Inadvertently leaving lights dimmed, a compromised NVG mod, no aural low fuel warning and negligible recent experience on type all feature in this NZ HEMS incident.
Dim, Negative Transfer Double Flameout Read Post »
NASA Aviation Safety Reporting System at 40 and the Continued Challenge of Timeliness for Safety Reporting On 16 April 16 2016 the National Aeronautics and Space Administration (NASA) Aviation Safety Reporting System (ASRS) celebrated 40 years of operation. Its origins highlights one major challenge of safety reporting, learning and action: timeliness. The Purpose and Administration of
NASA ASRS at 40 and the Continued Challenge of Timeliness for Safety Reporting Read Post »
C-130J Control Restriction Accident, Jalalabad The US Air Force (USAF) Air Mobility Command (AMC) has released its accident report into the fatal loss of control (LOC-I) accident involving of Lockheed Martin C-130J 08-3174 during a night-time take-off from Jalalabad Airfield, Afghanistan on 2 October 2015. The accident was caused by the failure to remove a loose article that had been deliberately placed
C-130J Control Restriction Accident, Jalalabad Read Post »
A Canadian Hawk pilot got a big surprise when rolling inverted: his flight crew bag contacted the firing unit of the canopy explosive fragmentation system with shattering results…
Crew Bag FOD Shatters Hawk Canopy Read Post »
A319 Double Cowling Loss and Fire – AAIB Safety Recommendation Update The UK Air Accidents Investigation Branch (AAIB) has issued an update on responses to their safety recommendations from their investigation into British Airways Airbus A319 G-EUOE. G-EUOE, powered by IAE V2500s, lost both engine fan cowlings and suffered an associated fire on take-off from London Heathrow
A319 Double Cowling Loss and Fire – AAIB Safety Recommendation Update Read Post »
C-130 Fireball Due to Modification Error A botched modification program unnecessarily changed the original design for a hydraulic system modification when a drawing was misread. A longer hydraulic hose was necessary after that change but an inappropriate design process short-cut meant the shorter hose remained listed as an alternative. The shorter hose was fitted to the modified fleet
C-130 Fireball Due to Modification Error Read Post »
Fatigued Flight Test Crew Crosswind Accident The Icelandic Transportation Safety Board (ITSB), the RNSA, recently issued their report into a wheels up runway excursion accident that occurred on 21 July 2013 to Sukhoi RRJ-95B ‘Superjet 100’ 97005 during flight tests by Sukhoi at Keflavik airport. The Flight Test Objective and the Accident Flight The purpose of
Fatigued Flight Test Crew Superjet 100 Crosswind Accident Read Post »
US Police Helicopter Night CFIT: Is Your Journey Really Necessary? On 27 March 2014, at 0147 local time, ex-military Bell OH-58A, N497E, operated by, the Kern County Sheriff’s Office (KCSO) collided with terrain near Tehachapi, California. The three occupants were uninjured, although the helicopter was substantially damaged. The Accident and Investigation The US National Transportation Safety Board (NTSB)
US Police Helicopter Night CFIT: Is Your Journey Really Necessary? Read Post »
On touch down a corroded MLG torque link lug fractures, the wheels turn 90 degrees and the aircraft veers off the runway. Continuing a/w changes followed,
Metro 23 MLG Corrosion Causes Runway Excursion Read Post »
Solent Hoegh Osaka Car Carrier Accident The Singapore registered 180m, 51,770 gross tonnage ‘pure car and truck carrier’ (PCTC) MV Hoegh Osaka, managed by Wallem Shipmanagement Pte Ltd, developed a significant starboard list when turning to port while departing Southampton on 3 January 2015. The Marine Accident Investigation Branch (MAIB) say in their recent report: As the list increased
Solent Hoegh Osaka Car Carrier Accident Read Post »
Marine Pilot Transfer Winching Accident (Brim Aviation AW109SP N361CR) During a night Marine Pilot Transfer (MPT) helicopter winching / hoist operation on 21 April 2014, the marine pilot being transferred, was injured. The marine pilot was being transferred from an outgoing ship to a container vessel, inbound to Astoria, Oregon, the 222 m, 27,437 gross ton MV Northern
Marine Pilot Transfer Winching Accident Read Post »
AAIB Report on 2013 Sumburgh Helicopter Accident (CHC Scotia AS332L2 G-WNSB) The UK Air Accidents Investigation Branch (AAIB) has published its report into the 23 August 2013 accident were CHC Scotia Airbus Helicopters AS332L2 Super Puma G-WNSB impacted the sea on approach to Sumburgh Airport in the Shetland Islands. The AAIB report is 266 pages long. This article is
AAIB Report on 2013 Sumburgh Helicopter Accident (CHC Scotia AS332L2 G-WNSB) Read Post »
Germanwings: Psychiatry, Suicide and Safety The French Bureau d’Enquêtes et d’Analyses (BEA) has issued their report into the loss of Germanwings Airbus A320 D-AIPX and 150 lives in the French Alps on 24 March 2015, which was due to the actions of the Co-Pilot. Below we focus on the highlights from the 110 page report. The Co-Pilot
Germanwings: Psychiatry, Suicide and Safety Read Post »
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 »
Step Change in Safety: Helicopter Safety Update 2016 Step Change in Safety held a webinar on North Sea helicopter safety (covering CA-EBS, emergency egress, FCOMs and airworthiness matters) on 9 March 2016 (following on from a March 2015 event we have previously covered). Introduction Step Change is a tripartite UK offshore health and safety organisation combining companies,
Step Change in Safety: Helicopter Safety Update 2016 Read Post »
Shell Pernis 11.2t Ethylene Oxide Leak The Dutch Safety Board has reported (in Dutch) on the leak of 11.2 tonnes of ethylene oxide from a overhead pipe at the 550 hectare Shell Pernis oil refinery on 30 December 2013. The leak was detected by a site worker at what is Europe’s largest refinery, surrounded by 500,000 inhabitants. Ethylene oxide is
Shell Pernis 11.2t Ethylene Oxide Leak Read Post »
Forgotten Fasteners – Serious Incidents We examine three incidents where fasteners were forgotten during maintenance. It two cases these maintenance errors resulted in parts falling from the aircraft. In a third, a massive fuel leak occurred. Incident 1 – Twin Otter Mission Pod The Irish Air Accident Investigation Unit (AAIU) has recently reported on a
Forgotten Fasteners – Serious Incidents Read Post »
Misrouted Engine Fuel Control Cable Hawker 800XP In Issue 4/2015 of TP 6980 – Canadian Aviation Service Difficulty Reports – Feedback an maintenance error involving a Hawker 800XP fuel control cable is reported: During a planned major structural inspection, the technician noticed that the no.1 engine high-pressure fuel lever cable was trapped under the cover of the electrical junction
Misrouted Engine Fuel Control Cable Hawker 800XP Read Post »
Pitot Punctures Floats in Icelandic SAR Ditching The ditching of Icelandic Coast Guard Aérospatiale SA365N Dauphin TF-SIF in the Atlantic off Reykjavik on 16 July 2007 highlights the importance of avoiding protuberances that can puncture emergency flotation systems, careful configuration management and establishing emergency drills. The Icelandic Transportation Safety Board (ITSB), the RNF, issued their report in
Pitot Punctures Floats in Icelandic SAR Ditching Read Post »
Falcon 7X LOC-I Due To Solder Defect On 25 May 2011, Dassault Falcon 7X business jet, HB-JFN, operated by Jet-Link, suffered a pitch trim runaway that caused a 40° pitch up, rapid climb and temporary Loss of Control Inflight (LOC-I) over Malaysia. First flown in 2005 and certified in April 2007, after a 590 flight, 1600 flying hour test programme,
Falcon 7X LOC-I Due To Solder Defect 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 »
US Helicopter Accident Rate Analysis Aerossurance recently looked at US Helicopter Emergency Medical Service (HEMS) accident data for the last 10 years and has also examined accident rates in Gulf of Mexico (GOM) oil and gas operations. We thought we would also look at published accident rates for all US helicopters and demonstrate the effects of choosing different start
US Helicopter Accident Rate Analysis Read Post »
First Eleven: RAeS Guidance for Design Organisations on Maintenance Human Performance The Royal Aeronautical Society (RAeS) Human Factors Group: Engineering (HFG:E) has published a short guidance document on 11 steps an aviation Design Organisation (DO) can take to “deliver safer, more effective and reliable aircraft through improved design for maintenance”. The RAeS say: Aircraft safety
First Eleven: Guidance for Designers on Maintenance Human Performance Read Post »
There is a danger that data that can give insight into safety is not combined because it is in multiple databases but there is a great potential opportunity.
Safety Data Silo Danger – Data Analytics Opportunity Read Post »
A maintenance error installing a TRDS bearing resulted in an EC130B4 LOC-I. An excellent AIBN report highlights the value of Independent Inspections.
EC130B4 Accident: Incorrect TRDS Bearing Installation Read Post »
