ON COMMERCIAL AVIATION SAFETY AUTUMN 2004

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ISSN: 1355-1523 AUTUMN 2004 ON COMMERCIAL AVIATION SAFETY

FOCUS is a quarterly subscription journal devoted to the promotion of best practises in contents aviation safety. It includes articles, either original or reprinted from other sources, related Editorial 2 to safety issues throughout all areas of air transport operations. Besides providing information on safety related matters, FOCUS aims to promote debate and improve networking within the industry. It must be Chairman’s Column 3 emphasised that FOCUS is not intended as a substitute for regulatory information or company publications and procedures. Adherence to Standard Operating Procedures 4 Editorial Office: Ed Paintin IATA Human Factors Working Group The Graham Suite Fairoaks Airport, Chobham, Woking, Surrey. GU24 8HX Tel: 01276-855193 Fax: 01276-855195 Access to the CAA Mandatory Occurrence Reports 9 e-mail: [email protected] Web Site: www.ukfsc.co.uk Office Hours: 0900 - 1630 Monday - Friday

Advertisement Sales Office: Military Interception of Civilian Aircraft 10 UKFSC The Graham Suite, Fairoaks Airport, Chobham, Woking, Surrey GU24 8HX Tel: 01276-855193 Fax: 01276-855195 UKFSC Members List 12 email: [email protected] Web Site: www.ukfsc.co.uk Office Hours: 0900 - 1630 Monday - Friday Medical Matters 14 Printed by: Woking Print & Publicity Ltd The Print Works, St.Johns Lye, St.Johns, Woking, Surrey GU21 1RS Tel: 01483-884884 Fax: 01483-884880 S61 Flying from Penzance to Isles of Scilly 16 ISDN: 01483-598501 e-mail: [email protected] Web: www.wokingprint.com Error Avoidance 20 FOCUS is produced solely for the purpose of improving flight safety and, unless copyright is Keith Frable indicated, articles may be reproduced providing that the source of material is acknowledged.

Opinions expressed by individual authors or in advertisements appearing in FOCUS are those Corporate Manslaughter 22 of the author or advertiser and do not Barlow Lyde & Gilbert necessarily reflect the views and endorsements of this journal, the editor or the UK Flight Safety Committee.

While every effort is made to ensure the UKFSC Annual Seminar 24 accuracy of the information contained herein, FOCUS accepts no responsibility for any errors or omissions in the information, or its consequences. Specialist advice should always be sought in relation to any particular circumstances. Front Cover Picture: Sikorsky S61 in the Livery of British International

1 Editorial

Ground Damage – Why No Management Interest?

■ Improve communication between contracts manager, the quality and safety department and the accounts department.

■ Review the balance between contract price and quality of service.

■ Review the terms of reference of the contracts manager.

■ Improve the contract terms with service providers to include penalties for accidental damage. Recently the Flight Safety Foundation design and implement? Perhaps this is not a traditional accounting function and released figures on the cost of damage to ■ Ensure service providers train their therefore someone else’s problem. aircraft arrived at during their project into staff properly. “Ramp Damage”. They estimate that the Is it because the contracts manager has global cost is in the region of US$ 6 ■ Implement a vigorous ramp safety been given a mandate to secure million a year. This figure seems audit programme particularly in the contracts at the lowest possible price and believable as two years ago the insurance area of vehicles in proximity to aircraft. industry estimated that the uninsured this is done irrespective of the quality of the service? Perhaps he has a cost ramp damage to aircraft was in the region A successful ramp safety strategy would; of US$ 4 million. saving “target” to achieve. The contracts manager seldom ever sees the poor ■ reduce repair costs and improve on quality of service provided and never Why is it then that few air operators have time departure rates a method of recording the cost of this sees the damage caused to the aircraft. Repairs and aircraft serviceability is a damage and why do they not have a ■ reduce the indirect cost due to delays maintenance or operations problem. robust programme for preventing it? (a/c leasing, hotel accommodation, meals, etc) Most air operators use third party Managers are appointed to supervise staff and tasks and yet few air operators contractors to carry out their aircraft ■ improve customer satisfaction and have a person responsible for the servicing. Gone are the days when the air Company image. operator’s personnel handled all the supervision and management of the ramp servicing function. Third party contractors servicing of the aircraft. Claims are made ■ improve profitability. that it is more cost effective to use third do their servicing task without supervision, even though the air operator party organization as it is not the air Ramp damage is a management problem is responsible for the conduct and safety operators “core business”. that erodes company profits! of these services. Is it that CEO is too busy worrying about profits, traditional cost cutting and It is in the interest of all operators to shareholder dividend to consider looking reduce the amount of damage caused at less traditional areas where costs can and at the shame time improve their be cut? profitability and on time performance.

Is it because the accountants have no To implement strategies to reduce these mechanism or process for costing such uninsured losses operators could; incidents? Do they see costing systems ■ as too much work or too difficult to Implement a ramp damage costing system.

2 Chairman’s Column

Communication is more than just an Art Form

some stage we all need to talk. captain) can make a reasoned judgement based on all the information and The tragic consequences of not comments made to them. It will always be communicating were brought home to us the case that some situations demand an in the UK with the crash of the Trident out autocratic solution, but perhaps CRM of London Heathrow in June 1972. should endeavour to make captains During the investigation it was found that ‘benevolent’ autocrats. In other words, be members of the flight deck were doing aware of others inputs and act for the little in the way of communicating. This greater good! Do we need to get on really probably led to a simple mistake which well to make it work? Well it helps, but it is caused the accident. The US had found our fundamental attitude that is the key to the same problems and Cockpit good communication. Resource Management (CRM) was born. It was quickly realised that all aircrew Unfortunately life is never this simple! So From cradle to grave we spend our lives needed to be involved and the ‘C’ what is the point of this Chairman communicating in some form or another. became ‘Crew’. As the process of CRM Column? The UKFSC seminar this year is The moment we are born we start to developed, its uses were seen in all parts looking at communication at all levels. make our feelings and desires felt (ask of the industry (and other industries too) Come and listen to a few different ideas any mother!) We develop our own and ‘Company Resource Management’ of how we can make life better. The large techniques to get what we want and when has now evolved. majority of people in the aviation industry we want it using language, facial are getting paid for a job they enjoy expressions and gestures. By the time Standard Operating Procedures (SOPs) doing. With a little bit of thought, we can we finish academic work and move into have been developed so that, not only do make it even safer as well as even more our chosen profession we will have our we operate to a safe and acceptable enjoyable! own unique style; this can make us standard, but also they are something to leaders or followers depending on our fall back on when all around is failing and by Stuart McKie-Smith brand of communication. the adrenalin is flowing. It is also . comforting to know that whoever is with In the aviation industry, communication you will be working to the same began from day one. In 1783, Pilatre de procedures, even if you have never met! Rozier, a science teacher, and the Marquis d’Arlandes, an infantry officer, But this is not always enough, and became the first human air travellers situations may arise where questioning when, in a hot-air balloon, they flew for 9 the way of working may be necessary – km over , As soon as two people this is a fundamental of CRM. However, began flying together, decisions were CRM is not intended to be an excuse for made, some democratic, some not so the ‘follower’ to contradict and overrule democratic! Add other crew members, the ‘leader’. The basic intention of CRM is engineers, ATC and all the many others to allow interaction of ideas between the who help us to operate means that at team so that the manager (in our case the

UK FLIGHT SAFETY COMMITTEE OBJECTIVES

■ To pursue the highest standards of aviation safety. ■ To constitute a body of experienced aviation flight safety personnel available for consultation. ■ To facilitate the free exchange of aviation safety data. ■ To maintain an appropriate liaison with other bodies concerned with aviation safety. ■ To provide assistance to operators establishing and maintaining a flight safety organisation

3 Adherence to Standard Operating Procedures An effective strategy in accident prevention IATA Human Factors Working Group

Introduction standard operating procedures. Second, need to implement an analysis Non adherence to Standard Operating management must review its and feedback tool (such as the British Procedures (SOPs) has been identified as standard operating procedures in the light Airways Flight Crew incident report a key factor in many accident scenarios. of these Human Factors issues to see if designed with Human Factors and IATA Human Factors Working Group there are inconsistencies in their markers and several other internal contributes to the industry safety effort by operations and eliminate them. Finally, reporting systems or Air Flight publishing this report on “Adherence to both the line pilot and the training and Data Monitoring program) so that their Standard Operating procedures” (SOPs). checking departments must analyze the crews can give the airline data on where This paper is based on: actual practice, that occur. For the line and why line operations are different from pilot this would take the form of a self and the “standard” set by management. This ■ Transport ’s “Human Factors crew appraisal, the airliner would need to analysis needs to be implemented as a for Aviation-Advanced handbook” on develop a more precise analysis tool that matter of routine, before incidents occur. why Standard Operating Procedures would highlight deviations from standard are critical to safe flight (study operating procedures on the line and in Also flight data recorder (FDR) technical reference TP12864,1996); the stimulator. Some good examples are: data (actual line practices) and line Line Operation Safety Audit program oriented flight training scenarios (LOFT) ■ Research by Degani and Wiener on (LOSA) from University of Texas, need to be combined into a matrix to the Philosophy, Policy, Procedures Procedure Event Analysis Tool (PEAT) capture and measure what really happens and Practices of an airline and how from , and Line Operations in normal and emergency conditions. they affect the implementation of the Monitoring System (LOMS) from Thus, the cause of the problem of standard operating procedures in line (all these programs are designed in deviation from SOPs could be flight; (study reference-”On the Design cooperation with airlines). The root cause ascertained. The root cause(s) could then of Flight-Deck Procedures”, NASA of the deviation would then be identified be identified more easily and the steps to Contractor Report 177642, June 1994) and finally a remedy would have to be put remedy the deviation(s) taken. The in effect. Boeing Accident prevention Strategies ■ The IATA Safety record (Jet) 1994 approach to accidents (adopted by IATA) which encompasses the Boeing cites that pilot non-adherence to SOPs Commercial Airplanes’ Accident and other non-compliance with Prevention Strategies (1992) which procedures were evident in (more than clearly link “flying pilot adherence to 40% of all accidents studied. The procedure” and aircraft safety;and question of why the procedures weren’t followed can be called a lack of discipline ■ On an example from a major airline on the part of the operating crew or a which clearly documents the real life more realistic and systemic analysis can systematic problems in implementing be taken. The IATA Human Factors and maintaining Cockpit Discipline Working Group sees the problem as and Standard Operating Procedures having its roots in surrounding in a large airline. operational circumstances and systemic causes. The report is written for upper airline management, standards and training and For crews to support and adhere to SOPs the line pilots who all must interface to there must be a number of precedents in support the adherence to safe operating place at the training and standards practices. The first step is to create a department at their airline. better understanding of the Human Factors involved in the creation, implementation and application of

4 Cockpit Discipline & Standard All instructors must be standardized in Operating Procedures how to teach the procedure in the same manner so that there is standardization The intertwined concepts that are across the airlines’ crews. Also the essential for the development of an checking department must reinforce the effective crew are cockpit discipline and same standards. Pilots are sometimes standard operating procedures, including caught in the position where they are and understanding of the Human Factors taught one procedure during training only issues involved in designing, writing and to be presented with another during line applying these in training and in actual indoctrination. This represents a clear flight. failure of the training system. A company culture that fosters consistency between Adherence to Cockpit Discipline is the training, checking and line adherence preceded by and the result of: to SOPs is one of the reasons that some airlines safety records are better than 1) Knowledge (the what) others.

2) Skill (the how) Attitude (the why) 3) Attitude (the why) An airline must have a philosophy, 4) Commitment (the adherence) policies and procedures that put safety This division of need to know “how the into the proper context by budgeting Adherence to SOPs are preceded by and system works” is essential in the complex adequate resources to training, the result of: aircraft and operational knowledge and developing SOPs and supporting its the rationale behind an SOP is lost in the Flight Safety Department before a safety 1) Philosophy (the beliefs of how the deluge of information that pilots are culture will develop. Lip service to safety business of the airline should be expected to absorb during a computer or a lack of commitment to safety is easily conducted) based training course. Training identified by any end-user population with departments should clearly identify what a the resulting degradation in standards. 2) Policy (how the philosophy will be pilot needs to know and why it is The operating crews must be listened to implemented) applicable to the operation of the aircraft. and their concerns addressed. For instance, if crews point out that the 3) Procedures (the training and procedures such as a full cockpit check monitoring policy) Skill Training (the how) before each flight were developed when there was adequate turn around times 4) Practices (the actual pilots Clear performance objectives must be and then shorter turns were implemented performance) predetermined so that both the pilot and then it is the responsibility of the instructor can measure the progress Standards Department to modify the SOP toward the required performance. Where to match the new reality. Only by Knowledge (the what) an instructor sees a number of his responding to input from line crews will students having difficulty with a procedure they become an active part of the “team” The Flight Operations Training he should be encouraged to report his in fact as well as in theory. This contention Department should filter the knowledge concern to operational standard could be backed up by looking at a few required to safely and effectively operate departments and/or the flight safety major airlines that entered a cycle of the aircraft in the particular airline department. A formal program for reducing training, having their crews lose environment into building blocks of feedback from check airmen could faith in their commitment to safety, having instruction proceeding in a sequence greatly support this process. numerous safety breakdowns and from vital through necessary to important. eventually going bankrupt.

5 develops its policies and procedures. The airline’s pilots are more likely to practise these procedures if they are well thought out and are consistent throughout the airline’s fleet.

■ SOPs create a logical ORDER. A repeatable sequence or rhythm is established. All items can be covered (dealt with) in a logical manner. If the sequence is interrupted for any reason, it is easier to pick up the sequence where you left off.

For example, one item in the SOP may be: All checks are done in the Commitment (the adherence) flying part of the business. It is a set of same sequence. This then translates procedures that personnel should follow into an operational procedure, such Adherence to SOPs is the outcome of to ensure the safe operation of all flights. as all ramp checks are done from top observing the three previous precedents: It is important that each organization has to bottom and left to right. the will to adhere to the standards set by a set of SOPs and is committed to having the company and the culture within that them followed: SOPs indicate the ■ SOPs improve COMMUNICATION. airline’s crews to always operate by these operational behaviours that management Use of standard phraseology keeps policies and procedures. Thus adherence expects from pilots. misunderstandings to a minimum. to SOPs is the result of consistent, well developed knowledge, skills, attitudes Analysis of aviation accidents indicates The SOP may state: Standard calls will and procedures being instilled, that a large proportion may have been be used. maintained and supported among the averted if Standard Operating Procedures pilot group. (SOPs) had been followed. This means Example: one jet has flap position 2~, that, in some cases, pilots are deviating 5~, 15~, 25~, and 30~. The flaps For example, airlines require crews to from procedures in ways that contribute were at 15~ and the pilot flying (PF) perform cockpit crew briefings related to to having an accident but in other cases, called for “Flaps two five.” The pilot some phase of flight. If the crew the SOPs were inappropriate, which can not flying (PNF) heard “Flap to Five” understands that this is done because the contribute to an accident. An thus retracting the flaps creating a review will refresh the procedure in their inappropriate or missing SOP is a latent hazardous situation (possible loss of minds (knowledge), they have been problem occurring at the line control). The standard call is now trained to actually perform the actions in management level. Either way, there is no “Flaps twenty-five” which avoids any the flight deck (skill), and if supported by doubt that following well established ambiguity. the company culture the operating crews procedures reduces the chances of will do this out of respect for the set having an accident. ■ SOPs support better ERROR standards (attitude) and as a matter of MANAGEMENT in the cockpit. rote (adherence). The following list from Transport Canada’s SOPs offer to the crew better Human Factors for Aviation (TP 12864, opportunities to detect and correct 1996) highlights the basis and the most errors. A SOP item may be: Any Standard Operating Procedures compelling reasons for having and irreversible item must be confirmed by enforcing the strict adherence to SOPs. the other pilot. This leads to the Standard Operating Procedures (SOPs) An airline’s safety culture should consider requirement, for example that any are a corporate document that captures these building blocks on which the irreversible action or item that will shut the company’s philosophy of running the standards and training department down an engine, such as movement

6 of fuel cut-off levels, and ■ SOPs raise SITUATIONAL ■ SOPs allow an inter-changeable disconnection of a generator; must be AWARENESS. Reviewing what you crew composition. TEAMWORK is confirmed by the other pilot. In newest are about to do keeps both pilots standardized so that any crew generation aircraft, entering data in the equally aware of what pilots flying is combination will know what to do and flight computer also falls under this planning on doing. to expect even if crew members have item, as recent accident experience A SOP item may be: Before each never flown together before. suggests. In other words, SOP’s take-off, descent or approach, the create a greater margin of safety. flying pilot flying will review the ■ SOPs facilitate CONFLICT speeds, altitudes and route to be RESOLUTION. The amount of ■ SOPs support a better flown. For example, V1, V2, Vr and the conflict over the best procedure to WORKLOAD MANAGEMENT. SOPs standard instrument departure (SID), use, for example, will be reduced by specify duties that each pilot is including the altitude cleared to, will SOPs that layout the company’s responsible for, thus saving mental be reviewed before each takeoff. policy regarding the procedure. resources and ensuring good WORKLOAD MANAGEMENT. ■ SOPs improve CROSS-CHECKING Fundamentally, SOPs indicate to pilots and monitoring by the other crew the manner in which operational AN SOP may be: Review memorized members. Unintentional deviations management wants the various piloting items of emergency drills before each from standard operating procedures tasks to be performed. Consistent and flight cycle. This would lead to the are more easily identified if SOPs are logical procedures provide guidance to following verbal statement said out adhered to. ensure the logical, efficient, safe and loud before take-off: A SOP item may be: SOP’s will be predictable conduct of flight operations; adhered to. Any deviations from SOP’s while evidence from accidents involving Captain: “In the event of a rejected will be raised by the pilot not flying. deviation from SOPs suggest that take-off, I will call out “STOP”, close For example, any autopilot mode inconsistent and illogical procedures lead the throttles, extend the speed brakes, change will be announced by reading flight crews to deviate from them. and....” the Flight Mode Announciator (FMA or PAM) display. This alerts the other Fundamental as they are, procedures are First Officer: “I will apply slight forward pilot that you are aware of the new AP not inherent to the equipment; that is to pressure on the control column. status and that you have checked it. If say, they are not hardware/software- Select idle reverse, call operating or the call is not made by the pilot flying, dependent exclusively. They depend also no reverse on #__ engine.” the other pilot will make the call to on the operational environment on the alert the pilot flying. people who operate them, on the Captain: “1 will ...... ” And so on. corporate culture of the company they ■ SOPs set LIMITS or acceptance work for and on the nature of the ■ SOPs specify PRIORITIZATION of tolerances. company’s operations. Procedures must duties. For example, aviate, navigate, That is, they impose a safe envelope be defined based on a broad concept of and communicate. This could lead to which must be adhered to. how an airline intends to build an the following procedural requirement AN SOP item may be. An approach operation. There is a link between when given a hold. The pilot not flying must be stabilized by one thousand procedures and the concept of the will select, check and set up the hold feet above the ground or a missed operation; and such link was researched in the FMS while the pilot flying approach must be initiated. This by Degani and Wiener in 1994. These concentrates on flying. PNF specifies that the aircraft must be researchers developed a model to aid announces the type of hold entry. The configured for landing and altitude understanding this link which they called PF will clearly state “You have control” and airspeed must be within the “The Four Ps of cockpit operations”. and will confirm the entry. He or she specified limits or tolerances. (Study reference - “On the Design of will then state “I have control.” and Flight-Deck Procedures”.NASA Contract return to flying the aircraft. The PNF Report 177642, June 1994) will communicate to ATC when they have entered the hold.

7 how the concept of the 4Ps lead to adapting the procedure from feed back from the real operational environment:

■ Philosophy: It is a corporate goal to be a safe and secure airline as stated in the corporate mission and goals.

■ Policy: In the event of a full, or partial “Pull-up” or other hard (red) warning, the following action must be taken promptly.

a) Below dominant MSA (Minimum Safe Altitude).

Announce “PULL-UP AROUND” Immediately complete the pull-up The model proposes that at the strategic developed, discrepancies and conflicting manoeuvre in all circumstances. apex of the airline top management procedures will be easily detected, and develops a philosophy, which is an flight crews will understand the logic b) At and Above MSA overarching view of how they will conduct behind the SOP. Immediately assess aircraft position, the business of the airline, including flight altitude and vertical speed. If proximity operations. Corporate culture is a major The fourth component of the model is the to MSA is in doubt, take action as in determinant of this philosophy, since it actual practices, which is encompassing a) above. permeates the company. the correct execution of a procedure, deviation from a procedure or omission of ■ Procedure: GPWS pull-up This philosophy of operations, in a procedure. Ideally, procedures and manoeuvre is described in fleet- combination with economic factors, practices should be the same, but this is specific manuals. Describe the call- public relations campaigns, and not always the case. A few reasons by outs by the handling pilot and the organizational changes generates policies which pilots may deviate from established non-handling pilot procedures at which are broad specifications of the procedures include: below MSA and procedure above manner in which management expects MSA; define during climb and descent ■ flying training maintenance personal Individualism; in case of ambiguities and include conduct, exercise of authority and so forth additional operational information ■ to be done. To indicate how these policies Complacency; deemed appropriate for the crews to will be implemented (i.e. how these tasks observe the GPWS policy. should be achieved) procedures are then ■ Humour; designed, which should as much as ■ Practices: do flight crews observe ■ possible be consistent with the policies, Frustration; the policy and follow the procedure in which in turn should be consistent with operational conditions? the philosophy. ■ Overproceduralisation; and In the GPWS example, discussed above, ■ In brief, if procedures should be based The procedures are inappropriate or the airline’s original policy mandated an upon a clearly stated (i.e. written, difficult to apply. immediate pull-up upon receipt of any philosophy and a set of policies, then a GPWS warning, regardless of altitude and logical and consistent set of cockpit The example of the Ground Proximity position of the aircraft. Operational procedures that are in accord with the Warning System (GPWS) Policy as feedback obtained through airline’s internal policies and the philosophy can be Instituted by a major airline, illustrates safety information system however,

8 indicated that during the first calendar year ■ Consistency, to assure the line pilot However, this violated the crews’ basic after this policy was implemented, GPWS that there are reasons for a given philosophy of safety and was not alerts had not been followed by a pull-up in procedure, and that this reason is practiced by many crews. Some Captains 60% of occasions. This was due to a variety pervasive throughout the company, began to brief that the SOP should be of reasons, including false and nuisance ignored. The Standards Department warnings. Of particular concern was the fact ■ Quality management, to provide quickly saw the problem developing and that pull-ups had not been initiated on 20% standardization and guard against reverted back to the previous policy thus of occasions when the warnings had been non-compliance, and eliminating the discrepancy. genuine. An obvious discrepancy between the three first Ps and the last one – ■ Feedback, to provide assurance from Practices - was evident The safety services the real world about the finality of any Conclusion of the airline determined that the reason for individual procedure or policy. this discrepancy between philosophy, The goal of management should be to policy, procedures and practice centered Looking at another example of non promote good practices by specifying around the unreliability of the technology adherence to SOPs which has its roots in coherent procedures. The next step is to which resulted in false and nuisance a discrepancy in the Four Ps is the case develop the tools for identifying where warnings. In some cases, warnings had of an airline where the Flight Operations and why there are inconsistencies been triggered at 37000 ft flying in cruise, philosophy was that the safest cockpit on between what is supposed to be done immediately after take-off, when there were take off was a silent one. The pilot flying and what is actually being done, and then no obstacles in the flight path or in holding would brief the speeds and initial SID to remove the discrepancies. The above patterns, with other aircraft 1000 ft below procedure upon lining up on the . will lead to a higher degree of conformity the host GPWS. This feedback data and its The policy from that point until the during flight operations and it will make analysis led the operator to review its “positive rate” call only discrepancies training and checking easier, and it will GPWS policy and amend it to that included from normal should be voiced. This enhance the overall quality of flight in this example, with the immediate intent of procedure called the “silent cockpit” was operations. Furthermore, it will provide a ensuring compliance with the policy on all supported by both the management and solid defence, increasing the tolerance occasions. the crews. The practice on the line and resistance of flight operations to adhered to this SOP. human error and making it viable. There are four factors which will minimise the difference between procedures and Industry standards indicated that most This article has been reprinted with practices: airlines and manufacturers had speed permission from and credit to The IATA callouts during the take off roll (e.g. Human Factors Working Group ■ Compatibility, to ensure that the 100kts, V1 and rotate). One airline’s procedure is logical and appropriate Standards Department decided to within the larger system within which it change the procedure a number of years is operated. ago and adopt a verbal calls philosophy.

Access to the CAA Mandatory Occurrence Reports

The CAA’s overall objective in operating changing this policy. As I explained at the CAA that immediately after the newspaper an Occurrence Reporting Scheme is to Flight Safety Committee’s meeting article had appeared the journalist use the information to improve flight immediately following the article, the concerned was invited to Gatwick to safety and not to attribute blame. The newspaper obtained their information discuss the matter with the Group CAA’s staff is well aware of the potential from a manual sift through safety Director Safety Regulation and Senior damage that could be caused to the summaries widely available throughout Managers where our points regarding MOR Scheme’s integrity. We do not allow industry. Certainly no access was flight safety reporting were robustly made representatives of the media access to requested, or would have been granted, and accepted. the database and have no intention of to the database. So concerned was the

9 Military Interception of Civil Aircraft by Sqn Ldr Gary Coleman MRAeS RAF, Strike Command Flight Safety

The events on Sep 11th 2001 were Outside of UK airspace there have been What triggers an intercept? Each State “perpetrated by fanatics who are utterly many intercepts of Commercial Air will react according to its own indifferent to the sanctity of human life, Transport (CAT) flights, some of which interpretation of the risk being faced. A and we, the democracies of this world, are have been highlighted by the media. In trigger could be a single event or a going to have to come together to fight it all cases the QRA aircraft have been combination of small errors. Historically and eradicate this evil completely from our scrambled because of concerns that the actions resulting in a scramble of QRA world” (PM Tony Blair). I will remember CAT may have been hi-jacked. Clearly it aircraft have been: that day for the rest of my life. Having just is not appropriate for the Ministry of ■ landed from a 1 v 1 air combat sortie, Defence to comment on other national Unauthorised deviation from the whilst serving as an instructor on the air-policing procedures, but you may find cleared flight profile. Tornado F3 Operational Conversion Unit, I the following generic details useful: ■ walked into the crewroom to be greeted Loss of radio contact, particularly if with the sight on TV of 1 of the Twin Under what basis does the military associated with a flight profile Towers burning. I sat down and watched conduct intercepts? At present each deviation. with interest, with thoughts like “how on State enjoys exclusive sovereignty over ■ earth did that happen?” running through the airspace above its territory and Unauthorised SSR Transponder code my mind. Within minutes the second territorial sea. Consequently, no one may changes or extended use of Ident. aircraft hit the other Tower and shortly fly through its airspace without prior ■ after, the Squadron Commander came in permission or authorisation by the Use of non-standard phraseology by and said “ We’re arming up the jets, Sovereign State. In addition, under ICAO the crew or other actions that could Gazzer, go get the crypto sorted…” (I was Article 9, each contracting State reserves be construed as a covert attempt to the cryptographic material custodian). the right, for reasons of military necessity alert agencies to a situation on board. Although no attack came, the events of or public safety, to restrict or prohibit ■ 9/11 increased the UK Air Defence aircraft from flying over certain areas of its Notification of a threat from official or posture and this posture endures today. territory. Finally, the rights to self-defence non-official sources. Armed aircraft are held on Quick Reaction are reserved under Article 51 of the UN Alert (QRA) ready to respond to any Charter. Some nations, such as France, have a airborne security threat to the UK. This very overt reaction policy. For example, position is replicated throughout most What are they protecting? The scrambling against any aircraft failing to European Nations. population and infrastructure of the State. establish 2-way communication as it

10 enters their airspace. Having scrambled Follow me.” Responsibility does not pass, visual identification of an intercepted they will often complete the intercept, however, until the intercepted aircraft aircraft are 200 ft by day/VMC and 600ft even though communications may responds with the signal for “Understood. by night/IMC. subsequently have been re-established. Will comply.” These signals are detailed In contrast, the UK has adopted a slightly within AIP ENR1.12. How do I report an Airprox in another less overt but reactive threat-based Air country? The countries AIP section Defence posture which is constantly What should you do if you believe the ENR1.14 should cover the Airprox changing to meet the perceived threat to interceptor is acting in an unsafe procedure. UK airspace and the homeland. manner? The incident should be treated Consequently, in UK airspace, it is highly as any other aerial confliction. However, Conclusion. The interception of civil unlikely that CAT aircrew will see UK QRA be aware that the interceptor could aircraft by Sovereign States is usually only aircraft at close quarters unless all other construe the manoeuvring of your aircraft, conducted when required under the methods of confirming the integrity of the so as to avoid what you perceive as a risk State’s ‘duty of care’. Whilst it might flight deck have been exhausted. To that of collision, as non-compliance. It is, seem unnecessary and a source of end, if you are intercepted in UK therefore, essential that you contact the annoyance to the aircraft involved, the airspace, you are advised to take the ATSU, intercepting aircraft or its intercept will almost certainly have been event very seriously. controlling agency on the in-use triggered due to a belief that, from frequency or 121.5 MHz or 243.0 MHz observed events or information received, What should you do if you are immediately. Once the situation is the integrity of the cockpit may have been intercepted? resolved, report an Airprox to the ATSU compromised. By way of a summary, I currently providing your service and on leave you with the following few ■ Follow the procedures and signals landing fill out an Airprox report form from recommendations: laid down in AIPs in ENR1.12 the national agency in whose airspace you are flying. In being intercepted you ■ Report the interception to the ATSU should note the prescribed separation and try to contact the interceptor or its minima that you were flying could be control agency on 121.5MHz or 243.0 eroded. For example, the RAF minima for MHz.

■ Comply with all instructions. Non- Key Recommendations for Pilots and Aircraft compliance will only give the Operators Operating in UK Airspace agencies on the ground cause for greater concern. In order to ensure that any event is handled in the most appropriate manner: Is it safe? British military aircrew that conduct air-policing duties are well ■ Be aware of potential situations such as loss of two-way communications or trained; in the RAF this can take over 3 inadvertent A7500 selection that may indicate to ATC a potential hijack or years. Routine air-policing training security threat to the aircraft. utilises the RAF’s own large aircraft assets; CAT are never used for routine ■ Communicate clearly when in your opinion there is an actual security threat. training unless the permission of the airline operating company has been ■ Volunteer information regarding the integrity of the flight deck to ATC in a secured. The intercepting aircraft will not timely manner. trigger the TCAS and will take responsibility to avoid the aircraft being ■ Use appropriate RTF phraseology and special purpose SSR Mode A codes. intercepted. The only time the collision avoidance responsibility is reversed is ■ Comply with government instructions whether given by radio or through when the interceptor gives the command visual intercept signals. signal “You have been intercepted.

11 Members of

Full members Air Atlanta BALPA Capt. Mario Kniege Carolyn Evans Chairman flybe. Air Contractors bmi regional Stuart McKie-Smith Capt. Tony Barrett-Jolley Capt. Steve Saint

Vice-Chairman Air Mauritius Capt. Francois Marion Steve Hull Rob Trayhurn British Airways CitiExpress Treasurer Jonathan Annet Capt. Ed Pooley Britannia Airways Jez Last Air Seychelles British International Ben L’ Esperance Capt. Terry Green External Affairs Officer RAeS Air British Mediterranean Airways Peter Richards Capt. David Warren Robin Berry

Aegean Airlines ALAE BUZZ Stansted Ltd Capt. Dimitris Giannoulatos Dave Morrison Peter Walton

Aer Arann Allianz Marine Aviation CAA Capt. Julie Garland Jerry Flaxman Dave Lewis - MRPS Chrys Hadjiantonis - Safety Data Dept. Aer Lingus Astraeus Ltd Ed Bewley - Flight Operations Tom Curran Capt. Simon Robinson Alison Thomas - Intl. Services

Aerostructures Hamble BAA plc CargoLux Airlines Dr. Marvin Curtiss Francis Richards Capt. David Martin

AIG Aviation BAC Express Cathay Pacific Airways Jonathan Woodrow Rick Howell

Airclaims BAE SYSTEMS Reg. A/C CityJet Paul Clark Alistair Scott Capt. Mick O’Connor

CTC Service Aviation (LAD) John Dunne ADVERTISING IN THIS MAGAZINE ADVERTISING IN THIS MAGAZINE DARA Brian Plenderleith

Focus is a Quarterly Publication which has a DHL Air highly targeted readership of 32,000 Aviation Peter Naz Safety Professionals worldwide. UK Ltd Capt. Jacqueline Mills

IfIf youyou oror youryour companycompany wouldwould likelike toto easyJet advertise in Focus please contact: Capt. Lance Jordan Emerald Airways Capt. Roley Bevan Advertisment Sales Office: EUJet UKFSC, The Graham Suite, Fairoaks Airport, Peter Delany Chobham, Woking, Surrey. GU24 8HX. Tel: 01276 855193 EVA Airways Richard Lovegrove [email protected]

12 Excel Airways MyTravel Peter Williams Capt. Phil Oakes Intl. Airport Alan Whiteside NATS Capt. Martin Pitt Paul Jones CHC Scotia Peter PrivatAir Capt. Derek Murphy Capt. Boris Beuc CHC Scotia Eng.

FLS Aerospace (IRL) Ryanair Eurocypria Frank Buggie Capt. Gerry Conway Capt. Constantinos Pitsillides

Flyglobespan SBAC Airways Adam Smith Martyn Graham - Secretariat Capt. Spyros Papouis Vic Lockwood - FR Aviation Ltd flybe. Tom Conlon ScotAirways Stuart McKie-Smith Paul Calder Ford Flight Europe flybe. Aviation Services Richard Newton Servisair/Globeground Chris Clark Eric Nobbs GATCO MOD Richard Dawson Shell Aircraft DASC Capt. Michael Evans Steve Walters DASC Eng. Cdr. Ian Peck GB Airways HQ STC MOD Sqn. Ldr. Paul Cox Capt. Phil Lintott-Clarke The Boeing Co. MOD (DASC RN) Cdr Steve Pearson Thor Johansen Goodrich Actuation Systems Ltd RAeS Keith Joyner Peter Richards Capt. Graham Clarke Hong Kong Dragon Airlines Ltd RAeS Eng. Alex Dawson Airways Jim Rainbow Alan Bradbury Independent Pilots Association Capt. Mike Nash Willis Aerospace Co-opted Advisers Ian Crowe Irish Aviation Authority AAIB Capt. Bob Tweedy Capt. Margaret Dean Group members Kent Intl Airport - Manston CHIRP Wally Walker bmi Peter Tait David Barry GASCo Capt. Keri Ellicott bmi Eng. John Thorpe Tom Webster Legal Advisor Simon Butterworth Simon Phippard Capt. Derek Whatling Barlow Lyde & Gilbert Lufthansa Consulting GmbH Capt. Simon Searle Bristow Helicopters Eng. Royal Met. Society Robert Taylor Dr John Stewart Malaysia Airlines Capt. Ahmed Zuraidi Britannia Airways Jez Last Airport plc Peter Hampson Britannia Airways Eng. Adrian Vaughan Capt. Tony Wride Intl. Airport Graeme Gamble

13 Medical Matters

with a statin actually seemed to protect people against dementia and Alzheimer’s lowering the risk by 70%.

What would account for the protective effect of statins? It is only at that, but it has been suggested that the gradual narrowing of tiny blood vessels in the brain might be a contributing factor in the complex puzzle of Alzheimer’s causation. The theory is that narrow blood vessels allow less blood to reach the brain; this in turn, kills off nerve cells, resulting in the buildup of the amyloid plaques in brain tissue that are the hallmark of Alzheimer’s. The authors of this study suggested that the statins might counteract this chain of events by dilating capillaries and increasing blood flow in the brain. Keep in mind, however, that this study was not a randomize, clinical trial, and the finding that statins protect against Alzheimer’s will remain an intriguing hypothesis until corroborating evidence from clinical trials is reported.

Eye Disease A New Treatment for Macular Degeneration

Age is hard on vision, but few things are harder on the eyes than age-related macular degeneration. The macula Brain Health (from the Latin word for spot) is in the Statins May Protect the Brain The study was based on analysis of data center for the retina and is about the size on about 60,000 people, age 50 and of this capital O. It is critical to reading Statin drugs (Lipitor, Zocor and other older, collected as part of the British- and the visual acuity needed for almost brand names) are prescribed principally based General Practice Research any level of detailed vision. There are two to lower cholesterol levels, but Database. They were followed from forms of macular degeneration, dry and researchers seem to be publishing 1992-98, and during that period, 284 of wet. People with dry macular studies left and right these days showing them developed dementia or Alzheimer’s degeneration often don’t even notice its that they have beneficial effects above disease. The researchers compared that effect on their vision because one eye and beyond their effect on cholesterol. group with 1,080 people in the database compensates for the other. The wet form, So in some ways it’s not surprising that a who didn’t have brain disease but were which can come on suddenly, is far more large study prublished in the Nov.11, similar with respect to age, sex, weight serious because it can lead to legal 2000, Lancet found that statins seem to and smoking. They found that high blindness, which is usually defined as substantially lower the risk of developing cholesterol that had been treated with 20/200 vision or worse. The underlying dementia, the loss of memory and drugs other than statins didn’t affect the cause is abnormal growth of tiny blood abstract thinking abilities that affects risk for dementia or Alzheimer’s one way vessels that leak blood and other fluid about 10% of everyone over age 65. or another. But high cholesterol treated into the retina, thus the “wet” label.

14 Laser Treatment

Most of the time it’s left untreated, the blood vessels of wet macular generation continue to grow and leak, and a small area of distorted or absent central vision can expand, blocking out all but peripheral vision. Ophthalmologists have used lasers to treat wet macular degeneration for years, but the treatments came at a steep price. Because the laser damaged the retina as well as the underlying blood vessels, patients were left with a definite blind spot in the middle of their vision that vessels behind the retina. The treatment circulating in the bloodstream. People could be even worse than what the starts with an intravenous infusion of have gotten bad sunburns on the way macular degeneration had caused. The verteporfin, which usually takes about ten home from treatments because they’ve trade-off was the possibility - and it was minutes. There is a five minute wait to had their arm resting on the edge of the only a possibility – that the laser treatment give the chemical time to travel to the car window. would stop the blood vessels from blood vessels. The laser treatment lasts leaking further. Essentially, the patient only about 1 minutes. The energy level of getting the laser treatment had to accept the laser is so low that it won’t even burn The Problems a small blind spot now in hopes of a hole in a piece of paper, but it’s enough forestalling a larger one later. to activate the verteporfin. When the laser This new, low-energy laser treatment of hits the verteporfin, it produces unstable wet macular degeneration is an advance, In April 2000, the FDA approved a new oxygen molecules that cause very but it can be oversold. Here are some of kind of treatment that uses a low-energy localized tissue damage, which is a good the caveats. It involves as many as seven laser that doesn’t harm the retina. It thing here because it prunes back the separate laser treatments over a two-year depends on a chemical called verteporfin blood vessels harming the retina. The period. It really is only effective in people (Visudyne) that has been used in cancer treatment is painless, although afterwards with what ophthalmologists call classic chemotherapy. Verteporfin is a patients must avoid sunlight for 24-48 lesions – in other words, the location of photodynamic, or light-activated, hours because of the verteporfin the culprit blood vessels is clear so the chemical that gravitates toward the blood ophthalmologist knows where to target the laser. Only about one in five people with wet macular degeneration has the classic lesions appropriate for treatment. In ideal situations, the treatment does halt the spread of the macular degeneration, but the goal is stablilization, not improvement, of vision. Finally, although medicare and insurance companies are covering the treatment, it is expensive: the verteporfin alone costs about $1,500 per treatment.

Reprinted with acknowledgement to PIA - Air Safety Magazine

15 S61 Flying from Penzance to Isles of Scilly by Capt. Tony Jones - Operations Director, British International

Way back in 1964 the “pipe dream” of of the 1500 visitor rooms are booked up soundproofing. These machines are well- Jock Cameron, then General Manager of well in advance by tourists who return to suited to carrying large numbers of British European Airways Helicopters, the Islands year after year. passengers in relative comfort. became a reality when on 2nd May that BI also has a base in Cardiff which is year a scheduled passenger transport British International (BI) prides itself on home to a Bolkow 105 and two Twin service provided by came into maintaining this high-density service to a Squirrel AS355F2 helicopters fitted in the being. Previously operated by a fleet of demanding customer-base and to an aerial police role, with visual/thermal six BEA Dragon Rapides, one Sikorsky even more demanding Island community imaging equipment and other evidence- S61N helicopter capable of carrying 28 which looks upon the two Sikorskys as gathering kit. Operating from the newly passengers took over the task and the the mainstay of their transport commissioned Cardiff Heliport, BI works route is still operated by that type today. infrastructure. not only for the South and East Wales Police Air Support Unit, but also provides Forty years on, the Penzance to the Isles During the season BI’s Penzance and aerial surveillance capability for Network of Scilly route is flourishing. Two S61s, fly Isles of Scilly Teams mount a shuttle flying Rail in their campaign to eliminate 130,000 passengers a year to the Islands programme beginning at 0800 and vandalism, and to repair track damage, to of St Mary’s and Tresco, and more that 3 continuing through to 1900, Monday to keep the trains moving. million people have used the service. Saturday inclusive, carrying up to 1500 Whilst these numbers are modest by passengers a day. The heliport on Tresco These activities are conducted under major airline figures, for a helicopter is run by staff from Tresco Estate, which rules set out in a Police Air Operators’ which can sometimes offer no more than like Penzance, operates under a CAA Certificate which enables the operation to 20 seats per sector, it is a remarkable Aerodrome Licence, including the take place without having a long list of achievement. provision of fire cover. exemptions from ANO so that, for

The development of large, twin-engine IFR machines enabled the launch of an experimental service to the Isles of Scilly which has developed into an aerial “life- line” to the Islands. Jock’s vision was to establish inter-city connectivity using helicopters, and then extend it to routes such as London to Paris, and other medium range (in helicopter terms!) opportunities.

Political and practical problems were put in Jock’s way, and whereas these more “sexy” routes have yet to be opened up to helicopters in the UK, the well-proven Isles of Scilly service has demonstrated the versatility and flexibility of large helicopters. (Fire simulator training at Penzance example, landings at unprepared sites Heliport) can be made. The Scillonians rely on the helicopters for their day-to-day transport, mostly to The Sikorsky S61s (BI has six of them in The Bolkow is used to recover Mirach air sustain their primary income source – all) have a spacious passenger cabin targets from the sea in missile ranges off tourism. From April through to November where every seat row is by a large Benbecula in the Hebrides, and it is almost impossible to find over-night panoramic window (each is a “push-out Aberporth in West Wales. The helicopter accommodation on Scilly as pretty well all emergency exit” if needed) and the carries an underslung net and scoops the internal noise levels are reduced by Mirach out of the water. The targets are

16 very expensive, don’t float for long, and Down in the far flung reaches of the environmental issues to cope with. The contain important research information. South Atlantic Ocean, BI has two Sikorsky Cardiff aircraft spend a large amount of QinetiQ (formerly DERA, the Defence S61N helicopters providing air support to time at low speed/low altitude looking for Evaluation and Research Agency) is the the Garrison. Based at criminals, and once discovered there is customer, and for the above reasons is RAF Mount Pleasant on East Falkland, the frenetic activity in the chase and capture keen for us to recover a high percentage two S61s are used to re-supply forward phase. Crew co-operation and the inter- of their Mirachs. It’s pleasing to say that troop locations, including carrying of weaving of pilot and police air observer to date none has been lost, in a external and internal cargo loads, skills is essential. In the heat of the demanding environment. conduct VIP transport (there are no roads pursuit it is tempting to let the chance of a “collar” override the prudent limits of safety.

When not engaged in police tasks the Cardiff pilots can find themselves flying a very VFR Bolkow 105 searching for, and recovering missile targets over the sea. There is a constant danger of becoming over-focussed on the job rather than the overall safety environment.

At Plymouth, the pressure to get the team of RN specialists on the deck of the Type 42 Destroyer bobbing about in a choppy sea, or hoisting them onto a confined winching area on a ship from a foreign (Police Operations Cardiff) to speak of in the Islands), general navy, must be balanced against the communication flying and to assist in the safety considerations of the task, At Plymouth, BI has two Dauphin role. The task especially as it is a single pilot (with AS365N2 helicopters on long-term involves the day-to-day carriage of a mix crewman) operation. Additionally, contract for the Royal Navy providing air- of passengers and freight, underslinging Plymouth Airport sits right on top of a hill, taxi services for essential personnel of fuel tanks (6000lbs each), including and whereas the weather out in the vessel between vessels, conducting radar operations into and out of mountain-top training areas may be good, it tends to calibrations and standing-by for casualty sites. change rapidly back at base - there’s evacuation flights. Often the task is plenty to think about all the time! highly demanding involving landing on Anyone who has visited the Falklands will small ships in high seas or winch-transfer tell you that the difference between winter In the Falklands pressure on the crews of of passengers to vessels with no heli- and summer weather there is hardly a different kind is ever-present. There is deck. noticeable, and the MoD contract warns huge reliance on BI’s S61s to stick to the potential bidders that the environment is “Helitasking Cell” schedule. At most of hostile. If one expects the worst one is the sites fuel, food, ammunition, mail, seldom disappointed! 70 knot fog, sleet, papers and beer can be delivered only by snow, sunshine and showers all before helicopter as there are no useable roads lunch, mixed in with often treacherous to them. Many of the personnel at these turbulence in the mountains all makes for remote locations spend 4 months there, an interesting and challenging operating sometimes with only 2 or 3 people in the environment. team. When it’s time to pick them up for the next-day flight back to UK it is of great Each of BI’s four present operating bases importance that they be collected on (Dauphin flying at Plymouth for MOD) has its own individual task pressures and time, for if not, they will miss the flight

17 (S61 Penzance to Isles of Scilly) approach can all-too-quickly disappear in Mary’s Airport or Tresco heliport has a fog/cloud whipped up the into-wind slope precision approach and the NDB/cloud home, and will be stranded for another engulfing the landing area at the last break procedures cannot be relied upon week! Similarly, if a site is running out of moment. to get you VMC-below to make a visual fuel for the generators which power the air arrival. defence radar, there is a threat to the Even when all else is going well, the early detection and protection system. crews have to remember that RAF Mount BI’s helicopters are no different from any Pleasant is their only “bolt-hole”. Stanley, other, in that the useful payload versus These “get-the-job-done” pressures are the only other airport in the Islands with fuel carried is always a compromise. there all the time. If there wasn’t a an ATC Service, has no precision Although fuel is available at St Mary’s it is pressing operational need for the instrument approach. MPA is effectively a inconvenient to plan to refuel there. To helicopters, they wouldn’t be there. “no alternative available” destination, shut down on the Islands would make it However, against this background the evidenced by the frequent inability of RAF impossible to meet the busy shuttle crews have to be vigilant at all times. Tri-Star to get in. schedule in the time available. With Mountain-top sites are often affected by At Penzance this common theme is also round-trip fuel the S61s can carry a full vigorous down-draughting air currents, present. BI’s customers are the paying load of passengers and baggage. Carry and a slight change in wind direction public on holiday. They want to get to the Exeter diversion fuel and you lose 4 during the approach can cause dramatic Isles of Scilly on schedule, and get back passengers and add an extra round trip wind shear. on time as well, because everywhere is a to the day’s programme. long way to travel from Penzance on the These sites can be in and out of journey home. Then there is the dreaded enemy….fog! orographic cloud, rain and snow. A pad A small cluster of Islands in a maritime which is in the clear at the start of an Neither of the Island destinations, St airstream. Moist air moving North-

18 pressures on the Company balanced against the different safety management requirements at each base, and who has active support from his Group Chief Pilot and all the Company’s aircrews. BI came into existence in May 2004 as a “descendant” of one of the world’s pioneer helicopter companies. Safety is our watchword and the maintenance of a robust safety record is our most important business objective.

So, 40 years of scheduled helicopter passenger service out of Penzance; here’s to the next 40 – but who is going to design and build a helicopter so safe reliable and passenger-friendly as the (Falkland Islands flying at Mount Pleasant) The pressures are there – all the time – at Sikorsky S61 eventually to replace it? all the bases, and they are of the same Eastwards over a progressively colder nature but caused for different reasons. sea. No need to dive for the Met To support the aircrews in their decision handbooks to work-out what that means. making processes it is essential that the It is frustrating for crews to be sitting in management team is Airstaff Associates Penzance in beautiful blue sky, unlimited pro-active, in association with viz when the Islands are fogged out. On encouraging open Nigel Bauer & Associates a busy day there can be 400 passengers reporting, acting at the Heliport by lunchtime, all wondering quickly and positively QUALITY MANAGEMENT FOR OPERATORS * JAR-OPS Quality Systems, documentation & auditing why we are not flying, and constantly when potential threats 5 days - LGW - 20 Sep, 22 Nov, 07 Feb enquiring as to when the fog will clear. If to flight safety are NEW SAFETY MANAGEMENT SYSTEMS only we knew! Then they ask the discovered, New enlarged SMS course for air & ground operators question “why can’t you fly over there and communicating them 3 days - LGW - 27 Sep, 14 Feb hover down through the fog?” No good to all staff and AUDITING IN AN OPERATIONAL ENVIRONMENT * trying to explain Vortex Ring to the reviewing safety Air & ground operations auditing harassed parents of, bored, snarling, performance 3 days - on request or ‘in-company’ grumbling, fed-up children. constantly. AUDIT IMPROVEMENT WORKSHOP Experience sharing & improvement of audit process 2 days - running shortly When there is a hint of a clearance the BI is fortunate in that crews’ self-imposed pressure to get it has an enthusiastic QUALITY FOR SENIOR MANAGEMENT JAR Quality Management Accountability airborne is huge, but balanced by the team of base Flight 2 days - ‘in-company’ only knowledge that it could all so easily be a Safety * Incorporating Nigel Bauer & Associates ‘sucker’s gap’. It’s not helped by the Representatives lead IRCA certificated Internal Auditor Training course telephone calls into the Penzance by a Group Flight For further details including In-Company courses and consultancy or Operations Room from disgruntled Safety Officer, auditing services please contact: passengers waiting on the Islands Captain Terry Green, Airstaff Associates: wanting to know why it is that “we can who has shown the Tel +44 (0) 1780 721223 e-mail: [email protected] Fax +44 (0) 1780 720032 url: www.airstaff.co.uk see the church in St Mary’s now, why rare skill of Nigel Bauer & Associates: aren’t you flying?” understanding the Tel +44 (0) 1243 778121 e-mail: [email protected] commercial Fax +44 (0) 1243 789121 url: www.nigelbauer.co.uk

19 Error Avoidance by Keith A Frable, Aviation Safety Inspector - London – IFO/FAA

Attention Factors that influence installation error in the application of maintenance/inspection task cards

Patel showed how poor design of paper- based work cards, in hangar inspection, led to errors and delays. They proposed information design guidelines that could be used for designing more user-friendly work cards. Another study by Chervak (1996) showed that work cards produced in Simplified English gave improved performance when compared to those prepared in Standard or Non-Simplified English.

Handling and usage of paper-based information is a critical factor in the maintenance environment. In the repair shop environment, paper can get dirty. In maintenance and inspection hangars or during outside line maintenance, environmental conditions like rain, snow Aircraft maintenance is an essential part When a lead mechanic looks for and wind can affect the use of paper- of the entire aviation system, which information on a microfiche or when an based information. Issues like providing supports the global aviation industry. As inspector looks for the next step of a task well-designed document holders must be aviation grows so will the demands upon in a work card, the information transfer is considered. aircraft technicians to increase onetime from the microfiche or the work card performance. This will only further open (display) to the person. Similarly, when an Computers are slowly becoming the window for human error and inspector visually inspects an aircraft commonplace in the inspection and subsequent break down in the system fuselage the information transfer is from maintenance work environment. They safety net we currently enjoy. The the aircraft (product). Finally, when a bring with them the promise of information the technician receives will mechanic uses an eddy current streamlining the workflow and delivering greatly affect his/her performance, and oscilloscope to look for cracks, the information efficiently. As a result, airlines many human factors issues are prevalent. information transfer is from the instrument (display). You can see that in each of are making the transition to electronic documentation, automated work card Human error in maintenance usually these examples there is an “information systems and computerized planning develops from an unintended aircraft interface,” either conceptual or physical, systems. The various software systems discrepancy attributable to the actions or that facilitated information “transfer” or on the computers, however, present their inaction of the aircraft technician. Any “access.” In the case of the inspector own unique problems to the maintenance maintenance task, performed on the using a work-card the interface is the workers using them. The display that the aircraft is an opportunity for human error. work card in itself. Additionally, all of the computer user sees on the screen is Each task requires the transfer of some above are effected by the various called the user interface (UI). The user type of information media. The attention factors, which will be mentioned interface must be designed correctly for “information content” of the information later. the system to be user-friendly and reduce system can be transferred from person to errors and frustration with the system. person (via communication), from In a workcard study carried out by Patel equipment to person (via displays), from (1993), most technicians in a Information access is inexorably tied with product to person (via inspection), or maintenance hangar felt that the work attention —to access information, from person to equipment (via controls). cards they used lacked adequate information and could be more readable. attention has to be directed at that information. Several types of tasks that

20 involve such direction of attention have operators and security guards viewing a been identified in human factors literature TV monitor, or technicians inspecting (Sanders and McCormick 1993). These many rows of rivets with no corrosion tasks can also be seen in the aircraft detected. maintenance environment: A good example of a selective attention Selective attention: The operator or causation factor is an NTSB investigation mechanic has to monitor several sources into the incorrect installation of O rings in of information to decide whether a a chip detector. Eastern Airlines particular event has occurred. Examples technicians, who regularly removed and include a pilot scanning several cockpit replaced this particular chip detector in instruments looking for a deviant reading. accordance with a maintenance task card, failed to replace O-ring seals. The Focused attention: The operator has to work card specifically required the attend to one source of information and replacement of the O-ring seals with new exclude all other sources. Examples serviceable ones. Nevertheless, the include a mechanic reading a technicians failed to perform the required maintenance manual in a noisy repair task, leaving the O-rings off. The shop. investigation revealed that there were The use of maintenance/inspection task informal procedures not written on the cards is inherent in the accomplishment Divided attention: Two or more separate ‘approved’ task card but known to be of aircraft maintenance. They are utilized tasks have to be performed adopted by most technicians in the during the accomplishment of routine simultaneously. Examples include driving maintenance and inspection maintenance to heavy “D” checks. It is a vehicle in the airport while carrying out a departments. The records suggest that clearly evident that during the conversation with the a co-worker. there were previous master chip detector development of those task cards, one installation problems and that the must incorporate the various attention Sustained attention: The mechanic has technicians were routinely not replacing factors identified above into the to sustain attention over prolonged the O-ring seals. What the NTSB completion of those work tasks. periods of time, without rest, in order to discovered was that the master chip detect infrequently occurring signals. detectors were received by the Clearly, today’s environments of Examples include air defence radar technicians with the new seals already in multifunctional displays, advanced place and had never actually had to technology, and even aircraft perform that task on the work card. So, maintenance manuals being retained on when one was received without the new a computer have bestowed upon us a O-rings, the technicians were pre- new level of human factors awareness programmed to not accomplish that item that must be considered. It is incumbent on the work card (Marx and Graeber, upon a maintainer of aircraft to address 1993). It is clear that this latent failure these issues as an ongoing improvement was caused by a breakdown in the to their operation. system; people involved were selecting what part of the task card to follow. Note: This article only reflects the views of Through a culture developed by the the author and is written without financial countless removal and replacements of gain or reward. chip detectors received with new seals, no one was paying any attention to the same detectors when they came without the seals. They selected what part of the card to pay attention to!

21 Corporate Manslaughter by Keith Richardson, Barlow Lyde & Gilbert

“…a full investigation into the circumstances of the disaster leads inextricably to the conclusion that the underlying or cardinal faults lay higher up the company….all concerned in management…..were at fault in that all must be regarded as sharing responsibility for the failure of management. From top to bottom the body corporate was infected with the disease of sloppiness...”

The inability to prosecute successfully large corporations after major disasters has led to increasing pressure from both unions and the public at large for more The recent criminal convictions of air However, in a large corporation it is often effective legislation to address the issue traffic controllers and airport managers very difficult to identify an individual who of corporate killing. In 1997 promises arising out of the fatal collision between satisfies the requirement of being the were made by the incoming Labour two aircraft at Milan Linate Airport in “controlling mind and will” of the government to introduce legislation so October 2001 has thrown the spotlight corporation. Large corporations have that: back on the issue of corporate and complex management structures where “…people cannot be criminally negligent individual responsibility for death caused decisions which may be criminally and allow innocent people to go to their by aviation accidents. The full judgment culpable are not readily attributable to any deaths and suffer no punishment” of the Italian criminal court is still awaited one person. In contrast, the decision and so we will only be able to report making structure in smaller companies is However, to date the government has yet further on that in a future issue of Focus. often more transparent and thus it is often to publish a draft bill. There appear to be In this article we consider the criminal easier to identify the person who is the two main obstacles to the preparation of liability of corporations for the death of “controlling mind and will” of the the draft bill: persons under current UK law and the corporation. proposals for new legislation to introduce ■ The question of whether government a new offence of Corporate Killing. Because of this “identification” based liability system, successful prosecutions bodies should be subject to prosecution i.e. Crown Immunity. As a Criminal prosecution for corporate against corporations for manslaughter matter of principle there seems to be manslaughter has been possible since have been very rare. In fact, only three no reason why government 1965. In order to establish criminal cases have been successfully prosecuted organisations should be immune from liability on the part of a corporation for to date, all of which related to smaller prosecution when private commercial death of an individual, it is necessary for companies where an individual could be companies performing many of the the prosecuting authorities to identify a proved to have had direct involvement same functions and activities face person who is the human embodiment of with causal elements of the disaster. potential criminal liability. However, if corporation’s “controlling mind and will”. There is a stark contrast between the no such immunity is granted the Conviction of the corporation is only exposure to criminal sanctions of these Crown may face a costly and time possible if that person is proved to have small companies and that of P&O, which consuming cycle of self prosecution. committed a criminal offence in the was unsuccessfully prosecuted following Interestingly crown immunity does course of his duties i.e. whilst acting as the 1987 Zeebrugge disaster, especially apply in relation to statutory health the “controlling mind and will” of the having regard to the damning report by and safety legislation, although the corporation. Lord Justice Sheen into the Zeebrugge disaster which stated that: government has indicated an intention to remove this “when parliamentary time allows”.

22 ■ The second issue is the concern that a On its face the suggested wording does that there is some certainty regarding the new offence of corporate killing may little to address the concerns referred to requirements of the various safety lead to “scapegoating” or “witch above regarding Crown immunity and regulations, whereas determining what hunts”. Fears have been raised as to scapegoating and so there must be some actually constitutes a “management whether it would be possible for a doubt as to whether the government will failure” is a much more nebulous concept corporation to have a fair trial especially adopt the draft bill. Absent government which may be open to flexible/expedient in the emotive aftermath of a major support the prospects of the draft bill interpretation in circumstances where disaster. Perhaps more worryingly becoming law are remote. there is significant public pressure for there is the risk that the prospect of “heads to roll”. criminal prosecution will discourage Although convictions for corporate open and transparent reporting to manslaughter have been hard to secure, The suggestion that there should be accident investigation authorities as corporations and their directors/managers measures in place to deal with has become an issue in other countries are not above all legal sanctions. corporations which are negligent and yet such as the . Prosecutions by the Health and Safety escaping criminal sanctions or that there Executive have been much in evidence in is a need to raise safety nearer to the top Absent a draft bill from the government, the aftermath of more recent major of the boardroom agenda are matters Frank Doran MP has introduced a private disasters and, in particular, the Ladbroke which are uncontentious in most quarters. member’s bill which seeks to create a Grove train crash where Thames Trains However, until the government clarifies its new offence of “corporate killing” which is was fined a record £2 million for failing to intentions with regard to “Corporate intended to apply to all companies and train its drivers adequately. Similarly Killing” doubt is likely to remain as to incorporated bodies i.e. no immunity for company directors can face fines and/or whether any new legislation will be the Crown. The bill has been derived imprisonment and/or disqualification from intended to improve safety or simply from a draft prepared by the Trade and acting as a company director for breach assuage public demands for someone or General Workers Union in 2003 and is of safety regulations. However, it seems some corporation to be seen to take the scheduled for its second reading before that the main distinction between blame and be punished. parliament later this year. We have not prosecutions by the HSE and potential seen the private member’s bill itself, but prosecution for corporate killing under the the T&G’s draft states that a corporation proposed draft private member’s bill is shall be guilty if: a) a management failure by the corporation is the cause or one of the causes of a person’s death; and b) that failure constitutes conduct falling far below what can reasonably be expected of the corporation in the circumstances..”

A “management failure” is defined as: “there is a management failure by a corporation if the way in which its activities are managed or organised fails to ensure the health and safety of persons employed in or affected by those activities; and such a failure may be regarded as a cause or a person’s death notwithstanding that the immediate cause is the act of an individual”.

23 UK FLIGHT SAFETY COMMITTEE

Annual Seminar 2004

BREAKING THE BARRIERS IN COMMUNICATION Enhancing Aviation Safety Through Better Communication

20th/21st September 2004 The Radisson Edwardian Hotel Heathrow

SEMINAR OBJECTIVE Compartmentalised management structures can be counter-productive from a safety perspective. This Seminar will raise awareness and enable discussion about breaking down these barriers and offer some constructive suggestions.

PROGRAMME

20th September 2004

2000hrs Seminar Dinner Jim Ratcliffe, Willis - After Dinner Speaker

21st September 2004

0800 - 0900 Registration 1155 - 1230 Questions

Session Chairman - Ian Crowe - Willis 1230 - 1340 Lunch

0900 - 0915 Welcoming Introduction 1340 - 1415 One Voice in European ATM Stuart McKie-Smith Kathy Nuttall - GATCO (Chairman - UKFSC) 1420 - 1455 Engineering Management and 0920 - 0955 Breaking the Barriers within Communication the Military Stewart John - Director of TAECO Arthur Gibson - Defence Helicopter Flying School 1455 - 1510 Comfort Break

1000 - 1035 The Legal Ramifications of 1510 - 1545 Transport Accident Investigation - Poor Communication Working together across the Modes Charles Haddon-Cave David King - AAIB

1035 - 1055 Refreshment Break 1550 - 1625 Lessons Learned in the Rail Industry Aidan Nelson - Rail Safety & 1055 - 1115 Keynote Speech Standards Board Rod Eddington - British Airways 1625 - 1655 Questions 1120 - 1155 Understanding how Communications Succeeds or Fails 1655 - 1700 Closing Speech James Reason Chairman UKFSC Seminar Information • Hotel Accommodation Hotel Accommodation is not included in the Seminar Registration Fee. A rate of £147 (including breakfast & VAT) has been negotiated with the Radisson Edwardian Hotel (Valid only until 10th September). If you require accommodation please contact the hotel directly on Tel: +44 (0) 20 8759 6311 and quote Block Booking Code 1019 UKF when making your reservation. • Seminar Dinner Dress for Dinner - Black Tie • Cancellations/Refunds Cancellations received prior to 23rd August 2004 will be refunded 50% of registration fee. Refunds after this date will not be given.

If you are unable to attend why not nominate a colleague to take your place. If so, please advise the UKFSC Fairoaks office of any changes prior to the Seminar. ✂ Seminar Registration Form Please complete in full one registration form per person. (Photocopies accepted)

REGISTRATION INFORMATION (Please print clearly)

First Name: Surname:

Company: Job Title:

Address:

Tel No: Fax No: e-mail:

PAYMENT INFORMATION Seminar Fee: £160 UKFSC Member £200 Non-UKFSC Member

This includes the Seminar Dinner on the evening 20th September, lunch, refreshments and car parking. This does not include hotel accommodation - please see 'Seminar Information' above.

Payment is by Sterling cheque only. No credit cards are accepted. Bank transfer is available, details on request (please note an additional cost of £6 will be added to cover handling charges). The UKFSC is not VAT Registered.

Sterling cheques should be made payable to UK Flight Safety Committee. • Do you plan to attend the Seminar Dinner on Monday 20th September? Yes No • Do you require a Vegetarian alternative? Yes No

PLEASE SEND YOUR COMPLETED REGISTRATION FORM WITH YOUR CHEQUE TO:

UK Flight Safety Committee, Graham Suite, Fairoaks Airport, Chobham, Woking, Surrey, GU24 8HX. Tel No: +44 (0)1276 855193 Fax No: +44 (0)1276 855195 email: [email protected] Confirmation will be faxed to you on receipt of your Registration Form and payment.