Culpable Culture of Compliance?
An ATSB report on a fatal man overboard incident questions if blindly valuing compliance may create a culture that actually undermines safety.
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Machining Defect Cause of V2500 Failure
Machining Defect Cause of V2500 Failure On 18 September 2014 JetBlue Airways Airbus A320-232 N656JB experienced a Number 2 IAE V2527-A5 engine failure and under-cowl fire during initial climb out from Long Beach, California. The US National Transportation Safety Board (NTSB) say in their report: The flightcrew shutdown the No. 2 engine, discharged both fire bottles, and
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Ignoring Corrosive Environment Brings Down B206 Helicopter
Ignoring Corrosive Environment Brings Down B206 Helicopter An operator that ignored the Rolls-Royce M250-C20 Series Engine Operation and Maintenance Manual classification of their entire island operating location as a “severe corrosion operating environment” and failed to do the associated maintenance requirements suffered the loss of the their Bell 206B3. Emerald Pacific Airlines B206B3 B-31019 was hovering at
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Leonardo Strives For Greater Gearbox Loss of Lube Capability
Finmeccanica Strives For Greater Gearbox Loss of Lube Capability Finmeccanica Helicopters (the recently rebranded AgustaWestland (UPDATE: and now Leonardo) is working to enhance the durability of helicopter Main Gear Boxes (MGBs) after a loss of lubrication. The company’s Marco Tamborini presented their approach at the European Aviation Safety Agency (EASA) 9th Rotorcraft Symposium held in Cologne in December
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Safety Lessons from TransAsia ATR-72 Flight GE222 CFIT
The ASC Taiwan has issued their investigation report into the CFIT of a TransAsia ATR 72-500 on 23 July 2014 during an attempted landing in bad weather.
Safety Lessons from TransAsia ATR-72 Flight GE222 CFIT Read Post »
NASA Challenger Launch Decision
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.
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HEMS S-76C+ Night Approach LOC-I Incident
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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CAP1145 Helicopter Water Impact Survivability Statistics – A Critique
CAP1145 Helicopter Water Impact Survivability Statistics – A Critique Eurocopter AS332L2 G-WNSB impacted the sea 1.5 nm west of Sumburgh Airport, Shetland Islands on 23 August 2013 (see the last AAIB Special Bulletin) with the loss of 4 lives. https://youtu.be/C_3xlunGUk0 Within weeks the UK Civil Aviation Authority (CAA) ordered a hurried safety review. This resulted in the CAP1145 report (‘Safety review of offshore public transport
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Maintenance Personnel Fatigue and Alertness
Maintenance Personnel Fatigue and Alertness Maintenance personnel fatigue and a consequential lack of alertness is regularly being identified as contributory, or potentially contributory, to maintenance related air accidents and serious incidents. We have covered three examples previously: Some involve poor shift patterns: Missing Igniters: Fatigue & Management of Change Shortcomings: The UAE GCAA investigation report explains most of the
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HUMS Vibration Health Monitoring Success
HUMS Vibration Health Monitoring Success Australia’s Civil Aviation Safety Authority (CASA) has published a Service Difficulty Report (SDR), dated 1 November 2015, that highlights a Health & Usage Monitoring System (HUMS) Vibration Health Monitoring (VHM) success. During investigation of a HUMS vibration alert, the main rotor head of an Airbus Helicopters EC225/H225 offshore helicopter was examined and wear was identified beyond the limits
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CSB: ‘Multiple Safety Deficiencies’ Led to ExxonMobil Refinery Explosion
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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The Passengers Who ‘Caused’ a 737 Tail Strike: Ground Handling Lessons
The Passengers Who ‘Caused’ a 737 Tail Strike On 12 January 2003 a serious incident occurred involving Transavia Boeing 737-800 PH-HZB at Rotterdam. The Dutch Safety Board (DSB) report says the aircraft: …pitched nose-up just after take -off thrust had been selected. The pitch up movement stopped when the aft fuselage and the tailskid assembly contacted the
The Passengers Who ‘Caused’ a 737 Tail Strike: Ground Handling Lessons Read Post »
Aerossurance Marks RAeS 150th Anniversary by Sponsoring Rotorcraft Automation Conference
Aerossurance Marks RAeS 150th Anniversary by Sponsoring Rotorcraft Automation Conference The Royal Aeronautical Society (RAeS) was founded on 12 January 1866, so is today celebrating its 150th anniversary (or sesquicentennial). To mark this significant milestone Aerossurance is pleased to be sponsoring the Society’s 2016 Rotorcraft Conference. This conference, to be held 6-7 July 2016 at the
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G-III Attempted Takeoff Using Runway Edge Lights as Centerline
We look at the lessons on aerodrome lighting and charts from a UK bizjet take off accident. Mistaking edge lights for the centreline is not uncommon.
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Procedural Drift at Saab 340 Operator Leads to Taxiway Excursion
An inappropriate, undocumented practice, coupled with a failure to follow the checklist contributed to writing off an SF340 while taxying.
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Our Top 20 Articles of 2015
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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Dangers of Aircraft Tyre Inflation
Dangers of Aircraft Tyre (US: Tire) Inflation The Royal Canadian Air Force are investigating two recent tyre inflation burst accidents. Both involve visiting aircraft using borrowed equipment: 25 August 2015 CT-114 Tutor CT114058 A Snowbird aircraft was diverted from the rest of the deployed team due to an in-flight emergency. The aircraft was repaired, including a successful
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UK BOSIET/FOET Cat-A CA-EBS HUET Update
UK BOSIET/FOET Cat-A CA-EBS HUET Update Category A Compressed Air Emergency Breathing Systems (CA-EBS) were introduced for helicopter passengers flying offshore over the UK Continental Shelf in September 2014. This followed the UK Civil Aviation Authority (CAA) North Sea Review, which resulted in the CAP1145 report. Oil and Gas UK, Step Change in Safety, OPITO, the International Association of Drilling Contractors
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B1900C PSM+ICR Accident in Pakistan 2010
B1900C PSM+ICR Accident in Pakistan 2010 The Pakistan Civil Aviation Authority (CAA) has recently published the report into the loss of a Beechcraft B1900C in 2010. The aircraft, AP-BJD, was being operated by JS Air (as subsidiary of the JS Group) when it crashed on 5 November 2010, killing 21 people. The accident featured what a
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Canadian Coast Guard Helicopter Accident: CFIT, Survivability and More
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 »
UK OHSAG Oct 2015 Minutes
UK Offshore Helicopter Safety Action Group (OHSAG) October 2015 Minutes The UK Civil Aviation Authority (CAA) has just published the minutes of the 16 October 2015 meeting of the Offshore Helicopter Safety Action Group (OHSAG). This is the third and last of the year (compared to six in 2014), postponed from July 2015. The OHSAG was formed as a result of the ‘Civil
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So You Think The GOM is Non-Hostile?
So You Think The Gulf of Mexico (GOM) is Non-Hostile? The Gulf of Mexico (GOM), off the coast of Mississippi, Louisiana and Texas in particular, remains a busy area for offshore helicopter operations with over 2 million passengers carried and nearly 300,000 flying hours last year (see our article: Helicopter Ops and Safety – Gulf Of
So You Think The GOM is Non-Hostile? Read Post »
Back to the Future: Error 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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Bell 407 Power Loss GOM Ditching: NTSB
Bell 407 Power Loss GOM Ditching: NTSB (RLC B407 N373RL) The US National Transportation Safety Board (NTSB) has reported on the ditching of a Bell 407 offshore helicopter in the Gulf Of Mexico (GOM) on 11 November 2014. The aircraft, N373RL operated by Rotorcraft Leasing Company (RLC), ditched following a partial power loss shortly after take off from an installation
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ANSV Highlight Procedures & HF After ATR72 Landing Accident
Landing briefing missed. ANSV claim Vapp too high (CIAS disagree). No go around after first bounce. NLG & MLG collapse.
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