BACK ON THE RADAR Obesity’s sleep apnea link MAINTENANCE INSPECTORS Grounding as last option FEELING OF DETACHMENT Fan cowling doors depart
OFF AND RUNNING PAN AMERICAN INITIATIVES THRIVE
THE JOURNAL OF FLIGHT SAFETY FOUNDATION NOVEMBER 2015 Multiple Aviation Industry Segments, One Message: Safety.
f the entire aviation industry should collaborate on one thing, it is safety. IAt a time of constrained resources, increased regulation and unprecedented scrutiny, the Flight Safety Foundation continues to be the leading advocate for safety and prevention of accidents, thereby saving lives. Show your commitment to the aviation community’s core value — a strong, effective global safety culture. Join the Flight Safety Foundation.
“The Flight Safety Foundation is the conduit for safety education and advocacy in aerospace. Embraer is proud to be one of the many organizations in our industry to join the Foundation in defining and championing best safety practices.”
— Dan Ramirez, Air Safety Officer and Manager of Flight Safety, Embraer Executive Jets
Flight Safety Foundation Member Enrollment Membership/Donations/Endowments BARS Program Office Headquarters: Ahlam Wahdan Susan M. Lausch Level 6 | 278 Collins Street 801 N. Fairfax Street, Suite 400 membership services coordinator vice president, business operations Melbourne VIC 3000 Australia Alexandria, Virginia U.S. 22314-1774 Tel.: ext. 102 Tel.: ext. 112 GPO Box 3026 Tel.: +1 703.739.6700 [email protected] [email protected] Melbourne VIC 3001 Australia Fax: +1 703.739.6708 Tel.: +61 1300 557 162 Fax: +61 1300 557 182 flightsafety.org [email protected] PRESIDENT’SMESSAGE
FSF, NEWSMAKERS and the Media
n October, Flight Safety Foundation air transport accident rates in the United In recent months, I’ve talked about relaunched the aviation Newsmaker States and around the world. the Foundation’s many “firsts,” such as Breakfast, a concept introduced by The next predictive step in improving the first accident investigator course and the Aviation Safety Alliance in 2002. aviation safety is refining how we identify the first aviation safety seminar. I’ve also IThese were popular monthly events that risk factors before they lead to an accident. talked about how the Foundation is con- featured a notable aviation VIP, a number I’ve written about the importance of this tinuing its tradition of serving as a neutral of aviation reporters and on-the-record before, and aviation safety professionals ground where competitors and allies can questions and answers in an informal everywhere are working in this area. The get together and talk about safety. setting. FAA’s compliance philosophy reflects that The Newsmaker Breakfasts, which In 2006, the Foundation absorbed the regulators understand the importance of we will hold on a quarterly basis in 2016, Aviation Safety Alliance but wasn’t able this as well. are another important aspect of the to continue the Newsmaker Breakfast To quote the administrator, “The Foundation’s outreach. As a respected series — until now. compliance philosophy is the latest step independent organization, we’re able to We welcomed U.S. Federal Aviation in the evolution of how we work with convene this forum for aviation VIPs, Administration (FAA) Administrator those we regulate. It focuses on the most the “newsmakers” of our industry, to sit Michael Huerta as the speaker for the fundamental goal: Find problems in the down with journalists covering aviation relaunch, and he took this opportunity National Airspace System before they to discuss important, often complicated to discuss the FAA’s new compliance result in an incident or accident, use topics away from the pressure of breaking philosophy and how this policy comple- the most appropriate tools to fix those news and deadlines. ments safety management systems. The problems, and monitor the situation to Foundation endorsed the compliance ensure that they stay fixed.” philosophy in a statement to the news Huerta also explained how this works media, and our statement can be viewed in practice, and I recommend you read on the FSF website. his entire remarks from that day to learn Administrator Huerta reviewed the more. We’ve included an online link to recent history of how airlines, other avia- them in our statement to the news media tion industry entities and the FAA have endorsing the compliance philosophy, worked together to address safety chal- and you can find them and the national Jon L. Beatty lenges, and how this cooperation has led policy order on the FAA’s website
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | NOVEMBER 2015 | 1 AeroSafetyWORLD
contentsNovember 2015 Vol 10 Issue 9 features
10 InSight | No Risk Metric, No Reward
16 CoverStory | Building RASG–Pan America
21 CoverStory | Safety Action in Costa Rica
25 CausalFactors | A319 Doors Unlatch on Takeoff
10 31 MaintenanceMatters | Risk-Based Decision Making
37 UnmannedAircraft | Enforcement Crackdown
16 | Sleep Apnea Concerns Grow 42 HumanFactors
departments
1 President’sMessage | FSF, Newsmakers and the Media
5 EditorialPage | Growing an Aviation Industry
7 SafetyCalendar | Industry Events
2 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2015 25 31 37 42 8 FoundationFocus | Just Culture in Accident Investigation
13 InBrief | Safety News
46 DataLink | Jump in Fatalities in 2014
51 OnRecord | Cabin Fire Traced to ELT
AeroSafetyWORLD telephone: +1 703.739.6700
Frank Jackman, editor-in-chief, FSF vice president, communications About the Cover [email protected], ext. 116 Six years of collaboration bind airlines and states in the Regional Aviation Safety Group–Pan America. Wayne Rosenkrans, senior editor © Renato Serra Fonseca | AirTeamImages.com [email protected], ext. 115
Linda Werfelman, senior editor [email protected], ext. 122
We Encourage Reprints (For permissions, go to
| | FLIGHTSAFETY.ORG AEROSAFETYWORLD NOVEMBER 2015 | 3 ZAS ASW Ad Nov 2015.pdf 1 10/5/2015 5:19:53 PM
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GROWING AN Aviation Industry
s I write this editorial, I’m sitting in a supporter Capt. Malcolm Chan a Sue, a primary hotel room near Georgetown, Guyana. organizer of the event. Earlier today, I had the privilege to sit in Everyone in the room recognized the impor- on a four-hour discussion on the future of tance of safe, efficient, reliable air transportation Aaviation in this country. The topics ranged from to the country’s economic future — to growing the difficulty of attracting large, international car- tourism, attracting industry and business and riers to Guyana; to the infrastructure needed to providing a better life for Guyana’s citizens, espe- develop the country’s remote interior; to tourism; cially to people in remote towns and villages in to search and rescue; to calls for a national aviation the country’s interior. plan; to safety; to achieving U.S. Federal Aviation Safety wasn’t the only topic discussed today, Administration Category 1 status; to compliance and it likely won’t be the only one during the next with International Civil Aviation Organization two days as this conference continues, but it struck standards and recommended practices. me while I was sitting there that I was taking part What most impressed me was not the scope of in an example of what we’ve been talking about the discussion in what was described as a “national in our Global Safety Information Project focus discourse” with stakeholders, or the passion with groups. Getting stakeholders together to talk which issues were discussed, but the breadth and through concerns, to share information and data, diversity of the stakeholders who took part. The to analyze issues and develop and share strategies event featured four government ministers, includ- and best practices is key not only to continually ing one of the country’s vice presidents, the acting improving aviation safety but also to growing an director general of the Guyana Civil Aviation aviation industry and a country’s economy. Authority, the CEOs of local and regional opera- tors, the heads of both local international airports, entrepreneurs, pilots, regulators, air navigation service providers, the chairman of the Caribbean Aviation Safety and Security Oversight System, a representative of the U.S. National Transporta- tion Safety Board, and local aviation legend and Frank Jackman longtime Flight Safety Foundation member and Vice President, Communications Flight Safety Foundation
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | NOVEMBER 2015 | 5 Serving Aviation Safety Interests for More Than 65 Years OFFICERS AND STAFF Chairman ince 1947, Flight Safety Foundation has helped save lives around the world. The Board of Governors Kenneth J. Hylander Foundation is an international nonprofit organization whose sole purpose is to President and CEO Jon L. Beatty Sprovide impartial, independent, expert safety guidance and resources for the aviation General Counsel and aerospace industry. The Foundation is in a unique position to identify global safety and Secretary Kenneth P. Quinn, Esq. issues, set priorities and serve as a catalyst to address the issues through data collection Treasurer David J. Barger and information sharing, education, advocacy and communications. The Foundation’s effectiveness in bridging cultural and political differences in the common cause of safety FINANCE has earned worldwide respect. Today, membership includes more than 1,000 organizations Vice President, Finance Brett S. Eastham and individuals in 150 countries.
MEMBERSHIP AND BUSINESS DEVELOPMENT Vice President, Business Operations Susan M. Lausch Senior Manager of Events and Marketing Christopher Rochette MemberGuide Manager, Conferences Flight Safety Foundation and Exhibits Namratha Apparao 801 N. Fairfax St., Suite 400, Alexandria VA 22314-1774 USA tel +1 703.739.6700 fax +1 703.739.6708 flightsafety.org Membership Services Coordinator Ahlam Wahdan Member enrollment ext. 102 Consultant, Caren Waddell Ahlam Wahdan, membership services coordinator [email protected] Special Projects Seminar registration ext. 101 Namratha Apparao, manager, conferences and exhibits [email protected] COMMUNICATIONS Donations/Endowments ext. 112 Vice President, Susan M. Lausch, vice president, business operations [email protected] Communications Frank Jackman Technical product orders ext. 101 Director of Namratha Apparao, manager, conferences and exhibits [email protected] Communications Emily McGee Seminar proceedings ext. 101 Namratha Apparao, manager, conferences and exhibits [email protected] TECHNICAL Website ext. 126 Vice President, Emily McGee, director of communications [email protected] Technical Mark Millam Basic Aviation Risk Standard David Anderson, BARS managing director [email protected] GLOBAL PROGRAMS BARS Program Office: Level 6, 278 Collins Street, Melbourne, Victoria 3000 Australia tel +61 1300.557.162 fax +61 1300.557.182 [email protected] Vice President, Global Programs Greg Marshall
BASIC AVIATION RISK STANDARD BARS Managing Director David Anderson
facebook.com/flightsafetyfoundation Past President Capt. Kevin L. Hiatt @flightsafety Founder Jerome Lederer 1902–2004 www.linkedin.com/groups?gid=1804478
FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2015 ➤ SAFETYCALENDAR
NOVEMBER 2–4 ➤ 68th annual NOVEMBER 19–20 ➤ Safety in African MARCH 14–15 ➤ Singapore Aviation International Air Safety Summit. Flight Aviation Conference. AviAssist Foundation. Safety Seminars (SASS): Maintenance and Safety Foundation. Miami Beach, Florida, U.S. Kigali, Rwanda. <2gether4safety.org>. Engineering. Flight Safety Foundation and Namratha Apparao,
NOVEMBER 17–18 ➤ Flight Data FEBRUARY 29–MARCH 3 ➤ HAI Heli-Expo Aviation safety event coming up? Management Course. AviAssist Foundation. 2016. Helicopter Association International (HAI). Tell industry leaders about it. Kigali, Rwanda. <2gether4safety.org>. Louisville, Kentucky, U.S.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | NOVEMBER 2015 | 7 FOUNDATIONFOCUS
BY GREG MARSHALL
JustACCIDENT Culture INVESTIGATION in
uring the early days of aviation, aircraft exceptions, pilots don’t go to work with the in- accidents were investigated using mainly tention of committing a malicious act. Accidents records of the flight and evidence gath- are often the product of system-based deficien- ered at accident sites. Basic investigative cies that may include human factors errors of Dtechniques matured as experience was gained, commission or omission. and, with technological developments, investiga- The following ongoing case illustrates the tions became more of a science. conflict between maintaining privacy and a The introduction of the flight data recorder just culture in aviation accident investigation, (FDR) added an information source of immense and meeting the demands of a judicial system’s value to the investigation process. Through the investigators. assessment of multiple FDR parameters, investi- On Aug. 23, 2013, a Eurocopter (now Air- gators could now “see” what the aircraft had been bus Helicopters) AS332 Super Puma, operating doing during the period before the accident itself. in support of North Sea oil and gas installa- The addition of the cockpit voice recorder (CVR) tions, crashed into the sea while on approach provided further insight and aided the process by to Sumburgh Airport in Scotland’s Shetland allowing the investigators to hear crew conversa- Islands. Of the 18 passengers and crew, four tions, cockpit noises and alarms. failed to escape the helicopter and died. The But CVRs introduced conflicts, originally accident investigation by the U.K. Air Ac- around privacy and later regarding protection cidents Investigation Branch is continuing, of data in the interest of everyone’s safety. After but preliminary reports said no technical fault years of advocacy by Flight Safety Founda- with the helicopter had been found. A Scottish tion and other aviation safety professionals, it court is now hearing evidence in support of a became accepted practice that, particularly in coroner’s inquiry. the case of fatal accidents, the audio recordings In workplace-related accidents involving from these devices would be accessible only to fatalities or injuries, the relevant authorities an official body’s investigators for the purpose may be required to conduct an investigation to of carrying out an investigation and preparing determine whether a criminal prosecution of transcripts typically included in the final report. any of the involved parties is warranted. In this Within the aviation safety community, it is still accident, as noted, the ongoing AAIB investiga- widely held that CVR audio recordings should tion has yet to reveal any technical fault with not be used to support adversarial proceed- the aircraft, and Police Scotland, in accordance ings, either criminal or civil. After all, with rare with their statutory obligations, is investigating
8 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2015 Gear’s up, flaps are up. Hot mike …
2248:27MCP Off, Pilot. 2248:28MCP Copilot. After-takeoff checks. 2248:29MP Complete, Engineer. 2248:30MCP Navigator. 2248:31MF In progress, Loadmaster. Navigator. 2248:32MN Clear on bleeds? Loadmaster. 2248:33ML You bet. 2245:36 MN And Copilot … The lights all the way 2248:36MF
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | NOVEMBER 2015 | 9 INSIGHT
BY BARRY C. DAVIS, JULIA POUNDS, PAUL KROIS AND MELISSA WISHY Can Risk Be Managed If It Can’t Be Measured? he U.S. Federal Aviation Administration’s used in everyday conversation or by experts in (FAA’s) new compliance philosophy1 different domains. In an effort to standardize has introduced an oversight approach the definition, the International Organization that proactively manages risks through for Standardization (ISO) defined risk simply Tthe “identification and control of existing or as “the effect of uncertainty on objectives.”3 emerging safety issues” and by concentrating However, uncertainty may exist because of resources on mitigating risk and problem solv- either potential events or their consequences, ing. Traditionally, safety professionals focused and whether information is ambiguous or miss- on controlling known hazards while also trying ing. Further, uncertainty can either positively or to anticipate if or when unknown hazards would negatively impact one’s objective. surface (Figure 1, p. 11). For example, a special Today, an organization’s capability to ac- issue of Risk & Regulation in 2010 devoted eight cumulate information about risk and to use articles2 to a discussion of risk management that information to develop mitigations can related to close calls, near misses and early be labeled risk intelligence (or risk intel), that warnings. The articles represented different is, generating previously unknown knowledge industries and issues, ranging from oil refinery or understanding from data. However, gather- accidents to failures in physicians’ clinical per- ing risk intelligence is dependent on correctly formance to vulnerabilities in nuclear reactors. positioning and providing resources to people, To complicate matters, many definitions of processes, systems and tools, including process-
risk exist, depending on whether the word is es for transforming data into useful information | istockphoto.com Stock; © stevanovicigor | Adobe Tifonimages ©
10 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2015 INSIGHT
for risk analysis, mitigation and planning Given that a common goal of the global avia- purposes. The ability of an organization to tion community is to continually increase the gather risk intelligence increases the quality and level of safety, we offer a very simple solution for quantity of information available for improved the complex problem of identifying risk: decision making.4,5 In the pursuit of safe outcomes, many • We define risk as unintended variation; and, aviation safety professionals have produced • We believe that today’s high level of safety vast amounts of risk intelligence about the can be increased by reducing unintended characteristics of known hazards. As illustrated variation. by Figure 1, however, we need better methods to develop risk intelligence about unknown Aviation relies on a system of systems highly hazards. We cannot directly understand some- dependent on procedures to maintain flight thing we do not know, so are there new ways to safety and efficiency. Rules and regulations for capture characteristic signals or markers that all airspace users specify procedures contain- can point out an underlying issue? This use of ing best practices for executing safe operations. such indicators is very common in the medi- Like drivers of cars approaching head-on must cal field, where a full blood test, for example, know to stay on their own side of the road, provides an analytically valuable dashboard of safe aviation operations depend on the shared chemical markers. expectation that applicable procedures and best Our operational definition of risk is an effort practices will be followed. to clarify the relationship between safety and Maintaining safety requires controlling risk. risk so that both can be measured. The intent However, safety is usually defined relative to is for aviation safety professionals to be able to absence of risk, a concept with no single agreed- better recognize how and when the risk occurs, upon definition. Instead, controlling risk often what influences it, etc. has involved various combinations of expecta- tion, intent, opacity, action and outcome regard- ing either an entity’s purposeful engagement Safety Compliance vs. Risk Management with an unknown or the outcome of an entity’s having encountered an unknown. This inconsis- tency poses problems for aviation professionals who are charged with identifying and reducing risk to improve safety levels. We suggest a com- mon definition so that safety professionals can objectively identify, measure, study and reduce risk; identify changes in risk; and determine the effectiveness of risk mitigation strategies. We defined risk as unintended variation because some intended variation among users of the National Airspace System must be toler- ated to permit them to flexibly respond in un- anticipated or uncontrollable circumstances. For example, some variation is tolerated and expected when users are allowed to exercise discretion and judgment to safely accomplish
Source: Barry C. Davis, Julia Pounds, Paul Krois and Melissa Wishy their goals. These situations are generally covered in safety controls within policies in Figure 1 phrases such as “the operator may discontinue
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | NOVEMBER 2015 | 11 INSIGHT
the alerts if …” and “the documentation • Process information through systems; should include … .” Unintended variation • Format information to be used by means that which is outside approved and systems; predetermined safe tolerance levels and is therefore not intended to occur. • Identify hazards; In sum, alertness for unintended variation • Describe a hazard’s characteristics; to identify risk provides an objective method for managers of aviation organizations in govern- • Describe hazards for developing mitigations; ment and industry to address risk. Measuring • Evaluate hazards for prioritizing resources; the presence or absence of unintended variation is an objective approach to the more imprecise • Implement mitigations in systems; concepts of risk. • Distribute mitigations in systems; The scientific concept of variation is not new. To apply risk intelligence to aviation, • Make decisions; however, involves understanding the nature • Implement security; and, of variation, whether variation is present and • Manufacture aircraft parts? where none is intended. Our definition also aims to help safety professionals to take advantage While this is not a complete list, unintended of statistical methods For example, statistical variation clearly is a marker that signals risk process-improvement techniques have long been whether it involves a safety-related decision, used to identify and remove the causes of vari- mechanism, aircraft part or other element ability in manufacturing. Processes have charac- within the aviation system.
teristic attributes that can be measured, analyzed, Barry C. Davis manages FAA’s Air Traffic Safety Oversight controlled and improved. Any variation during the (AOV) Information Standards. Paul Krois is involved process or in its outcomes can be identified and with FAA human factors research. Julia Pounds, Ph.D., corrected by effective quality assurance and quality manages AOV’s Research and Analysis. Melissa Wishy is a control programs. Stable and predictable results subject matter expert and senior policy analyst with AOV Information Standards. are attained by reducing variation in processes. This insight into processes extends across This article represents the opinions of the authors and does many domains of human activity, including not reflect FAA policy. aviation safety, as illustrated by the examples Notes below. It also can lead us to a better understand- ing about how, when and where unintended 1. FAA. “National Policy: Federal Aviation InSight is a forum for Administration Compliance Philosophy.” Order variation goes unnoticed in processes and sys- expressing personal 8000.373. June 26, 2015. tems. To appreciate the pervasive nature of the opinions about issues of problem, we need only to begin asking questions 2. ESRC Center for Analysis of Risk and Regulation. importance to aviation like the following. Special issue on close calls, near misses and safety and for stimulating early warnings. London, U.K.: London School of constructive discussion, • Do we want unintended variation in ma- Economics and Political Science, July 2010. pro and con, about the chine parts that are used in safety-critical expressed opinions. Send 3. ISO. ISO 31000/ISOGuide 73. Risk Management — equipment? your comments to Frank Vocabulary, 2009. Jackman, vice president, • Do we want unintended variation in 4. Apgar, D. Risk Intelligence: Learning to Manage What communications, Flight information that is used in critical safety We Don’t Know. Boston: Harvard Business School Safety Foundation, 801 decisions? Publishing, 2006. N. Fairfax St., Suite 400, Alexandria VA 22314- 5. Funston, F. Surviving and Thriving in Uncertainty: 1774 USA or jackman@ Is risk introduced if there is unintended varia- Creating the Risk Intelligent Enterprise. Hoboken, flightsafety.org. tion in how we: New Jersey, U.S. John Wiley and Sons, 2010.
12 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2015 Safety News INBRIEF FAA Compliance Philosophy
he U.S. Federal Aviation Administration (FAA) is implementing a new “compliance philosophy” to guide its strategic safety oversight of the aviation industry, Administrator TMichael Huerta says. Speaking at a Flight Safety Foundation Newsmaker Breakfast in October in Washington, Huerta said the agency’s approach relies heavily on establishment of safety management sys- tems at individual aviation operations, and on data collection. “Our traditional approach to aviation safety was to look backward,” Huerta said, referring to decades in which safety advances came only after accidents — and subsequent accident Wayne Rosenkrans Wayne investigations — revealed critical safety hazards. Huerta The FAA said its new approach — outlined in National Policy Order 8000.373, published in June — is designed to “enhance our ability to find safety problems before they result in an incident or accident, use the best tools to fix those problems and then monitor the situation to ensure that no new problems develop.” Huerta said the compliance philosophy encourages openness between the FAA and the operators it regulates. “The FAA wants safe operators, not operators who inadvertently make a mistake and then hide it because they’re afraid they will be punished,” the agency said. Flight Safety Foundation President and CEO Jon Beatty praised the new compliance philosophy as “an important step forward for aviation safety,” adding that the Foundation “has long called for the increased use of data from normal operations to identify precursors to risk.”
Glide Path Disruption
he European Aviation Safety Agency (EASA), citing a 2012 occurrence in which the crew of an Airbus A320 rejected a landing because of a glide path signal disruption, is recommending that airport operators ensure that established runway-holding posi- Ttions are located outside instrument landing system (ILS) critical areas. In the March 28, 2012, occurrence, the A320 crew was forced to go around during an ILS Category I (CAT I) approach at Ham- burg, Germany, because of a signal disruption attributed to a Boeing 737 that had been directed by air traffic control (ATC) to stop at the CAT I runway-holding position. The position was inside the critical area of the glide path, EASA said. “The purpose of the critical areas that have to be established for ILS signals is to keep these signals protected, because any pres- ence of an aircraft or vehicle within these areas is likely to create a disruption of the signals and therefore an unacceptable risk for aircraft operations,” EASA said in Safety Information Bulletin 2015-20, issued in October. EASA also recommended that air navigation service providers ensure that their procedures for ILS approaches “contain the unconditional requirement that ILS critical areas are kept clear during ILS approaches to avoid permanent infringements of these are a s .” National aviation authorities should consider the recommendations during their safety oversight work, EASA said. In the event cited by EASA, the 737 had just landed and was being taxied to the terminal when ATC told the flight crew to hold short on the taxiway. The subsequent disturbance in the glideslope signal led to the display of erroneous information on the A320’s primary flight display, which showed that the airplane was on the glideslope; in reality, it had descended below the glideslope.
© Airbus SAS 2013
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | NOVEMBER 2015 | 13 INBRIEF
Battery Precautions
.S. air carriers and other commercial operators should take extra steps to ensure the safe handling of spare lithium batteries in both carry-on and checked baggage, the U.S. UFederal Aviation Administration (FAA) says. “Lithium batteries present a risk of both igniting and fueling fires in aircraft cargo/baggage compartments,” the FAA said in Safety Alert for Operators (SAFO) 15010, issued in October. U.S. hazardous goods regulations, as well as technical instructions from the Interna- tional Civil Aviation Organization, prohibit spare lithium batteries from being transported in checked baggage, with certain exceptions. The FAA recommended that operators, “during ticket purchase and check-in processes, inform passengers that spare lithium batteries are prohibited from checked baggage (including checked baggage at the gate),” and added that additional information for passengers is avail- able at
‘Challenging Year’ Implementation Procedures
viation safety data for 2014 depict “a very challenging year,” European Aviation he European Aviation Safety Safety Agency (EASA) Executive Director Patrick Ky says in his foreword to Agency and the U.S. Federal Athe agency’s Annual Safety Review — 2014, issued in October. TAviation Administration (FAA) EASA and aviation safety in general faced challenges, Ky said, citing, among say they have agreed to a new system other events, “radar interferences over Central Europe” and the “dramatic loss” of of airworthiness and environmental Malaysia Airlines Flight 17, which investigators say was shot down July 17 over east- certification designed to speed the ern Ukraine by a Russian-made missile, killing all 298 passengers and crew. installation of safety-enhancing These events, along with occurrences in other parts of the world, “have remind- equipment on airplanes. ed us that the safety of passengers can never be taken for granted,” Ky said. The agreement, signed in mid- He noted that in 2014, EASA began changing the way it operates “to allow for a September, also aims to eliminate more proportionate and performance-based approach to safety.” duplicate processes by allowing the Among the changes, he said, is a simplified method of regulation and oversight two agencies to “rely on each other’s of European general aviation, with an emphasis on “safety culture, safety promotion regulatory systems,” they said. and … common sense. It should also be seen In a joint statement, the agencies as the precursor of a better, lighter approach to added, “Strong partnerships are a key aviation regulation in Europe, with the ultimate to establishing consistent standards goal of increasing the level of safety” (ASW, of safety around the world. Based on 5/15, p. 16). more than a decade of cooperation EASA created a new Strategy and Safety … the authorities have established Management Directorate in 2014, with the goal of confidence in each other’s regulatory developing “a single, more transparent, evidence- systems. Rooted in that confidence, based and data-driven strategy,” Ky said. the new safety agreement allows The report noted that one fatal accident in reciprocal acceptance of the majority 2014 involved an EASA member state’s aircraft of technical standard order–approved — the July 24 crash of a Swiftair McDonnell articles.” Douglas DC-83 in Gao, Mali. That crash killed The FAA said it also had reached all 116 people on board and destroyed the a similar agreement with Transport airplane. Canada.
14 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2015 INBRIEF
Gust Lock Retrofit
he U.S. Federal Aviation Administration (FAA) should require retrofitting of the gust lock system on Gulfstream G-IVs to limit the Tairplane’s operation in case the system has not been disengaged be- fore flight, the U.S. National Transportation Safety Board (NTSB) says. The NTSB included the recommendation in its final report on a May 31, 2014, accident involving a G-IV that crashed when it overran a runway at Hanscom Field in Bedford, Massachusetts, U.S., during a rejected takeoff, killing all seven people on board. The NTSB said the probable causes of the accident were the flight crew’s “failure to perform the flight control check before takeoff, their attempt to take off with the gust lock system engaged and their delayed execution of a rejected takeoff after they became aware that the controls were locked.” Contributing factors included the flight crew’s “habitual noncom- pliance with checklists, Gulfstream Aerospace Corporation’s failure Ian Abbott | FLICKR CC-BY-NC-SA 2.0 to ensure that the G-IV gust lock/throttle lever interlock system would prevent an attempted takeoff with the gust lock engaged and the [FAA’s] failure to detect this inadequacy during the G-IV’s certification.” Other NTSB recommendations included: • That the FAA “place increased emphasis on replacing nonfrangible fittings of any objects along the extended runway center- line up to the perimeter fence with frangible fittings”; • That the International Business Aviation Council amend the auditing standards of its International Standard for Business Aircraft Operations to include “verifying that operators are complying with best practices for checklist execution”; and, • That the National Business Aviation Association “work with existing business aviation flight operational quality assurance groups … to analyze existing data for noncompliance with manufacturer-required routine flight control checks before takeoff and provide the results of this analysis to your members.”
Safety Project for the Pacific Airways, New Zealand’s air navigation service provider, says it has agreed to conduct a two-year project surveying runways and developing satellite-based approach procedures to airports in eight Pacific countries. The Pacific Aeronautical Charting and Procedures program is intended to “improve the ability of aircraft to land safely, espe- cially in poor weather,” Airways said in its mid-October announcement of the program. Work was expected to begin in late October in Vanuatu and the Cook Islands and eventually will involve airfields in Niue, Kiri- bati, Samoa, Tonga and other Pacific nations, Airways said. “Safe aeronautical procedures are critical to aviation safety,” said Airways Chief Executive Ed Sims. “While these new proce- dures contribute to safer air travel, they also enable a far greater range of options and flexibility for the airlines and other commer- cial operators.”
In Other News … Eurocontrol and the General Civil Aviation Authority of the UAE have signed an agreement calling for an exchange of flight data, updated flight plan information and airport departure planning information. The agreement is aimed at addressing “the current lack of predictability of traffic between the Middle East and Europe,” Eurocontrol said. … The Australian Civil Aviation Safety Authority is proposing new safety regulations for most passenger airplane flights, calling for the same rules to be applied to regular public transport flights and charter flights — a development that the agency says means safety standards will be tightened for some aspects of charter operations.
Compiled and edited by Linda Werfelman.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | NOVEMBER 2015 | 15 COVERSTORY
lmost as soon as the International Civil according to documents and data published on Aviation Organization (ICAO) estab- the ICAO website
Embracing ICAO’s approaches to collaborative risk mitigation, Pan American states and airlines mark six Safety years of advances.
OversightBY WAYNE ROSENKRANS
16 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2015 Composite: Susan Reed; flags: Wikimedia; map: Cocoloi|Wikimedia CC-BY-SA 3.0 report team. training team and an annual safety team–Pan an America, aviation safety ing groups: aregional aviation safety ning, and has continued, three work- and data.” cross-sharing of safety practices best may arise, as well as promote important pate problems and opportunities that RASG-PA as an agent that can antici- committee, said, who “We the view and amember ofBoeing, its steering chief engineer, aviation system safety, by Gerardodescribed Hueto, now quickly.” to effect take toneed begin RASG-PAnew initiatives and strategy and it demonstrates, why inpart, the dents in2007.This is aserious concern sectors compared flown, to 1.61acci- climbed to 2.55accidents million per Pan2008, the American accident rate Association (IATA), told attendees, “In structure, International Air Transport president, safety, operations and- infra Günther Matschnigg, senior then vice cooperationmilitary inaviation safety. reporting culture and improve civil- buildthem afair and safety effective thatset ICAO’s framework would help Some participants at out the expected - and Caribbean the South America.” in North America, Central America, at reducing aviation hazards and risks and coordination of safety efforts aimed pointfocal to ensure harmonization …RASG-PAactivities. as a serve will and operational safety implementation address gaps the air between navigation “investigated how to incorporate ment. Specifically, ICAO said they from existing research and develop- on possibility the of benefiting quickly RASG FLIGHTSAFETY.ORG FLIGHTSAFETY.ORG At next the year’s meeting, RASG-PA established at- its begin ICAO cited also group aspirations At group’s the first meeting, ‑ PA’s leaders held discussions |
AEROSAFETY WORLD | NOVEMBER 2015 NOVEMBER 1 improvements ICAO’s latest master plan for worldwide Global Context ICAO’s annual global reports. other content have in reflected been produce report, the and its analyses and safety report team has continued to Airplanes, ICAO and IATA. The annual regional data Commercial from Boeing by adding comprehensive analyses of working paper, but it to led cooperation first-year prototype asimple had been making on safety-related matters.” The having atool to enable sound decision aviationall stakeholders interested in safety-related information essential for unbiased and transparent source of The report was promoted as “a timely, nual safety report by an ICAO RASG. to publication of world’s the first an- system safety.” enhancedthe ability to assess aviation tion of safety information and therefore frameworklegal to ensure protec the - would provide with necessary them the tools for Pan American states that safety enhancements] and [to develop] Safety Team (CAST) initiatives [i.e., [U.S.]several Commercial Aviation improvements insafety through use the to assist states and regions to make provides a familiar planning framework Aviation Safety Plan 2014-2016(GASP)] airtheir transport sectors. [The Global continuethey to encourage expansion of and addressing safety their priorities as onmain establishing, focused updating imperative that states and regions re - structure developments. It is therefore through strategic regulatory and- infra is carefully managed and supported that significant this capacity expansion must addressed proactively be to ensure years, current and emerging safety risks projectedfic to double next inthe 15 The launch of RASG-PA quickly led 2 says, “With air traf- ated with [controlled into flight terrain number of risks, including- associ those “[PBN] enhances safety by addressing a performance-based navigation (PBN). ogy, and infrastructure procedures for complete introduction their of technol- and inthat near-term frame, time will tive safety oversight system by 2017, countries implement will an- effec contextthe of expectations that all that of other is RASGs, conducted in ICAO regions.” inall have which RASGs, established been by of GASP the supporting regional the implementation under [GASP]. the … Coordinating and world pursuedbeing region inevery clear affirmations for objectives the now Safety Conference inFebruary “delivered thatported organization’s the High Level Programme (SSP) framework.” implementfully ICAO the State Safety proper governance arrangements) and tive safety oversight systems (including in place, over- next the effec decade, It that vital is states particularly all put and safety information exchange. … standardization, collaboration, resources of four the safety performance enablers: The work of RASG-PA, as well as The first ICAO Journal of 2015re - has been entrusted has to been the 3 COVERSTORY |
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(CFIT)], runway excursions and the Effective Implementation of Eight Critical Elements of ICAO USOAP CMA loss of aircraft separation,” the master plan says. Among their affirmations in the Montreal Declaration of 2015,
ICAO member states committed to The Bahamas Mexico Cuba “expedite full implementation of [PBN] Haiti regulatory oversight.” Jamaica Puerto Rico Belize Dominican By “effective oversight system,” Honduras Republic Guatemala Nicaragua ICAO means adopting its standards El Salvador Trinidad and Tobago Guyana and recommended practices (SARPs) Costa Rica Venezuela Panama Suriname for every state’s approval, authorization, French Guiana Colombia certification and licensing processes. A Ecuador high priority in doing this is providing adequate resources — including legal, Percent of e ective Peru regulatory and organizational struc- implementation Brazil 90–100 tures — to effectively perform univer- 80–89.99 Bolivia sal state safety oversight obligations 70–79.99 through a robust state safety program. 60–69.99 Paraguay 50–59.99 “[RASGs’] annual safety reports … 40–49.99 provide regular updates on the level of 30–39.99 20–29.99 Chile Argentina progress achieved with respect to the 10–19.99 [global] objectives through measure- 0–9.99 Uruguay
ment of reactive, proactive and pre- Not included in area dictive safety indicators,” ICAO said. RASG-PA has focused and prioritized actions to improve runway safety, reduce CFIT accidents and reduce loss of control–in flight (LOC-I) accidents and incidents. As of 2015, RASG-PA USOAP = Universal Safety Oversight Audit Programme; CMA = Continuous Monitoring Approach has added reduction of risk of midair Note: Software dashboards on the ICAO website enable viewing of safety data from subregions involved in the Regional Aviation Safety Group–Pan America. collisions as a fourth safety priority.4 Source: International Civil Aviation Organization (ICAO)
18 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2015 the region.the Moreover, qualification and … of ICAO SARPs insome states of level of lack of implementation effective of USOAP findings that showed “a high of mitigation strategies.” maintainedbe to determine impact the behavior should of occurrences these region.in the The monitoring of the areoccurrences emerging categories (non- system-component failure/malfunction ing five-year averages]; meanwhile, showed decreasing trends [compar active data for “LOC-I and CFIT predictive sections. data inseparate reactive, proactive and currentthe and long-term value of reports has drawn distinctions between excursions, CFITand LOC-I. on risk mitigation related to runway companied in2010by training focused American Aviation Safety Summit, ac- tion (ALTA) introduced also Pan the and Air Caribbean Transport Associa- Data, Improving Safety,’ p. 21).” ‘Sharing (see Rica] [inCosta airport ect of unstabilized approaches at proj the - time. …Early data suggest areduction risks,”those RASG-PA reported at the tions and how to manage and mitigate tion of risks related to routine opera- authorities] to facilitate early recogni- FLIGHTSAFETY.ORG FLIGHTSAFETY.ORG Proactive data that year enabled use The 2011report noted that re- ofEach RASG-PA’s annual safety RASG-PA and American Latin the powerplant) …and unknown … |
AEROSAFETY WORLD | NOVEMBER 2015 NOVEMBER - predictive safety information.” would “advance capabilities to produce to initiatives already under way that Significantly, however, group the pointed cessing predictive safety information.” mechanismsoped for gathering and pro- that region this “had not devel yet- fully information,ty RASG-PA said in2011 ing ICAO’s 70percent target. 70 percent —that is, inarange- exceed corresponding values were greater than member states audited by ICAO, the 65.21 percent. For more than of half elements of state safety oversight was implementationeffective for critical the percentage.” issue [implementation] the affecting qualifications and training …is top the region.the …Technical personnel element mostthe critical affected in training of became staff technical the its of summary a2014safety team to 2014data) —and, as examples, in 2015 annual safety report (referring Information published group’s inthis Fast Forward to 2015 thanhigher world the average (4.137).” [accidents million departures]; per can] region, accident the rate was 4.196 world average, but [South inthe Ameri regionCaribbean] remained below the dent rates [North in the American– The 2011report added, “Acci- As for exploiting any predictive safe- Specifically, region’s the average - challenges to improve safety levels; [South American] Regions facemany informed that and [Caribbean] the 2010–2014 as 25percent. its safety enhancement initiatives during risk reduction due to implementation of ity risk of 0.3in2020;and calculated the RASG-PA the Caribbean; as goal afatal- 2010 asand America 0.6inLatin the five-year-averagethe fatality risk) in analysis states inpart (i.e., baseline the the Caribbean.” [of 2010]for and America 2020inLatin risk fortality [air carriers] to 50percent and “aims to reduce operations the fa- now 2010as reference, abaseline uses retariat said that group’s the safety goal meeting presentation by ICAO the - Sec forgoal safety Aplenary- metrics. meeting enhancement initiatives. of issue the to safety the team for safety said, noting assignmentmary the also data,”(RA) safety the meeting sum- system] (TCAS) resolution advisory and collisionby avoidance [traffic-alert onconcern trend the based exhibited air collision as] emerging the area of constant on focus agreed priorities. investment of and time resources, and PA has come through uninterrupted provides insights into how far RASG- “The [2015 plenary] meeting was [2015plenary] “The The corresponding RASG-PA risk RASG-PA recently also aspecific set …[mid- meeting reviewed “The 5 and meeting 2015plenary COVERSTORY 6 — |
19 © FF MM|Wikimedia CC-BY-SA 3.0 COVERSTORY
however, both [subregions] have shown the highest fatality risk type of accidents, de-identified data from their flights to/ progress on safety in the recent years. while midair collision … is an emerging from specific non-U.S. airports within The meeting agreed that RASG-PA is category in the Pan American Region, the Pan American Region. one of the key contributors of the prog- according to this analysis. Precursors of The 2015 annual safety report said, ress,” the report said. [runway excursions] and CFITs, identi- “ASIAS analysis was conducted using RASG-PA also was tapped by fied through the analysis of predictive [three years of flight data] provided ICAO to pilot-test in 2014 a method of safety data, show decreasing trends. By by … 30 North American airlines that measuring the institutional strength of contrast, TCAS RA events, identified as included operations in aerodromes civil aviation authorities using a survey a precursor of [midair collision] occur- with the following criteria: at least two instrument. rences, is showing an increasing trend in airlines, each operating with 360 flights The plenary meeting also heard a the Pan American Region. or greater; runways with at least 95 per- broad description of the latest confiden- “The proactive safety data used in cent [usage]; and airplane fleet groups tial shared data analyses, which have be- this report, extracted from the results of of three or more airlines operating in come routine because of memorandums the [USOAP], showed 11 states in the the [Caribbean] and [South Ameri- of understanding among ALTA, the Pan American Region that maintain can] Regions. … IATA provided Flight U.S. Federal Aviation Administration’s low levels of effective implementation of Data eXchange (FDX) data, to show Aviation Safety Information Analysis ICAO SARPs. Moreover, lack of effective 2013 [Latin American and Caribbean] and Sharing (ASIAS) program, Boeing, technical staff qualification and training regional trends of some of the top ac- CAST, IATA and RASG-PA. continues to be the most significantly cident categories’ precursors from Latin Far advanced from the 2011 annual affected USOAP critical element … in American and Caribbean airlines.” safety report, the 2015 report says the the region. Of particular significance, In summary, RASG-PA has evolved group now monitors the following the technical areas showing lowest in a relatively few years from being able accident/incident precursors using rou- levels of effective implementation were to utilize mainly reactive safety data and tine flight data monitoring and other air navigation services … aerodromes proactive ICAO audits in 2009 — with sources: runway excursion precursor and ground aids … and accident and limited or no data about precursors – unstable approach; CFIT precursor incident investigation. Improvements within airlines’ or states’ systems — to – events related to enhanced ground- in these areas should have priority in routinely working in 2015 with predic- proximity warning systems; and midair the [Caribbean subregion] and [South tive data that set the stage for extensive collision precursor – TCAS RA. American subregion] due to the contin- use of state or subregion sources. Also in contrast with the 2011 uous growth of commercial air transport Notes report, the following excerpts from the operations being forecast. … 2015 report indicate areas of progress: “The average effective implementa- 1. ICAO. Regional Report: The Americas. “The number of fatal accidents in 2013 tion [of critical elements of state safety 2010. RASG-PA. Annual Safety Report, Second Edition. September 2011. in the Pan American Region for sched- oversight] in the Pan American Region uled commercial air transport opera- … increased from 65.2 percent in 2010 2. ICAO. 2014–2016 Global Aviation Safety tions involving aircraft with maximum to 69.18 percent as of February 2015. Plan. 2013. takeoff mass above 5,700 kg [12,566 lb] This was mainly due to improvement 3. ICAO. “High-Level Safety Event Takes was higher than the previous year but … achieved by the states audited since Urgent Action While Respecting Strategic slightly below the latest 10-year moving 2010. According to ICAO, states [in Goals.” ICAO Journal, Issue 1, 2015. average (2003–2012). Nevertheless, the 2015] should target their efforts to 4. RASG-PA. Annual Safety Report, Fifth number of total accidents and total fa- increase and maintain effective imple- Edition. May 2015. talities remained below the mentioned mentation above 60 percent.” 5. RASG-PA. Summary of Discussions: Sixth moving average. Some of the most advanced predic- RASG-PA Aviation Safety Team Meeting. “Notably, LOC-I, CFIT and [runway tive metrics and analyses available to Dec. 16–17, 2014.
excursion] occurrences showed decreas- RASG-PA come from the agreements 6. RASG-PA. Final Report: Eighth RASG- ing trends, especially at the end of the pe- involving the ASIAS program and IATA. PA Annual Plenary Meeting. Medellín riod; however, they continue to represent So far, U.S. airlines have contributed Colombia, June 25, 2015.
20 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2015 FLIGHTSAFETY.ORG FLIGHTSAFETY.ORG |
AEROSAFETY WORLD P analyzed and shared, according by to interviews and interms of of type data the that is collected, program the like to see expanded geographically International and supporters Airport, would | NOVEMBER 2015 NOVEMBER at San José, Rica’s Costa Juan Santamaría has had ademonstrable impact on safety (FOQA) information sharing program, ASO, operational aflight quality assurance cussed duringcussed an ICAO Aviation Global Safety that eventually PASO became was first dis- or Safety Action Program. The pilot program grama deAcción Operacional, Seguridad dela documents. Organization (ICAO) working papers and other AeroSafety World, International Aviation Civil PASO is Spanish the acronym for Pro- BY FRANKJACKMAN COVERSTORY |
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© rubiopic|iStockphoto 22 | Costa Rica. Costa Dirección deAviación General (DGAC) Civil of an air operating and carrier Rica the inCosta in apartnership involving COCESNA/ACSA, ment program. the Implementation resulted for Aeronautics Safety) to imple was selected - American Agency tion Services/Central tion for Air Naviga- - American Corpora ACSA (Central and COCESNA/ andcussed approved, projectthe was dis- (RASG-PA) meeting, Group–Pan America Aviation Safety first ICAO Regional In November, at the Colombia.Bogotá, in May 2008in Roadmap workshop the program.the among potential stakeholders to participate in mistrust of DGAC the and alack of motivation had overcome to be included operators’ the was ‘over my body.’” dead Early obstacles that said. “I remember reaction the from some operationsflight data with regulators, Brenes importantit was very for operators to share” ASW. Rica’s DGAC —recently PASO discussed with coordinator, state safety program inCosta —alongwho with Frazier Rodr captain and now safety manager at ACSA, according Brenes, to Rodrigo aformer airline Association), support initial was not universal, American(Latin and Air Caribbean Transport RASG-PA, as well as from Airbus and ALTA referred to as PASO. Aviation Safety Plan. The project now usually is from athen-current version of ICAO the Global of12 —use to technology enhance safety — its alignmentreflect with Safety Global Initiative Project 3,but was later changed to GSI-12 to COVERSTORY While PASO had early backing from The project initially was named RASG-PA At that first RASG-PA “we meeting, said 1,2
3 í guez, safetyguez, the stakeholders.the stakeholders; and develop mutual among trust and coordinated fashion inpartnership with operations; work inacooperative, collaborative ards; monitor regional safety trends inaircraft andidentify mitigate operational safety haz- ship are to share information among parties; the OEN/CADA-prtr partner COCESNA/ACSA-DGAC-operator guys learning lessons and we are not? And why ing lessons, and “we thought, ‘why are these operatorsthe were checking data the and- learn eventticular but authorities the because knew policeman, but as someone you can trust.” way little by little. …The state is not as a seen according to COCESNA/ACSA documents. to interests balance the of participants, the all or there actions. disciplinary is Overall, an effort through mitigation rather than through punitive stipulates that safety resolved issues be will 2010 provides for nonpunitive reporting and (MOU) by signed stakeholders initial the in identified. Amemorandum of understanding are trust are mation,” Brenes two key words said. “The here looking at of part that operations] [flight infor ity and ACSA we can decided sit down and start tor we had at that time, aviation civil the author FLIGHT SAFETY FOUNDATION FOUNDATION SAFETY FLIGHT PASO was created not of because one par The fundamental objectives of the “We developed an MOU opera the - inwhich The data inPASO flight used are de- and sharing. and 4
We have working been this |
AEROSAFETY WORLD | NOVEMBER 2015 NOVEMBER - 5 - - -
© DmitriyBurlakov|iStockphoto COVERSTORY
are they not sharing with us?’” Brenes (TMA) by creating a visual flight rules determined, using high-precision global said. Among the likely reasons was the corridor for general aviation traffic positioning system equipment, that the possibility of punishment or sanction using the secondary San José airport — actual locations of the anemometers from the DGAC, he said, adding, “We Tobías Bolaños International Airport, did not match the published locations, decided that sharing this [informa- also known as Pavas International and that the equipment heights did not tion] is more important that giving a Airport after its location in the Pavas comply with Annex 3. As a result, it was punishment.” district of San José — and designing a recommended that three anemometers As of late 2014, more than two dozen new procedure for circling to land on — one at each end of the runway, and PASO meetings had been conducted Juan Santamaría’s Runway 25.8 one at the center — be installed and that to analyze and manage negative trends The results of the mitigation the new locations be published.10 highlighted by operators participating measures were positive, according to The runway safety team in late 2013 in the program. According to Rodrí- COCESNA/ACSA data, which show was charged with carrying out the rec- guez, PASO meetings initially were that the number of RAs declined from ommendations and submitting a report held on a monthly basis, but that has 13 in 2009 to four in 2010. The average to PASO when completed. According to been changed to every other month to number of TCAS RAs in the Juan Santa- COCESNA/ACSA data, there were 185 give stakeholders more time to work maría TMA has held steady at just under excessive tail wind events in 2014, of on issues that are identified. Also, since four per year since 2010, and the severity which 115 involved excessive tail wind 2012, PASO has worked in coordination of events has declined as well. Most are on takeoff and 70 involved excessive tail with Costa Rica’s runway safety team now “adjust vertical speed, adjust” RAs.9 wind on landing. The number of events on issues identified at Juan Santama- In a second example, the analysis is not expected to decline until the ría International Airport. In turn, the of FOQA data for operators participat- recommended infrastructure changes runway safety team has worked with ing in PASO showed a large number of are completed. senior management at the DGAC to takeoffs and landings with excessive tail In the third example, operators raise awareness of identified hazards winds in operations at Juan Santama- in 2012 reported an issue with flight and associated risk mitigation measures, ría. Working with the runway safety crews conducting instrument landing according to working papers presented team, PASO compared wind readings system (ILS) approaches to Runway by COCESNA/ACSA at the ICAO High communicated from the control tower 07. The operators detected a dis- Level Safety Conference (HLSC) in Feb- to flight crews with wind-related data crepancy between the electronic and ruary and a RASG-PA executive steering extracted from the on-board aircraft visual glide paths when flying near the committee meeting in March. 6, 7 communications addressing and re- minimum descent altitude and when “Runway safety teams are a valuable porting system (ACARS) and operators’ the flight crew have visual references partner,” Rodríguez said. “This is part flight data analysis systems. PASO also and are transitioning to the precision of the sharing. PASO is really a sharing analyzed anemometer use and mainte- approach path indicators (PAPIs). program.” nance information; the anemometers, Crews following the PAPI lights were The working paper presented at the radio antennas and other equipment getting indications to stay above the HLSC in Montreal outlined three safety were checked for physical condi- glide path depicted on the approach issues that were, or are in the process tion, and the civil aviation authority profile view, resulting in situations in of being, mitigated at Juan Santama- was asked to check that anemometer which the pilots would tend to pitch ría. The first issue involved operator heights complied with ICAO Annex 3, down the aircraft to fly the PAPI glide concern over the number and severity Meteorological Service for International path, increasing vertical speed to 1,000 of traffic-alert and collision avoidance Air Navigation, Chapter 4. fpm or greater, possibly resulting in system (TCAS) resolution advisories The analysis showed a high range of unstabilized approaches and increasing (RAs) they were experiencing in the error for data from meteorological sta- the risk of runway safety events in the terminal area of Juan Santamaría. A tions located near the threshold of Juan form of hard landings, long landings, number of mitigation measures were Santamaría’s Runway 07. These data are short landings and runway excursions. proposed, such as restructuring the used in wind direction and wind speed After analyzing the information Juan Santamaría terminal control area readings in the control tower. It was also and performing an analysis, it was
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | NOVEMBER 2015 | 23 24 | safety culture.’ need to changethe little by little, we means,thinking ‘This new way of COVERSTORY
© Bernal Sabori|Wikimedia CC-BY-SA 2.0 FOQA events. a“considerablehas been reduction” of related calibration out, carried and since there then, The contract was amended andservices. the contract for radionavigation and calibration calibrationtheir had not included been inthe tamaría were not calibrated correctly because thatdetermined PAPI the lights at Juan San- provement approaches,” intheir Rodr were calibrated, operator the saw alot of im- maintainswhich PAPI the lights, and after they program extended to other countries. COCESNA/ACSA would also the like to see from considered. be personnel technical also working paper that suggests voluntary reports of technology,” according to aCOCESNA/ACSA through ofbeyond detected scope the use those wards amore comprehensive coverage of events, there for is aneed programme this to evolve to- mation about safety-related events. “As aresult, but it obtaining has begun of other types infor through of use the FOQA data and information, its analysis and management of risks primarily operator, said Rodr issues, “we gaining started that trust” with the regulatorthe and worked airport to correct the indicators and PAPI the lights as examples. As past;in the he to pointed wind the specifically by state the having done or not done something ered that errors insome the cases, were caused continued root tothe find causes, it was discov- there were errors, he said, but as investigations errors on of part the operators.” the Ofcourse, thought maybe we were going alot to of see improvement groups, such [runway as airport industry,the authorities and other safety demonstratedbeen that joint the effort with “As astate, we coordinated with COCESNA, Since its inception, PASO out has carried In discussing PASO, Brenes said, “We “Through the application the “Through of PASO, it has 11 íguez. 12 guez said.íguez
- Notes 2. 1. with operator the and share safety information.” [PASO] aviation civil the inwhich authority can sit is one of our dreams, to have more groups like little, we to need change safety the culture. This way new said. of means, “This thinking little by 13. 12. 11. 10. 9. 8. 7. 6. 5. 4. 3. achieved by individual efforts.” could not havetion, …otherwise which been more and effective comprehensive risk mitiga- safety teams] creates [resulting] asynergy in
FLIGHT SAFETY FOUNDATION FOUNDATION SAFETY FLIGHT Punta Cana, Dominican Republic, 2010. October ACSA. “GSI-12 FOQA Information Sharing Program.” Organizations, Montreal, 2011. October Symposium on Regional Safety Oversight of ACSA. “Management of Safety Information.” Ibid. COCESNA/ACSA. March 2015. Ibid. Ibid. Ibid. Ibid. ESC/23), Miami, March 2015. Update.” Twenty-ThirdRASG-PA ESC(RASG-PA Assurance (FOQA) Data Sharing (PASO): PASO COCESNA/ACSA. “Flight Operations Quality Improvement, Montreal, February 2015. (HLSC 2015)Planning for Aviation Global Safety WP/95. ICAO High-Level Second Safety Conference for Safety Improvement America.” in Central Technology and Exchange of FOQA Information COCESNA/ACSA. “PASO Programme: Use of Ibid. ACSA. 2011 October Colombia,Bogotá, June 2012. RASG-PAthe Executive Steering Committee (ESC), Sharing Programme.” WP/08.Thirteenth Meeting of COCESNA/ACSA. “GSI-12 FOQA Information “Some places are resistant to change,” Brenes |
AEROSAFETY 13 WORLD | NOVEMBER 2015 NOVEMBER
CAUSALFACTORS
ritish Airways (BA) has taken steps to passengers and five crewmembers evacuating mitigate human factors–related risk in its the aircraft after it came to a stop on the runway. line maintenance operations by applying AAIB’s probe pinpointed two primary causal lessons learned during the investigation of factors in the accident: Two technicians who aB 2013 accident involving one of its Airbus A319s. serviced the airplane “did not comply with the The airplane departed London Heathrow applicable AMM [aircraft maintenance manual] Airport (LHR) on May 24, 2013, with both sets procedures,” and pre-flight walk-around inspec- of fan cowling doors on its two International tions by a tug driver and the flight’s first officer Aero Engines V2500 engines unlatched, the U.K. “did not identify that fan cowl doors on both Air Accidents Investigation Branch (AAIB) said engines were unlatched.” in its final report on the accident.1 The doors The report also noted three contributing detached during takeoff, and the flight crew re- factors: the fan cowling door latch design; the turned to LHR, shutting down the right engine position in which the technicians left the latches to extinguish a fire fed by leaking fuel along — a configuration that was intended to make the way. The aircraft arrived safely, with all 75 follow-up maintenance easier but that made the FAST FixesBY SEAN BRODERICK
U.K. AAIB cites maintenance human factors after Airbus A319 fan cowling doors detach during takeoff.
London Heathrow Airport Heathrow © London FLIGHTSAFETY.ORG | AEROSAFETYWORLD | NOVEMBER 2015 | 25 CAUSALFACTORS
AAIB’s probe, and the airline has made changes, according to the AAIB’s report.
First Flight The fan cowling door loss occurred on the airplane’s first scheduled departure on the day of the accident. The work that led to the fan cowling doors being left unlatched was part of a sched- uled overnight maintenance check package. The aircraft was one of six assigned to two Visible gap BA maintenance employees—identified as Technicians A and B in AAIB’s report — work- ing their shifts as limited maintenance authority (LMA) technicians. Also assigned to the aircraft were B1 licensed aircraft engineers (LAEs), re- sponsible for “scheduled and defect-driven me- Latches in open position chanical maintenance outside the scope of LMA work,” and B2 LAEs, responsible for avionics systems work certification. LAEs only worked on aircraft when needed, and “no one individual unlatched condition harder to notice; and faded had effective oversight of the work undertaken paint on the airplane’s latches that also made on the aircraft as a whole,” the AAIB report said. their position harder to detect. The overnight shift in question was from AAIB made five recommendations that 1845 local time on May 23 to 0645 on May 24. addressed the latch’s design and certification The pair was assigned work on six aircraft: two standards, BA’s crew training on in-flight dam- A319s, two A320s, an A321 and a Boeing 767. age assessments, the carrier’s evacuation proce- Each required daily maintenance checks, and dures and industrywide maintenance technician two of them — the accident airplane and an fatigue risk management systems. A321 — also required weekly checks. Both tech- Also, two general issues combined to create nicians later told AAIB that the workload was a series of maintenance human factors issues not “unusual or excessive,” and both considered that laid the groundwork for the occurrence. it achievable. One, which AAIB concluded was significant Each of the six aircraft was parked within enough to be cited as a contributing factor, was LHR’s Terminal 5 complex. Four of them were the A320-family fan cowling door latch design. at the main Terminal 5 building, one was at As a result of the probe and related incident Terminal 5B, and one was at Terminal 5C. (One analysis, Airbus is working on retrofits and of the aircraft that the technicians worked on, forward-fit modifications on the system (see an A320, was a late addition to their list when A320 Fan Cowling Latch, p. 28). an aircraft originally assigned to them ended up The other factor was BA’s overnight line not coming to LHR.) The two airplanes under- maintenance protocol. AAIB neither identified going weekly checks were parked on the east BA’s organizational procedures as a contributing side of the main Terminal 5 building, at stands factor to the accident nor addressed any of its 513 and 517, respectively. five recommendations to the carrier’s mainte- Aircraft assignments did not come with nance and engineering division. But the inves- ancillary information, such as “the number tigation helped BA identify several areas that it and scope of any recently incurred defects,”
determined needed to be strengthened based on AAIB found. “This encouraged technicians to Branch Investigation Accidents Air © U.K.
26 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2015 CAUSALFACTORS
prioritize those aircraft scheduled for topping off, or “uplifting.” This, Techni- would have been considered abnormal, weekly checks (or larger aircraft, such cian A told the AAIB, is why the oil requiring follow-up action,” AAIB as 767s and A321s) early in their shift, and oil gun were not routinely carried noted. to assess the magnitude of any addi- on overnight service vehicles, even After their initial stop at the ac- tional work required that might impact when A320 weekly checks were on the cident airplane, next on the technicians’ the progress of their other tasks during schedule. (A BA analysis done as part list was the A321’s daily and weekly the shift.” of the investigation found that adding checks. They then moved on to daily Technicians A and B began their oil was needed on about 3 percent of checks on another A319 and an A320. work traveling in a single operations A320-family weekly checks.) Following a break, the technicians vehicle, and opted to start at Terminal The technicians decided to finish collected a second vehicle and headed 5B, with a daily check on the 767. They the rest of the accident airplane’s daily back to work. then moved to the accident airplane’s and weekly service, move on to other During the break, Technician B stand. The aircraft arrived at 2138. aircraft, and come back to the A319 checked the BA engineering materials Shortly after the A319’s engines later in the shift after obtaining the stores near the break room in Terminal were shut down, the technicians needed supplies. Technician A entered 5A, but could not find the needed IDG checked integrated drive generator the airplane’s flight deck and completed oil and gun. When the break ended, (IDG) oil levels. Following AMM pro- a technical log entry for the daily check, Technician B drove his vehicle to an cedures, Technician A went to the left marking the time at 2300. He then ancillary stores location located on the engine, unlatched the inboard fan cowl- made an open entry for the weekly other side of Terminal 5C to find the ing door, and raised it high enough to check, but did not make a required oil and gun. Technician A requested see the IDG oil level indicator. He con- entry for the IDG work. that they meet at the final aircraft of cluded the IDG needed oil. Technician “If an IDG oil uplift was required, the night, an A320 on stand 509, on the A lowered the door to its hold-open po- an open defect entry relating to the same side of Terminal 5 as the accident sition — one of five possible positions required uplift had to be entered in the airplane. for the door/latch combination — but technical log, and could only be closed After completing the stand 509 did not close or latch it. Technician B and certified when the oil uplift had A320’s daily check, the technicians performed the same check on the right been completed, and the additional oil set off for the accident airplane, with engine, and determined that it needed quantity determined,” AAIB said. Technician A leading and Technician oil as well. He also lowered the door to BA’s AMM did not require a sepa- B following. But instead of stopping at the hold-open position and left it there. rate entry to record the opening of fan stand 513, they proceeded to stand 517 The oil and a special gun to service cowling doors. But it did call for warn- and the A321 that had its weekly check. the IDGs were not in the technicians’ ing notices to be placed in the cockpit Upon pulling up to the stand, the service vehicle. While the IDG oil level before doors are opened. No notices technicians did not verify the aircraft’s inspection is part of all A320-family were placed in the cockpit. registration before attempting to com- weekly checks, the oil rarely needs “Such warning notices would have plete the IDG servicing. When they London Heathrow Airport Heathrow © London been seen by the flight crew … dur- found the fan cowling doors closed, ing their preparation for the flight and they thought it was “strange,” the
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AAIB report said. But Technician B relayed an A320 Fan Cowling Latch instance in which he took a break while work- ing on an engine, only to find the cowling doors closed when he returned. his 2013 Heathrow accident was the 35th instance of in-flight The technicians opened the A321’s fan cowl- fan cowling door detachment on Airbus A320-family aircraft — Tincluding 21 events for aircraft fitted with IAE V2500 engines and ing doors and double-checked the IDG oil. It 13 events for aircraft fitted with CFM International CFM56 engines did not need servicing. The technicians — still — according to the U.K. Air Accidents Investigation Branch (AAIB), believing they were back at the accident airplane underscoring an issue that can be traced to the aircraft’s certification. — reasoned that the engines had cooled in the The certification basis applied to the A320 family categorized fan three hours since their original check, allowing cowling doors as structural elements. This meant the manufacturer residual oil to drain back into the oil sump. had to demonstrate the cowlings could sustain any loads likely to be experienced in service without rupturing or permanent deformation. Concluding that their work was done, “Once this has been satisfactorily demonstrated by testing, the the technicians closed and latched the cowl- theoretical probability of failure is zero, and does not need to be con- ing doors on both engines, following required sidered further,” AAIB explained in its final report on the accident. procedures. The aircraft’s technical log had been Systems certification standards, on the other hand, do not permit taken to an engineering office for a routine eliminating systems failures as possibilities. Applicants therefore weekly administrative check, a task that was in must determine the risk of failure using system safety assessment (SSA). Once risk probabilities are determined, mitigation techniques line with the carrier’s Terminal 5 short-haul line are adopted, ranging from regular maintenance checks to flight deck maintenance procedures for weekly checks. warnings. When they returned to the crew room, their Other exterior openings — such as access panels, fuselage doors tasks included completing the weekly check work- and hatches — are systems subject to SSAs. But because fan cowl- sheet and technical log for the accident airplane. ing doors are considered structural, their certification testing did not The technicians also relayed their story about find- include evaluating the ramifications of a maintenance error that would leave doors open. ing the fan cowling doors closed and the change in In 2000, AAIB recommended that France’s Direction Générale de oil levels. Nobody questioned whether the techni- l’Aviation Civile (DGAC) and Airbus consider a flight deck warning cians had returned to the correct aircraft. system to detect unlatched fan cowling doors. But DGAC, concerned AAIB’s report identifies the technicians’ about unintended consequences such as false alarms that might result failure to follow the AMM, as noted, as one in rejected takeoffs, opted to mandate latching system modifications. of the two causal factors in the accident. But Over the next decade, several changes were either recommended or mandated, including “hold open” devices that — when used — created BA recognized that many factors endemic to a visible gap between an open cowling door and the engine, and fluo- its procedures — or not accounted for in the rescent paint on the latches to make them more visible when not flush procedures — set the stage for the technicians’ against the cowling, indicating they are unlatched. Airbus also revised mistakes. In the months after the accident, BA the A320 Aircraft Maintenance Manual to warn against closing fan cowl- made a concerted effort to change its system. ing doors without latching them if a maintenance task is interrupted, The most significant change was organizing and incorporated changes on the production line. The changes didn’t sufficiently reduce the risk. Three more fan line maintenance teams. “Through the recruit- cowling door events occurred after the Heathrow accident and before ment of 26 additional staff, the line mainte- AAIB’s release of the final report. nance team structure has been altered to form As part of the probe, Airbus took its most detailed look yet at the individual teams” of [LMA], B1 and B2 staff problem and concluded that more changes were needed to mitigate “operating under the oversight of a maintenance the risk of the fan cowling doors being left open. supervisor,” the AAIB report explained. “Aircraft Airbus is introducing a new latch with a key, which will be installed on A320neo aircraft starting in 2016 and made available as a retrofit. assigned for maintenance will be processed by a Airbus said the A320neo “will incorporate a mechanical solution to single team providing improved supervision and indicate the fan cowl doors are unlatched,” as well as a cockpit warning oversight of maintenance tasks.” system. The carrier’s A320 line maintenance proce- — SB dures have been updated to require open techni- cal log entries whenever fan cowling doors have
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been opened. BA also has staggered IDG checks result, there was limited opportunity to intro- during weekly checks “to prevent the possibil- duce mitigating actions.” ity of both sets of fan cowl doors having to be BA has added a category in its reporting opened on any one occasion,” AAIB said. scheme for recording aircraft swap errors. BA also created special “wet” and “dry” kits AAIB noted that Technicians A and B had especially for A320 daily and weekly checks. several opportunities to detect their swap error, “The non-availability of equipment … nearby to but failed to follow proper procedures. Perhaps [the accident airplane] may have played a role” the greatest chance for them to catch their in the technicians leaving the fan cowling doors mistake — placing the technical logbooks in open “by inciting the technicians to postpone every aircraft with open tasks — was taken from completion of the work until they had an oppor- them by BA’s logbook review practice. “This tunity to collect the IDG gun from stores,” the working practice inadvertently removed the AAIB report said. “The company’s vehicles have main safety barrier for trapping the aircraft swap been modified to carry the kits and a replenish- error, as it is probable that the error would have ment process established to enable engineering been discovered had the technicians attempted staff to collect serviceable kits prior to com- to sign for [the accident airplane’s] weekly mencing maintenance work,” the report said. check in [the other airplane’s] technical log on BA has taken steps to boost general aware- board the aircraft.” AAIB’s probe found differ- ness of aircraft undergoing line maintenance. It ent logbook protocols within BA, even at LHR. mandates that technicians performing line main- The short-haul line maintenance team was the tenance on any short-haul aircraft place a red card only one that removed logbooks for administra- marked “AIRCRAFT IN MAINTENANCE” along tive checks. BA now keeps technical logs in all with the aircraft’s registration on the flight deck aircraft during line maintenance activity. pedestal. It also requires special gaiters, or high- BA’s application of lessons learned from the visibility covers, to be placed over the nosewheel accident go beyond its procedures. The carrier’s of any aircraft on which “there has been a break in human factors training has been updated to an airworthiness-related task,” AAIB said. Each reflect what it gleaned from the occurrence and gaiter includes an identification number belonging subsequent investigation. to the maintenance team working on the aircraft. The carrier also created an engineering safe- During its probe, BA discovered that aircraft ty culture team “to conduct on-the-job compe- “swap errors” (mistakes in which maintenance tence assessments of maintenance staff across all personnel confuse one airplane for another) oc- production areas on an unannounced, random casionally occurred during line maintenance, but basis,” the accident report said. “The assessment these events were rarely reported. Several factors includes checking interpretation of procedures, played a role here: the fact that the errors were observation of tasks accomplished and attitudes considered routine and usually discovered before toward safety. Where areas of improvement are leading to any notable ramifications, and that BA’s identified, the team will focus on improvement occurrence reporting system did not have a cat- of procedures and supporting systems.” egory for tracking swap errors. In the case of the Sean Broderick, a former editorial staff member of the accident airplane, the fact that the same techni- American Association of Airport Executives and the civil cians were assigned to both aircraft removed the aviation–maintenance, repair and overhaul team of Avia- possibility that other workers assigned to service tion Week & Space Technology magazine, is a freelance the other airplane would detect the errors. aviation journalist. “The low level of reporting of aircraft swap Note error events stemmed from these behaviors 1 AAIB. “Report on the Accident to Airbus A319– having become accepted as a ‘norm’ within the 131, G-EUOE; London Heathrow Airport; 24 May line maintenance operation,” AAIB noted. “As a 2013.” Aircraft Accident Report 01/2015, July 2015.
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BY WAYNE ROSENKRANS Decision Making
everal factors have prompted princi- FAA maintenance inspectors will be pal maintenance inspectors in the U.S. trained to favor well-reasoned risk Federal Aviation Administration (FAA) mitigations, if possible, instead of to avoid precipitous enforcement action Sagainst air carriers, such as grounding an grounding aircraft fleets. aircraft fleet, if alternative corrective action resolves the safety issue. According to Keith Frable, FAA principal maintenance inspector for United Airlines, risk-based decision making, is being introduced as “a new way forward … a new path where we are not inconveniencing passengers but we’re still having continual op- erational safety at the airlines,” he said. Frable spoke in April at the World Aviation Training Conference and Tradeshow (WATS 2015) in Orlando, Florida, U.S. © Mathieu Pouliot | AirTeamImages
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The policy shift considered poor deci- Prescriptive Culture sions about grounding airline fleets1 based Before being hired to oversee airline main- on non-risk-related practices, reductions in tenance operations under Federal Aviation the number of FAA maintenance inspectors, Regulations (FARs) Part 121, FAA maintenance reductions in the number of maintenance inspectors had been indoctrinated for years in professionals at airlines, and the numbers prescriptive system safety. “We teach the regula- of new maintenance engineers added in the tions [under that philosophy]. We teach people context of required qualifications and em- to follow the regulations. … We teach people ployee turnover. “It was an initiative about a to follow a prescribed procedure in the aircraft year and a half ago to get a team together and maintenance manual. … We teach people to start this process; however, the training [for follow the airworthiness directive [AD]. … We some categories of inspectors] is not out yet,” teach people to follow the checklists and to stick he said in April. to prescriptive language. … This culture of … Risk-based decision making involves FAA adherence to rules and regulations was devel- flight standards district offices, principal main- oped way before [most of today’s aviation safety tenance inspectors and their ongoing relation- inspectors, with average age in their 50s and 60s, ship with the airline counterparts that they were hired],” he said. oversee. This means airline maintenance leaders Frable’s presentation objective, he noted, was and maintenance technicians — as represen- explaining “why risk-based decision making tatives of the regulated entity — will play an is so new for Flight Standards and why [it is] important role in adjusting local safety cultures, such a struggle to change the culture of Flight in communicating and in providing informa- Standards. … This is very foreign to [principal tion that enables the newer process to work as operations inspectors] to be able to make those
intended, he said. decisions of not grounding an airplane because © Denis Roschlau | AirTeamImages
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an airworthiness directive isn’t accomplished on operation?’ … How do we get in there and an airplane. Their initial reaction is ground it, change the way they think about this entire then fix it, then fly it.” process?” To launch the process while training catches Examples of how the process works — as up with policy, Frable made other requests of part of Flight Standards’ transition from the Air the attendees. “As an operator, you can also Transportation Oversight System to the Safety provide risk-based analysis to your [principal Assurance System (SAS) of risk-based analy- maintenance inspectors]. … You need to be in sis — were taken from real-life stories of FAA the forefront … I told United [Airlines], ‘It’s experiences at United Airlines, “where we’ve your operation. You have the problem. … You worked through these issues and they’ve let me operate the airplanes. Tell me the risk analysis release this information … because it was done you performed, the SMS [safety management in a methodical, thorough process,” he said. system] process you used, what the initial risk “For the Part 135 inspector and the Part 145 assessment is [and] what the mitigations are go- inspector, it incorporates decisions based on ing to be. … We don’t always know [at FAA] the risk, so they have to go out and do their inspec- proper mitigation and then what’s going to be tion, bring that data back and then decide what the [post-mitigation action].” implications that has on the operation of your Principal maintenance inspectors need all the fleet or in the operation of your certificate. relevant information to determine what the level There’s no training for them on that, so it’s a … of risk would be in continuing to operate affected very big gap.” ‘If you come up airplanes, whether flight operations should be with a risk-based shut down and whether FAA and the operator Thrust Reverser Example need to put fixes in place right away, he said, not- Regarding the FAA–United Airlines relation- decision [and] ing that FARs Part 135, commuter and on-de- ship while implementing risk-based decision mand operations, and Part 145 repair stations, are making, Frable said, “We have [real-time] a risk-based not required to have a safety management system feedback, we have meetings. [We ask,] ‘Where (SMS) but stand to benefit from incorporating are we on the project?’ if they put a mitigation mitigation, you SMS components into their operations. in place. ‘Are we seeing the event [recur]? Has have to stick to “The better you get [with SMS,] the better [your] mitigation worked?’” (See “Nonpunitive you’re going to help the FAA inspector help you Interviews Yield Insights Into Aircraft Ground that plan.’ make … sound decisions based on identified Damage,” p. 34.) risk. … If you come up with a risk-based deci- The new process came into sharp focus in sion [and] a risk-based mitigation, you have to the case of noncompliance with an AD concern- stick to that plan,” Frable said. “You’ll want to ing thrust reversers. The stated intent in the AD make that decision based on the likelihood and was to prevent a thrust reverser from deploying severity of the event, and what that really means in flight, he said, and the wording of the intent to your company.” itself implied high risk. Frable said, “They didn’t perform an AD Gradual Implementation task, so their initial conversation was, ‘We Frable said this cultural shift will take time and missed the AD cycle on these airplanes because experience, as well as training of FAA principal the [task] card wasn’t done, whatever the maintenance inspectors. “[The question now reason. And now we have airplanes flying out is,] ‘How can we get them past initial reactions there with the potential of a thrust reverser to violate you [i.e., to allege airline noncompli- opening up in flight because we didn’t accom- ance with a regulation or a requirement] or to plish the AD.’” ground your airplanes without having severe He said that, historically, a principal main- consequences to the flying public and to your tenance inspector’s immediate reaction likely
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Nonpunitive Interviews Yield Insights Into Aircraft Ground Damage
o investigate an uptick in aircraft damage in the ground “When we found nonconformances by employees, environment, United Airlines recently cross-referenced we would fix them. [We told ourselves,] ‘So this employee Tits internal safety-intelligence sources, including data didn’t follow the SOP and we worked with that employee, from flight operational quality assurance (FOQA), aircraft- we trained them, we disciplined [them]. Whatever the path damage databases, injury databases, line operations safety was — that employee is fixed. Then [at another] location, the audit (LOSA) observations, data on compliance with stan- same thing happened: aircraft damage, nonconformance to dard operating procedures (SOPs), quality assurance audit the standard operating procedures, [and] we fixed that one.” data, and employees’ voluntary reports to aviation safety She became dissatisfied with the prospect of repeating action programs (ASAPs). this cycle without resolving issues at one time for the entire The results led to insightful, nonpunitive interviews with airline. “We decided to look at the problem systemically — employees involved in aircraft damage events, said Lisa when we found factors, we would map them to a human Crocket, senior manager, quality assurance for line opera- factors model [that] encourages us to look not only at ‘what tions safety assessment, United Airlines. “The data I have so happened’ and ‘why it happened’ on the employee level, but far already give a completely different picture of what [SOP] also look for factors higher in the organization,” Crocket said. compliance looks like and why. We’re going from [assum- “It’s a little harder to [turn] that ship, but you’re fixing [the ing] complacency to [saying,] ‘Holy smokes, they didn’t have issue] across the organization.” the materials they needed!’ That is … a completely different To look deeper into causal factors, she proposed a hybrid way to mitigate the issue.” She spoke in April at the World of well-established, peer-to-peer LOSA techniques and a Aviation Training Conference and Tradeshow (WATS 2015) in quality assurance audit. “When we found a nonconformance, Orlando, Florida, U.S. our goal was to interview the employee nonpunitively. … “We collected data and used that data to point to very Something happens in the real world that prevents employ- specific systemic fixes. ASAP can tell you what’s wrong. LOSA ees from following that procedure [learned in training,] or can tell you how often it happens in the real world. I hope you something impacts their work out in the organization that use this example to look beyond the ‘who’ and get to the ‘what’ causes them to make different decisions. … We visited 19 — and find a model that works for you, that helps you get to locations and collected 225 observations [and] great inter- risk-based decision making,” Crocket told the audience. “I hope view notes from people who didn’t conform to SOP. [I told [trainers and training content developers] actually incorporate interviewees,] ‘Listen, we have something to learn [and] I’m [our example] into some of your training so you can see these gathering data. [Can you] help me understand why you took underlying factors where people are not compliant, [and] this path instead of this path?’ … I cannot tell you how rich find a way to train those out of your organization. … We the data are when you don’t ‘hammer’ the person … when always want get to the ‘why.’ How did it happen?” you give them free reign to talk.” She described her study as involving an unidentified Several factors driving SOP nonconformance emerged organization within the airline that had resisted previous from these interviews and the related sources of factual in- efforts to resolve this ground-damage trend, and some em- formation. “The first driver of nonconformance … was called ployees had told her that the problem seemed too large to a decision error — when the employee consciously decides fix. “They didn’t necessarily see it as a high risk or they didn’t to vary from that procedure. It’s the wrong decision, but it’s understand the ‘why’ [of] it. [They were] great at telling a decision. [Some said,] ‘I did it this way because I was in a us what the problem was and how often it happened, but hurry. I did it this way to get the plane out because we were [they] weren’t getting to the correction.” behind. Previous attempts had recognized that equipment fail- “The second [driver was called] a skill-based error. … It’s ures and malfunctions sometimes were factors in a specific something you do time after time, and you hardly even have case, Crocket said. “But largely, the problem … was that to think about it. It’s the same thing as ‘being on autopilot.’ employees failed to follow standard operating procedures. We would approach an employee and say, ‘We noticed you … They were being complacent. …Complacency [seemed missed a step … and they would say, ‘[No,] I did that.’ And to be] a big issue, but how do we know it’s really compla- we said, ‘You didn’t, actually. … That’s part of your checklist, cency? Is it an assumption? Can we measure it? … We also and you missed that. So we dug deeper to ensure that they wondered if there were other factors underneath that were weren’t just kind of smoking us [i.e., trying to mislead investi- causing people to not comply with procedures. gators]. If they really believed that they had completed
Continued on p. 35
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would be to say, “Let’s shut down 85 derived from detailed analysis of the [in-flight thrust reverser deployment]. It airplanes around the world, inconve- thrust reverser situation, he said. is there as a backup check. You [check] nience passengers and shut the opera- “The [uncompleted] task was an a pin [on a circuit board and] make sure tion down until we get that checked ancillary task; it wasn’t part of the AD. It [you don’t] have voltage at a certain spot. out .” was a task that was done on a secondary … Even if voltage is there, it wouldn’t In the risk-based decision making backup system that had a 4,000-hour contribute to what the AD was for.” paradigm, inspectors make a more cau- flight-cycle check [interval] on it. … Instead of grounding aircraft, FAA tious and deliberate assessment first. In Where’s the criticality on a 4,000-hour permitted a staged-but-rapid assess- the example, United Airlines brought check? [It’s] pretty minor. [The mainte- ment of the risk factors by United a sound decision to the discussion nance task is not done] to prevent the Airlines, starting on a Friday night with
Nonpunitive Interviews Yield Insights Into Aircraft Ground Damage
the checklist, that was a skill-based error, and we classified it were not reinforcing the employee’s training on how to as that. correct a known problem. “When I did the study, I was taken “The third driver of nonconformance … was called a aback by [some supervisors’] failure to correct a known prob- routine violation. … It’s a variance from the rule [because I lem, which actually relates back to my routine violation.” know] I’m not going to get in trouble and they let me [devi- At the highest level of the scope of the study, the LOSA ate]. We found that was a high driver.” staff identified aircraft damage causal factors at the orga- Compared with these insights, attributing aircraft-damage nization level. “What we found in that category was either events to the vague category of complacency fails to explain that there was no accountability or weak accountability for or solve correctable issues. “[As to deliberate choices in] standard operating procedures,” she said, recalling her rec- decision making, the skill-based error, being on autopilot and ommendations to senior management. “We should be mak- routine violations, we can train and we can set up processes ing sure that supervisors are out in the operation more, and to engineer those out of our company,” Crocket said. that they have the tools they need to ensure that people Investigators recognized another causal level in some are adhering to SOP consistently. In addition, the leadership interviews. These background factors — overconfidence, needs to provide those supervisors with the structure to lack of proficiency and complacency — came into play by accomplish this. … Now, we have actually trained our LOSA influencing the employee to decide not to comply with the observers to interact with the person who didn’t conform SOP. “Overconfidence [is apparent if the person says,] ‘I’ve been to SOP so that they can grab those interview notes and use doing this job for 30 years; nothing bad ever happened. I’ve [them] so we can give ‘color commentary’ [i.e., background never hit an airplane; I’m fine. … [Or they say,] ‘I haven’t worked details as] to the reasons why people aren’t following SOP. in this area for a while.’ Largely, in training [on belt loaders, for We just implemented this April 1, and it already has trans- example, or] whatever the procedure is, they should be famil- formed how we look at what’s wrong out there.” iar with it. [They’ve done] it 1 million times, they should know Crocket said such LOSA data are considered to be how even if they haven’t done it in three months.” ‘owned’ by each stakeholder entity, such as the mainte- Because of these beliefs, the airline had not recognized nance division, station operations or ground operations. the actual risks of taking people out of their normal area of “They own their data, and we’ve given them a really easy operation or out of their normal job position, then returning tool that — literally, in three clicks [of a computer mouse] them several months later to their original position, although inserts the data and ranks it by risk. … I do it on a system- some struggled at first to meet the required level of commu- wide basis so that I can take that information and roll it up nication and coordination of the team. to leadership as a system compliance.” “We [also] did find complacency in the study. … It didn’t In sum, noncompliance with SOPs cannot be presumed even make it past 5 percent [of causes of aircraft damage],” to occur solely because people are complacent or because she added. they don’t care, Crocket said, adding, “We have to find those With the human factors model, supervision also was ad- reasons so that we can make better decisions — [through] dressed. Regarding inadequate supervision, the study noted risk-based decision making — on how to mitigate them.” cases in which supervisors were not adequately monitoring maintenance employees’ work or, when monitoring, they — WR
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | NOVEMBER 2015 | 35 MAINTENANCEMATTERS
four airplanes already in “remain over- that potential severity was high but the company [because an airplane was night” status, including one in a hangar that probability of an unsafe outcome dropped on the nose]? Typically, I’d say for a heavy maintenance check. was extremely remote. Frable ruled no,” he said. “If on Saturday [morning,] those that no grounding would be required, “If you put a different person in the four airplanes had voltage [present and and further analysis justified the risk- same position, would they make the so] met the … required-maintenance based decision making. The engineers same mistake? If the answer is ‘no,’ the [criteria], then … this would raise the ultimately concluded that performance procedures are there, the task cards are likelihood and, in my opinion, raise the or nonperformance of the third bear- written properly, the requirement to severity. That would tell me that [Unit- ing wash actually had no effect on pin the nose gear when [the airplane] ed Airlines] needed to do more of those safety, and that ironically, all the APUs comes into the hangar is there. … The checks quicker,” Frable said. “On Saturday of initial concern were in maintenance company has established a protocol, morning, all four checked out ‘good.’ On parts stores at the time. “We could have everything is there. … Sunday, they [planned to check] another grounded airplanes. We could have “So you go to the individual who 10 [but instead of continuing checks for made that decision based on a knee-jerk made a conscious decision not to follow four to five days], all were checked [in reaction,” Frable said. the procedures set forth by the company. three days, which brought them into AD I want [the airline] to fix the guy who compliance]. … Our risk assessment was Hangar Nose Drop was not following them … to fix that valid, and we proved it was valid. There Another event raised similar initial culture. I don’t want [them] to fix what’s was no risk to the flying public, and concerns of potentially catastrophic already in place and what’s already there was no risk that [noncompliance outcome. In this case, Frable received working. … We have an ASAP [aviation with] this AD was going to cause the a late-night message saying that the safety action program, and this situa- catastrophic loss of an airplane.” nose of a United Airlines aircraft had tion] would be handled through ASAP.” A similar situation at United Airlines dropped to the hangar floor during Ultimately, post-mitigation analy- occurred when FAA inspectors discov- maintenance. No one was injured or sis by the airline is critical in all such ered that a manufacturer of auxiliary killed in this ground accident. “So situations, he said. “Did it work? Was it power units (APUs) had discontinued again … you don’t shut everything effective? What were the lessons learned? a process called the third bearing wash. down. You let the company work the Is there something else we should have FAA’s immediate theoretical concern process. The airplane is safe. It’s in the done for that event? … If it wasn’t a good, was that, potentially, this practice could hangar,” Frable said. He visited the site comprehensive fix and it was ineffective, have a life-limiting effect on bearings — to observe whether the nose gear safety how can we make it effective and what essentially a type of damage that could pins had been inserted, and assisted follow-up do we need to do to make that lead to bearing failure and an uncon- otherwise in the airline’s investigation mitigation effective?” he said. tained failure of the APU. the next morning. Note “[We found] out that that the third “[Critics] could say, ‘You’re letting bearing wash was required as a result of them fly around with AD noncompli- 1. In 2008, for example, the FAA was involved a [another manufacturer’s] maintenance ances. You’re letting them drop airplanes in grounding of airplanes by American task card vetted by United Airlines,” and on the nose, and you’re not shutting Airlines, Southwest Airlines and Delta Air Lines, Frable said, adding, “[Delta’s apparently APUs were being returned them down. You’re not stopping [their McDonnell Douglas MD-88] fleet was to line service without the benefit of investigation] process. You could say grounded for basically the routing of this process, although still specified in that, but in reality — if you have deci- wiring in the landing gear and for [cable- the aircraft maintenance manual. Frable sions based on risk and you have a great sheath] tie wraps. … If you risk-rate that, worked with United Airlines engineers relationship — [this] is going to help was it a high risk? I would say no. The to check for bearing discrepancies and to [the airline] and it is going to help the likelihood of a catastrophic event would be low and the severity would be low. … rate the risk based on checking bearings FAA make those calls. [Airlines still] However, the decision was made based from a sample of APUs. do get violated [but] that’s the last thing on it being [noncompliance with] an air- The engineers’ report at the end of we want to do. As a [principal mainte- worthiness directive and an airworthiness this work led to a risk-based decision nance inspector], am I going to violate directive alone.”
36 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2015 City: © romanslavik.com | AdobeStock; Drone: © Kletr | AdobeStock Drone in title: Federal Aviation Administration FLIGHTSAFETY.ORG in-hand,” said Michael G.Whitaker, deputy operator. aircraft the detect and against penalty astiff one airspace, proposing ahigh-tech campaign to U “Education and enforcement must go hand- aircraft and near airports inrestricted aircraft systems (UAS) and model stop operation illegal the of unmanned . S. authorities are intensifying efforts to |
WORLD AEROSAFETY | NOVEMBER 2015 Representatives aviation subcommittee that met mony inearly before October aU.S. House of aircraft inan unsafe manner.” or illegal actions against anyone an unmanned flies who but we won’t hesitate to strong take enforcement people to voluntarily comply with regulations, Administration (FAA). “Our preference is for administrator of U.S. the Federal Aviation Whitaker made remarks the during testi- operations incongestedairspace. operator accusedofunauthorized The FAA has proposed itslargest civil penaltyeveragainstaUAS BY LINDAWERFELMAN UNMANNEDAIRCRAFT |
37 UNMANNEDAIRCRAFT
to consider methods of ensuring aviation safety required to operate in that airspace; the aircraft as UAS aircraft are integrated into the National also lacked the required two-way radio, tran- Airspace System (NAS). sponder and altitude-reporting equipment, the A day earlier, the FAA proposed what it said FAA said. was the largest civil penalty ever against a UAS op- “Flying unmanned aircraft in violation of erator for “endangering the safety of our airspace.” the Federal Aviation Regulations is illegal and The agency proposed a $1.9 million civil can be dangerous,” said FAA Administrator penalty against SkyPan International, alleging Michael Huerta. “We have the safest airspace that the company conducted 65 unauthorized in the world, and everyone who uses it must operations between March 21, 2012, and Dec. 15, understand and observe our comprehensive set 2014, “in some of our most congested airspace of rules and regulations.” and heavily populated cities, violating airspace SkyPan has 30 days after receiving the FAA’s regulations and various operating rules. … These enforcement letter to respond to the agency’s operations were illegal and not without risk.” allegations. In announcing the proposed penalty in Octo- ber, the FAA said that the flights — photographic ‘Clear Message’ missions conducted over New York and Chicago In his testimony before the House Committee The New York — were conducted “in a careless or reckless man- on Transportation and Infrastructure’s aviation Police Department ner so as to endanger lives or property.” subcommittee, Whitaker said that the proposed investigates an All 65 flights were operated without a civil penalty “sends a clear message to others occurrence involving required airworthiness certificate and effective who might pose a safety risk — operate within an unmanned registration, the FAA said, adding that SkyPan the law or we will take action.” aircraft during the also lacked a certificate of waiver or authoriza- The SkyPan occurrences were among hun- US Open Tennis tion for the flights. Forty-three of the flights dreds of incidents that the FAA has investigated Championships in were operated in New York’s controlled airspace regarding reports of UAS being operated outside September 2015. without an air traffic control clearance, which is existing regulations. In August, the agency re- leased data on 765 reported UAS aircraft sight- ings from Nov. 13, 2014, through Aug. 20, 2015, and noted that, although most of the events were simple sightings of UAS aircraft, 27 could be considered near-midair collisions (ASW, 10/15, p. 30). A number of the events involved small UAS aircraft being flown in restricted airspace. Whitaker said that — unlike SkyPan, which he said “knowingly conducted dozens of un- authorized flights” — many operators of these small UAS are “completely new to the aviation experience” and, as such, “unaware that they are operating in shared airspace.” He added, “The vast majority of these opera- tors do not have the basic aviation training or experience required for pilots of traditional aircraft. They have no knowledge that they may be flying in controlled airspace. Some may have no recognition that their actions could have serious consequences. They are simply having
fun with a toy.” | Dreamstime.com © Zhukovsky
38 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2015 © SamiVector | VectorStock.com Washington area. inanational flown craft had been park inthe ninththe in2015that time an unmanned air that, to knowledge, their incident the marked report quoted U.S. the Park Police as saying cited by and police facesapossible fine.The said that operator the of quadcopter the was after subcommittee the hearing. News reports aircraft crashed near White the House two days —an areaAirport where unmanned asmall of15 mi(24km) Reagan Washington National well as other sensitive areas, including within such games as football and outdoor concerts, as unmanned aircraft to large public gatherings Zone campaign remind operators not to take manned aircraft. manned aircraft, with an emphasis on avoiding guidance on responsible the operation of un- Before You Fly program, to designed provide UAS have joined forced forces for Know the senting operators of aircraft model and small why our emphasis on has education.” been where that is strike coming from is …which pilot the strikes, with laser usually knows exactly tell us where operator the is. If you contrast that tell us where UAS the [aircraft] is, but don’t they penalty. …If you at look pilot the reports, they It’s less aquestion of authority or magnitude of issuethis is locating actually UAS operators. authority to punish rogue operators. thatdetermined problem the is not alack of inprohibitedflown airspace and that have they operators of unmanned aircraft that are being ing authority their to and identify penalize FAA and other government agencies are- review some makes level certainly sense.” organization “understand that registration at of Model Aeronautics, said that members of his ernment and regulatory affairs for Academy the have made. Rich Hanson, been director of gov- forcalling registration of UAS, but no decisions ker said that FAA the is considering proposals FLIGHTSAFETY.ORG Other programsOther such as No the Drone The FAA and organizations several repre- Instead, he said, “One of challenges the with Whitaker told subcommittee the that the In response to lawmakers’ questions, Whita- |
WORLD AEROSAFETY 1 | NOVEMBER 2015 - of Model Aeronautics says. fencing features into aircraft, their Academy the aircraftmodel have to incorporate begun geo- are off-limits to UAS Manufacturers flight. of ing system information to establish areas that of use the geo-fencing position —using- global and at Whitaker airports, which said. details, including tested be system the when will said. users’ right to operate aircraft,” their Mengucci airspace supporting while responsible UAS drones near U.S. airports.” airspace from inadvertent or misuse of unlawful ground-based operators, inorder to protect andly identify detect, track UAS …and their with FAA the “provides aproven way to passive- operations for CACI, said that agreement the able hazard.” nearflown abusy presents airport “an unaccept- reported unmanned seeing aircraft nearby.” flying increasing number of instances where pilots have Whitaker said, “and we are concerned about the operatedbeing of within 5nm(9km) airports. system, using it to unmanned identify aircraft company’sthe prototype UAS sensor-detection CACI firm technology International to evaluate it has reached an agreement with information not sufficient, FAA the be that said inOctober He evaluate that added will agency also the are working still Officials program to finalize The program help “will ensure asafe, shared John Mengucci, CEOand president of U.S. The FAA that added an unmanned aircraft “Safety is always FAA’s the top priority,” educational the Because efforts alone might UNMANNEDAIRCRAFT ‘have noknowledge flying in controlled these smallUAS … Many operators of that they may be airspace.’ |
39 UNMANNEDAIRCRAFT
The CACI program is part of the UAS Path- could be operated only during daylight, only finder Program, announced by the FAA earlier within the operator’s line of sight, at altitudes this year as a plan for the agency and the industry no higher than 500 ft and at speeds no faster to “explore the next steps” in UAS operations. than 100 mph (161 kph). The FAA’s other partnerships in the Path- The proposed rule also said that UAS opera- finder Program are with three companies, tors would be required to be at least 17 years old, including CNN, which is determining how UAS pass an initial FAA aeronautical knowledge test might be used within the operator’s line of sight and recurrent tests, obtain an unmanned aircraft in newsgathering operations in urban areas. operator certificate with a rating for small UAS The two other partnerships involve flights of aircraft and be vetted by the Transportation unmanned aircraft in rural areas: Security Administration. The proposal included the FAA’s request •• PrecisionHawk, which is exploring how for public comments on whether the agency UAS flights “outside the pilot’s direct The FAA’s regulatory should establish a new category for “micro” UAS vision” might allow for expanded use of — systems with aircraft weighing less than 4.4 unmanned aircraft in monitoring agricul- framework ‘needs lb (2.0 kg) — that could be flown only in Class tural crops; and, G uncontrolled airspace and only if they are at to keep pace with •• BNSF Railroad, which is determining how least 5 nm from any airport. technology.’ unmanned aircraft might be used beyond The final rule will not apply to model the operator’s line of sight to inspect rail aircraft operators, who are subject to another infrastructure. law that requires them to avoid interfering with manned aircraft, to keep their models within Regulatory Framework the operator’s line of sight at all times and to fly In his testimony, Whitaker said that the FAA’s them only for recreational purposes. Operators regulatory framework “needs to keep pace with of model aircraft who fly their aircraft within 5 technology” and that, to accomplish that goal, nm of an airport must notify the airport opera- the agency was continuing to review 4,500 pub- tor and air traffic control tower. lic comments on its proposed small UAS regula- Whitaker told the subcommittee that the tions in preparation for issuing final rules. timing of the subsequent development of rules “The rulemaking approach we are using for larger UAS would depend on commercial seeks to find a balance that allows manufactur- demand and technology. ers to innovate while mitigating safety risks,” “The primary goal of the FAA is to integrate Whitaker said. “We also recognize the need to this new class of aircraft and their operators be flexible and nimble in how we respond to safely and efficiently into the NAS, regardless the emerging UAS community. As technolo- of whether the operations are recreational or gies develop, and as operations like beyond commercial in nature,” he said. “Because this line of sight are researched, we want to be new branch of aviation is changing at the pace of able to move quickly to safely integrate these human imagination, the FAA believes a flex- capabilities.” ible framework is imperative. … Our goal is to The FAA has said that it expects to issue a provide the basic rules for operators, not iden- final rule in 2016. That rule, first proposed in tify specific technological solutions that could February, will apply only to small UAS aircraft quickly become outdated.” — those that weigh less than 55 lb (25 kg) — and is designed to allow routine use of small Note UAS in the aviation system. 1. Hermann, Peter; Norwood, Candice. “Police Cite Under the proposed rule, small UAS air- District Man After Drone Lands on Ellipse Near craft being flown for non-recreational purposes White House.” The Washington Post. Oct. 9, 2015.
40 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2015 SINGAPORE AVIATION SAFETY SEMINARS Save the Date
SASSSingapore Aviation Academy March 14–18, 2016
Maintenance and Engineering Seminar March 14–15, 2016
Safety Management Information and Sharing Seminar March 16, 2016
Flight Operations Seminar March 17–18, 2016
The Singapore Aviation Safety Seminars (SAAS) are organized annually by the Flight Safety Foundation and Singapore Aviation Academy. The objective of the multi-day events are to bring together aviation safety professionals from civil aviation authorities, air navigation service providers, airlines, maintenance, repair and overhaul organizations (MROs) and airports to discuss the latest safety challenges and issues. The seminars will include a Maintenance and Engineering Safety Seminar on March 14–15, 2016; a Safety Management Information and Sharing Seminar on March 16 (complimentary); and a Flight Operations Safety Seminar on March 17–18. Participants are invited to attend any one event or combination of events. For further information please visit: <flightsafety.org/meeting/singapore-meetings-2016> HUMANFACTORS
Aeromedical group endorses sleep apnea screening for the most obese pilots.
BY LINDA WERFELMAN
42 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2015 Composite: Susan Reed Sleeping man: @ Aleutie|Vectorstock Suit jacket: © viktorijareut|Vectorstock the Aerospacethe Medical Association (AsMA). report that was approved as aposition paper of mance,” ateam of said ina specialists sleep cognitive performance and daytime perfor arewho found to have disorder. the S tors (such as obesity) were present before the dent, captain the with severe OSA. was diagnosed controller and turned back to Hilo. response. After 18minutes, crew the contacted a toedly contact crew flight but the received no on incident, the control air traffic repeat tried - Transportation Safety (NTSB) Board report According26 nm(48km). to U.S. the National Honolulu to Hilo, Hawaii, and Hilo overflew by fell asleep during amidmorning from flight offirst officer ago! Bombardier CL-600 both Feb. 13,2008,incident captain the inwhich and accident reports. mentionedder has occasionally been inofficial causal factor inan aviation accident, disor the that, although named OSA has never as been a of data,” pilot-specific report the said, adding motor vehicle accidents, but there is “a paucity at or just over 40. weighed 245lb would (111kg);both have BMIs 295 lb (134kg)or 5-in(1.7-m)pilot a5-ft who example, pilot weighed (2-m-tall) who a6-ft-tall with a BMIof at least 40.That would mean, for “morbidly obese” category —that is, those requiredbe for pilots BMIs whose are inthe Performance sue of AsMA’s Aerospace Medicine and Human of apnea” sleep “Calculating (see BMI,” p. 44). count aperson’s height and weight] and presence mass index, agauge of fat body that into takes ac- strong relationship elevated between BMI[body FLIGHTSAFETY.ORG OSA is “strongly associated with impaired “Symptoms (such as snoring) and risk fac- The NTSB report said that, after soon inci the - As an example, AsMA the report cited a Studies have found that OSAplays arole in The report, published September inthe is- In turn, report the said, is avery “There tive apnea sleep (OSA)and to treat those screen extremely pilots obese for- obstruc have revived acontroversial proposal to and insleep aviationpecialists medicine | , said that OSA screening should
WORLD AEROSAFETY | NOVEMBER 2015 2 - 1 - conducting an “integrated assessment” of apilot’s examiners, on calling to them screenfor OSAby that plan, and instead issued guidance to medical (ASW for OSAbefore receiving certificate amedical andspecialists required to undergo treatment scores of 40or more should referred be to sleep pilot BMIof andthe every that pilots with BMI examinerscal should required be to calculate U.S.the air federal surgeon, said that FAA- medi proposal Fred in2013when policy Tilton, then likely should undergo screening.” morbidly and obese inwhom OSAis highly debatedbeing and refined, individuals are who screening of general the pilot population is population. While approach the to optimal the consideredbe [morbidly inthis pilot] obese that screening and treatment for OSA should less cognitivelybe demanding) strongly suggests from motor the vehicle data (asetting likely to BMI of more than report 30,the said. for commercial driver license candidates with a Administrationty recommended OSAscreening risk forcreased accident.” atraffic with OSAwere diagnosed had “at been in- noncommercial drivers found that who those accidents, adding that of areview 40studies of studied morebeen frequently inmotor vehicle The AsMA report said that apnea sleep has Motor VehicleData the FAAthe said. not listed as afactor inany of accidents, those pilot’sthe background. medical Sleep apnea was including 32fatal accidents, as present being in in its reports on 34accidents and incidents, indicatedtabase that apnea sleep was mentioned (FAA) has said that an analysis of NTSB’s the da asleep during incident the flight.” daytime fatigue and contributed to his falling order “likely caused chronic himto experience incident,” NTSB the said, adding that dis the - By early FAA 2015,the had backed away from Similar reasoning was paired with asimilar The AsMA report said that “extrapolation In U.S. 2008,the Federal Motor Safe Carrier - The U.S. Federal Aviation Administration , 2/14,p. 34). 3 HUMANFACTORS - |
43 HUMANFACTORS
medical history, symptoms and clinical findings OSA Risk Factors and not by relying solely on the pilot’s BMI. A number of factors put people at risk of The FAA requires pilots who have been developing OSA, including smoking tobacco; diagnosed with OSA to obtain medical certifi- drinking alcohol; being male, black, overweight cates by special issuance — a requirement that is or between the ages of 18 and 60; having chronic satisfied after the pilot demonstrates, usually by nasal congestion; and having a large neck (with submitting sleep records and other information a circumference greater than 17 in [43 cm] for about what action he takes to eliminate daytime men or 16 in [41 cm] for women). At the top sleepiness, that the disorder does not interfere of the list, however, is overweight or obesity, with performance of pilot duties. which the AsMA report described as “the most important modifiable risk factor for developing Risk Factors obstructive sleep apnea.” The authors of the new report endorsed by About half of all people with OSA are over- AsMA said their conclusions were based on weight, the Mayo Clinic said, adding that depos- a review of major risk factors for sleep apnea, its of fat around the upper airway may obstruct as well as treatment of the disorder and infor- breathing. Nevertheless, not everyone with OSA mation about its effects on “performance in is overweight, and the disorder also occurs in transportation-related occupations.” thin people, the clinic said. OSA — the most common form of sleep apnea — occurs when muscles in the throat ‘Nearly Universal’ relax enough to block the airway, interrupting The AsMA report, however, noted that, among breathing for 10 to 20 seconds at a time. These people with BMIs of 40 or higher, sleep apnea interruptions may lower the oxygen level in the is “nearly universal,” citing data that show the blood. The brain “senses this impaired breath- ing and briefly rouses you from sleep so that you can reopen your airway,” the Mayo Clinic says in Calculating BMI its discussion of OSA.4 “This awakening is usu- ally so brief that you don’t remember it.” ody mass index (BMI) — a widely used method of measuring The interruptions can occur 30 times or overweight and obesity — is determined by using an online more an hour, preventing normal restorative Bcalculator1 or by dividing weight in kilograms by height in meters sleep and increasing the likelihood of sleepiness squared, or weight in pounds by height in inches squared and multi- during normal waking hours. plying by a conversion factor of 703. Someone with a BMI between 18.5 and 24.9 is considered to be People with OSA “often experience severe at a normal weight. Those below 18.5 are considered underweight. A daytime drowsiness, fatigue and irritability,” the person is considered overweight with a BMI between 25.0 and 29.9, or Mayo Clinic says. “They may have difficulty con- obese if the BMI is 30.0 or higher. An additional category of morbidly centrating and find themselves falling asleep at obese applies to BMI scores of 40 and higher. work, while watching TV or even when driving.” For example, a pilot who is 6 ft (2 m) tall and weighs 175 lb (79 OSA causes “significant stress” on the cardio- kg) would have a normal BMI of 23.7. At 195 lb (88 kg), he would have a BMI of 26.4, in the overweight category; at 230 lb (104 kg), his vascular system, with the heart rate and blood BMI would be 31.2 and he would be considered obese; and at 300 lb pressure increasing during the sleep interruptions (136 kg), he would have a BMI of 40.7 and be considered morbidly and decreasing to normal levels as the person obese. goes back to sleep, the AsMA report says. “This —LW may ultimately result in hypertension [high blood Note pressure], congestive heart failure and other 1. Online BMI calculators are available on many health-related websites, cardiovascular complications.” Among those including the U.S. National Institutes of Health at
44 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2015 © designer491|Adobe Stock FLIGHTSAFETY.ORG |
WORLD AEROSAFETY by and aspecialist “can in to only rule used be laboratory test, sleep require they interpretation Although home tests are less expensive than a an at-home test developed for has been OSA. brain activity, and movement. monitor patient’s the breathing, pulse, and heart study —an overnight session sleep to designed often who specialist, recommendssleep asleep typically are sent for evaluation clinical by a among symptoms the of OSA. pressure,ence of blood high of both are which such factors as morning headaches and pres the - problem. is considered, The BMIalso along with andwaking daytime whether sleepiness is a snores loudly, he feels whether refreshed upon answering questions about he or whether she general physical examination, with patient the tween 1980and 2008.” increased from 6[percent] to 12percent- be [percent] to 34percent, and … of obese being [according to BMIcriteria] increased from 25 “Worldwide, prevalence the of overweight being report said, citing U.S. and worldwide data. rising atbeen arapid rate since 1980s,” the the group. disorder inan estimated 98percent of that | NOVEMBER 2015 The AsMA report said that inrecent years, People initially found at risk of high OSA Screening for during OSAusually begins a weight“Body general inthe population has Notes 4. 3. 2. 1. occupationalern environment.” apnea reasonably can be managed- mod inthe and follow-up risks associated …the with sleep objective,” AsMA said. “With proper screening that prevent high-quality is sleep an achievable personnel arethese from free treatable disorders quality situations, inall sleep ensuring that occupation from receiving consistent, high- may prevent person inasafety-sensitive every oral designed appliance.a specially erate apnea sleep —involve or of surgery use the fortypically designed people to- with mild mod toflow is designed keep open. airway the goldthe standard” for OSAtreatment. The air nose, or and nose the both mouth —“remains tube and into amask that covers patient’s the blowsdevice asteady stream of air through a pressureairway (CPAP) therapy a —inwhich ever, treatment prescribed. can be again laboratory.” inthe test means that patient the must process the start apnea,”sleep report the said. “A negative home
2015.
Aerospace Medicine . 45 DATALINK BY LINDA WERFELMAN Rising Fatalities Boeing’s annual commercial aviation accident data show a jump in fatalities in 2014, with a total still below the 10-year average. estern-built commercial jets were August, Boeing noted three fatal accidents, two involved in 29 accidents in 2014, down of which killed a total of 278 people — everyone from 31 the previous year, but the in both airplanes. In the third accident, a Boeing number of fatalities more than quadru- 737 landing in Libreville, Gabon, struck and Wpled to 279, up from 62 in 2013 (Table 1), accord- killed a person on a runway; all 137 passengers ing to data from Boeing Commercial Airplanes.1,2 and crewmembers survived. In its annual Statistical Summary of Com- Malaysia Airlines Flight 370, a Boeing 777 mercial Jet Airplane Accidents, published in that disappeared during a March 8 flight from Kuala Lumpur, Malaysia, to Beijing with 239 people aboard, did not meet Boeing’s defini- 10-Year Accident Rates, by Type of Operation, Worldwide Commercial Jet Fleet, 2005–2014 tion of an accident and was not included on the list.3 Debris from the 777 has washed ashore on Réunion Island, but the main wreckage has not Fatal accident rate been found. 1.59 Hull loss accident rate The 2014 fatality count of 279 compared with an annual average of 399 over the previ- ous 10-year period (from 2004 through 2013), Boeing said. 0.73 Of the 29 accidents, Boeing classified three 0.58 0.56 as major — a classification that means “the 10-year accident rate accident 10-year (per million departures) 0.28 0.32 airplane was destroyed, [or] there were multiple fatalities, [or] there was one fatality and the air- plane was substantially damaged.” Ten accidents All other operations* Total Scheduled commercial were considered hull loss accidents — accidents passenger operations 33.9 million departures 225.9 million departures 192.0 million departures in which an airplane is “totally destroyed or damaged and not repaired” — compared with a * Charter passenger, charter cargo, scheduled cargo, maintenance test, ferry, positioning, training and demonstration flights. 10-year average of 17 per year. During the most recent 10-year period, from Source: Boeing Commercial Airplanes 2005 through 2014, there were 404 accidents, Figure 1 including 165 hull loss accidents and 72 fatal 46 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2015 DATALINK 2014 Airplane Accidents, Worldwide Commercial Jet Fleet Event Model Type of Accident Phase of Damage Date Airline (Age in Years) Operation Location Flight Event Description Category Jan. 5 Saudia 767-300(17) 1 Medina, Landing The airplane landed with right main landing gear retracted. There were Substantial Saudi Arabia injuries during the evacuation. Jan. 5 Air India A320 (20) 1 Jaipur, India Landing While landing in dense fog, the airplane veered off the runway and Substantial collided with an object. There were no injuries. Jan. 18 Aeronaves TSM DC-9 (46) 2 Saltillo, Mexico Landing The nosewheel landing gear collapsed during landing, and the airplane Substantial veered off the runway. Minor injuries were reported. Jan. 26 Airwork NZ 737-300 (26) 2 Honiara, Landing The right main landing gear collapsed during landing. There were no Substantial Solomon Islands injuries. Feb. 1 Lion Air 737-900ER (7) 1 Surabaya, Landing The airplane sustained damage during a hard landing. Substantial Indonesia Feb. 2 East Air A320 (20) 1 Kulob, Tajikistan Landing The airplane landed on a poorly prepared runway and struck a snow Substantial bank; the nosewheel landing gear collapsed. There were no injuries. Feb. 17 Jet2.com Ltd. 737-800 (15) 1 Funchal, Landing A tail strike occurred during landing. There were no injuries. Substantial Portugal Feb. 17 Ural Airlines A321 (14) 1 Dubai, United Load/ A ground vehicle collided with the A321 while the passenger door was Minor Arab Emirates Unload open, causing a flight attendant to fall from the airplane. Feb. 22 Travel Service 737-800 (2) 1 Terceira, Landing The airplane was damaged during a hard landing in gusting winds. Substantial Portugal There were no injuries. March 4 LAN Airlines A320(11) 1 Buenos Aires, Taxi The airplane’s tail was struck during taxi by the wingtip of another Substantial Argentina airplane. There were no injuries. March 13 US Airways A320 (14) 1 Philadelphia, Takeoff The airplane contacted the runway during a rejected takeoff, and the Substantial U.S. nosewheel landing gear collapsed; the airplane veered off the runway. There were no injuries. March 28 Avianca F-100 (21) 1 Brasília, Brazil Landing The crew was unable to extend the nosewheel landing gear due to a Substantial hydraulic failure. There were no injuries. April 11 Kenya Airways ERJ 190 (2) 1 Dar es Salaam, Landing The airplane veered off the runway during landing; both engines failed. Substantial Tanzania There were injuries during the evacuation. April 29 Air Contractors 737-400 (24) 2 East Midlands, Landing The left main landing gear collapsed during landing. There were no Substantial (Ireland) Ltd. United Kingdom injuries. May 8 Ariana Afghan 737-400 (21) 1 Kabul, Landing The airplane overran the end of the runway and came to a stop; all Destroyed* Airlines Afghanistan landing gear collapsed. There were no injuries. May 9 Avior Airlines 737-400 (25) 1 Panama City, Takeoff During a high-speed rejected takeoff, tires burst and mechanical parts Substantial Panama separated from the airplane. There were no injuries. May 10 Iran Aseman F-100 (21) 1 Zahedan, Iran Landing The left main landing gear would not extend on approach, and the crew Substantial Airlines conducted a partial gear-up landing. There were minor injuries during the evacuation. May 10 IRS Airlines F-100 (24) 3 Kano, Nigeria Landing The nosewheel and right main landing gears failed during an Substantial emergency landing in the desert. There were no injuries. May 12 Aegean Airlines A320 (6) 1 Moscow, Russia Load/ After removal of the stairs, a flight attendant stepped out to close the None Unload passenger door and fell from the airplane. June 20 Omni Air 767-300 (15) 4 Kabul, Landing A tail strike occurred during a hard landing. There were no injuries. Substantial International Afghanistan June 28 Ryanair 737-800 (8) 1 Stansted, United Tow During pushback, the 737’s tail was struck by the wingtip of another Substantial Kingdom airplane. There were no injuries. July 7 AirAsia A320 (4) 1 Bandar Seri Landing During landing, the A320 veered off the runway onto soft ground, and Substantial Begawan, Brunei both engines ingested mud. There were no injuries. July 17 Eastern SkyJets 737-300 (23) 1 Libreville, Landing During landing, the airplane struck and killed a person on the runway. None† Gabon All 137 people in the airplane survived. July 24 Swiftair MD-83 (18) 1 Gao, Mali Cruise In cruise, the crew lost control of the airplane and it struck the ground, Destroyed*† killing all 116 people on board. Nov. 7 Ariana Afghan 737-400 (21) 1 Kabul, Landing The main landing gear collapsed during landing. There were no injuries. Substantial Airlines Afghanistan Nov. 24 Cargolux 747-8F (3) 5 Libreville, Landing The airplane was damaged in a hard landing. There were no injuries. Substantial Airlines Gabon Dec. 28 PT. Indonesia A320 (6) 1 Java Sea Cruise In cruise, the crew lost control of the airplane and it struck the Java Sea, Destroyed*† AirAsia killing all 162 people on board. Dec. 30 Shaheen 737-400 (21) 1 Lahore, Pakistan Landing The airplane struck a bird during landing and ran off the side of the Substantial International runway; the left main landing gear collapsed. There were no injuries. Dec. 30 Zest Airways Inc. A320 (8) 1 Kalibo, Landing The A320 overran the runway during landing and the landing gear sank Substantial Philippines into soft ground. There were no injuries. 29 total accidents; 278 onboard fatalities; 1 external fatality Type of operation: 1 = scheduled passenger 2 = scheduled cargo 3 = charter passenger 4 = positioning 5 = charter cargo * Major accident † Fatal accident Source: Boeing Commercial Airplanes Table 1 FLIGHTSAFETY.ORG | AEROSAFETYWORLD | NOVEMBER 2015 | 47 DATALINK Accidents, Worldwide Commercial Jet Fleet, by Type of Operation On-board Fatalities All Accidents Fatal Accidents (External Fatalities)* Hull Loss Accidents Type of operation 1959–2014 2005–2014 1959–2014 2005–2014 1959–2014 2005–2014 1959–2014 2005–2014 Passenger 1,501 327 493 56 29,165 (792) 3,888 (124) 704 118 Scheduled 1,380 302 447 53 25,039 3,872 634 111 Charter 121 25 46 3 4,126 16 70 7 Cargo 265 65 79 13 273 (342) 41 (15) 178 39 Maintenance test, ferry, positioning, 124 12 44 3 208 (66) 17 (0) 76 8 training and demonstration Totals 1,890 404 616 72 29,646 (1,200) 3,946 (139) 958 165 U.S. and Canadian operators 564 75 182 12 6,202 (381) 26 (7) 227 25 Rest of the world 1,326 329 434 60 23,444 (819) 3,920 (132) 731 140 Totals 1,890 404 616 72 29,646 (1,200) 3,946 (139) 956 165 *External fatalities include ground fatalities and fatalities on other aircraft involved, such as helicopters or small general aviation airplanes, that are excluded. Source: Boeing Commercial Airplanes Table 2 departures (Figure 1, Accidents, by Injury and Damage, Worldwide Commercial Jet Fleet p. 46). For scheduled commercial passen- 1959 through 2014 Total 1,890 616 fatal accidents 1,274 non-fatal accidents ger operations, the (33% of total) (67% of total) rates were slightly 501 accidents with hull loss 457 hull loss accidents lower — 0.58 acci- 27 accidents with 751 substantial damage accidents dents and 0.28 fatal substantial damage accidents without accidents without substantial accidents per million substantial damage damage (but with serious injuries) departures. 0 100 200 300 400 500 600 700 800 900 1,000 1,100 1,200 1,300 1,400 1,500 1,600 1,700 1,800 1,900 From the time Number of accidents Boeing’s data collec- 2005 through 2014 Total 404 tion began in 1959 72 fatal accidents 332 non-fatal accidents (18% of total) (82% of total) through 2014, there 62 accidents hull loss 103 hull loss accidents were 1,890 accidents, 3 accidents with including 958 hull 207 substantial damage accidents substantial damage losses and 616 fatal 7 accidents without 22 accidents without substantial substantial damage damage (but with serious injuries) accidents (Figure 2). Breaking down 0 100 200 300 400 Number of accidents accidents accord- ing to terminology Source: Boeing Commercial Airplanes developed by the U.S. Figure 2 Commercial Aviation Safety Team (CAST) accidents that killed 3,946 passengers and crew- and the International Civil Aviation Organiza- members and 139 people on the ground, Boeing tion (ICAO), the data showed that 17 accidents said (Table 2). from 2005 through 2014 resulted from loss of The data showed that the accident rate for control–in flight — a greater number than were that period was 0.73 per million departures, attributed to any other cause (Figure 3). Sixteen and the fatal accident rate, 0.32 per million accidents each were attributed to controlled 48 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2015 DATALINK flight into terrain and Fatalities by CAST/ICAO Taxonomy Accident Category, to runway excur- Worldwide Commercial Jet Fleet, 2005–2014 sions on landing — a category that includes 2,000 On-board fatalities [Total 3,946] the subcategories 1,800 | , External fatalities [Total 139] of abnormal run- 1,600 way contact and 1,400 1,200 undershoot/ overshoot. 1,000 | | Six additional runway Fatalities 800 excursion accidents 600 occurred during take- 400 | | | 200 153 12 | | off, the report said. | | | | 0 The data also LOC-I CFIT RE UNK SCF-PP MAC OTHR WSTRWRE RAMP RI-VAPF-NI showed that, in (Landing) + (Takeo ) ARC + USOS 2005 through 2014, Number of fatal accidents nearly half of all fatal (72 total) 23161617 122 1273 accidents occurred CAST = U.S. Commercial Aviation Safety Team; ICAO = International Civil Aviation Organization; ARC = abnormal runway during final approach contact; CFIT = controlled flight into terrain; F-NI = fire/smoke (non-impact); LOC-I = loss of control – in flight; MAC = midair/ and landing — sig- near-midair collision; OTHR = other; RAMP = ground handling; RE = runway excursion; RI-VAP = runway incursion – vehicle, aircraft or person; SCF-PP = system/component failure or malfunction (powerplant); UNK = unknown or undetermined; USOS = nificantly more than undershoot/overshoot; WSTRW = wind shear or thunderstorm. any other phases of No accidents were noted in the following principal categories: aerodrome; abrupt maneuver; air traffic management/ communications, navigation, surveillance; bird strikes; cabin safety events; evacuation; external load-related occurrences; fire/ flight. Seventeen fatal smoke (post-impact); fuel related; ground collision; icing; low altitude operations; loss of control – ground; runway incursion – accidents (24 percent) animal; security related; system/component failure or malfunction (non‑powerplant); turbulence encounter; wildlife. during that period Note: Principal categories are as assigned by CAST. Airplanes manufactured in the Commonwealth of Independent States or the Soviet Union are excluded because of lack of operational data. Commercial airplanes used in military service are also excluded. occurred during final Source: Boeing Commercial Airplanes approach, and another 17 occurred during Figure 3 landing, the report Operations 1959–2014. August 2015. FLIGHTSAFETY.ORG | AEROSAFETYWORLD | NOVEMBER 2015 | 49 Basic Aviation Risk Standard Many organizations engage the services of aircraft operators to provide support for their activities. These include the transportation of government or company personnel, exploration and survey, humanitarian, medevac and other activities that often involve operations within remote and challenging environments. The Basic Aviation Risk Standard (BARS) is designed to assist any organization that uses contracted aviation services to support their activities with the management of aviation risk for their people. For more information, contact the BARS program o ce or visit our website. BARS Program O ce Flight Safety Foundation ® GPO Box 3026 Headquarters: Melbourne VIC 3001 Australia 801 N. Fairfax Street, Suite 400 Tel.: +61 1300 557 162 Alexandria, Virginia U.S. 22314-1774 Fax: +61 1300 557 182 Tel.: +1 703.739.6700 bars@ ightsafety.org Fax: +1 703.739.6708 ightsafety.org/bars ightsafety.org ONRECORD Cabin Fire Traced to ELT Short circuit caused a thermal runaway of the emergency locator transmitter’s lithium battery. BY MARK LACAGNINA The following information provides an awareness of problems that might be avoided in the future. The in- formation is based on final reports by official investigative authorities on aircraft accidents and incidents. JETS Crossed Wires There were no injuries, but “the aircraft Boeing 787-8. Substantial damage. No injuries. suffered extensive heat damage in the upper fter an early morning landing at London portion of the rear fuselage, in an area coinci- Heathrow Airport on July 12, 2013, the 787 dent with the location of the emergency locator Awas towed to another stand in preparation transmitter (ELT),” the report said. “The absence for a scheduled flight later that day. The ground of any other aircraft systems in this area con- handling agent turned off ground power at the taining stored energy capable of initiating a fire, stand’s control box but did not disconnect the together with evidence from forensic examina- power cables from the aircraft. However, an en- tion of the ELT, led the investigation to conclude gineer aboard the aircraft confirmed that ground that the fire originated within the ELT.” power no longer was available to the 787. Investigators found wires crossed and The engineer secured the aircraft and trapped beneath the ELT battery compartment disembarked at 0730 local time. About eight cover plate. They concluded that contact be- hours later, an employee in the air traffic control tween one of the wires and the cover plate likely (ATC) tower saw smoke emanating from the created a short circuit that caused one of the five aircraft and activated the crash alarm. cells in the lithium manganese dioxide (non- About one minute after the alarm was rechargeable lithium metal) battery to discharge sounded, aircraft rescue and fire fighting rapidly. (ARFF) personnel arrived and sprayed water “Neither the cell-level nor battery-level and foam on the aircraft. “One fire fighter re- safety features prevented this single-cell failure, moved the power umbilical cables from the air- which propagated to adjacent cells, resulting in a craft as a precaution,” said the report by the U.K. cascading thermal runaway, rupture of the cells Air Accidents Investigation Branch (AAIB). and consequent release of smoke, fire and flam- ARFF personnel encountered thick smoke mable electrolyte,” the report said. inside the aircraft and saw signs of a fire be- The flames caused the resin within the com- tween two overhead luggage bins near the rear posite fuselage crown near the vertical stabilizer of the cabin. They removed some ceiling panels to decompose and ignite. The slow-burning and doused the fire with water. fire continued to propagate after the energy FLIGHTSAFETY.ORG | AEROSAFETYWORLD | NOVEMBER 2015 | 51 ONRECORD from the battery thermal runaway was Indicated airspeed was 13 kt braking, but the brake pedals felt exhausted, the report said. above the reference landing speed at ‘hard’ and would not move,” the report AAIB safety recommendations 50 ft, and a 10-kt tail wind increased from the U.S. National Transportation based on the investigation led to groundspeed further to 163 kt. “This Safety Board (NTSB) said. The copilot several industry actions, including op- particular condition was classified as an also attempted unsuccessfully to apply erator bulletins by Boeing and Honey- unstabilized approach and requires the manual braking. well, the ELT manufacturer, calling for pilot to go around,” the report said. “The pilot felt that he had to stop inspections of 787 ELT battery wiring. The crew continued the approach, and could not go around,” the report The bulletins subsequently were in- and the 737 bounced once on touch- said. He engaged the emergency brak- corporated in airworthiness directives down. The pilot deployed the thrust ing system but found that it, too, was issued by U.S. and European aviation reversers but did not feel the aircraft ineffective. “Examination of airport authorities. decelerate. He disengaged the au- security camera images and decelera- The U.S. Federal Aviation Admin- tobrake system and applied manual tion values (determined by using time, istration (FAA) and other aviation braking. Investigators determined that distance and velocity calculations) in- authorities also launched a safety re- the deceleration rate then began to dicated that the airplane’s deceleration view of lithium-powered ELTs in other decrease. was consistent with a lack of braking,” aircraft models and the certification The 737 stopped with its main the report said. standards for the devices. landing gear on the edge of the de- The Citation ran off the end of the parture end of the 7,382-ft (2,250-m) 4,801-ft (1,463-m) runway and came to Approach Briefing Omitted runway, and the nose landing gear sank a stop after entering a 340-ft (104-m) Boeing 737-400. Minor damage. No injuries. into soft terrain. No one was hurt, and engineered material arresting system n route on a scheduled flight from ARFF personnel assisted the 166 oc- (EMAS). The overrun resulted in minor Jakarta to Pontianak, Indonesia, cupants in deplaning. damage to the nose landing gear, left Ethe afternoon of Oct. 19, 2012, Damage to the main landing gear main landing gear door and forward the flight crew learned from ATC that tires and white tire marks on the fuselage, but there were no injuries weather conditions at the destination runway indicated that the aircraft had among the five occupants. included heavy rain, thunderstorms, a experienced reverted-rubber hydro- “Examination of the normal hy- 1,700-ft ceiling, 6 km (4 mi) visibility planing on the wet runway. draulic braking system and antiskid and surface winds from 270 degrees The NTSC concluded that the system did not reveal any malfunctions at 5 kt. probable cause of the accident was that or failures that would have precluded The pilots selected a higher auto- “the absence of an approach briefing, normal operation of the brakes,” the brake setting (medium) but otherwise particularly on reviewing landing dis- report said. “Examination of the cock- did not conduct an approach brief- tance, might have decreased the pilot’s pit revealed that the T-handle for the ing or review their landing distance [situational] awareness.” emergency [landing] gear extension calculations before they were vectored system had been activated. This handle to join the instrument landing system Wrong Handle is located immediately to the right of approach to Runway 15, according to Cessna Citation 550. Minor damage. No injuries. the emergency braking handle and was the report by the Indonesian National he pilot said that he flew the final most likely pulled during the incident Transportation Safety Committee approach to Key West (Florida, landing instead of the emergency (NTSC). The crew reported the run- TU.S.) International Airport at 106 brake handle.” way in sight at 800 ft and were cleared kt and that the Citation touched down The report noted that the EMAS to land. “While on final approach, at 95 to 100 kt and 800 ft (244 m) from had been installed to meet FAA the pilot noticed on the navigation the approach threshold of Runway 09 requirements for a runway safety area display that the wind was calm, while the afternoon of Nov. 3, 2011. (RSA) because the proximity of a on short final the wind changed and “At touchdown, he extended the mangrove swamp precluded a standard the pilot felt the aircraft shaking,” the speed brakes, and, after traveling an- 1,000-ft (305-m) RSA off the end of report said. other 800 feet, he began to apply wheel Runway 09. 52 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2015 ONRECORD TURBOPROPS Battered by Hail established by the manufacturer. “It is likely Beech King Air F90. Substantial damage. No injuries. that the hydraulic issues allowed for a move- he aircraft was en route from Beira, Mo- ment in the landing gear shuttle valve, which zambique, to Lanseria, South Africa, the resulted in an uncommanded gear unlock and Tafternoon of Nov. 28, 2013, when the pilot subsequent collapse of the left main landing requested clearance from ATC to alter course to gear,” the report said. circumnavigate a thunderstorm. The controller approved the deviation and Mistaken Landing Site told the pilot to fly directly to Lanseria when Saab 340B. No damage. No injuries. able. After flying about 15 nm (28 km), he he weather was clear, but daylight was fad- turned toward the destination. ing as the aircraft neared Newcastle Airport “Although the aircraft was equipped with Tin Williamstown, New South Wales, Austra- weather radar and the pilot utilised it, he mis- lia, during a scheduled flight the evening of Nov. calculated the size of the storm and turned too 8, 2012. The airport tower controller cleared the soon,” said the report by the South African Civil flight crew to conduct a right traffic pattern to Aviation Authority. “The aircraft experienced Runway 12. heavy wind shear and hail. The captain previously had experienced “Once the aircraft was out of the thunder- difficulty in sighting the airport during visual storm, the pilot advised radar control that his approaches from the south and was guiding the aircraft had suffered hail damage.” He diverted first officer, the pilot flying, toward buildings he to Johannesburg and landed the King Air with- perceived as associated with the airport, accord- out further incident. ing to the report by the Australian Transport Examination of the aircraft revealed hail Safety Bureau (ATSB). damage to the wing leading edges, fuselage, pro- The buildings actually were on a coal- peller spinners and engine exhaust stacks. storage facility 6 nm (11 km) south of the airport. The facility had ground structures and Life Limits Neglected lighting features similar to the airport, as well Fairchild Metro 3. Minor damage. No injuries. as a long line of coal aligned almost identically ight visual meteorological conditions pre- with Runway 12. vailed as the Metro neared Minneapolis- The first officer became increasingly unsure NSt. Paul (Minnesota, U.S.) International of the aircraft’s position as he was guided onto Airport on a cargo flight on Nov. 9, 2012. The a right downwind leg and a right base leg, and pilot confirmed that all three landing gear transferred control to the captain. The cap- indicator lights were green before landing the tain, who “could not see the runway” but “had airplane. formed a strong belief that they were in the air- Shortly after touchdown, the left main port environment,” continued to descend while landing gear collapsed, and the airplane establishing the aircraft in landing configura- veered off the left side of the runway. Ex- tion, the report said. amination of the airplane revealed two loose Meanwhile, the approach controller had electrical connections on the landing gear continued to monitor the aircraft’s progress hydraulic power pack and “several anoma- on radar and had become concerned about lies in the hydraulic shuttle valve,” the NTSB its position and track. He called the airport report said. traffic controller and suggested that he query Investigators determined that the power the crew about their intentions. “In response to pack had not been replaced at the life limit the [tower] controller’s query if they were still FLIGHTSAFETY.ORG | AEROSAFETYWORLD | NOVEMBER 2015 | 53 ONRECORD visual, the crew responded that they had just runway lights. The crew subsequently landed ‘lost’ the runway and were continuing the right the Saab without further incident. turn,” the report said. “This occurrence highlights the possibility Using binoculars, the tower controller spot- of crews misidentifying ground features for the ted the aircraft and advised the crew that they airport environment during visual approaches, were 6 nm south of the airport. “When told they especially in conditions of poor light,” the ATSB were not at the airport, the captain immediately said. “To avoid misleading visual cues during requested radar vectors to resolve the uncer- visual approaches, crews should confirm that tainty,” the report said. they have correctly identified and are tracking to The controller suggested a heading toward the intended destination by cross-checking with the airport and increased the intensity of the the aircraft’s navigation equipment.” PISTON AIRPLANES Refueled With Jet-A climbed through 2,100 ft. The pilot was seri- Cessna 421B. Substantial damage. One serious injury, two minor ously injured and his two passengers sustained injuries. minor injuries during the subsequent forced fter a previous flight, the pilot had asked landing on a highway median. the fixed-base operator (FBO) in Lufkin, ATexas, U.S., to refuel the airplane, but he Landing Checklist Neglected did not observe the fueling. “The FBO employee Piper Chieftain. Minor damage. No injuries. who fueled the airplane … mistook it for a he pilot flying was receiving pilot-in- similar airplane that uses Jet-A [turbine engine] command supervision by another pilot fuel,” the NTSB report said. “He brought the Tduring a charter flight with seven passengers Jet‑A truck over and fueled the airplane.” to Townsville, Queensland, Australia, the after- The report said that the fuel nozzle on the noon of Jan. 9, 2015. During a visual approach, Jet-A truck had been changed to facilitate the both pilots conducted the pre-landing checks fueling of military helicopters that frequented from memory, rather than using the checklist, the airport. They were round and smaller than said the ATSB report. the J-shaped nozzles used to dispense Jet-A, ac- The pilot neglected to extend the landing cording to the report. gear. “The supervising pilot confirmed the mix- Moreover, the airplane’s filler ports had not ture, fuel pumps and landing lights had been set been fitted with restrictors, as required by an correctly, and assumed the rest of the checks had airworthiness directive intended to prevent the been similarly completed,” the report said. misfueling of piston aircraft with turbine fuel. Neither pilot recalled hearing the landing The next morning — April 17, 2015 — the gear warning horn, but investigators later found pilot signed a receipt showing that the airplane that the system was operational. had been fueled with 53 gal (201 L) of Jet-A. After the aircraft was flared for landing, both The pilot said that during his preflight inspec- pilots sensed that the landing gear did not touch tion of the airplane, the fuel samples appeared the runway as expected. The pilot initiated a to be blue, like 100LL aviation gasoline, and go-around at the same time the supervising pilot that no anomalies occurred during the engine called “go around.” run-ups. A radio antenna separated when the fuselage However, shortly after takeoff, he noticed scraped the runway, but the pilots were able to a slight vibration and decreased climb per- complete the go-around and land the Chieftain formance. Both engines lost power as the 421 without further incident. 54 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2015 ONRECORD Miscalculated Fuel Reserve airport when the right engine lost power. “The Piper Aztec. Substantial damage. No injuries. pilot feathered the right propeller, secured the he pilot departed from Destin, Florida, U.S., right engine and continued toward the planned with a partial fuel load, estimating that the destination,” the report said. “Shortly there- TAztec would have about 4 gal (15 L) of fuel after, the left engine lost total power, and the in its tanks after landing in Quincy, Illinois, on pilot feathered the propeller and secured the Oct. 26, 2014. engine.” “The pilot [later] acknowledged that he The pilot was unable to extend the landing failed to account for the 6.8 gallons [26.0 L] of gear normally and did not activate the emer- unusable fuel within the fuel system,” the NTSB gency gear-blowdown system before conducting report said. a forced landing in a soybean field. The Aztec The Aztec was descending through 3,500 was substantially damaged, but the pilot and his ft about 7 nm (13 km) from the destination three passengers escaped injury. HELICOPTERS Blinded by a Movie Light All three occupants were killed when the Bell 206B. Substantial damage. Three fatalities. JetRanger struck the riverbed. The NTSB con- he JetRanger was engaged in the filming of a cluded that the probable cause of the accident movie sequence at a ranch in Acton, Califor- was “the pilot’s decision to conduct a flight in Tnia, U.S., the night of Feb. 10, 2013. “During dark night conditions with an illuminated cock- the first flight … several of the pilot’s comments pit light that degraded his visibility and his abil- indicate that he was trying to be amenable to ity to identify and arrest the helicopter’s descent the production company’s requests, [but] he while maneuvering.” repeatedly remarked on the limited visibility and the brightness of a flexible light pad affixed to Rushed Into Clearing the center windshield frame in the cockpit,” the Robinson R44. Substantial damage. No injuries. NTSB report said. he pilot said that he radioed his position Before the second flight, in which the regularly while flying the landing pattern at helicopter was to ascend to a plateau from an TBeaumont, Texas, U.S., the evening of Sept. unlighted riverbed, the cameraman in a rear seat 15, 2014. While flaring to land at midfield, he showed the actor, who was in the left front seat, heard an airplane pilot radio that he was depart- how to operate the light pad. ing on the same runway. The light was set to its lowest brightness “The [R44] pilot attempted to depart the level for takeoff. While the helicopter was being runway area for the taxiway,” the NTSB report maneuvered over the riverbed, the actor contin- said. “As he turned the helicopter toward the ued with scripted dialogue for about a minute taxiway, he felt it ‘swing hard and turn,’ then be- until he was interrupted by the pilot, who said gin to spin. The pilot stated that he lost control that he needed the light pad turned off. and landed hard, crushing the skids.” “The camera operator acknowledged him The NTSB concluded that the probable and informed the actor to turn off the light by cause of the accident was “the pilot’s loss of tail pressing a button twice,” the report said. “The rotor effectiveness while attempting a taxiway actor cycled through the light’s settings and side-step during landing” and said that a con- eventually turned it off while the pilot stated tributing factor was “another pilot’s failure to ‘okay, okay, I can’t ….’ The camera operator ensure the runway was clear before occupying interrupted, saying ‘pull up, pull up.’” the runway for takeoff.” FLIGHTSAFETY.ORG | AEROSAFETYWORLD | NOVEMBER 2015 | 55 ONRECORD Preliminary Reports, August 2015 Date Location Aircraft Type Aircraft Damage Injuries Aug. 1 Santa Paula, California, U.S. Cessna P337G substantial 1 fatal Instrument meteorological conditions (IMC) prevailed when the Skymaster struck mountainous terrain shortly after takeoff. Aug. 1 Georgetown, Kentucky, U.S. Beech King Air C90 substantial 2 serious, 2 minor The pilot diverted to Georgetown after the right engine lost power during cruise flight. The King Air veered off the runway on landing. Aug. 7 Saranac Lake, New York, U.S. Piper Malibu Mirage destroyed 4 fatal Visual meteorological conditions (VMC) prevailed when the airplane struck terrain about 0.5 nm (1.0 km) from the runway on takeoff. Aug. 8 Vereda Guarigua Cajicá, Colombia Cessna 402B substantial 3 fatal VMC prevailed when the 402 struck terrain during a training flight. Aug. 8 Istra, Russia Cessna U206F, Robinson R44 destroyed 9 fatal The five occupants of the airplane and the four occupants of the helicopter were killed when the aircraft collided while maneuvering over a reservoir. Aug. 9 Clovis, New Mexico, U.S. Cessna 421B destroyed 1 serious The 421 struck terrain after the left engine lost power on final approach. Aug. 12 Ninia, Indonesia Pacific Aerospace 750XL NA 1 fatal, 5 serious The copilot was killed when the aircraft overran the runway while landing in strong winds. Aug. 12 Saba, Netherlands Antilles Cessna 208B destroyed 1 none The aircraft was on a cargo flight from Puerto Rico to Saint Kitts when the pilot diverted to Saba for an emergency landing. The 208 was unable to reach Saba, and the pilot ditched the aircraft offshore. Aug. 15 Charlotte, North Carolina, U.S. Airbus A321-231 substantial 159 none The A321 struck approach lights and experienced a tail strike after encountering wind shear on final approach. The flight crew conducted a go-around and subsequently landed the airplane without further incident. Aug. 16 Cape Town, South Africa Cessna 441 destroyed 5 fatal Marginal VMC prevailed when the air ambulance struck a mountain on approach. Aug. 16 Oksibil, Indonesia ATR 42-300 destroyed 54 fatalities IMC prevailed when the aircraft struck a mountain while descending to land at Oksibil. Aug. 16 San Diego, California, U.S. Sabreliner 60SC, Cessna 172M destroyed 5 fatal The pilots and two passengers aboard the Sabreliner, and the pilot of the 172 were killed when the airplanes collided in VMC about 1 nm (2 km) northeast of Brown Field. Aug. 20 Dubnica, Slovakia Let 410MA, Let 410UVP destroyed 5 fatal, 15 none Fifteen skydivers were able to bail out, but both pilots and three other skydivers were killed when the aircraft collided during an airshow practice flight. Aug. 23 Les Bergeronnes, Quebec, Canada de Havilland Beaver destroyed 6 fatal VMC prevailed when the Beaver descended out of control and struck mountainous terrain during a sightseeing flight. Aug. 26 Charallave, Venezuela Cessna Citation SII destroyed 8 NA The flight crew rejected their first landing attempt and then touched down at about the midpoint of the 2,000-m (6,562-ft) runway. The Citation overran the runway and traveled down an embankment. No fatalities were reported. Aug. 28 Wamena, Indonesia Boeing 737-300 substantial 2 none The freighter touched down short of the runway and came to a stop on a taxiway. Aug. 28 Aguni, Japan Viking Air Twin Otter substantial 14 NA Some of the occupants sustained minor injuries when the aircraft veered off the 800-m (2,625-ft) runway and struck a fence and trees while landing. Aug. 28 Cheyenne, Wyoming, U.S. Robinson R44 substantial 3 serious, 3 minor A low-rotor-speed warning was generated during approach, and the R44 touched down hard while landing. Aug. 29 Casale Monferrato, Italy Technoavia SM-92 destroyed 11 NA All the occupants were injured, some seriously, when the single-turboprop struck terrain after an engine problem occurred on initial climb. Aug. 29 Kaduna, Nigeria Dornier 228-212 destroyed 7 fatal The aircraft, operated by the Nigerian air force, crashed into a house shortly after takeoff. NA = not available This information, gathered from various government and media sources, is subject to change as the investigations of the accidents and incidents are completed. 56 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2015 Save the Date and Don’t Miss the Beat of BASS2016 from the Live Music Capital of the World For details, visit our website at <flightsafety.org/BASS2016>