiness / CAMOs, Offshore, Oil & Gas / IOGP / Energy, Safety Culture, Safety Management, Survivability / Ditching

An overweight helicopter, flown with a known defect, ditched during a poorly executed approach to a GOM drilling rig, then water taxying was attempted…

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James Reason’s 12 Principles of Error Management

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

James Reason’s 12 Principles of Error Management James Reason, Professor Emeritus, University of Manchester, set out 12 systemic human factors centric principles of error management in his book Managing Maintenance Error: A Practical Guide (co-written with Alan Hobbs and published in 2003). These principles are valid beyond aviation maintenance and are well worth re-visiting: Human error is both universal

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US Vehicle Regulator in Firing Line

Accidents & Incidents, Design & Certification, Regulation, Safety Culture, Safety Management

US Vehicle Regulator in Firing Line The US National Highway Traffic Safety Administration (NHTSA) has been criticized by politicians and safety advocates this week for its handling of critical safety defects with the air bags on millions of vehicles.  It is reported that: The faulty air bags can explode with too much force and spray shrapnel at

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