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ATSB's report into the collision between the Australian fishing vessel Apollo S and the Liberian registered bulk carrier Grand Rodosi

ATSB's report into the collision between the Australian fishing vessel Apollo S and the Liberian registered bulk carrier Grand Rodosi | Creating designs 'fit' for people! | Scoop.it

The ATSB's report into the collision between the Australian fishing vessel Apollo S and the Liberian registered bulk carrier Grand Rodosi contains important messages for pilots and ships' crews.The collision occurred at Port Lincoln, SA, on 8 October 2012 while Grand Rodosi was berthing. As a result of the collision, Apollo S was crushed against a wharf and sank. Grand Rodosi sustained small holes in its bow shell plating. The investigation found that despite the pilot ordering astern movements, the ship's main engine did not respond. The chief engineer, who was operating the main engine start/fuel lever in the engine room control room, did not allow sufficient time for starting air to stop the ahead running engine. Consequently, when fuel was introduced into the engine, it continued to run ahead, despite the astern telegraph orders.

The investigation also found that the chief engineer's mistake was not noticed on the ship's bridge or in the engine control room until after the collision; that the master/pilot information exchange was less than optimal; and that bridge resource management could have been better during the passage to the berth.

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Creating designs 'fit' for people @ CQUniversity, Australia

Creating designs 'fit' for people @ CQUniversity, Australia | Creating designs 'fit' for people! | Scoop.it

I hope you enjoy and gain value from this curated topic which includes 'scoops' from official reports, articles, blogs, video and photo galleries.  The posts have been selected through the lens of an active researcher and educator in safety science and human factors design (you can learn more about how that perspective is informed at https://www.linkedin.com/in/yvonnetoft ).

 

Watch this space for updates on our Bachelor of Accident Forensics, Masters in Accident Investigation, Human Factors and OHS education and research programs at CQUniversity; food for thought more generally about the relationship between accidents, design and human error; and other interesting human factors and safety science tidbits!  You can follow this topic here in Scoop.it! or @MsMischiefmaker (twitter) or subscribe to the RSS feed for regularly updated posts at http://lnkd.in/R7vGS6.

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DJI drones gain geo-fencing safety feature opt-out - BBC News

DJI drones gain geo-fencing safety feature opt-out - BBC News | Creating designs 'fit' for people! | Scoop.it
DJI has updated its app to allow drone owners to fly its aircraft into restricted areas they were previously prevented from entering.
Vonny~'s insight:

I wonder if they have also updated the user interface to reduce accidents in these restricted areas!!!

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Facebook 'hack' victim exposes passport scam - BBC News

Facebook 'hack' victim exposes passport scam - BBC News | Creating designs 'fit' for people! | Scoop.it
An identity thief gains access to a Facebook account by sending a fake passport and asking the social network to turn off log-in approvals.
Vonny~'s insight:

surely a design issue!

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Tesla told regulators about Autopilot crash nine days after accident

Tesla told regulators about Autopilot crash nine days after accident | Creating designs 'fit' for people! | Scoop.it
By Alexandria Sage and Paul Lienert SAN FRANCISCO/DETROIT (Reuters) - Tesla Motors alerted regulators to a fatality in one of its electric cars in partial self-driving Autopilot mode nine days after it crashed, the company said on Tuesday, defending...
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CQUni secures aircraft for 'crash lab' on Bundaberg campus

CQUni secures aircraft for 'crash lab' on Bundaberg campus | Creating designs 'fit' for people! | Scoop.it
CQUniversity is very grateful to receive a donation of aircraft accident artefacts for its Accident Investigation Laboratory on Bundaberg campus. The laboratory supports the delivery of CQUniversity’s Accident Forensics and Accident Investigation programs.
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Cody Matthews's curator insight, July 29, 12:04 AM
Keyword: Research

I scooped this post because of its significance towards research at our CQUni. I think it is fundamental that we learn from our mistakes and use this knowledge to minimise accidents/incidents from further occurring. A particular quote from CQUni's Yvonne Toft in the text emphasis this well: "speak for the dead to protect the living". Although it is tragic that aircraft accidents occur (and accidents in general), a large amount of information can be drawn from the mistake. 
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Mosul dam engineers warn it could fail at any time, killing 1m people

Mosul dam engineers warn it could fail at any time, killing 1m people | Creating designs 'fit' for people! | Scoop.it
Iraqis who built dam say structure is increasingly precarious and describe government response as ‘ridiculous’
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Hannah Lynch's curator insight, July 29, 12:04 AM
I agree, this is ridiculous to see and no one should have to work knowing they are putting their lives at risk everyday.
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Woman dies after being struck by car

Woman dies after being struck by car | Creating designs 'fit' for people! | Scoop.it
A female pedestrian has died after being struck by a vehicle while crossing the Stuart Highway at Knuckey Lagoon on Wednesday night.
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Hannah Lynch's curator insight, July 28, 11:57 PM
This is a tragic event and surely is heartbreaking to read.
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Paraglider injured in Bulwer KZN accident

Paraglider injured in Bulwer KZN accident | Creating designs 'fit' for people! | Scoop.it

A 45-year-old man has suffered serious injuries after he experienced difficulty while paragliding in Bulwer, Kwa-Zulu Natal. Reports from the scene indicate

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70 cancer patients prescribed wrong chemo dosage at Sydney hospital

70 cancer patients prescribed wrong chemo dosage at Sydney hospital | Creating designs 'fit' for people! | Scoop.it
Up to 70 cancer patients at Sydney's St Vincent's Hospital have been given markedly lower doses of a chemotherapy drug for up to three years, an ABC 7.30 ...
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ATSB Report: In-flight breakup involving PZL Mielec M18A Dromader aircraft, VH-TZJ, 37 km west of Ulladulla, NSW on 24 October 2013

ATSB Report: In-flight breakup involving PZL Mielec M18A Dromader aircraft, VH-TZJ, 37 km west of Ulladulla, NSW on 24 October 2013 | Creating designs 'fit' for people! | Scoop.it
On 24 October 2013, the pilot of a modified PZL Mielec M18A Dromader, registered VH-TZJ, was conducting a firebombing mission about 37 km west of Ulladulla, New South Wales. On approach to the target point, the left wing separated. The aircraft immediately rolled left and descended, impacting terrain. The aircraft was destroyed and the pilot was fatally injured.

What the ATSB found
The ATSB found that the left wing separated because it had been weakened by a fatigue crack in the left wing lower attachment fitting. The fatigue crack originated at small corrosion pits in the attachment fitting. These pits formed stress concentrations that accelerated the initiation of fatigue cracks.

The ATSB also found that, although required to be removed by the aircraft manufacturer’s instructions, the corrosion pits were not completely removed during previous maintenance. During that maintenance, the wing fittings were inspected using an eddy current inspection method. This inspection method was not approved for that particular inspection and may not have been effective at detecting the crack.

Data from a series of previous flights indicated that the manner in which the aircraft was flown during its life probably accelerated the initiation and growth of the fatigue crack.

Finally, the ATSB also found a number of other factors which, although they did not contribute to the accident, had potential to reduce the safety of operation of PZL M18 and other aircraft. These included the incorrect calculation of the flight time of M18 aircraft and a lack of robust procedures for the approval of non-destructive inspection procedures.
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ATSB Report Released: Man overboard fatality from Cape Splendor Port Hedland, Western Australia 2014

ATSB Report Released: Man overboard fatality from Cape Splendor Port Hedland, Western Australia  2014 | Creating designs 'fit' for people! | Scoop.it

On 6 October 2014, Cape Splendor’s boatswain (bosun) descended to the lower platform of the ship’s accommodation ladder during his lunch break. He intended to fish from this location and asked a seaman to assist. At 1250, the bosun lost his balance and fell into the sea.

The seaman immediately returned to the ship’s deck and threw a lifebuoy toward the bosun, before raising the alarm. The ship’s crew deployed its rescue boat within 10 minutes, and an extensive air and sea search continued for 3 days. However, the bosun was not found.

The ATSB found that the bosun and the seaman were not wearing any flotation devices or fall prevention equipment. The bosun had seen fish below the accommodation ladder that was in the shade, and he probably saw it as a good opportunity to fish without considering the risks involved. The lack of a lifejacket, wet clothing, and possible entanglement with fishing gear, sea conditions, and the current would have adversely affected the bosun’s ability to stay afloat and swim.

The ATSB investigation also identified that the ship’s safety management system procedures for working over the ship’s side were not effectively implemented. Hence, the ship’s crew routinely did not take all the required safety precautions when working over the side. It was also found that the crew had differing attitudes to taking safety precautions during work and recreation times as the safety culture on board was not well developed.


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ATSB Report: Pilot incapacitation occurrences 2010–2014

ATSB Report: Pilot incapacitation occurrences 2010–2014 | Creating designs 'fit' for people! | Scoop.it

Occasionally pilots become incapacitated during flight. Incapacitations can arise from different reasons. They include the development of an acute medical condition, changes in environmental conditions during the flight, or the effects of a pre-existing medical condition. The effect of incapacitation on a pilot can be restricting their flight duties for the remainder of the flight, or for single-pilot operations, a collision with terrain.

This research report documents pilot incapacitation occurrences in high capacity air transport, low capacity air transport, and general aviation to help educate industry about the causes and risks associated with inflight pilot incapacitation.

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Kat Clark's curator insight, March 21, 1:53 AM
I love reading ATSB reports! It is my dream to establish myself within the Australian Transport Safety Bureau with possibilities of further advancing to the National Transport Safety Bureau (NTSB).

I find this report quite interesting, as I never would have imagined that the major effect of pilot incapacitation would be due to gastrointestinal illness. I personally thought heart attacks or epileptic seizures would have been at a higher rate. In fact, I delved deeper into this query and found another ATSB report documenting pilot incapacitations between January 1975 and March 2006 (http://www.atsb.gov.au/media/29965/b20060170.pdf). This report reflected my thoughts and showed heart attacks as being a major cause, along with gastro. This could indicate an increase in OHS standards and/or medical technology over the years within Australia. Interestingly, I found another article from England 2012 (http://www.avmed.in/2012/02/pilot-incapacitation-what-is/), stating that heart attacks and epileptic seizures were at the very top. This scoop poses many questions surrounding the currently diverse safety practices and principles across the world.
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Fury after Adobe Creative Cloud deletes files

Fury after Adobe Creative Cloud deletes files | Creating designs 'fit' for people! | Scoop.it

Adobe patches its Creative Cloud apps after people notice the software is deleting Mac users' files without warning.

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Crash course booming as students flock to CQUni

RENEE Sorbello feels like Sherlock Holmes when she turns up for university.
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South Korea launches first Internet of Things network - BBC News

South Korea launches first Internet of Things network - BBC News | Creating designs 'fit' for people! | Scoop.it
South Korea launches its first commercial, low-cost Internet of Things network which helps devices talk to each other, making the country even more connected.
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Common Mobile App Design Mistakes to Avoid

Common Mobile App Design Mistakes to Avoid | Creating designs 'fit' for people! | Scoop.it
No one wants to build a poorly designed mobile application. Unfortunately, many mobile apps fail because of the critical design mistake.
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NTSB Press Conference - Panhandle, Texas - 29 June 2016

NTSB Investigator In Charge Richard Hipskind briefs the media on the collision of two freight trains in Panhandle, Texas June 29, 2016
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Graduate steams ahead for 'advanced accident investigation' focused on rail safety

Graduate steams ahead for 'advanced accident investigation' focused on rail safety | Creating designs 'fit' for people! | Scoop.it

Bachelor of Accident Forensics graduate Adam Holstein is on track for his advanced accident investigation specialisation this year.  

Thanks to a new relationship between CQUniversity and the Rail Industry Safety and Standards Board (RISSB) Mr Holstein will focus on rail-safety projects as he embarks on his Master of Advanced Safety Science Practice.

After an impressive undergraduate journey based at CQUniversity Townsville, Mr Holstein becomes the inaugural student to progress to the RISSB placement, involving a 22-week internship and generous stipend.

 

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BREAKING Possible missing Boeing 777 #MH370 horizontal stabilizer found off Mozambique | AIRLIVE.net

BREAKING Possible missing Boeing 777 #MH370 horizontal stabilizer found off Mozambique | AIRLIVE.net | Creating designs 'fit' for people! | Scoop.it
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Nissan Leaf electric cars hack vulnerability disclosed

Nissan Leaf electric cars hack vulnerability disclosed | Creating designs 'fit' for people! | Scoop.it

A researcher reveals a flaw that allows Nissan Leaf cars' heating and air-conditioning systems to be hijacked, and journey data leaked.

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Three women injured as car plunges into excavation pit in Flemington

Three women injured as car plunges into excavation pit in Flemington | Creating designs 'fit' for people! | Scoop.it
Three woman are in hospital after a car fell an excavation pit in Flemington in the early hours of Thursday morning.
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News: Good fuel management saves the day

News: Good fuel management saves the day | Creating designs 'fit' for people! | Scoop.it
Good fuel management saves the day
This incident shows how a pilot’s good fuel management ensured the safe landing of a Piper Chieftain aircraft after an unexpected incident.


On 12 October 2015, the pilot and three passengers were conducting a survey flight over the southern highlands area of New South Wales.

After departure, the pilot reported that clouds (both towering cumulus and cumulus) were beginning to form in the area, producing some light turbulence. The pilot remained concerned about one of the passengers, seated at the rear of the aircraft, who appeared to find the conditions difficult to tolerate.

The pilot’s workload remained high. Apart from flying to each of the pre-arranged waypoints, additional landmarks were being relayed to the pilot from the client’s operator on the ground.

The pilot kept a very detailed fuel log, and continually cross-checked the fuel in each of the four fuel tanks. The weather had deteriorated even further as the pilot prepared to fly to the last waypoint before a return to Bankstown. The pilot delayed a scheduled fuel tank change to maximise the fuel remaining in the main (inboard) tanks.

As the pilot was maneuvering around large banks of cloud and thunderstorms, the left auxiliary (outboard) tank ran dry and the engine surged. The aircraft yawed. The pilot reacted immediately and changed the fuel selectors onto the main tanks. The engine responded and power was restored. The aircraft returned to Bankstown without incident.

In this incident, the pilot followed all the key suggestions in the ATSB’s Avoidable Accident Series No 5 – Starved and exhausted: Fuel management aviation accidents. These being

  • Knew exactly how much fuel was on board
  • Knew how much / what rate fuel was being consumed
  • Knew the aircraft fuel system and keep a detailed fuel log of the four tanks during flight.
Despite a high workload, deteriorating weather, and untimely distractions the pilot was well prepared to handle an unplanned outcome of temporary fuel starvation of the left engine.
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Cody Matthews's curator insight, July 29, 12:12 AM
Keyword: Professional

These articles are extremely important to read if anyone is chasing the aviation profession. It reiterates that every flight something can go wrong and the pilot must be prepared. It is often labelled that complacency is the number one killer in the aviation world. This is because many of the flights go according to plan, and when something goes wrong, the pilot is unprepared. A pilot should always be attentive and maintain professional attributes. 
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Toyota announces RAV4 recall over faulty seatbelts

TOYOTA Australia has announced a recall of almost 100,000 RAV4 vehicles built between August 2005 and November 2012 after discovering issues with seat belts.
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India Struggles with Drone Issues

India Struggles with Drone Issues | Creating designs 'fit' for people! | Scoop.it

The Indian government is looking at regulating drone use after high-profile incidents.

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CCTV footage shows boy falling down gap at Brisbane train station

CCTV footage shows boy falling down gap at Brisbane train station | Creating designs 'fit' for people! | Scoop.it

Boy falls down gap between platform and train at Bowen Hills station in Brisbane, moments after breaking free from parents and running towards the train.

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Hannah Lynch's curator insight, July 29, 12:00 AM
The parents shouldn't have let him break free, especially when it is very dangerous at train stations as there are many people and trains crossing at once. Although I'm glad he is safe
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Scalpels left inside bodies and wrong organs removed in NHS blunders

Scalpels left inside bodies and wrong organs removed in NHS blunders | Creating designs 'fit' for people! | Scoop.it
The incidents – mistakes categorised as so serious they should never happen – are blighting the lives of hundreds of patients, figures show. Other errors include patients being given drug overdoses.
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