HAZREP PROGRAM - ARMOR Quarterly... · Small flight departments face a scale deficiency regarding...

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HHAZAZRREPEP PPROGRAMROGRAM

Report: Report:

Second Quarter 2012 Summary of reports spanning April 2012– June 2012

Helicopter Services Division

Hazards are something each of us encounter every day simply due to the nature of op-erating in the aviation environment. PRISM has created a system (similar to NASA’s ASRS) designed to diminish the risks your organization and its’ employees face while performing their jobs. Our vision is to elevate every subscriber’s awareness of com-mon industry hazards, thereby mitigating the associated risks. But we need your help in order to identify these hazards. Please consider participating in this program by en-tering your hazard information into the Aviation Risk Management Online Resource (ARMOR) on the PRISM website (Professional subscribers only) [or emailing a soft copy if you prefer] to PRISM any hazard reports submitted to you via your reporting process. Your information will be completely sanitized to ensure anonymity, and your submission will then be destroyed to ensure confidentiality. We will compile the infor-mation and create a hazard knowledgebase for the sole purpose of safety analysis. This will allow us to provide you with the most current and applicable hazard identifica-tion and risk mitigation information available. There are currently over 180 PRISM sub-scribers; with adequate participation this hazard knowledge base will become a benefi-cial component of your Safety Management System. We want to dispel any misgivings and reassure you that the information will not be identifiably associated with any com-pany, and will be used for the stated safety purpose only.

This report is created for inclusion into your Safety Management System to aid in iden-tifying hazard trends present in organizations with similar operating characteristics. Small flight departments face a scale deficiency regarding report submissions; this re-port is designed to mitigate that deficiency by increasing the swath of hazard data ac-cumulated for your use in comparison and trending analysis.

A Valuable SMS Component

HazRep Program Review:

HHAZAZRREPEP PPROGRAMROGRAM

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One hundred and thirty helicopter specific reports are contained in this quarter’s sum-mary. The reports are grouped into twelve basic hazard categories. Click on the sec-tion of the graph to view the corresponding, de-identified, reports.

Hazard Data

Hazard Details Corrective Action

Severity Hazard Details Completed Corrective Actions

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Continuous Improvement

Catastrophic I was on standby all day as always. I received a call to fly at 12:30 am, 20 minutes after I feel asleep. I was told I had to be at the airport at 2am for a 2 hr flight. Other factors caused the trip not to go, however with zero rest time and being ready standby all day, a redeye duty day is not at all safe. I know my body and to ask it to stay awake over 24 hrs and fly is very dangerous. There should be a minimum of 5 hrs notice prior to a redeye flight.

This was brought up at the Safety Committee Meeting and it was agreed that we will give more notice for redeye flights.

Marginal It has come to my attention that the emergency assembly area is different than what is listed in the Emergency Procedures flip chart. The meeting point is actually pretty far from the point diagrammed in the chart. T his could cause much confusion in times of emergency.

Negligible Jeppesen updates in base offices accumulate where 1 person updates the charts. When they are busy or not in town no one updates them with the result being that flights are dispatched without current charts and that is a violation of our IS-BAO manual possibly FARs. Suggestion: Each base have a designated person responsible to verify that Jeppesen revisions to include iPads are available for revision. Each pilot prior to the trip should be made responsible to check to see if there are revisions due and to post these to the aircraft manuals at some point during the trip. The iPads are required by SOP to be checked by the PIC prior to flight, but need to be amended to update the iPad at some point prior to completion of the trip. The designated person in each base is still responsible to make sure this happens, but each pilot should be responsible to post revisions when available and not wait for the designated person to do so. Our manual should be augmented to reflect this policy.

It is the responsibility of the crewmember doing the preflight inspection to check and update the Jepp charts for the operating region, both paper and aircraft iPads, and make sure they are compliant with our Air Transportation Operations Manual. If there is an anticipated revision, this crewmember will be expected to show early as to comply with the revision sometime before the trip. This Duty will be shared by all crew members as they see revisions come due. We will strive to share these responsibilities among all flight crewmembers. Best practices would be for all flight crewmembers to be issued an iPad with chart subscriptions, and be responsible for preflight actions on the issued iPad.

Negligible How about iPads for every aircraft? We could have every pilot get one?

Idea passed on and will be evaluated this season.

Negligible A year ago [company] was a smaller company that needed everyone to step up and do everything it took no matter what is was to get the job done. Commonly if you heard someone say "its not my job" it was looked down on. While we still need everyone to step and do anything to get the job done, this needs to be more organized. I am starting to see that efforts are being duplicated to complete the same task. People are trying to take on tasks of other departments without any

This issue was discussed at the safety committee meeting. It was agreed that this has become a problem in our organization. Everyone agreed to take a more hands off approach instead of trying to get involved in every aspect of every problem.



PRISM Solutions

Continuous Improvement

idea of the big picture consequences. Sometimes critical items are being communicated to the incorrect persons. The downside to this overlap/incorrect communication is that it does not follow the correct communication structure and is incorrectly addressed. The more people a piece of information goes through the farther from the correct it becomes. Everyone needs to understand their position and do 110% of their job.

Negligible I have noticed an increase in use of cell phones for personal calls, texting and ear bud usage. It is my belief this hinders productivity and creates a safety hazard in some cases. Immediately stop the use of ear buds and blue tooth ear devices unless their use is for business purposes and limit the use of cell phones for personal calls.

Negligible During a department meeting, it was discovered that many team members had not recently completed SMS training. Require team members to login to the PRISM website and complete the Safety Management Systems for Employees Computer Based Training (CBT) module. Document their completion and keep certificates on file.



PRISM Solutions

Deviation

Critical Flight Crews are not remaining current in their FAA instrument currency, namely in their execution of six approaches within the last six months. In order to do this training it requires two pilots and an aircraft. Aircraft have had limited hours available due to maintenance issues and other training requirements namely hoisting. End results pilots are not completing their required instrument training for both the FAA and the 28 day cycle proficiency training.

The main portion of hoisting has been completed and more hours for training should be available. [Company] have been notified to monitor the status of their people and take proactive steps to ensure compliance.

Marginal Maintenance personnel observed working on lift with out safety harness, improper work shoes, complete disregard for Safety Policy & Program.

Negligible A recent analysis of MEL entries was conducted and it appears that a number of MEL log entries were being entered into the airplane flight log on the final leg or upon the return to home base.

The D.O. has sent a personal letter, as well as addressing each pilot individually, expressing the importance of writing MELs as they happen en-route. We have developed a maintenance trend tracking system to monitor write ups. There has been a revision to our GOM addressing this issue and we are providing additional training on the topic to all flight crews.



PRISM Solutions

Equipment

Catastrophic Recently a crack was found on one of the tail rotor blades. Due to the documented problem of defective blades on the Augusta AW139 Helicopters, I am submitting this report to request that a daily inspection be completed by a qualified and trained mechanic on the tail rotor blades of all AW139 aircraft before the first flight of each day. This alarming discovery warrants extra safety precautions to eliminate a catastrophic failure of the tail rotor system and a possible loss of life.

The Safety Committee convened to discuss the safety concerns. Recommendations were agreed upon as specified. It was determined to leave this issue open and revisit it on a weekly basis.

Catastrophic While departing from the elevated helipad, the left side rear passenger door slammed into the open position. This incident occurred while transitioning from the roof top into forward flight. The Medical crew began yelling and moving about the cabin securing bags and equipment, at which time, [name1] who was positioned on the left side had a high potential of unexpectedly exiting the aircraft if any left cyclic input would have been introduced, which in my opinion would have been catastrophic. It should be noted that crew confirmed the cass message displays and/or caution warning lights DID NOT illuminate, therefore we were unable to immediately identify the problem and the corrective action for the problem. Proposal : The medical crew should have the option to utilize the harnesses, which are used by crew members during hoist operations. When the medical crew are not seatbelted and are moving freely around the cabin they should be connected to harness rings, which would eliminate many potential hazards that could be life threatening.

After speaking with crew,along with the Maintenance Personnel, I have three recommendations to mitigate the reported hazardous condition. 1. A proper crew briefing involving specific, step-by-step instructions for the correct cabin door closing sequence. Pilots should emphasize that the door needs to be fully slid forward and seated in the door jamb prior to rotating the door handle forward. Once the handle is fully rotated forward, ensure that the locking/releasing button has popped up. The closing of the cabin door should be done using two hands, whether inside or outside of the aircraft. There are two grab handles located on the inside of the door for this purpose. 2.Pilots need to ensure that all passengers are seated with seat belts fastened prior to all takeoff and landings. Once in level flight, if a medical crew member needs to unbuckle to perform his or her medical duties, that is acceptable. However, the medical personnel need to reacquire a seat belted position prior to landing. 3.Pilots also need to ensure that all of the medical equipment and the passenger personal belongings are secured prior to flight. There has been no reported, nor any finding, of a mechanical defect related to this un-commanded cabin door opening, so that has been ruled out. Pilots should remind their medical crews that there are four locking points on the AW 139 Cabin Door and if the door is not properly seated in the door jamb prior to rotating the locking handle, there is a high probability that all of the four locking points will not to engage. This can result in an unsecure door and/or a damaged locking mechanism. Also, once the door is closed, or believed to be closed, a cabin door CAS message will not illuminate until the door handle is rotated past the approximate 45 degrees position. So if a cabin door is not properly closed, but believed to be closed and secured, and it releases and opens, no CAS message will be received due to the door handle still in



PRISM Solutions

Equipment

the 3 o’clock (locked position). Gunner’s belts could be used by the medical personnel when seatbelts are not required and while in the performance of their medical duties, however this does not relieve them from the regulatory requirement to be wearing a seatbelt for takeoffs and landings.

Catastrophic Getting ready to take off for a troopshuttle mission, the parking tender suddenly yelled of the radio to "HOLD!" as I was ready to lift my collective. After the Helitack ran over and worked on the ship I was informed that the rear baggage door had popped open when the aircraft started getting light on the skids. The helitack who last checked the doors said that she ran her hands over every door and it looked locked. After the flight we looked over the door. It turns out the door can be closed and it locks slightly but the spring is not strong enough to fully engage the bolt. The immediate corrective action was to mark the door with a permanent marker to show where the fully locked position is on the handle.

I agree, those latches make it much more apparent whether they are properly latched or not. For working with the variety of crews we do in the field, it would be nice to have those more straight forward latches. For now, the additional marking added to the latch is definitely helpful.

Critical Engine Chip Light Bell 407, Total time airframe and engine: 2430.3 This aircraft experienced an engine condition deterioration while in flight. The aircraft was at 3500 feet, VFR conditions prevailed. The aircraft had been flying for three hours that day prior to the incident. While in cruise flight, at approximately 80% power applied, the engine made a loud pop, followed immediately by what sounded like a bullet ricochet. The engine chip light illuminated. Engine oil pressure was fluctuating slightly, but power remained steady. Engine oil temperature remained steady. I immediately reduced power to 65%, and descended to 1000 feet, where I stayed for the remainder of the flight. The nearest suitable landing area was approximately 10 minutes away, so I turned northwest, where I landed at [company] former base. Upon shutting down the engine a constant “crinkling” sound came from the engine. No other defects were noted until I removed the lower engine chip plug, which showed a large number of chips on it. When the mechanic removed the CEFA oil filter, a large amount of brass and steel chips were found.

Engine replaced-awaiting teardown analysis.

Critical I found the recently installed eye wash station in the hangar without any water. I filled it with water from the garden hose figuring that water would be better than nothing. It makes me wonder if there is

Station refilled



PRISM Solutions

Equipment

any system in place to keep track of the condition of the safety equipment at the [location] facility.

Critical When crew arrived a line serviceman gave them a part that he thought might have came off the aircraft. The crew did not recognize the part and continued the next leg. A post flight inspection of the aircraft revealed that the oil filler cap access door had departed the aircraft causing damage to the MR blades and TR blades. Photos attached.

Critical Power cart on hangar floor (blue unit) has many cuts that penetrate the rubber outer jacket of the cable. The unit needs to be red tagged until repairs can be completed.

Power cable has been replaced.

Critical Upon pre-flight inspection discovered a small crack on the lower rear portion of the fire wall. This was brought to the attention of [name1] immediately after being discovered. [name1] and [name2] subsequently received and conducted a search mission assisting the US Coast Guard, which required extensive hovering and slow speed operations. At some point after returning to [airport] the cracked area was inspected by [personnel] and found the crack to be substantial enough to warrant further inspection. [name1] confirmed the crack was larger than first observed and because of heavy vibrations during the search most likely caused the crack to spread. This fire wall separates the engine #1 compartment and the tail rotor drive compartment. In the event of a compartment fire and/or fire wall failure it is believed this would have an effect/damage on the tail rotor drive shaft because of the close proximity to the shaft itself. The amount of damage cannot be determined. All necessary Maintenance personnel was notified as well as Agusta.

Critical After leaving [helipad] I noticed a rhythmic yaw of the air craft and noted that the N2 and Rotor were fluctuation about 6 to 8%. I also noted a Torque fluctuation from 72 to 82%. I tried to adjust N2 RPM but settings would not last. I climbed to 2500 feet and prepared for a possible water landing. I notified Operations through the MMU that I was experiencing a Fuel Control or Governor with a problem. The weather was clear and this was approximately 18:00 hours and all other instrument indications were in the normal range. It yawed about 10 to 15 degrees in a rhythmic manner until and uneventful



PRISM Solutions

Equipment

landing. After landing I called Operations and talked with maintenance personnel about the flight and reported the indications to them as I had observed. I then checked the PC lines and connections to ensure the fittings were tight. All checked to be tight.

Marginal Pilot noticed higher than usual TOT during flight. After consulting with more experienced pilots a power check was suggested. Power check was performed the following day. Power check revealed unsatisfactory performance from engine. Pilot subsequently grounded aircraft until maintenance could be performed. Visual inspection of engine reveled a cracked burner can. Damage to burner can was consistent with the high TOT observed. Burner can was replaced and TOT was observed to be normal. Post maintenance power check was performed and found to be satisfactory. Aircraft returned to service.

Alert maintenance about this issue and see if there are similar incidents of cracked burner cans in our fleet or seen at maintenance facility. Pilots: keep an eye on your gages. You will know when something is "off" especially when you fly the same aircraft all day. After a particular "tough" take-off using a lot of power, do a power check when you can to double check (recommendations by chief pilot - to be discussed during training).

Marginal Fuel pump light came on during high power setting. Reduced power and light went out. Returned to airport for maintenance.

Mechanic found o-ring missing in the fuel filter housing bypass valve. Cleaned filter and installed new o-ring. Due to frequent change in fuel filter the standby clean unit did not get inspected before final installation.

Marginal Prompted by an article in Aviation International News, I became interested in the risks associated with spontaneous lithium battery thermal runaway and the fires that sometimes accompany them. I researched the characteristics of the batteries and the circumstances surrounding some incidents of lithium battery fires onboard aircraft. Multiple threats were uncovered, which included excessive heat, sparking, molten metal being ejected from the battery, and subsequent fire. I reached out to a friend, who happens to work for a private fire research / materials flammability company. He, in turn, contacted an inspector at the FAA Technical Center in Atlantic City for suggestions on the topic. One suggestion was to invest in fire containment bags for the aircraft. In the event of a lithium battery fire, the device is to be placed in these bags, thereby isolating the device from causing further damage.

Based on guidance from the FAA and from the lack of a response from the company offering the bags, a conclusion was made that the bags do not have to meet any particular flammability standards and, therefore, probably wouldn't be a good option for our department at this time. Furthermore, the risk of personal injury potential of handling an overheating / burning device trumps any potential benefit of a containment bag. If future research indicates otherwise, then that option will be explored again. For now, it was decided that the FAA's guidance on the issue, contained in a SAfO, is sufficient in dealing with lithium battery fires. An email was sent out to team members with a link to the SAfO.

Marginal While in cruise flight (straight and level, 140 kts) Master Caution light illuminated with an 'ENG OIL TEMP' CAS message (#1 ENG Oil Temps was 141 degrees.) Referred to the QRH and followed and instructions of lowering power. ENG Oil Temp slowly continued to rise, so we elected to land at [airport]. Landed and shutdown without incident.



PRISM Solutions

Equipment

Upon inspection of the engine, the ENG Oil level was near the top of the sight glass (Possibly over filled). Consulted [name1] regarding the situation and decided to wait a 30-45 minutes, then startup and return to [airport]. During startup and idle, #1 ENG Oil Temp was approx. 15 degrees higher than the #2 ENG, but within the normal, green range. With the approval of maintenance, we elected to take off and return. Enroute, #1 ENG Oil Temperature began to rise again and it was apparent it was going to go into the caution range. We landed and shutdown. Notified maintenance of our situation and [personnel] responded. [personnel] inspected and removed oil from the ENG. We again started up and flew back to [airport. Temperatures between #1 & #2 ENGs were within 4 degrees of each other, (normal / green range) for the entire flight. Landed and shutdown at [airport]. In the hangar, [personnel] again inspected the ENG and noticed no oil was observed in the sight glass. Aircraft was grounded until maintenance could complete a thorough inspection.

Marginal With the number of electronic devices carried on board theses days, consideration should be given to the fire hazard their batteries create.

Marginal While descending to the water source with a 180 gallon Bambi bucket, the down wash from the rotor blades over the water pushed the Bambi bucket forward and sidewards enough to wrap one of the cables of the bucket around the ground handling ring on the inside of the forward part of the skid which was seen through the cargo mirror. A slow taxi to the support truck located 100 yards away and the crew members response to the issue was to unwrap the cable which was done very easily.

Marginal Cell phones and various electronic equipment have caught on fire on various airlines. A specially bag for these situations would be a good idea.

Negligible Floats Blown!! Float test complete. Trigger and Test switch were released and clear. Float system rearmed to insure normal operation. Floats fired without trigger pull. Further inspection revealed firing circuit was intermittently active when armed.

Float switch was sticking-replaced switch.



PRISM Solutions

Equipment

Negligible The mounting for 2 fire extinguishers on the hangar floor have broken away leaving the fire extinguishers sitting on the floor. Also, the mounting for the fire extinguisher located near the south door entrance needs to be relocated a few inches so that the fire extinguisher hangs properly.

Negligible EFB Power Source: Several aircraft are not equipped to charge EFB’s from the flight deck. According to our manuals we are required to keep the second unit charged.

Negligible Yellow gov light illuminated on approach. Upon landing experienced slight surging. After shut down VEMD recorded a failure, bleed air valve.

Mechanic pulled bleed air valve and found it to be very dirty. Cleaned and inspected it. Reinstalled and test flight checked out good.

Negligible Helicopter starter generator in-flight deterioration and after landed and shut down gen failed.

Replaced starter generator.

Negligible Have someone look at the flight deck clips in the aircraft and change the Velcro straps on them. They are worn out and do not even strap anymore.

The Velcro was replaced on the clip decks. Asked maintenance to add checking the portable medical equipment in the aircraft to the inspections.

Negligible The helicopter should have a catch for the cot. This catch prevents the forward wheels from coming off the helicopter edge before the cot wheels have come down and locked into position. Without this the cot could collapse or fall. Every ambulance that uses this cot system has a safety catch. I am unsure why the helicopter doesn't.

The way our interior is designed doesn't allow use of the cot stop as designed. Our cot is moved inboard 3 inches from standard to allow room for pt and equipment access in flight. Due to the design of the cot and the floor structure of the helicopter it is not possible to install a physical stop.

Negligible 3 ladders are missing safety stickers as well as electricity conductor stickers

Purchased stickers stating "this ladder conducts electricity" and "Safety Instructions."

Negligible Erratic rotor RPM's, random low RPM horn during any part of flight, and RPM over limit codes.

Found ASU 1 card is bad. New one on order.

Negligible Three times in the past month, my IPad locks up and reboots in flight while trying to load approach plates in Jeppview.

Noted, will monitor. Several software updates have been applied.

Negligible Discovered dirt covering the top left aircraft side static port orifice during preflight. Upon further inspection, mud daubers were found to have nested in the port.

Negligible Aircraft had previously been shut down approximately 10 minutes prior to this flight. Aircraft was on the second start of the day, having previously flown for approximately 2.3 hours, with approximately 10 takeoffs/landings. Following the second start and during the pre take off check, the anti torque pedals were found to be immobile. Upon

This incident stresses the importance of checking all flight controls prior to run-up to 100%. Whereas the incident may have been related to the clogged hydraulic filter it is unlikely. Pilots should watch for additional anomalies in the hydraulic system over the next few days to ensure this was an isolated issue. During start up and while in idle



PRISM Solutions

Equipment

discovering this condition, maintenance personnel was notified, and while at flight idle on the ground, the mechanic verified that the pedals were immobile. The aircraft shut down procedure was instituted and pedal function returned during the during the shut down procedure after depressing the hydraulic accumulator switch. Maintenance commenced checking flight control continuity and found no issues. Some weeping and oil/dust was found on the tail rotor servo. Aircraft was restarted, flight controls were checked and no anomalies were found. On the previous day, the left side hydraulic bypass indication button was popped. The button was reset and following a second indication, the filter was replaced.

always ensure the HYD ACCUM switch is depressed and ensure released. Because this is a Dual Hyd. B3 it is possible to be under the impression that the Hyd. are functioning normal. Remember that your first indication of a Hyd. failure will be the Gong and Light followed immediately by very stiff pedals. Really it happens all at once. You may all remember the ENG A-Star that crashed because the pilot misinterpreted a hyd failure for a tail rotor failure. Review emergency procedures in the flight manual.

Negligible The blue medical kit in the break room needs/require evaluation. Needed a band-aid for contract flight attendant and I opened this kit only to find it doesn't contain band-aids.

Negligible During two separate fires when using the “belly bucket” configuration I had the wire that extends from the control head of the bucket “pull out” of the plug terminal. On the first occasion I thought the screws just became loose but after it happened the next time I used the bucket I figured there must be something wrong. Upon landing and inspecting the wires I noticed the control head wire had “stuck” in the bottom of the control head. After re-attaching the control head wire to the plug terminal I realized the pig tale was too long and had been able to reach down too far and get stuck. I reduced the length of the pig tale with electrical tape and believe that will fix the problem.

Recommend checking all pig tails, especially the electric plug to make sure the screws didn't loosen up and the wires came out.

Negligible On Monday June 18 while flying in the Canyon, the PG&E Tait radio was suction mounted to the left side wind screen. The mount lost suction and fell onto the left side chin bubble. The result was a hole in the chin bubble roughly the size of a softball. Fortunately the radio was not lost. As a result, I will be placing the radio on a clip in a new location.

Negligible During bucket drills with the helitack crew a large loop was found tied in the cinch strap of the bucket. This loop/knot prevented the bucket being cinched normally to it's designated capacities. Additionally it was found that the bucket release cable would not retract back into the head reliably during ground checks. Both of these faults should have been identified before the bucket was put in service in the field



PRISM Solutions

Equipment

for the season.

Negligible Ng gauge reading incorrect and often high due to inop. particle separator switch / particle separator defaulted to "on" all time. Especially an issue when OAT very high....have to fly by Ng gauge at reduced power.

Negligible I attempted to bring Engine #1 to idle by using the engine Mode Select switch. I did not make a smooth turn, momentarily hesitating before completing the turn. Once the switch reached the idle position "1 ENG MODE SEL" CAS appeared and the engine remained at 100% NF/NR. The QRH states to "Continue Flight" and to "Monitor engine parameters being aware that engine may need to be shutdown using ECL." When we shutdown the aircraft we turned both engine Mode Select switches to idle, Engine #1 still remained at flight. We then used the ECL and brought it back to the MIN line. The engines were now at 75% NF/NR. After 2 minutes we turned off both engine Mode Select switches and shutdown the aircraft. Several minutes later we turned on the Battery Master, Main and AUX and the CAS message had cleared. We were then able to perform a normal battery start without incident. I was advised that another pilot had the same issue and was able to fix it by cycling the Engine Gov switch between Auto and Manual.

Negligible [name1] and I were picking up [aircraft] from the facility at PNE. Upon starting the #2 engine with use of a ground power cart, the engine accelerated from idle to fly with the mode switch still in the idle position. We received a CAS message of "Eng Mode Switch Fail." We moved the mode switch to fly and back to idle but the engine stayed in fly. The QRH said to continue flight, but we were on the ground. So I put the #2 Eng Gov into Manual with no change and then I put it back into Auto, this corrected the problem and the engine correctly came back to idle. This corrected the problem and there has not been any problems since.

Negligible On several instances during flight, the portable Garmin GPS lost power. MX was notified and will check for discrepancies in the power supply. On one occasion, I was attempting to enter coordinates for a fire.



PRISM Solutions

Equipment



PRISM Solutions

Facilities

Catastrophic The cigarette butt container outside the lobby caught on fire. DO retrieved a fire extinguisher from inside the hangar and extinguished the fire.

There is no procedure for the continual assurance of an empty butt can. Butt can was replaced with a metal ash tray. Line service will empty butt can each month and the item has been placed on the monthly inspection punch list.

Catastrophic Overhead hangar beam (structural support) is cracked/split with a 1-2" gap visible through one of two planks making up the support beam assembly. Beam is located on the north end of the hangar about midway/western side of the hangar. If allowed to continue, all of the support strain is on half of the assembly and if a failure occurs, the result could be overhead structure falling on and damaging aircraft, equipment, and personnel

Beam needs to be replaced or reinforced.

Critical In the hangar under the loft there are a number of electrical boxes hanging down to about chest height. Not only do they make the space less useable but they are easily walked into and could cause injury. 2. Around the perimeter of the hangar there are a number of electrical outlet boxes that are no longer secured to the wall. When you put in, or remove, a plug the whole box moves. This could lead to an electrical shock to the user.

Florescent red / pink tape has been placed on all electrical items hanger form loft roof. We are awaiting.

Critical In the street next to the pad (approx 30ft) there is orange snow or construction type fencing surrounding an area of road work. It was not secured very well and was blowing around during landing. The possibility exists for it to blow into the main or tail rotor system.

DOT is doing a sidewalk and curb project. I left a message with the DOT and the DOT shop called and said the fence in the area of the pad has been replaced with cones and should be clear by weeks end. I emailed the RW pilots informing them of the situation. I called the on call pilot to let him know. He was going to include it in his pass down to the oncoming aircrew and put a reminder in the crew quarters. The pilot reporting it stated he thought operations could proceed with caution. The RW DO was kept in the loop throughout.

Critical The terminal building is not equipped with smoke alarms. There is one fire extinguisher near the front entrance, but that is it. This could be very dangerous if a fire occurred after hours and there were no detectors to notify anyone. Part of the electrical system recently overheated, and luckily was caught by someone before closing, but it potentially could have been a much worse situation.

Marginal I have observed equipment and trash receptacles in the hangar blocking fire extinguishers from view/accessibility. I moved the equipment away from the extinguishers on the most recent occurrence.

Email sent to all maintenance technicians to remind them that all emergency equipment should be kept clear at all times.



PRISM Solutions

Facilities

Marginal Multiple times I have found power cart cords and cord dolly’s in positions to cause trip hazards in the hangar. Suggest leaving them in positions to minimize the hazard, see "normal procedures" picture attached.

I agree with (the submitter) on his action. Also, we have crossed this bridge before with extension cords, which is the same issue. Until we have people clean up there own messes and not leave it for other people to clean up this will keep happening. When done with cords, put them up.

Marginal Upstairs hallway of Hanger Two has coffee bar and water bottle in a major escape route for fire evacuation of the building. Coffee and water should be moved to employee break area with more room around the devices.

Marginal There are several doors leading from the helipad to the Emergency Room that are not automatic. This poses not only a safety concern but a quality restraint as well. Security is often very helpful, however, it is a very narrow hallway. I have gotten my foot run over a couple times trying to hold the door while making certain there is nothing that is going to catch on the door frames while we are going through. I would like to suggest placing automatic door openers from the flight hanger all the way to the flight elevator. It is difficult when working a patient coming from the pad to hold both of the doors into the stairwell. It would be very helpful to have an automatic door from the pad as well. I'm not certain that they would need to be swipe accessible but it would be a great time saver and safety improvement for the flight team!

Marginal I feel that we should have all automatic door openers between the helicopter hangar and skywalk. It is very difficult to hold door open and get patient through doors safely. It is also difficult to return the bed to the hangar solo. Automatic door openers on all doors between hangar and skywalk.

This is the second HAZREP submitted on this issue. It is in work and will be documented on the original HAZREP/suggestion report.

Marginal I've gotten a couple complaints from staff regarding a rug on the 3rd floor by the elevator. It often gets wrinkled and is a big tripping hazard along with catching the cot wheels on it and shaking our patients around on the bed. This elevator is frequently used for flights and is just something that could be a potential problem. Is it possible to have the rug removed? Not sure the reasoning behind having it there if its just a high traffic area but I don't think I've ever seen it laying completely flat.

The rug was removed from this location.



PRISM Solutions

Facilities

Marginal There is an open drain in the hangar floor about 6 inches in diameter just to the left of the door leading to the restrooms in the building. The drain is uncovered with out a top on it possibly causing a hazard if someone were to accidentally step where the drain is.

Covered drain with grate.

Marginal Lights in hanger where off at 6:00 am; someone could trip or run into airplane.

Contacted the property manager and he said he will set the timer to make the lights come on earlier.

Marginal Hoses on ground, no clear pathways, etc Evaluating facilities and will have a plan in place by the end of the month.

Marginal Rain puddles in hanger. Spoke and trained all line service to be pro-active on mopping up puddles and slippery when wet signs.

Marginal Hangar floor drain grates have been removed for paint and re-installed. While removed, it was noticed that the drain spacers were rusted and unserviceable. Floor drain grates have been re-installed without spacers, rendering the grates very unstable. Do not attempt to walk, or tow an airplane over the grates until [company] is able to re-install the spacers. Cones have been placed over the drains to prevent a fall hazard. Employees have been briefed not to tow aircraft of tug across the drains.

Floor drain grate spacers have been re-installed

Marginal Please fix large sink hole in our parking lot. Landlord was notified of the sink hole and responded immediately. The sink hole was repaired.

Marginal We are out of earplugs and we only have one caution sign for the floor.

There are no procedures in place to assure the continued safety of the facility. Ordered signs and earplugs

Marginal A cord running from the dispatcher desk to the monitors is a trip hazard.

Did not think ahead when running the cable. Additionally, there is no policy manual for installation of equipment. Dispatch was asked to tape the cord down, they complied.

Marginal The hangar floor is often oily and slippery. There is no schedule for cleaning the hangar floor. The hangar floor is cleaned on a 'time permitting' basis by line service. Line service does not have much time. Alerted line service to clean the floor more often, which they have, as far as I know.

Marginal The hallway upstairs is slippery when the hangar floor is wet (either from washing or from rain)

Obtained an entry rug at the top of each stairway to limit the risk of slip and fall.



PRISM Solutions

Facilities

Marginal The ice machine located in Mx Hangar constantly has a puddle of water around it from condensation and/or ice cubes being dropped. People step in the water and walk around the hangar creating a slip/fall hazard. Purchase a water absorbent mat to place in front of the ice machine.

I would get a mat like they have in school kitchens, the one with holes in it made of rubber or neoprene. Anti-slip mat ordered will place in front of ice-machine on its arrival.

Marginal There are no working light switches in the Hangar, Saturday night I walked into a pitch black hangar and i could not locate the light switch. I had to walk to the back of the hanger trying to avoid multiple tripping hazards and turn the lights on using the circuit breaker panel. After I was done with my work inside the hangar I then had to turn the lights off at the back of the hangar and I nearly tripped on the press brake foot lever. Please install some type of light switch on the entrance door.

Negligible While conducting annual severe weather drill, it was discovered 3 people in facility never reported to shelter. I discovered they were in a huddle room in a meeting. I realized huddle rooms have no PA speakers and are sound proof by design. I talked to one person who told me they did not hear any announcements over the PA system. I suggest we add to the shelter procedure that office personnel look in huddle rooms and notify anyone occupying them to take shelter. This can easily be accomplished as office personnel make their way to the shelter area.

Negligible The eye wash station has limited access. The eye wash station has been cleaned out and is accessible

Negligible Emergency evacuation maps should have clarification as to where on the map a person is located.

Marginal Electrical Outlets over workbench have been out of service for several weeks. Workers have strung/draped extension cords from opposite wall, but this creates a trip and snag hazard made worse because lots of heavy items are hand-carried in and out of the shop.

Catastrophic The cigarette butt container outside the lobby caught on fire. DO retrieved a fire extinguisher from inside the hangar and extinguished the fire.

There is no procedure for the continual assurance of an empty butt can. Butt can was replaced with a metal ash tray. Line service will empty butt can each month and the item has been placed on the



PRISM Solutions

Facilities

monthly inspection punch list.

Catastrophic Overhead hangar beam (structural support) is cracked/split with a 1-2" gap visible through one of two planks making up the support beam assembly. Beam is located on the north end of the hangar about midway/western side of the hangar. If allowed to continue, all of the support strain is on half of the assembly and if a failure occurs, the result could be overhead structure falling on and damaging aircraft, equipment, and personnel

Beam needs to be replaced or reinforced.

Critical In the hangar under the loft there are a number of electrical boxes hanging down to about chest height. Not only do they make the space less useable but they are easily walked into and could cause injury. 2. Around the perimeter of the hangar there are a number of electrical outlet boxes that are no longer secured to the wall. When you put in, or remove, a plug the whole box moves. This could lead to an electrical shock to the user.

Florescent red / pink tape has been placed on all electrical items hanger form loft roof. We are awaiting.

Critical In the street next to the pad (approx 30ft) there is orange snow or construction type fencing surrounding an area of road work. It was not secured very well and was blowing around during landing. The possibility exists for it to blow into the main or tail rotor system.

DOT is doing a sidewalk and curb project. I left a message with the DOT and the DOT shop called and said the fence in the area of the pad has been replaced with cones and should be clear by weeks end. I emailed the RW pilots informing them of the situation. I called the on call pilot to let him know. He was going to include it in his pass down to the oncoming aircrew and put a reminder in the crew quarters. The pilot reporting it stated he thought operations could proceed with caution. The RW DO was kept in the loop throughout.

Critical The terminal building is not equipped with smoke alarms. There is one fire extinguisher near the front entrance, but that is it. This could be very dangerous if a fire occurred after hours and there were no detectors to notify anyone. Part of the electrical system recently overheated, and luckily was caught by someone before closing, but it potentially could have been a much worse situation.

Marginal I have observed equipment and trash receptacles in the hangar blocking fire extinguishers from view/accessibility. I moved the equipment away from the extinguishers on the most recent occurrence.

Email sent to all maintenance technicians to remind them that all emergency equipment should be kept clear at all times.



PRISM Solutions

Flight Crew

Catastrophic Ave landing zone with EMS. Upon loading patient into aircraft it was noted that pilot was agitated about scene security and individuals he felt were to close to aircraft. While attempting to depart with patient the aircraft lifted off, but engine sounded different than usual and helicopter begins to settle and drifting hard to right side. At this time the aircraft seemed to rev and climb out of scene. Once patient was off-loaded crew met to debrief about scene incident. Pilot still agitated about scene security, was told that security of scene was being investigated, but that he could not get so overwhelmed by scene that he forgets about safety of crew and patient. He stated that aircraft was not at 100% for departure.

Catastrophic The PIC talks on his cell phone while conducting taxi operations as the PF. The PIC attempted to answer his cell phone while on landing rollout while acting as the PNF, PF asked him not to, he complied. The PIC attempted to answer his cell phone during taxi ops as the PF. PNF demanded phone not be answer, PF complied.

Failure of flight crew to adhere to sterile cockpit procedures. Deemed action could be careless/reckless and followed company guidelines for careless reckless. DO/CP did not find careless/reckless occurred. DO issued an immediate memo to all flight crews as immediate corrective action. Process accepted.

Critical Approaching KHUM in VMC, was cleared for visual approach to runway 36 and handed off to the tower. As has been the case occasionally in the past, the tower controller was constantly giving out helicopter clearances leaving no time on frequency for us to check in. There were numerous TCAS targets all around as we continued our visual approach from a 5 mile final approach. Still unable to check in due to constant radio chatter, and approaching short final, we noted a helicopter above and at 12 oclock and another one parked right in the middle of runway 36. PIC immediately initiated a missed approach, deviating to the left to avoid the airborne helicopter. I called “going around, aircraft on the runway”. The controller seemed genuinely surprised by our presence and told us, “when we are busy, stay away from the airport”. I explained that we were IFR, cleared for the visual approach and were unable to contact the tower due to no breaks in the issuance of clearances. We landed after flying around the pattern and the controller told us “sorry that we are so busy sometimes”. This is happened before at KHUM, but this instance was especially disturbing as clearly the controller was so engrossed in other tasks that he did not seem to have any idea that a fixed wing aircraft was inbound.

I have previously brought safety concerns to this ATC facilities attention and the information was not welcome. I have educated other pilots who go into this airport of these hazards and also filed a NASA report.



PRISM Solutions

Flight Crew

Critical Last week I was called at 11:45pm about a possible trip leaving whenever they could get trip sheets built.(PROBABLY 01:00AM) The plan was to dispatch a plane with two pilots to depart in the middle of the night to fly for 3 hours. I know I have all these rights and can turn it down and actually did turn it down and said it wasn't safe. I know there wasn't a crew available that took the trip so that is why it departed at 0600am. I'm glad there were some people thinking of safety that night and hope this doesn't fall in the wrong hands down the road. [company] should have a policy that states in the event of a late night pop up and there must be a 5 hour notice and scheduled departure so the crew can have some rest before they depart. It is one thing to know about a trip that is going to fly through the middle of the night/morning. Usually you can plan a nap throughout the day so you are ready for it but with a pop up middle of the night there is no notice to get rested. I'm afraid you are going to get some crew members that aren't going to say no to a possible trip that is dangerous, unsafe, flying in the middle of the night/morning. Having a policy would set a guideline and protect employees, customers and the future of [company].

This subject was discussed between managers. It was agreed that forcing a pilot into this situation would not be repeated, but would follow the current scheduling practice: Example, if a pilot is ON standby-duty at 1000L, any flight assignment would have to be completed by 2330L+ 30-minutes for post flight activities.

Critical I encountered severe weather and I was unable to circumnavigate these storms. I had to fly between storms to get over land, and I had to land in a sugar cane field due to driving rain and very poor visibility. Later, I was able to fly on and park for a couple hours and wait until storm passage. Later, I was able to reposition to [destination] without further incident.

No corrective action required. Pilot-in-Command made the right decision and made a safe landing at the nearest suitable area to wait out the in-climate weather. Passengers and aircraft were unharmed as a result of PIC's actions.

Critical Pilot uses camera in the cockpit below 10k feet. Failure of flight crew to adhere to sterile cockpit procedures. Notice was issued to all flight crews. Sufficient Action taken.

Critical Pilot regularly uses his cell phone camera on approach to take photos Failure of flight crew to adhere to sterile cockpit procedures. Notice was issued. Process for determining careless and reckless operation was developed and accepted by the committee.



PRISM Solutions

Flight Crew

Critical While engaged in bucket operations on a fire with an AS350, one of the bucket suspension lines became entangled with the rear of the right skid. The flight to the dip, and setting the bucket in the water all appeared normal, but while coming out of the dip with the bucket, I noticed something pulling the aircraft to the right. Looking in the mirrors, I quickly determined that one or more of the bucket suspension lines appeared to be hooked over the rear “spring” area of the right skid and it's weight was pulling on the skid, causing the roll as the weight of the bucket came on to the skid and out of the water. My best guess of what happened is that I descended too quickly, putting slack in the lines before the bottom of the bucket had started to sink into the water, causing the bucket to tip to the right and probably twisting as well, causing slack in the lines and simultaneously flinging the wire line out far enough to hook the rear of the skid. In this instance, the bucket water release remained functional, allowing the water to be drained from the bucket at which point the weight of the empty bucket was not causing an adverse CG situation, and I was able to fly to the location of some helitack personnel in an open field and they were able to remove the entangled line. A more difficult situation would have been created if the water would not have released from the bucket, as the aircraft would have been stuck hovering in the dip until the line was unhooked by some means.

Pilots should use caution while dipping the bucket that they don't create too much slack in the lines, allowing this to occur. Additionally, pilots should remain vigilant every time they pick the bucket out of the dip to identify if a snag has created a problem, as a dynamic roll-over could certainly occur if the weight was rapidly added to the skid.



PRISM Solutions

Flight Crew

Critical I was off on personal day with family. Drove home and arrived home at 11:00 p.m. expecting to be back on duty at (or around) 8:00 a.m. Received a call from at 11:00 p.m. dispatching me for a 4:00 a.m.trip. (....I believe that was the time) show the following morning as Dispatcher on duty put me back on at midnight. I had barely even parked the car in the driveway and would have gotten a minimal amount of sleep (maybe 3 hours if I were lucky) after having been up for 18 hours so far. I did not expect to be on duty at midnight.

I spoke to the chief pilot and although we currently do not have a standard policy as to exactly when the pilot is available for duty following a scheduled time off, the dispatchers know to try to avoid scheduling a pilot before 8am on the day he returns to work. There was a miscommunication that allowed for a pilot to be called for duty during the night of his day of return to work.

Critical Cervical immobilization block on patients passenger side (Left) was sucked out of passenger side window during flight. Pilot notified immediately. Post-flight inspection revealed no damage to helo. No adverse outcome. Post-flight debriefing with pilot/crew, discussed difficulty of crew to visualize window open during night operations and patient transport. Windows in helo open when parked on ramp for heat dissipation. Pilot & crew agreed to keep passenger side window closed at all times during helo operations.

Marginal WE OBTAINED PHF ATIS. WE REQUESTED RWY 7 WITH ORF APPROACH. SWITCHED TO TOWER FREQ AND REQUESTED THE SAME. WE WERE TOLD THAT WE WOULD HAVE TO HOLD 10 MINS TO ACCOMMODATE OTHER TRAFFIC. WE SAID WE WOULD. WE WERE TOLD TO MAINTAIN 2000' (OUR CURRENT ALTITUDE) AND FLY RUNWAY HEADING, SWITCH TO DEPARTURE FREQUENCY. WE DID, AND THEN HAD TO RESPOND TO A TA FOR TRAFFIC 300' BELOW AND CLIMBING. WE CLIMBED TO 2500'. WE NEVER SAW THE TRAFFIC. WE WERE VECTORED FOR 10 MINUTES OR SO AND THEN CLEARED FOR A



PRISM Solutions

Flight Crew

VISUAL FOR RUNWAY 7 WITHOUT FURTHER INCIDENT.

Marginal Up at 0330 departed at 0350, arrived at 0500 report time. Duty period was scheduled for 14.2 hours. Attempted to sleep at the FBO but it was interrupted due to people coming and going, a cold pilot lounge, various noise, lights, and TV.

Marginal I was at an FBO away from home base awaiting the arrival of one of our aircraft. When the pilots arrived they I could tell they had something on their mind. After speaking with the pilots it turned out they had a confrontation with one of our managers/clients to the point where a heated exchange of words took place. This presents an unsafe condition because instead of devoting 100% of their attention to safely flying the plane on this short hectic flight they were undoubtedly fuming over this confrontation. On top of this the aircraft was late getting out of maintenance which put the aircraft at the destination FBO literally within 5 minutes of the client's scheduled departure time. All of these things combined can add up to take a lot of the pilots' focus off of flying. There is no doubt that there are always going to be outside pressures on pilots we need to eliminate any of these pressures that we can, such as this aircraft manager/client coming out and getting confrontational with the pilots instead of following the correct channels such as contacting the Chief Pilot or Director of Operations and letting them sort whatever problems he had out.

I spoke with the company president regarding this matter. He in turn contacted this a/c manager/client and informed him not to speak to any of our pilots directly if he has any issues. The client was informed that any issues that he may have in the future need to be addressed through our Chief Pilot, Director of Operations or the President himself.

Marginal While on visual approach to runway 03 KFSD I had a green laser light flashed multiple times into the co-pilot's window or towards the left side of the aircraft. I determined the came from south and east of Falls park (it was not part of their laser light show). The building was small and faced N/S and it came from the SE corner of the building. I talked with tower as it happened and after we landed. They went through their protocol, notified the police and talked with the national center that deals with these issues. We landed without incident.



PRISM Solutions

Flight Crew

Negligible Trip sheet did not have pax weights. Noted

Negligible The pilot monitoring was on the number 2 radio using the speaker to listen to arrival ATIS. The pilot flying was monitoring ATC on number 1 radio on the speaker. Due to the loud volume in the cockpit of the ATIS and the other air noises, two radio calls from ATC were reported missed by ATC. No deviation or clearance violation occurred.

Negligible A runway hold line was crossed by a flight crew at a controlled airport without proper clearance. Training was given to Captain which in turn at a pilot meeting informed the rest of flight crews on event and recommendations on operating procedures to alleviate the event from occurring again in the future.

Training was given to flight crew involved and to all other flight crew.

Negligible Tower cleared us to land on RWY XX while we were about 3 miles out. About 30 seconds later we heard him issue LUAW instructions to departure traffic for our runway. We observed the departure traffic pull onto our runway ahead of us, and because tower was conversing with another aircraft we could not immediately reach them to advise what was happening. With our runway fouled by the other aircraft, we initiated a go around and announced same on tower freq. Tower came on freq seconds later acknowledging an error in sequencing and issued us a crosswind turn into a visual downwind, from which we landed uneventfully after the other traffic departed.

Submitted to database for tracking.

Negligible I have noticed a few captains saying "Standard" when giving their takeoff briefings. Others give very complete briefings. There is a huge disparity and inconsistency. I would suggest the Pilot Flying make a full (or at least what we can call a "comprehensive" )takeoff brief, making sure both pilots are aware of what is said and both are in understanding instead of just saying "Standard" which really doesn't mean anything if we don't have a standard.

We will advise pilots to make complete briefings on all departure legs. A memo is being drafted for the pilots discussing the importance of a full briefing.



PRISM Solutions

Ground Handling

Critical While on the ground at Signature Flight Support in KBNA, the customer service representative let multiple groups of passengers out to the ramp. This occurred after the main group of passenger was lead out to the aircraft. After I brought the passengers to the aircraft, I noticed additional passengers walking unescorted to the plane. I exited and walked the two passengers back to the plane. I made the decision to talk to the CSR and remind them that our policy does not permit unescorted [company] employees on the ramp. On my way to the door, another late passenger presented herself. I escorted her to the airplane and walked back to the FBO. Another passenger was late and called wanting to hold the shuttle. I decided to wait for the passenger until such time that I could remind the CSR of our policy. After waiting five minutes, the representative was still engaged with other clients so I found the Line Manager. By chance the General Manager was in his office. I took the opportunity to inform them of our policy. They were in complete agreement not only mentioning safety, but security concerns. Subsequent to that conversation, I boarded that aircraft and was informed that we were to wait for the passenger. This was after I had closed the cabin door. About that time the passenger in question started to run on the ramp. They did not appear to know where the aircraft was. I opened the cabin door and let the passenger on. This was about two minutes after the conversation with the General and Line Managers not to let [company] personnel unescorted on the ramp. One compounding circumstance related to this safety report is the Cessna Caravan that came onto the ramp with unescorted passengers. This aircraft was taxiing at a high rate of speed and could have posed a life threatening in situation.

Letter sent to all FBO managers explaining the situation and asking for their help with our boarding process. We will keep an eye on the situation.

Marginal The increase in aircraft occupancy of the hangar, increases the likelihood of collision between aircraft during towing operations between aircraft, equipment and other obstructions (crates, pallets, work benches, etc).

A discussion during the quarterly safety meeting detailed these changes to identify and analyze the potential hazards created by these conditions. Corrective actions include increased observation of towing operations, adequate manpower requirements during A/C movement and discussion with FBO management and operations about the increased risk of damage associated related to the increase in hangar occupancy.

Marginal Today while pushing [aircraft] into the hangar there was a "near miss". As the main wheels hit the step in at the hangar door threshold,

Refer to Lektro operating manual for proper towing procedures. Install safety brackets on tugs to help prevent nose wheels from lifting



PRISM Solutions

Ground Handling

forward momentum caused a shift in center of gravity resulting in the tail dropping and the nose strut extending. Normally this would not be a problem because the winch strap would hold the nose wheels in the tug cradle. However this time the winch strap was not tightened sufficiency resulting in the nose wheels rising off the cradle about 12 inches. Brakes were applied by the tug operator and the nose settled back into the cradle on it's own. Please review the attached LEKTRO Tug operating procedures to insure you understand the correct winch strap and cradle adjusting. In addition I am in the process of purchasing Hold Down Adapters from LEKTRO to install on all tugs. We will also look reducing the threshold step. Until these measures are in place please follow the manufactures procedures.

up off of tug cradle.

Negligible Waiting on our passengers to arrive to be taken back. I was finishing up the aircraft cockpit set up and [name1] was in lounge waiting for pax to arrive. Out of the corner of my eye, I noticed people walking up on the right side of the aircraft. I saw a string of our 9 pax walking across the ramp from the terminal building to the aircraft. The passengers stopped out in front of the aircraft not knowing what to do. When the passengers got on board I questioned them as to why they had walked from the terminal. They said the [company] driver did not know where the hangar was. They drove around for a while and then dumped them at the terminal building and left. I find those actions unacceptable to allow our customers to walk across active ramp unescorted.

Negligible Line-serviceman brought to my attention that he discovered one of the fuel caps was on backwards (but secured in place).

Negligible [aircraft] was found with ground power unit turned on, while aircraft battery was in the off position. This occurred twice.

This item was investigated by the maintenance lead technician to clarify the mechanical logic behind this restriction. The line crew has been trained in this procedure and the training syllabus updated.

Negligible Employees of [company1] will be on the ramp with [company2] airplanes and could possibly injure themselves on/around the plane.

Badged company qualified escorts required for non-badged personnel. Company safety training required to qualify for a badge. Company procedures are in effect and will be reviewed as needed.



PRISM Solutions

Ground Handling

Critical While on the ground at Signature Flight Support in KBNA, the customer service representative let multiple groups of passengers out to the ramp. This occurred after the main group of passenger was lead out to the aircraft. After I brought the passengers to the aircraft, I noticed additional passengers walking unescorted to the plane. I exited and walked the two passengers back to the plane. I made the decision to talk to the CSR and remind them that our policy does not permit unescorted [company] employees on the ramp. On my way to the door, another late passenger presented herself. I escorted her to the airplane and walked back to the FBO. Another passenger was late and called wanting to hold the shuttle. I decided to wait for the passenger until such time that I could remind the CSR of our policy. After waiting five minutes, the representative was still engaged with other clients so I found the Line Manager. By chance the General Manager was in his office. I took the opportunity to inform them of our policy. They were in complete agreement not only mentioning safety, but security concerns. Subsequent to that conversation, I boarded that aircraft and was informed that we were to wait for the passenger. This was after I had closed the cabin door. About that time the passenger in question started to run on the ramp. They did not appear to know where the aircraft was. I opened the cabin door and let the passenger on. This was about two minutes after the conversation with the General and Line Managers not to let [company] personnel unescorted on the ramp. One compounding circumstance related to this safety report is the Cessna Caravan that came onto the ramp with unescorted passengers. This aircraft was taxiing at a high rate of speed and could have posed a life threatening in situation.

Letter sent to all FBO managers explaining the situation and asking for their help with our boarding process. We will keep an eye on the situation.

Marginal The increase in aircraft occupancy of the hangar, increases the likelihood of collision between aircraft during towing operations between aircraft, equipment and other obstructions (crates, pallets, work benches, etc).

A discussion during the quarterly safety meeting detailed these changes to identify and analyze the potential hazards created by these conditions. Corrective actions include increased observation of towing operations, adequate manpower requirements during A/C movement and discussion with FBO management and operations about the increased risk of damage associated related to the increase in hangar occupancy.



PRISM Solutions

Ground Handling

Marginal Today while pushing [aircraft] into the hangar there was a "near miss". As the main wheels hit the step in at the hangar door threshold, forward momentum caused a shift in center of gravity resulting in the tail dropping and the nose strut extending. Normally this would not be a problem because the winch strap would hold the nose wheels in the tug cradle. However this time the winch strap was not tightened sufficiency resulting in the nose wheels rising off the cradle about 12 inches. Brakes were applied by the tug operator and the nose settled back into the cradle on it's own. Please review the attached LEKTRO Tug operating procedures to insure you understand the correct winch strap and cradle adjusting. In addition I am in the process of purchasing Hold Down Adapters from LEKTRO to install on all tugs. We will also look reducing the threshold step. Until these measures are in place please follow the manufactures procedures.

Refer to Lektro operating manual for proper towing procedures. Install safety brackets on tugs to help prevent nose wheels from lifting up off of tug cradle.

Negligible Waiting on our passengers to arrive to be taken back. I was finishing up the aircraft cockpit set up and [name1] was in lounge waiting for pax to arrive. Out of the corner of my eye, I noticed people walking up on the right side of the aircraft. I saw a string of our 9 pax walking across the ramp from the terminal building to the aircraft. The passengers stopped out in front of the aircraft not knowing what to do. When the passengers got on board I questioned them as to why they had walked from the terminal. They said the [company] driver did not know where the hangar was. They drove around for a while and then dumped them at the terminal building and left. I find those actions unacceptable to allow our customers to walk across active ramp unescorted.

Negligible Line-serviceman brought to my attention that he discovered one of the fuel caps was on backwards (but secured in place).

Negligible [aircraft] was found with ground power unit turned on, while aircraft battery was in the off position. This occurred twice.

This item was investigated by the maintenance lead technician to clarify the mechanical logic behind this restriction. The line crew has been trained in this procedure and the training syllabus updated.



PRISM Solutions

Ground Handling

Negligible Employees of [company1] will be on the ramp with [company2] airplanes and could possibly injure themselves on/around the plane.

Badged company qualified escorts required for non-badged personnel. Company safety training required to qualify for a badge. Company procedures are in effect and will be reviewed as needed.



PRISM Solutions

Ground Handling/Flight Crew

Catastrophic Mid season during the start up sequence on a response with blades climbing through low RPM’s with winds gusting 30KTS I had a fully briefed and trained helitack crew followed the Manager in the crouched position to the helicopter to load up. After the fire during the debrief I brought this to the crew’s attention and they acknowledged that they realized what they had done after they had already committed themselves under the rotor disk. They agreed they were breaking procedure and would make every effort to not let it happen again. Factors I think contributed to this incident include but are not limited to complacency and rushing.

Brief all crews about how to approach the helicopter AT THE BEGINNING OF THE SEASON! and make sure to brief again every time the helitack crew changes. Also, let’s make sure our new pilots are on the up-and-up on this and don't forget about briefing their helitack crews properly from the beginning. Reiterate that working around a helicopter should never be rushed, no matter how big the fire is. Remind them fire is our job, not an emergency!

Catastrophic While operating a running aircraft on the ramp it was brought to my attention afterwards that a maintenance person approached the running aircraft from out of the view of the crew. The purpose for this was to check if the A/C was running. The crew was never aware of the proximity of the personnel to the aircraft causing a hazardous condition.

Personnel should receive formal training on proper procedures for working on an active flight line with particular attention to having the flight crew acknowledge personnel prior to them approaching an aircraft. Additionally the ramp is need of proper markings and personnel that routinely work on the ramp should be equipped with and wear high visibility garments.

Critical Main cabin door stairs/handrails on G550s and CL300s are steep, slippery at times, and present a tangling hazard during passenger egress. Best practice is for a crew member to exit the aircraft first and wait at the bottom of the stairs in order to direct and/or catch passengers exiting the aircraft. Further, once passengers are safely on the ground, managing their movement is necessary to reduce their risk of being struck by equipment, wandering into controlled areas, or trying to help with their bags. Keeping passenger movement under control and preventing them from walking behind the wing ensures the same level of safety consciousness they enjoy while airborne.

Flight Operations Bulletin #4 published to address this issue, outlining flight crew awareness and a procedure to follow. This includes briefing the passengers in order to identify aircraft danger areas. Passenger Deplaning Procedures: We have had several occurrences recently where passengers were not monitored properly after deplaning the aircraft. We had a mechanical problem with the main cabin door which caused the first passenger to nearly fall down the stairs. Due to numerous hazards around an aircraft, at least one pilot shall stand at the bottom of the stairs and provide assistance to passengers. In addition, it is imperative that we do not allow passengers to walk behind the wing of the airplane to retrieve their baggage. There are numerous safety concerns aft of the wing including static wicks, APU noise, etc. Crews may need to brief the passengers on the requirement that they walk around the nose of the aircraft. Passengers may not be aware of the dangers of an aircraft movement area. Crews are expected to escort passengers at all times until they are clear of all hazards.

Critical It might be a safer practice not to fill out the inflight sheet after landing, during taxi operations. Having both pilots with heads up to increase awareness is a better practice. This paperwork is not time

Emailed Chief Pilot recommending change and that the change come from that person. Will also brief Safety Committee of the change.



PRISM Solutions


critical. This procedure is recommended by the FAA. AC120-74a; Wait to finish inflight sheet until the aircraft is shut down and the pax have started to unload. The remaining flightdeck pilot then has plenty of time to finish any paperwork and get flight times from the FMS.

Critical Landing offsite at a farm; the aircraft on the last occasion sunk into the grass surface up to its main struts and hydraulic lines. The nose wheel sank into the surface up to the nose wheel gear doors almost causing damage to same. It is recommended that this landing area is unsafe should not be utilized as a landing zone. Passengers can be picked up and dropped off at [airport] 6 miles East.

Critical Aircraft taxied between building and G4 - Was about 2-3 inches away from wing with no wing walkers.

Discussed incident with pilot and gave him a copy of the safety report. Pilot admitted that he taxied too close to the GIV and stated that "It will not happen again."

Critical AVOIDED START WITH TIE-DOWNS ON. Later in the day the aircraft was almost started with the tie downs for the main rotor still engaged. Pilot was already getting ready to start the helicopter when a driver, noticing the mistake, was running out to the aircraft preventing the start up. After a brief discussion on the spot it was determined the pilot was distracted numerous times during pre-flight with other company business and questions and at one point walked away from the helicopter for more than an hour where he put the blade tie-downs back on. When he came back out to take the flight he was already 3 hours late for his flight which seemed not much of a big deal since he only had to fly one fuel cycle before the end of the day even though he wanted to get the mission done rather earlier than later. The pilot had already flown two prior flights in two different model helicopters that morning with one of the flights being his 135 check ride and the other one being a training flight with a trainee. Fatigue, distraction and too many missions scheduled for the same day to close together might have contributed to this incident.

CRM I was conducting a AW139 power assurance check on the concrete pad. Upon completing our second power assurance check and taxiing back to the front of the hanger for parking, I didn't realize that the nose wheel had locked while pulling power for the check. I should have called for the pre-taxi check prior to movement due to the fact that the nose gear may become airborne sufficient enough to cause it

Always use the checklist.



PRISM Solutions


to lock. Lesson learned, I will always call for the checklist before each aircraft movement.

Marginal During parking of the EC135 in the Hangar, Black Nylon Pads are used to support the skids when the Chopper Spotter lowers the helicopter to the floor. The pads must be moved and positioned when the skids are in close proximity to the floor. As one person controls the Chopper Spotter lowering operation, the person or persons are positioning the pads for correct location under the skids. At this point, they are at risk of a finger pinch/smash/severe type injury.

Installed handles on nylon pads so they can be pushed in place keeping fingers away from the skids as they lower to the pads.

Negligible Our recent trip the efb's were left at [origin]. We did however both have the GOM-POM, and we had charts. This was a legal issue more than a safety one.

Crewmembers Debriefed by CP.

Negligible I recommend permanent chocks or parking blocks be attached to the hangar floor. These parking blocks would serve as a positive guide so as to minimize any potential damage when backing the [helicopter] into the hanger.

I will contact fleet management or the warehouse to source parking blocks. Parking blocks were sourced from a Grainger catalog and an order for two sets will be placed through our parts department.



PRISM Solutions

Hazmat

Critical We responded to an overturned Big-Rig on an agricultural farm. The Big-Rig was hauling ammonia. We were informed the scene was safe but still landed at a distance and upwind of the incident. Ammonia and diesel fuel was leaking from the Big-Rig. The patient was saturated in diesel fuel. We attempted to decontaminate the patient but had no success. We were unable to transport the patient because of the patient contamination of the diesel fuel with the strong fuel odor.

Marginal DURING FUELLING OPERATIONS A MODERATE AMOUNT OF FUEL WAS SPILLED IN THE PARKING LOT:- INCIDENT OVERVIEW: The Peterbuilt was to be topped off by a delivery truck tanker trailer and the operation was taking place in the parking lot. The mechanic involved in the fueling operation was under the impression that the transfer between the compartments was open and all tanks would fill at the same time. Such was not the case, only one compartment was getting filled. Initially the mechanic was watching the level come up on top of the truck but since he thought there was still time and the truck can easily hold 4000 Gal he climbed down from the top and went to check the connections of all the valves. Before he could climb back up and take another look, the compartment overflowed and started spilling fuel at a very fast rate. The vapor recovering system shut off worked properly and the truck shut everything down within seconds but not after some fuel spilled. Numerous employees jumped into action pulling spill kits from the other trucks to contain the spill. - PROBLEMS ENCOUNTERED WHILE CONTAINING THE SPILL: The spill kits proved to be to small to stop 30 gal. Only after utilizing spill kits from 3 trucks and some supplies from the shop was the spill under control. None of the spill kits were marked as to where they are located on the truck, except on Truck#2. FURTHER: there was a question on how to properly dispose of a spill of this size but it was determined that the spill could be taken care of by the resources at hand. The spill was properly dammed and no fuel reached any storm drains or other areas where it couldn't get wiped up. RECOMMENDATIONS by the CP who was present to help with the spill:- Clearly mark the location of the spill kits.- Let's expand spill kits so they can hold more fuel and put them in containers so they can easly be retrieved from the truck. - Either keep

A procedure should be constructed and put in place to reduce the risk of another spill in the future. For example, no personal changes during the refueling process. Only one company personal should operate the fuel truck from start to finish of the refueling process. Next we should consider a 100 to 200 gallon spill kit for the facility and be located in ready access by all company personal. Also upgrading the truck spill kits to a 35 gallon kit is a good idea and has already been done.



PRISM Solutions

Hazmat

them unlocked or at least have the right keys clearly marked so no time is wasted searching for the keys (to be discussed with all drivers and fleet manager because theft might be an issue) - When the big truck is getting filled, use at least 2 personnel, one on the top watching and one at the valves.

Negligible We could provide better information to our passengers regarding items we cannot carry on the aircraft. The suggestion is that we develop a handout with information on items that are not allowed on the aircraft. This handout would be mailed to all current clients, and sent in electronic or paper form to all new clients going forward.



PRISM Solutions

Maintenance

Critical [name1] was in our hangar cleaning the airplane when he was struck by lightning. [name1] is okay now but he lost feeling in his feet and arm, he had a headache and ringing in his ear. I think we should investigate to see if there are any precautions we can take to minimize the chance of this happening again.

Critical Tool found left on top of helicopter, safeties missing on rotor-head and roll pin was backing out of plunger on rotor-head. All found after Maintenance was performed.

Critical Power checks dropping from +60 to +45 during operations. Looked over engine and found a crack just behind the aft engine mount/diffuser on 9:00 side of craft

Remove engine and deliver for inspection and repair.

Critical Found surface crack on left hand blade set during daily inspections. Remove and replace left hand blade set, package and ship cracked set.

Critical Flight Crew and Maintenance need to come up with a better way to communicate aircraft maintenance issues while the aircraft is away from [home base]. 1. Often the flight crews call when there are time constraints, i.e. often I hear the passengers are coming in 15 min and we have a problem. With communications between flight crew and maintenance you are dealing with different levels of knowledge, with that being said assumptions can be made on both sides that can create a hazard. Often the maintenance person is called while away from the hanger; this creates a problem because the maintenance person has no resources to reference, i.e. maint. manuals, Ops manuals, MEL's wiring prints, system diagrams, etc.

[name1] and I will meet to discuss this issue and come up with guidelines to assist crews and maintenance personnel in dealing with aircraft issues on the road.

Marginal While doing a return to service check of the aircraft I am continuously finding aerosols labeled as flammable such as Lysol etc... This has been addressed in the past but no policy was created. A policy needs to be in place to regulate what we carry aboard in regard to flammability.

Marginal [aircraft] had the mast tape scrape off for the second time in since it came out of the 12 year inspection. Time since 12 year on aircraft at the time of the second mast tape issue aprox 30hrs. This event happened while on contract in -14 Degree weather and resulted in extra travel expenses to fly out a mechanic. Upon fixing the issue the mechanic surmised that the problem was that the Uniball had been

THE DEFORMITY WAS BLENDED OUT AND NO FURTHER DEFECTS NOTED. MECH STAFF NOTIFED TO KEEP A CLOSER EYE ON AREA FOR FUTURE DEFECTS IN THAT AREA.



PRISM Solutions

Maintenance

dropped at some point during the 12 year inspection causing a deformity that was the culprit causing the tape to rub off.

Marginal While conducting inspections on the RH engine the scissors lift contacted the aft portion of the flap damaging it. Contributing factors were the failure to properly anticipate the time required for the inspections leading to fatigue after a long (7 day) work week.

We have implemented a policy of chocking a wheel on the lift once it is in position when near the aircraft. The lift will have a placard stating this policy and a set of chocks hanging on it for this purpose.

Marginal Maintenance event. We flew a short test flight then flew back to [airport]. During the post flight our maintenance noticed a secondary cowl latch was not secured. Attached are some pics. They are the small latches, not the larger vertical ones. They are a little harder to see. Gulfstream signed the aircraft off as airworthy and then I missed it on the preflight. I’d like to bring it to the department’s attention to heighten our awareness during prefights.

Marginal A glass jar was left on top of the waste fuel barrel. It could easily have gotten knocked off and shattered resulting in broken pieces of glass being scattered all over the hangar floor causing a hazardous condition for maintenance or line crew personnel.

A SOP has been written and technicians instructed to the proper procedures for fuel sampling. This policy has been incorporated into the Maintenance Department Policy and Procedures Manual.

Marginal Servicing tires, air hose ruptured in right hand of mech. Mechanic suffered no cuts or treatable injuries from the incident.

A low pressure hose was attached to a high pressure regulator, which is against recommended procedures. High pressure hose was installed and low pressure regulator was installed. MX says this was against best practice and should not have happened. "It was an isolated event."

Negligible No approved maintenance provider list which is current and readily available to maintenance providers and crews.

The approved vendor checklist has been updated and it is now accessible online through the company website at all times for maintenance personnel and crews who may need to access the list when away from home base or when en-route maintenance needs to be performed.



PRISM Solutions

Maintenance

Negligible Four fuel system indicator lights were re-installed incorrectly following maintenance on the overhead panel.

Director of Maint. established inspection procedures to help prevent a similar recurrence of the error.

Negligible I completed a pre-flight inspection of helicopter in the hangar. No issues were initially found until a final walk around when I noticed broken glass on the floor around the tail of the helicopter. It was at that point that I recognized the rear tail bulb cover was broken. The bulb was not damaged and it was still operational. I conducted a further inspection of the tail and did not notice any other damage. At that point, I advised the maintenance crew who said he completed the preflight and did not notice the broken cover during his preflight. I pointed out the damage and he subsequently repaired and inspected the tail finding no additional damage. It was never determined how or when the bulb cover was broken. I suggest all personnel be cognizant of the equipment stored around the area where the Bell's are parked.

Posted to public safety locker.



PRISM Solutions

Other

Marginal Just raising a concern about a PR that took place at the Hospital hangar. A group of fourth graders came to tour the helicopter. While I think PR is an important part of our operation, my concern is this age group in the hangar with all of the mechanic's tools and equipment. While we attempted to watch the group very closely they were testing their boundaries and had to be scolded multiple times for attempting to stray away and go to the mechanic's equipment. My other concern is that no hospital representative who arranged the tour was present.

These concerns were brought to the attention of the director and clinical manager to ensure adequate staff is assigned to support these larger PR events.



PRISM Solutions

Personal Injury

Critical Hangar facilities do not have an AED

Marginal When filling the ice buckets with ice from the ice machine, I noticed that the floor can get very slippery when the ice spills and then melts.

I think that a mat might help but the main problem is not being careful filling the ice bucket and not cleaning up the floor when ice has fallen on the floor. Not just leaving it there for someone to get hurt.

Marginal Slipped off ladder during preflight due to moisture on sole of shoe.

Marginal [company] does not have a procedure or training in place for employees to deal with non-life threatening injuries.

Pilot hit his head on aircraft and cut his head requiring stitches, highlighting need to have an employee injury procedure. We will develop, train and implement a procedure for this. Initially, it will be trained separately, then will be incorporated into the CERP training after the new year. Committee accepted the process. Will integrate into SMS.

Marginal I was helping MX wheel bags out to aircraft and notice a crew member helping outside the aircraft loading bags was not wearing ear plugs while APU was running. Friendly reminder that all crew should wear ear plugs when APU or engines are running and they are outside by the engines.

Marginal A used syringe (presumably for self-administered injections) was recently found near the lavatory sink area in one of the aircraft by the post flight detailing crew. This could cause personal injury and/or biological contamination to unsuspecting persons. A sharps management program should be implemented to allow such medical devices to be securely and discretely disposed of by passengers without having to disclose sensitive medical information to the crew, as well as to prevent personal injury.

A contract was signed with a local medical waste disposal service in order to provide sharps containers as well as removal on an as-needed basis. Select team members will be trained on waste acceptance protocol, to include guidelines from the U.S. DOT, MIOSHA, and all other federal, state and local laws and regulations. A vendor-supplied CD-ROM will be reviewed by such team members outlining relevant HazMat material.

Negligible Co-workers believe headsets are spreading germs and pilots are becoming Ill. Everyone carries their personal headset.

Critical Hangar facilities do not have an AED



PRISM Solutions

Personal Injury

Marginal When filling the ice buckets with ice from the ice machine, I noticed that the floor can get very slippery when the ice spills and then melts.

I think that a mat might help but the main problem is not being careful filling the ice bucket and not cleaning up the floor when ice has fallen on the floor. Not just leaving it there for someone to get hurt.

Marginal [company] does not have a procedure or training in place for employees to deal with non-life threatening injuries.

Pilot hit his head on aircraft and cut his head requiring stitches, highlighting need to have an employee injury procedure. We will develop, train and implement a procedure for this. Initially, it will be trained separately, then will be incorporated into the CERP training after the new year. Committee accepted the process. Will integrate into SMS.



PRISM Solutions

Security

Critical Flight Ops back door to employee parking lot was found propped open this morning at 830 am. There were no employees at work.

Critical

Marginal Best practices indicate a need for a safety briefing when personnel that are unfamiliar with an aircraft hangar environment are allowed entry. Slippery floors and static wicks are just a couple potential hazards that should be discussed. Security should also be considered when escorting these personnel.

Marginal

Negligible [name1] was working the reception desk and identified a tailgater behind a fed-x truck. Person remained inside suspicious vehicle and [name1] contacted me to help identify the vehicle. As it turns out the person is a [company] contractor that was here to look at the roof and was in violation of not contacting [name1] at the gate; I had a training session with the contractor as a result of the violation and the contractor knew he had made a mistake.

Negligible

Negligible 11:00, I went out in the mx hanger and noticed 3 individuals (2 males and 1 female) walking on the tarmac. I went up and challenged the individuals. They responded by saying that they were pilots and that they were intrested in renting hanger space to house a CJ3 that the 1 male said he was about to purchase. I then told the male that this is a mx hanger and that they were not allowed to walk around the facility. I then offered to escort them over to the corporate hanger where they could talk to the proper personnel about hanger space. They agreed and I escorted them over to the coporate hanger office.

Negligible

Negligible Annual general security training is not being conducted for all employees.

Negligible

Negligible There have been a few occasions lately of unescorted personnel or visitors on our ramp. It has been noticed that some employees have noticed the security breeches but did nothing. I think we need to re-stress the importance and vigilance of our security to our employees.

Negligible

HAZREP PROGRAM - ARMOR Quarterly... · Small flight departments face a scale deficiency regarding...

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