Andrew McGregor CPEng – Publications
The 2010 Fox Glacier Air Accident Re-investigation – A TV3 Documentary
According to the official finding published by New Zealand’s Transport Accident Investigation Commission, the 2010 Fox Glacier air crash that killed nine people was caused by improper loading of the skydive plane. At least that was the official finding published by the Transport Accident Investigation Commission. But as this story asks, could that be wrong? And why was some of the wreckage buried within days of the disaster? Families demanded a new investigation after 3rd Degree reporter Michael Morrah enlisted the help of top accident investigators Andrew McGregor and Tom McCready to dig up the remains of the aircraft and look for new evidence. Watch Video:
Andrew McGregor also wrote a report criticising the official report published by NZ’s Transport Accident Investigation Commission (TAIC) and recommended that the original TAIC investigation be re-opened. Under the heading “Justification and Guidance for a Resumed Investigation”, Andrew writes “there is a need for confidence and integrity to return to TAIC’s investigative processes”.
Read Andrew McGregor’s Technical Critique: Fox Glacier Crash Investigation-Technical Critique
The next story is a TV3 news item, advising that as a result of TV3’s earlier documentary and the investigative work by Andrew McGregor and Tom M’Cready, TAIC altered its earlier findings. Read PDF
The Crash of the Warbirds Devon
In February 2006 a warbirds Devon crashed while landing at Ohakea. The New Zealand CAA initially investigated the accident for safety and prevention reasons only and information was sought and obtained from the pilot on that basis without any threat of legal action. Later however, the CAA used that same information to lay charges against the pilot and he was tried in the Hamilton District Court in 2008. His lawyer engaged Andrew McGregor to lead an investigation into the cause of the crash which was found to be due to the failure of a mechanical flap actuator while the aircraft was on final approach to land, not pilot error. The Jury acquitted the pilot based on Andrew McGregor’s evidence. This article questions the integrity of the CAA’s investigative processes and whether it was acceptable for the CAA to use information provided in the interest of air safety to be later used to lay criminal charges against the informant. Read more: Right to Remain Silent-Pacific Wings 2008
Cognitive Bias and Investigations
In this article Andrew McGregor CPEng and Dr Barry Hughes consider the role of cognitive biases in accidents and incident investigations. One of the points highlighted is that without an awareness of heuristics and biases, the investigator could interpret the evidence at hand in favour of an established system, and at the expense of the individual involved. Read more: Blinkered Vision
In flight breakup of a Robinson R44, Nadi Fiji
In December 2006 on the same day of the last Fijian Militiary coup, a Robinson R44 helicopter crashed into the sea off the coast of Nadi. The Civil Aviation authority of Fiji (CAAFI) engaged Andrew McGregor to lead an investigation into its crash. Andrew McGregor found that the cause of the crash was dis-bonding of one of the main rotor blades, a manufacturing defect. The investigation was carried out under Annex 13 of the International Civil Aviation Organisation which sets out a comprehensive air accident investigation process for investigating air accidents and is primarily concerned with preventing a recurrence. The result of the investigation attracted the interest of the United States National Transportation Board (NTSB) who issued 5 recommendations to the FAA and the manufacturer, and also the FAA who considered it not just a manufacturing problem but an industry systemic issue. During the investigation, Andrew engaged a specialist in adhesive bonding Dr Max Davis of Brisbane, to assist him. This paper which has been co-written with Dr Davis, technically appraises problems of adhesive bonding in primary flight structures and introduces a failure mode called ‘mixed mode failures’ which to date has not been properly classified in literature. Read more: Assessing Adhesive Bond Failures – Mixed-Mode Bond Failures Explained
Organisational Accident Theory
This paper discusses the causal factors of accidents and failures in two totally different contexts: The Erebus plane crash and the Leaky Building Syndrome (LBS), two major calamities in New Zealand’s history.
Erebus occurred over 25 years ago and its lessons emerged painfully within a cloud of conflict and controversy. LBS has not been comprehensively investigated but remains a multi-billion dollar problem that continues to plague many New Zealanders. These are both organisational accidents with multiple causes and although they are grounded in totally different contexts and timeframes, their causal factors nonetheless have remarkably similar features which if understood and appreciated, can be used to prevent organisational accidents in other contexts. The work of safety thinkers such as James Reason and Sydney Dekker is introduced and applied to these two case studies. Read more: CALAMITIES, CORROSION, LEAKY BUILDINGS AND THE LAW A Paper presented at Corrosion and Prevention 2008 Wellington New Zealand November 2008 Andrew McGregor
Other Articles By Andrew McGregor, CPEng
Thinking Illusions and Lost Opportunities
Thinking illusions and second guessing Angle of Attack Instruments
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