International Law Office website 27 June 2011
An Italian court has sentenced the chief executive officer (CEO) of a company to 16 years' imprisonment for an offence related to the deaths of seven employees. This is the first such case in Italy in which a CEO has been found guilty of homicide, rather than manslaughter. The court found the company liable under Law 231/2001 and ordered it to pay a fine of €1 million. In addition, it confiscated a further €800,000 and banned the company from receiving public funds for six months.
The case concerned an incident at a factory operated by the company ThyssenKrupp. On the night of December 6 2007 a fire broke out on the production line and could not be extinguished because of a lack of fire extinguishers and the absence of other safety features. Seven workers were killed.
At trial, the prosecutor claimed that ThyssenKrupp's senior management had decided not to invest in health and safety at the factory, since they had decided to relocate production to another site. Therefore, the management knew that it was accepting a risk that a serious accident could occur and was aware of the potential legal consequences of the decision.
The prosecutor argued that if a senior manager decides to reduce investment in health and safety, he or she is aware that there is a high probability of a serious accident. If an accident occurs and someone dies as a result, the manager in question must be deemed guilty of homicide. Although the grounds have not yet been published, the decision indicates that the court appears to have agreed with this argument.
Wednesday, June 29, 2011
Friday, June 24, 2011
FDA's new guidance tackles device usability, safety
http://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/UCM259760.pdf
Osprey pilots were blameless victims, widow says
Article at newsobserver.com by Marth Quillin and Bob Cox on 19 June 2011
On 8 April 2000 a newly developed V-22 Osprey crashed during a 'mock exercise,' killing those on board. This is an aircraft with tilting rotors, which can land and take off like a helicopter but fly more like a fixed wing aircraft. Following the crash the Marine Corps investigation concluded that "This mishap appears not to be the result of any design, material or maintenance factor specific to tilt-rotors. Its primary cause, that of a MV-22 entering a Vortex Ring State (Power Settling) and/or blade stall condition, is not peculiar to tilt rotors. The contributing factors to the mishap, a steep approach with a high rate of descent and slow airspeed, poor aircrew coordination and diminished situational awareness, are also not particular to tilt rotors." And in announcing the findings of the report, the Marine Corps said in a press release that it "confirms that a combination of 'human factors' caused the April 8 crash of an MV-22 Osprey tilt-rotor aircraft that killed 19 Marines near Marana, Ariz."
However, the families of those who died feel the language used by the Marine Corps was intended to put most of the blame for the accident on the pilots. They feel that the tragic accident "was the direct result of the crewmen being tasked with an insurmountable, premature mission in a dangerously immature aircraft and not "human factors." They feel the fact that another fatal accident occurred later that year and the aircraft had to be grounded for 18 months for further testing and development back up their opinion.
These were experienced pilots who believed in the Osprey project. In the exercise, pilots were to rescue a group of "hostages" and bring them back to base. The task introduced several variables: night flight, a heavy load of Marines and their gear, and a different environment from the coastal one where the pilots had done most of their training. But as the mission unfolded that night in Arizona, not everything went according to plan. A computer malfunctioned in the lead plane, the pilots decided to continue with the exercise and try to reset the computer after landing. As they approached the landing zone, the planes were too high and were hit with an unexpected tailwind. They began a steep descent aiming for the runway - a piece of cake for an experienced military helicopter pilot. The pilots, doing as they were trained, were following the lead plane, but got out of position and tried to manoeuvre back into line. They had little forward airspeed, and the rotors began to stall, losing the lift that holds the aircraft in vertical flight. Just 200 feet above the ground, in a span of about three seconds, the aircraft rolled uncontrollably to the right and turned upside down before slamming into the ground.
The pilots had gotten into an aerodynamic condition called "vortex ring state" or "blade stall." The lead plane may have had the same problem, but it simply landed very hard, crushing the landing gear and skidding several hundred feet and off the runway.
The family feel there were so many factors in the accident that the pilots should exonerated so that the dishonour can be removed.
I think the comments left on the article make some great points:
* "This aircraft was called the widow maker. This Crash was not an isolated incident."
* "Given the many lessons learned from the tragedy that claimed the lives of the aircrew and the passengers, it seems reasonable to assume that had they not been the ones to experience this mishap, another crew and aircraft would have at another time. Clearly none of the pilots involved in the mishap understood the hazards they faced that evening, or both lead and trail aircraft would certainly have gone around for another pass."
* "If Boeing felt compelled to add warning devices to the cockpit to alert pilots, it sounds that the greatest cause of the crash may well have been the initial design. I hope that the powers that be might eventually reconsider."
On 8 April 2000 a newly developed V-22 Osprey crashed during a 'mock exercise,' killing those on board. This is an aircraft with tilting rotors, which can land and take off like a helicopter but fly more like a fixed wing aircraft. Following the crash the Marine Corps investigation concluded that "This mishap appears not to be the result of any design, material or maintenance factor specific to tilt-rotors. Its primary cause, that of a MV-22 entering a Vortex Ring State (Power Settling) and/or blade stall condition, is not peculiar to tilt rotors. The contributing factors to the mishap, a steep approach with a high rate of descent and slow airspeed, poor aircrew coordination and diminished situational awareness, are also not particular to tilt rotors." And in announcing the findings of the report, the Marine Corps said in a press release that it "confirms that a combination of 'human factors' caused the April 8 crash of an MV-22 Osprey tilt-rotor aircraft that killed 19 Marines near Marana, Ariz."
However, the families of those who died feel the language used by the Marine Corps was intended to put most of the blame for the accident on the pilots. They feel that the tragic accident "was the direct result of the crewmen being tasked with an insurmountable, premature mission in a dangerously immature aircraft and not "human factors." They feel the fact that another fatal accident occurred later that year and the aircraft had to be grounded for 18 months for further testing and development back up their opinion.
These were experienced pilots who believed in the Osprey project. In the exercise, pilots were to rescue a group of "hostages" and bring them back to base. The task introduced several variables: night flight, a heavy load of Marines and their gear, and a different environment from the coastal one where the pilots had done most of their training. But as the mission unfolded that night in Arizona, not everything went according to plan. A computer malfunctioned in the lead plane, the pilots decided to continue with the exercise and try to reset the computer after landing. As they approached the landing zone, the planes were too high and were hit with an unexpected tailwind. They began a steep descent aiming for the runway - a piece of cake for an experienced military helicopter pilot. The pilots, doing as they were trained, were following the lead plane, but got out of position and tried to manoeuvre back into line. They had little forward airspeed, and the rotors began to stall, losing the lift that holds the aircraft in vertical flight. Just 200 feet above the ground, in a span of about three seconds, the aircraft rolled uncontrollably to the right and turned upside down before slamming into the ground.
The pilots had gotten into an aerodynamic condition called "vortex ring state" or "blade stall." The lead plane may have had the same problem, but it simply landed very hard, crushing the landing gear and skidding several hundred feet and off the runway.
The family feel there were so many factors in the accident that the pilots should exonerated so that the dishonour can be removed.
I think the comments left on the article make some great points:
* "This aircraft was called the widow maker. This Crash was not an isolated incident."
* "Given the many lessons learned from the tragedy that claimed the lives of the aircrew and the passengers, it seems reasonable to assume that had they not been the ones to experience this mishap, another crew and aircraft would have at another time. Clearly none of the pilots involved in the mishap understood the hazards they faced that evening, or both lead and trail aircraft would certainly have gone around for another pass."
* "If Boeing felt compelled to add warning devices to the cockpit to alert pilots, it sounds that the greatest cause of the crash may well have been the initial design. I hope that the powers that be might eventually reconsider."
Thursday, June 09, 2011
Pilot's bereavement 'crash factor'
Belfast Telegraph 9 June 2011
A helicopter crash involving a police air crew assisting at the scene of an earlier accident may have happened because the pilot was coping with a recent family bereavement, a report has said. The helicopter was destroyed but the occupants suffered only minor injuries.
The pilot, who had completed all the helicopter and role training required by the operator, arrived in Northern Ireland from England two days before the accident, for the start of a five-day period of duty.
"Immediately beforehand, he had suffered a family bereavement. He did not report this to his company and considered on the day that he was fit for flying duty. However, when the pilot subsequently informed the AAIB of the fact, he thought it possible that it may have been a contributory factor in the accident."
The report says that the pilot lost control of the helicopter, which was engaged on a task for the Police Service of Northern Ireland, while manoeuvring at low speed to approach a hilltop landing site in quite strong wind conditions. It descended rapidly before striking the ground short of the point of intended landing and passing through a substantial stone wall.
"The investigation determined that an error of judgment or perception led the pilot to attempt a downwind approach. A combination of human factors was thought to have contributed to the accident," the report said.
The report quoted experts who said the death of a close family member has been found to lead to higher levels of stress than any other experience, with the exception of the death of a spouse or partner, and that such stress will likely to cause loss of concentration and performance. The task to be carried out on the day of the accident, although demanding, was within the capabilities of the pilot.
"However, although the effects on an individual of a recent family bereavement cannot be measured, it is considered that this was probably the most significant contributory factor in the cause of the accident," the report said.
A helicopter crash involving a police air crew assisting at the scene of an earlier accident may have happened because the pilot was coping with a recent family bereavement, a report has said. The helicopter was destroyed but the occupants suffered only minor injuries.
The pilot, who had completed all the helicopter and role training required by the operator, arrived in Northern Ireland from England two days before the accident, for the start of a five-day period of duty.
"Immediately beforehand, he had suffered a family bereavement. He did not report this to his company and considered on the day that he was fit for flying duty. However, when the pilot subsequently informed the AAIB of the fact, he thought it possible that it may have been a contributory factor in the accident."
The report says that the pilot lost control of the helicopter, which was engaged on a task for the Police Service of Northern Ireland, while manoeuvring at low speed to approach a hilltop landing site in quite strong wind conditions. It descended rapidly before striking the ground short of the point of intended landing and passing through a substantial stone wall.
"The investigation determined that an error of judgment or perception led the pilot to attempt a downwind approach. A combination of human factors was thought to have contributed to the accident," the report said.
The report quoted experts who said the death of a close family member has been found to lead to higher levels of stress than any other experience, with the exception of the death of a spouse or partner, and that such stress will likely to cause loss of concentration and performance. The task to be carried out on the day of the accident, although demanding, was within the capabilities of the pilot.
"However, although the effects on an individual of a recent family bereavement cannot be measured, it is considered that this was probably the most significant contributory factor in the cause of the accident," the report said.
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