Line Operations Safety Audit (LOSA)
Flight Safety DIGEST FEBRUARY 2005 Line Operations Safety Audit (LOSA) Provides Data On Threats and Errors Flight Safety Digest Flight Safety Foundation For Everyone Concerned With the Safety of Flight Vol. 24 No. 2 February 2005 www.fl ightsafety.org
OFFICERS AND STAFF
Chairman, Board of Governors Amb. Edward W. Stimpson President and CEO Stuart Matthews In This Issue Executive Vice President Robert H. Vandel Treasurer David J. Barger General Counsel and Secretary Kenneth P. Quinn, Esq. Line Operations Safety Audit (LOSA) Provides Data on Threats and Errors ADMINISTRATIVE Structured observations of routine fl ight operations help reveal Manager, Support Services Linda Crowley Horger an airline’s strengths and weaknesses. The nonpunitive data- FINANCIAL 1 collection program — a planned cornerstone of internationally required safety management systems — is being adapted to Director of Finance other areas, including fl ight dispatch, apron operations and air and Administration Juan G. Gonzalez traffi c control. Accountant Millicent Wheeler
MEMBERSHIP Clear Air Turbulence, Downdraft Cited STATS Director, Membership Most Often in U.S. Weather Turbulence and Development Ann Hill Accidents, 1992–2001 Membership Services Coordinator Ahlam Wahdan No fatalities occurred as a result of weather turbulence in air carrier operations during the study period. Eight fatalities PUBLICATIONS occurred in weather turbulence accidents in commuter and 19 Director of Publications Roger Rozelle on-demand operations. Senior Editor Mark Lacagnina Senior Editor Wayne Rosenkrans Simplifying Processes and Tools Senior Editor Linda Werfelman Aids Project Risk Management Associate Editor Rick Darby Web and Print A qualitative methodology, such as posing and answering Production Coordinator Karen K. Ehrlich LIBRARY key questions, is often the best framework for project risk Production Designer Ann L. Mullikin management; nevertheless, say the authors, quantitative Production Specialist Susan D. Reed 24 analysis has its place as well. Librarian, Jerry Lederer Aviation Safety Library Patricia Setze Overfl owing Sink Blamed for 28 TECHNICAL Short Circuit, Fumes in B-717 Director of Technical Programs James M. Burin The accident report said that an electrical odor in the cabin Technical Programs Specialist Joanne Anderson during a domestic fl ight in Australia led to an unscheduled BRIEFS Managing Director of landing. Internal Evaluation Programs Louis A. Sorrentino III Q-Star Program Administrator Robert Feeler Manager, Data Systems and Analysis Robert Dodd, Ph.D. Manager of Aviation Safety Audits Darol V. Holsman
Founder Jerome Lederer 1902–2004
Flight Safety Foundation is an international membership organization dedicated to the continuous improvement of aviation safety. Nonprofi t and independent, the Foundation was launched offi cially in 1947 in response to the aviation industry’s need for a neutral clearinghouse to disseminate objective safety information, and for a credible and knowl- edgeable body that would identify threats to safety, analyze the problems and recommend practical solutions to them. Since its beginning, the Foundation has acted in the public interest to produce positive infl uence on aviation safety. Today, the Foundation provides leadership to more than 900 member organizations in more than 150 countries. Cover photo: © Copyright 2005 Getty images Inc. © Copyright Niels Laan
Line Operations Safety Audit (LOSA) Provides Data on Threats and Errors
Structured observations of routine flight operations help reveal an airline’s strengths and weaknesses. The nonpunitive data-collection program — a planned cornerstone of internationally required safety management systems — is being adapted to other areas, including flight dispatch, apron operations and air traffic control.
—FSF EDITORIAL STAFF
he line operations safety audit (LOSA) strengths and weaknesses. LOSA also enables air- — which involves the collection of data lines to compare data among de-identifi ed data by trained observers during routine gathered by other airlines. Tfl ights to determine how fl ight crews detect, manage and mismanage threats and errors “Document 9803 is the bible of LOSA,” said Capt. — has been endorsed by the International Civil Don Gunther, director of human factors and safety Aviation Organization (ICAO) as a tool for moni- for Continental Airlines.2 “The beauty of following toring normal fl ight operations and developing the guidelines in ‘9803’ is that you can compare countermeasures against human error.1 your data with all other airlines that have done LOSAs. You don’t know who the other airlines ICAO in 2002 published Document 9803, Line are, but the de-identifi ed data indicate how you Operations Safety Audit (LOSA), which contains compare to the industry. detailed information on planning and conduct- ing a LOSA. The manual provides guidelines for “If you have an issue, and no one else does, you airlines on using LOSA data to gauge operational can fi nd out what you’re doing wrong. If you have
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an issue, and everybody else does, psychology at the University of Texas and leader too, you know it’s an industry is- of the UTHF, said that the fi rst fl ight observations sue; and collectively, we might be were conducted in 1994 at the request of Delta able to fi nd a solution.” Air Lines.4
LOSA complements other safety- “This study involved the observation of 480 line data-collection systems such as flights,” Helmreich said. “Delta Air Lines had fl ight-data monitoring (e.g., fl ight developed and implemented an intensive multi- operational quality assurance day CRM training course, which it believed had [FOQA] programs) and voluntary improved crew coordination and enhanced reporting (e.g., aviation safety ac- safety. However, senior airline management felt tion programs [ASAP]). it important to confi rm whether the behaviors being taught were, in fact, practiced during line Capt. Daniel E. Maurino, coordi- operations.” nator of the ICAO Flight Safety and Human Factors Program, Similar fl ight observations were conducted by said that the organization currently is drafting Air New Zealand, American Airlines, Continental standards for safety-management systems that Airlines, Trans World Airlines and US Airways. The will include LOSA, FOQA and ASAP as essential observations showed that the practice of CRM on components.3 the fl ight deck was substantially different than in airline training environments and resulted in the “LOSA has raised the level of safety analysis and development of advanced CRM concepts and provides airlines with earlier warnings of potential “new ways of thinking about crew performance,” problems,” he said. “With FOQA, for example, we ICAO said. know that we have a problem with unstabilized approaches, but we need to experience the unsta- Helmreich said that the early fl ight observations bilized approaches to trigger the data capture. It’s did not provide adequate information about how the same thing with ASAP.” fl ight crews adhere to standard operating proce- dures (SOPs) or about environmental infl uences LOSA conferences are conducted annually by on crew performance. UTHF and Continental ICAO. The fi rst conference was in Hong Kong, Airlines in the late 1990s expanded the concept China, in 2000. Subsequent conferences were con- and methodology to include the recording of ducted in Panama City, Panama; Dubai, United threats (e.g., adverse weather conditions) and er- Arab Emirates; Dublin, Ireland; and Seattle, rors (e.g., human mistakes) and how fl ight crews Washington, U.S. The next conference will be deal with them. conducted Sept. 27–28, 2005, in Kuala Lumpur, Malaysia. “This change greatly enhanced the usefulness of LOSA for airlines, expanding it from a CRM audit to one which places CRM skills into perspective Program Initiated to as operational threat-and-error countermeasures,” Check CRM he said.
ith funding from the U.S. Federal Aviation WAdministration (FAA), the University of TEM Model Provides Focus Texas at Austin (Texas, U.S.) Human Factors Research Project (UTHF) in the early 1990s he concept and methodology of LOSA placed trained observers in aircraft jump seats Tcurrently are based on the threat-and- to help airlines gauge the effectiveness of crew error management (TEM) model developed by resource management (CRM) during routine UTHF (Figure 1, page 3). ICAO calls TEM the airline fl ights. “fi fth generation of CRM,” which, in the context of LOSA, is based on the premise that “human The fl ight observations were the precursors of error is ubiquitous, inevitable and a valuable LOSA. Robert L. Helmreich, Ph.D., a professor of source of information.”5
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Figure 1 Threat-and-error Management Model
Threats
Threat-induced Inconsequential Threat Management Incident or Accident
Crew Error
Crew Error Responses
Undesired Aircraft State
Crew Undesired Aircraft Error-induced State Responses Incident or Accident
Source: Adapted from James R. Klinect, University of Texas at Austin (Texas, U.S.) Human Factors Research Project
“Essentially, the model posits that threats and er- Threats are defi ned as expected or unexpected rors are integral parts of daily fl ight operations external situations that must be managed by the and must be managed,” ICAO said.6 “Therefore, fl ight crew. observing the management or mismanagement of threats and errors can build the desired systemic “[Threats] increase the operational complexity snapshot of performance.” of the fl ight and pose a safety risk to the fl ight at some level,” ICAO said. ICAO said that the TEM model provides a frame- work for data collection and categorization, and helps to answer questions such as the following: Threats Include Errors by Others • “What type of threats do flight crews most frequently encounter? When and where do hreats include adverse weather conditions, they occur, and what types are most difficult Thazardous terrain, aircraft and aircraft system to manage? abnormalities and malfunctions, time pressures and unfamiliar airports. Threats also include er- • “What are the most frequently committed rors that are committed by others — including crew errors, and which ones are the most ground-handling personnel, maintenance techni- difficult to manage? cians, dispatchers, fl ight attendants and air traffi c controllers — and that must be managed by the • “What outcomes are associated with misman- fl ight crew. aged errors? How many result in an undesired aircraft state [e.g., altitude deviation, marginal Flight crew errors are defi ned as actions and inac- fuel supply, unstable approach]? [and,] tions that lead to deviations from the intentions or expectations of the fl ight crew or the airline. • “Are there significant differences between airports, fleets, routes or phases of flight vis- “Errors, in the operational context, tend to à-vis threats and errors?” reduce the margin of safety and increase the
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probability of accidents or incidents,” that an operational decision error includes ICAO said. at least one of the following conditions: the flight crew ignores a more conservative op- The TEM model characterizes fl ight tion; the crewmember who took the decision crew errors as follows: does not brief other crewmembers about the decision; or the crew does not use available • Intentional noncompliance er- time to evaluate options. Examples include rors are “willful deviations from navigating through known areas of adverse regulations and/or operator pro- weather and accepting ATC instructions that cedures,” ICAO said. Examples in- result in an unstable approach. clude violating the “sterile-cockpit rule,”7 omitting required callouts, The TEM model posits that when an error occurs, using nonstandard pilot-controller the fl ight crew either traps (i.e., detects and man- communication phraseology, con- ages) the error, exacerbates the error with action ducting checklists from memory, or inaction that results in additional error, or fails and failing to respond to traffic to respond to (i.e., ignores) the error. alert and collision-avoidance system (TCAS) warnings or terrain awareness and warning system Crews Trap Most Errors (TAWS) warnings;8 ost errors that occur during routine fl ight • Procedural errors are “deviations in the execu- Moperations are trapped and thus have in- tion of regulations and/or operator procedures consequential outcomes, ICAO said. When a crew [in which] the intention is correct but the ex- exacerbates an error or fails to respond to an error, ecution is flawed.” This category includes er- the outcome could be an undesired aircraft state, rors in which flight crewmembers forget to do an accident or an incident. something. Examples include failing to conduct checklists, incorrectly setting instruments and Maurino said that the concept of undesired air- failing to cross-check instrument settings; craft state is a hallmark of LOSA.
• Communication errors include “miscom- “An undesired aircraft state is a transitional munication, misinterpretation or failure to state, and the crew is still in the ‘driver’s seat,’ communicate pertinent information among so to speak,” he said. “An airspeed deviation, for the flight crew or between the flight crew and example, might be corrected by the crew before an external agent [e.g., air traffic controller, the approach becomes unstabilized. The observer ground-handling personnel].” Examples in- can capture what the crew is doing — successful clude failing to hear air traffic control (ATC) strategies to prevent an unstabilized approach. instructions, failing to read back ATC instruc- And that is a success story.” tions and crew miscommunication; Following are examples of incidents observed • Proficiency-based errors involve “lack of during fl ight observations and how they fi t in the knowledge or psychomotor (‘stick-and- TEM model:9 rudder’) skills.” Examples include inadequate knowledge of aircraft systems and equipment • Before departure, the first officer commit- that contribute to hand-flying errors, auto- ted a procedural error when he entered an mation errors or other errors that can influ- incorrect waypoint in the flight management ence the direction, speed or configuration of system (FMS). The error was inconsequential the aircraft; and, because it was trapped during a subsequent cross-check of FMS data; • Operational decision errors are “decision- making errors that are not standardized by • A communication error was committed when regulations or operator procedures and that the pilot not flying told the pilot flying to unnecessarily compromise safety.” ICAO said taxi onto the wrong runway. The pilot flying
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exacerbated the error by taxiing onto the “For any observer, there is a learning curve,” he wrong runway. The outcome was inconse- said. “Our initial observer training is a two-day quential because the undesired aircraft state course. Then, after conducting a couple of fl ight (being on the wrong runway) was managed observations, the observers and the trainers go by a review of the airport chart and by taxiing over the observations and recalibrate the observ- the aircraft off the wrong runway; and, ers, to make sure they are on track.”
• Nearing Flight Level (FL) 220 (approximately Most flight observations are conducted by 22,000 feet) during climb, the controller told Continental line pilots. Gunther said that about the crew to maintain FL 220; the captain 15 percent are conducted by non-pilots. committed a procedural error when he inad- vertently pushed the autopilot altitude-hold “There’s very little difference in the observations button twice, thus engaging and disengaging as far as content and grading,” he said. the altitude-hold mode. The crew did not notice the error, but the captain observed Capt. Bruce Tesmer, manager of LOSA and ASAP the undesired aircraft state (altitude devia- for Continental, said that non-pilot observers have tion) and recovered by flying the aircraft to included former FAA fl ight standards district of- the assigned altitude and properly engaging fice managers, a former vice chairman of the the altitude-hold mode. U.S. National Transportation Safety Board and human factors specialists trained in the airline’s operations.10 Continental Did First TEM LOSA “We put them in the simulator, and until they [the observers] can land the airplane, they cannot con- ontinental Airlines in 2000 conducted the duct an audit,” Tesmer said. Cfi rst systemwide LOSA based on the TEM model. The airline conducted the second system- Gunther said that Continental pilots have be- wide LOSA in 2004. Gunther said that LOSAs will come increasingly enthusiastic about LOSA. At be conducted about every four years. fi rst, pilots agreed to be observed because of the ‘no-jeopardy’ [i.e., anonymous and nonpunitive] “It’s a cycle,” he said. “We do the LOSA, we make provisions of the program. In subsequent LOSAs, the changes, and we work with the check airmen most pilots openly welcomed the observers. to make sure that they understand why those changes were made, so that they can pass that “The majority of our pilots are very pleased with information on to the pilots. All that occurs over the observations, and the reason is because they a two-year to three-year period; then, we prepare have seen positive safety changes that have come for the next LOSA.” out of it,” he said.
Continental also has conducted what it calls “spot Continental’s LOSAs include a brief safety survey LOSAs,” focusing on specifi c fl eets or regions. In and crew interview. The survey 1998, for example, the airline conducted a spot focuses on the company’s safety LOSA of its South American operations. culture. A typical question is: “What are your feelings about “We wanted to see how our policy and procedures safety issues and how they are ad- were fi tting into what we consider a high-threat dressed?” The interview questions environment,” Gunther said. “Some of the airports cover specifi c issues. have mountainous terrain and various approaches, and there are other differences from our domes- “There are only about four or fi ve tic operations. We collected some good data and questions, and they are targeted,” made a few changes based on that data.” Gunther said. “We go to our fl ight standards, training, fl ight opera- Gunther said that observer training and observer tions and safety departments, and “calibration” are critical to the success of a LOSA. determine what we need to know.
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For example, we might want to know The fi rst offi cer used a small clipboard, demanding clearances and 20 per- how a checklist change has affected their with an attachment that allows it to be cent involved a runway change; 14 productivity. There’s an open question stowed near his right leg when not in use, percent of these threats were mis- at the end, asking if they have anything to organize paperwork. managed; and, to add. Pilots always have something to add.” “Every time he needs a document, it’s • Of the mismanaged ATC threats, 66 right at his fingertips,” Tesmer said. percent occurred during descent, “Those little things — those personal approach and landing. Observations Reveal strategies that work — when you pass ‘Best Practices’ them around, people say, ‘That’s a good The data showed the following results idea. I think I’ll try that.’” about errors: hat has Continental Airlines Wgained from LOSA? How does the airline pass the informa- • One or more errors occurred during tion around? 64 percent of the flights; “Because of the information from LOSA and the adjustments in our training, “The most effective document that we give • The most frequent errors involved including implementing a threat-and- our crews is the newsletter,” Tesmer said. hand-flying (21 percent); checklists error management program, we have seen “You can give crews a research report, and (20 percent) and communication/ tremendous improvements in the use and most of them won’t get past page two. Give coordination between flight crews standardization of our checklists, in the them a newsletter that’s brief and has good and ATC; and, way our crews fl y their approaches and information, and they will read it.” in overall crew performance,” Gunther • Most of the errors (43 percent) oc- said. “One of the things you learn is curred during descent, approach and what ‘good’ crews do — what are the ATC Threats Are landing; 27 percent occurred before best practices out there — and you can Most Frequent departure; 22 percent occurred on pass that information along.” takeoff; and 4 percent occurred dur- s of October 2004, 21 airlines world- ing cruise. Continental found that crews who ver- Awide had conducted LOSAs or were balize their actions make fewer automa- conducting their fi rst LOSA. Three air- tion errors. lines had conducted multiple LOSAs.11 Multiple Audits Identify Trends “For example, ATC says that the al- UTHF presented data from 1,310 U.S. timeter setting now is 29.32; one pilot airline flight observations at an FAA ata collected by a U.S. airline during enters 29.32 in his altimeter, the other conference in October 2004; the data Dits fi rst systemwide LOSA showed pilot enters 30.32 in his altimeter and showed the following: an undesired number of below-standard levels off 1,000 feet from the assigned leadership ratings of captains, a high num- altitude,” Gunther said. “What if the • One or more threats occurred during ber of approaches that did not meet the fi rst pilot had verbalized, ‘The altimeter 90 percent of the flights; airline’s criteria for stabilized approaches is twenty-nine thirty-two.’ With that little and a low rate of error trapping.12 bit of verbalization, the other pilot might • Crew error resulting from misman- have caught the mistake.” aged threats occurred during 22 Among actions taken by the airline were percent of the flights; the implementation of a leadership Tesmer gave another example that in- module in its recurrent training syl- volved a fi rst offi cer’s personal strategy • The most frequent threats were from labus, revision of stabilized-approach for stowing paperwork. ATC (encountered during 47 percent procedures and implementation of of the flights); weather conditions error-management training for pilots “There’s very limited space in the cockpit (40 percent of the flights) and and check airmen. for paperwork,” Tesmer said. “I have seen aircraft malfunctions or minimum- paperwork strewn all over the console equipment-list items (23 percent of When the second LOSA was conducted and wedged between the fi re handles and the flights); three years later, the airline found a behind the fi re-extinguisher bottle on the signifi cant improvement in leadership circuit breaker panel. None of those is a • Among the ATC threats, 50 percent ratings, a 70 percent reduction in un- good option.” involved the issuance of difficult/ stabilized approaches continued below
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1,000 feet and a twofold increase in the including names, flight numbers and and manuals, before any statistical error-trapping rate. dates. “This allows for a level of pro- analysis is performed”; tection against disciplinary actions,” ICAO said. “The purpose of LOSA is • Data-derived targets for enhance- Specifi c Operating to collect safety data, not to punish ment. “As the data are collected and Characteristics Defi ned pilots. … If a LOSA observation is analyzed, patterns emerge,” ICAO ever used for disciplinary reasons, said. “Certain errors occur more fre- lthough airlines are encouraged to the acceptance of LOSA within the quently than others, certain airports Aset their own goals and to determine airline will most probably be lost or events emerge as more problem- how a LOSA can be conducted most ef- forever”; atic than others, certain SOPs are fectively to meet their needs, ICAO has routinely ignored or modified, and established the following specifi c operat- • Targeted observation instrument. certain maneuvers pose greater dif- ing characteristics that must be incorpo- Most airlines use the LOSA obser- ficulty in adherence than others. rated in a LOSA: vation form developed by UTHF These patterns are identified for the (see Appendix A, page 12) to airline as LOSA targets for enhance- • Jump-seat observations during nor- record general flight information ment. It is then up to the airline to mal line operations. Observations (e.g., city pairs, aircraft type, crew develop an action plan based on must be conducted during routine experience), crew performance in these targets”; and, flights, rather than during line detecting and managing threats and checks or training flights when the errors during various phases of the • Feedback of results to the line pilots. presence of another observer would flight, and other information. “It is “Pilots will want to see not only the increase “an already high stress level, not critical that an airline use this results but also management’s plan thus providing an unrealistic picture form, but whatever data-collection for improvement,” ICAO said. of [flight crew] performance”; instrument is used needs to target issues that affect flight crew perfor- • Joint management/pilot sponsorship. mance in normal operations,” ICAO LOSA Collaborative Among the first steps in conducting said; Provides Assistance a LOSA is to achieve a signed agree- ment between airline management • Trusted, trained and calibrated ost airlines that have conducted and pilots (typically, the pilot or- observers. Observers typically are MLOSAs since 2001 have engaged ganization) and to form a steering selected from among the airline’s the services of a private organization, the committee comprising representa- line pilots, instructor pilots, safety LOSA Collaborative, in the program. tives of both parties. The function pilots and management pilots, and of the steering committee is to from the pilot organization’s safety James R. Klinect, CEO and managing oversee the planning and schedul- committee members. “It is critical to director of the LOSA Collaborative and ing of flight observations, and the select observers [who] are respected a part-time UTHF researcher, said that verification of data collected during and trusted within the airline to en- he formed the organization after FAA the observations; sure the line’s acceptance of LOSA,” reduced funding for LOSA.13 ICAO said. Before conducting flight • Voluntary crew participation. A flight observations, the observers must re- “FAA was interested in funding work observation cannot be conducted ceive training on LOSA concepts and done with U.S. airlines,” he said. “Over without the flight crew’s permis- methodology, including the use of the time, we noticed that the funding was sion. “The crew has the option to targeted observation instrument; constantly being cut. Because of the fund- decline, with no questions asked,” ing shortfalls and because we had done ICAO said. “The observer simply • Data-verification round tables. “A cross-cultural work before and wanted approaches another flight crew on round table consists of three or to branch out from the U.S. airlines, we another flight and asks for their four department [representatives] formed the LOSA Collaborative. Instead permission to be observed”; and pilots’ association representa- of having airline LOSAs funded by re- tives who scan the raw data for search dollars, we have passed the costs • De-identified, confidential and safety- inaccuracies,” ICAO said. “The end along to the airlines.” minded data collection. Observers product is a database that is vali- must not record anything that could dated for consistency and accuracy Among the organization’s services are identify flight crews or flights — according to the airline’s standards participation in program planning and
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observer training. Independent observers trained “When we provide the fi nal report, we include a by the LOSA Collaborative are available to partici- comparison with other airlines on data such as pate in fl ight observations.14 threat-management rates, automation errors and so forth,” Klinect said. “We might say, for example, “We have a cadre of about 12 observers based that 40 percent of the customer-airline’s observed around the world (Australia, England, New fl ights had an aircraft-malfunction threat that the Zealand, Singapore and the United States),” Klinect crew had to manage, compared to 10 percent to said. “All of our observers are retired pilots. Many 15 percent of the observed fl ights at other airlines. of them are former check airmen, and some were We’ll tell the customer airline that this is a target training-program developers. We ask the airline for enhancement, that they might want to look for copies of their manuals several weeks before at this because their rate is so much higher than a project, so we can have some familiarity with other airlines.” their operation. Fees for the organization’s services vary accord- “Since the start of the LOSA Collaborative in 2001, ing to the scope of the LOSA. Klinect said that the only non-pilot from our group conducting fees typically range from about US$50,000 for observations has been me. I try to conduct one a relatively small airline to about $100,000 for a or two observations during every project to keep large airline. current.” “Seventy-fi ve percent of that fee is for data veri- Nevertheless, airlines sometimes use non-pilot fi cation and analysis, and for preparing the fi nal employees as observers. report,” he said.
“Non-pilots are not used unless they have enough Klinect said that he knows of only two airlines familiarization with company SOPs and are able that have conducted LOSAs adhering to all 10 op- to anticipate fl ight crew actions in a cockpit,” erating characteristics specifi ed by ICAO without Klinect said. “Therefore, non-pilot ground school the assistance of the LOSA Collaborative: Futura or simulator instructors are great examples and International Airways and Lan Chile. have been used as LOSA observers representing the airline. This is rare, though; most LOSA “I don’t know of any major carriers that have done observers representing their airline are current it by themselves,” he said. “Airlines that conduct line pilots.” their own LOSAs do not send their data to the LOSA Collaborative; their data likely would not The LOSA Collaborative provides match our database.” a computer program that facilitates the recording of notes and data gath- Klinect said that only UTHF researchers have ac- ered by observers. cess to de-identifi ed data that airlines have agreed to submit for research. Otherwise, all data are kept “The files are sent to the LOSA in confi dence within the LOSA Collaborative. Collaborative, and we build a da- tabase,” Klinect said. “We conduct round tables with airline personnel Steering Team Guides Program to verify the data — ensuring, for ex- ample, that the observed errors are ac- he LOSA steering team should be led by the tually errors according to the airline’s Tairline’s safety department, which typically fl ight standards. We then analyze the conducts internal audits, confi dential incident- data and provide a full report of our reporting systems and fl ight-data-monitoring pro- fi ndings to the airline.” grams, and “often holds the trust of the line pilots regarding confi dential information,” ICAO said.15 The final report identifies targets for enhancement and de-identifi ed, The steering team decides which fl ight operations aggregate data from other airlines, will be observed and selects specifi c targets for the where appropriate. observations.
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“One common mistake is to try to tackle too much Results Should Be at one time,” ICAO said. “When doing this, the Shared With Pilots effort can be enormous and the data fi ndings can be overwhelming.” fter analysis of the data is Acompleted, a written report Focusing a LOSA on a specifi c fl eet or fl ight opera- should be prepared for airline tion can help keep the program manageable. For managers and pilots. The report example, one airline decided to conduct its fi rst should present the overall fi nd- LOSA on international operations and to focus on ings clearly and concisely. domestic operations in a later LOSA. Capt. Alex de Silva, division vice ICAO said that although observations of every president of safety, security and en- fl ight crew would be ideal, this is not necessary to vironment for Singapore Airlines, collect suffi cient data. Depending on the size of the which conducted a LOSA in 2003 fl eet or fl ight operation, observation of 30 fl ight and will conduct another audit in crews to 50 fl ight crews is suffi cient to provide 2006, said that the recommenda- statistically valid data. tions included in the fi nal report are a crucial element.16 Findings from confi dential-reporting programs and from FOQA can help in the selection of spe- “The LOSA steering committee should address cifi c targets, such as checklist usage and approach all the issues identifi ed in the report,” he said. stabilization. “Subject-matter experts from each area should formulate a two-pronged action plan that Good Observers combines specifi c approaches and systemic ap- Are ‘Flies on the Wall’ proaches to resolve the areas identifi ed as targets for enhancement.” bservers should be selected carefully because ICAO said, “The LOSA report should clearly “the quality of data collected depends en- O describe the problems the analyzed data suggest tirely on who is collecting that data,” ICAO said. but should not provide solutions. These will be An important requirement is knowledge of the better provided through the expertise of each of airline’s procedures and operations. Check airmen the areas in question [e.g., operations, training, and instructors, however, must step out of these standards].” roles when conducting LOSA observations. ICAO recommends the following report outline: “Observers should create an environment where the crews hardly realize that they are being ob- • “Introduction — Define LOSA and the rea- served,” ICAO said. “It is imperative that crews sons why it was conducted; do not feel as if they are being given a check ride. … The LOSA observers must clearly understand • “Executive summary — Include a test sum- that their role is limited to collecting data, not to mary of the major LOSA findings (no longer disciplining or critiquing fl ight crews.” than two pages);
Experience has shown that the best data-collection • “Section summaries — Present the key results have been achieved by observers who used findings from each section of the report, a “fl y-on-the-wall” approach. including:
“The best observers learn to be unobtrusive and – “Demographics; nonthreatening; they use a pocket notebook while in the cockpit, recording minimal detail to elaborate – “Safety interview results; on later,” ICAO said. “At the same time, they know when it is appropriate to speak up if they have a – “External threats and threat-management concern, without sounding authoritarian.” results;
FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • FEBRUARY 2005 9 LOSA PROVIDES DATA
– “Flight crew errors and error-management should be a tool for enhancing safety and not used results; for disciplinary purposes or personnel checking. LOSA meets our requirements.” – “Threat-and-error countermeasure re- sults; [and,] Capt. Carlos Arroyo-Landero, chairman of the IFALPA Human Performance Committee, said • “Appendix — Include a listing of every ex- that a recent resolution adopted by the ICAO ternal threat and flight crew error observed, Assembly is “the necessary fi rst step” to ensuring with the proper coding and an observer the protection of aviation safety data.18 narrative of how each one was managed or mishandled.” The resolution, adopted by the ICAO Assembly in September 2004, instructs the ICAO Council to ICAO said that the airline must then take action develop legal guidance to assist member states to on the identifi ed targets for enhancement, or the “enact national laws and regulations to effectively LOSA data “will join the vast amounts of untapped protect information from safety-data-collection data already existing throughout the international systems, both mandatory and voluntary, while civil aviation community.” allowing for the proper administration of justice in the state.” Data Must Be Protected Concept Expands to Other pecialists agree that LOSA — like other avia- Operations Stion-safety-data-collection tools — will not be effective if the data cannot be protected from he LOSA concept currently is being applied to unwarranted use in judicial proceedings and dis- Tother operations. Continental Airlines has ap- ciplinary actions. plied the concept to monitor dispatch operations and apron (ramp) operations. ICAO is adapting LOSA has the support of the International the concept to monitor ATC operations. Federation of Air Line Pilots’ Associations (IFALPA) because of the protections included in In late January 2005, Continental had completed its defi nition. the fi rst phase of its dispatch LOSA, which in- volved observations of routine dispatch opera- “It is interesting to note that six out of the 10 tions by three dispatchers trained in the LOSA operating characteristics of LOSA specifi cally concept and methodology. The airline also had protect pilots who take part in a LOSA audit,” completed the training of ground-handling said James Eales, technical offi cer for the IFALPA personnel to conduct the observations of routine Human Performance Committee.17 “An audit will ramp operations. be successful only if the safeguards incorporated are enforced; without them, the “The preliminary data from the fi rst phase of the audit will have a negative effect on dispatch LOSA looks really promising,” Gunther safety.” said. “Again, we’re going to do the data collection in three parts: the observations, the survey and Eales said that IFALPA has drafted the interview. a policy on auditing systems for consideration at the organization’s “The ramp is very different than fl ight operations, annual conference in April 2005. which has two people in a very confi ned environ- ment. On the ramp, there are several people in a “The [draft] policy clearly states the much more open environment. We have studied requirements necessary for an audit the ramp, and we know what areas we’re going to be acceptable to IFALPA and to target.” highlights the safeguards that we think are necessary,” he said. “The Maurino said, “We have received a mandate from main requirement is that the audit our customers — our states — to explore the
10 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • FEBRUARY 2005 LOSA PROVIDES DATA extension of the concept of monitoring 2. Gunther, Don. Telephone interview to describe equipment meeting ICAO routine operations to ATC, using as a by Lacagnina, Mark. Alexandria, standards and recommendations for basis the LOSA methodology adapted to Virginia, U.S. Jan. 28, 2005. Flight Safety ground-proximity warning system Foundation, Alexandria, Virginia. U.S. (GPWS) equipment that provides predic- the ATC environment.” tive terrain-hazard warnings; enhanced 3. Maurino, Daniel E. Telephone interview GPWS and ground collision avoidance ICAO has formed the Normal Operations by Lacagnina, Mark. Alexandria, Virginia, system are other terms used to describe Safety Survey (NOSS) Study Group to U.S. Jan. 7, 2005. Flight Safety Foundation, TAWS equipment. advance the concept. Alexandria, Virginia, U.S. 9. Helmreich, Robert L.; Wilhelm, John 4. Helmreich, Robert L. “Crew Performance A.; Klinect, James R.; Merritt, Ashleigh “Instead of calling it LOSA in ATC, we’re Monitoring Programme Continues to C. “Culture, Error and Crew Resource calling it NOSS,” Maurino said. “The Evolve as Database Grows.” ICAO Journal Management.” In Improving Teamwork in NOSS Study Group has had one meet- Volume 57 (Nov. 4, 2002). Organizations: A Guide for Professionals, ing, and we have made an analysis of the edited by Salas, E.; Bowers, C.A.; Edens, 5. ICAO. Human Factors Training Manual. LOSA methodology. We identifi ed aspects E. Hillsdale, New Jersey, U.S.: Erlbaum, Document 9683. First edition, 1998. that can transfer directly to ATC and other 2001. aspects that need considerable rework. All 6. ICAO. Document 9803. 10. Tesmer, Bruce. Telephone interview in all, the conclusion of this fi rst meeting 7. The sterile cockpit rule refers to U.S. by Lacagnina, Mark. Alexandria, is that we can develop a methodology to Federal Aviation Regulations (FARs) Virginia, U.S. Jan. 31, 2005. Flight Safety observe normal ATC operations based on Part 121.542, “Flight Crewmember Foundation, Alexandria, Virginia, U.S. the LOSA methodology.” Duties,” which states: “No flight crew- 11. Helmreich, Robert; Klinect, James; member may engage in, nor may any Merritt, Ashleigh. “Line Operations Safety pilot-in-command permit, any activity Development of NOSS methodology, Audit: LOSA Data From U.S. Airlines.” during a critical phase of flight which including an observation form and ob- Paper presented at FAA Shared Vision of could distract any flight crewmember server-training procedures, currently Aviation Safety Conference, San Diego, from the performance of his or her du- is underway. The group plans to hold California, U.S., October 2004. ties or which could interfere in any way a conference in Europe near the end with the proper conduct of those duties. 12. Ibid. of 2005 to brief the community on its Activities such as eating meals, engaging progress. in nonessential conversations within the 13. Klinect, James R. Telephone interview by cockpit and nonessential communica- Lacagnina, Mark. Alexandria, Virginia, U.S. Jan. 6, 2005. Flight Safety Foundation, Maurino said that the LOSA concept likely tions between the cabin and cockpit Alexandria, Virginia, U.S. will be extended into other operations. crews, and reading publications not re- lated to the proper conduct of the flight 14. Klinect, James. E-mail communica- are not required for the safe operation “There is no question that the meth- tion with Lacagnina, Mark. Alexandria, of the aircraft. For the purposes of this Virginia, U.S. Feb. 7, 2005. Flight Safety odology is valid across the board for section, critical phases of flight include Foundation, Alexandria, Virginia, U.S. different activities in aviation,” he said. all ground operations involving taxi, “There is no reason why the methodol- takeoff and landing, and all other flight 15. ICAO. Document 9803. ogy could not be applied in maintenance, operations conducted below 10,000 feet, for example. It should be, and it’s quite except cruise flight.” 16. De Silva, Alex. E-mail communica- possible. The crux of the question is the tion with Lacagnina, Mark. Alexandria, European Joint Aviation Requirements Virginia, U.S. Jan. 31, 2005. Flight Safety level of trust between the work force and JAR–OPS 1.085, “Crew Responsibilities,” Foundation, Alexandria, Virginia, U.S. the organization. If there is no trust, it is states that the commander (pilot-in-com- impossible to have an external observer mand) “shall … not permit any crewmem- 17. Eales, James. E-mail communication looking over your shoulder. You have to ber to perform any activity during takeoff, with Lacagnina, Mark. Alexandria, be comfortable.” ■ initial climb, fi nal approach and landing Virginia, U.S. Dec. 20, 2004. Flight Safety except those duties required for the safe Foundation, Alexandria, Virginia, U.S. operation of the aeroplane.” Notes 18. Arroyo-Landero, Carlos. “IFALPA’s View 8. Terrain awareness and warning system on LOSA.” Paper presented at the Second 1. International Civil Aviation Organization (TAWS) is the term used by the European ICAO/IATA LOSA/TEM Conference, (ICAO). Line Operations Safety Audit Joint Aviation Authorities and the U.S. Seattle, Washington, U.S., November (LOSA). Document 9803. First edition, 2002. Federal Aviation Administration (FAA) 2004.
FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • FEBRUARY 2005 11 LOSA PROVIDES DATA
Appendix University of Texas Line Operations Safety Audit (LOSA) Observation Form With Sample Observations
Observer Information
Observer ID (Employee number) 3059 Observation Number #1
Crew Observation Number of (e.g., “1 of 2” indicates segment one for a crew that you observed across two segments) 1 1
Flight Demographics
City Pairs (e.g., PIT-CLT) PIT – LAX A/C Type (e.g., 737-300) B-757 Pilot flying (Check one) CA FO X
Time from Pushback to Gate Arrival Local Arrival Time (Hours:Minutes) 4:55 (Use 24 hour time) 09:55 Late Departure? (Yes or No) Yes
Predeparture/Taxi
Your narrative should provide a context. What did the crew do well? What did the crew do poorly? Narrative How did the crew manage threats, crew errors, and significant events? Also, be sure to justify your behavioral ratings.
The CA established a great team climate — positive with open communication. However, he seemed to be in a rush and not very detail oriented. The FO, who was relatively new to the A/C, tried to keep up but fell behind at times. The CA did not help the cause by interrupting the FO with casual conversation (marginal workload management).
All checklists were rushed and poorly executed. The CA was also lax verifying paperwork. This sub-par behavior contributed to an undetected error — the FO failed to set his airspeed bugs for T/O (poor monitor/cross-check). The Before Takeoff Checklist should have caught the error, but the crew unintentionally skipped over that item. The FO noticed the error upon commencing the takeoff roll and said, “Missed that one.”
The Captain’s brief was interactive but not very thorough (marginal SOP briefing). He failed to note the closure of the final 2000’ of their departing runway (28R) due to construction. Taxiways B7 and B8 at the end of the runway were also out. The crew was marked “poor” in contingency management because there were no plans in place on how to deal with this threat in the case of a rejected takeoff.
[A/C = Aircraft CA = Captain FO = First offi cer SOP = Standard operating procedure T/O = Takeoff]
12 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • FEBRUARY 2005 LOSA PROVIDES DATA
Appendix University of Texas Line Operations Safety Audit (LOSA) Observation Form With Sample Observations (continued)
Takeoff/Climb
Your narrative should provide a context. What did the crew do well? What did the crew do poorly? Narrative How did the crew manage threats, crew errors, and significant events? Also, be sure to justify your behavioral ratings.
Takeoff was normal. ATC granted a right turn VFR climb which was commenced at 600 ft. Climb to flight level 20000 with step climbs to 35000 ft. Eventually leveled at 31000 ft about 90 miles North. When established at FL200, ATC cleared the crew to FL270. They accepted and the First Officer dialed 230 instead of 270 in the MCP. The Captain caught the error on cross-verification.
[ATC = Air traffi c control FL = Flight level ft. = Feet MCP = Mode control panel VFR = Visual fl ight rules]
Cruise
Your narrative should provide a context. What did the crew do well? What did the crew do poorly? Narrative How did the crew perform during the handover?
Crew stayed attentive to aircraft position throughout cruise.
FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • FEBRUARY 2005 13 LOSA PROVIDES DATA
Appendix University of Texas Line Operations Safety Audit (LOSA) Observation Form With Sample Observations (continued)
Descent/Approach/Land/Taxi
Your narrative should provide a context. What did the crew do well? What did the crew do poorly? Narrative How did the crew perform during the handover?
Briefing to TOD — The approach brief much better than their takeoff brief. They expected runway 25L from the Civet Arrival for a straight-in visual approach. Jepp charts were out, contingencies talked about, and everything was by the book (outstanding SOP brief and plans stated).
10000’ to slowing and configuring — ATC cleared the crew to 25L, but at 8000’, ATC changed us to the Mitts Arrival for runway 24R due to a slow moving A/C on 25L. The CA changed the arrival and approach in the FMC, tuned the radio, and quickly briefed 24R. As soon as everything was clean, ATC called back and told the crew they could either land on 25L or 24R at their discretion. Since time was a factor, the crew discussed and decided to stick with the approach into 24R. The crew was flexible and the CA did a nice job assigning workload. FO flew the plane while the CA checked everything over one more time (outstanding evaluation of plans). The crew was also better monitors and cross checkers. However, their execution of checklists was still a little sloppy — late and rushed (marginal monitor and cross check).
Bottom lines to Flare/Touchdown — The approach was stable, but the FO let the airplane slip left, which resulted in landing left of centerline. Since the FO was new to this aircraft (1 month flying time), the observer chalked it up to a lack of stick and rudder proficiency.
Taxi-in — The crew did a great job navigating taxiways and crossing the active 24L runway. Charts were out and both heads looking for traffic (outstanding taxiway/runway management). However, there were no wing walkers meeting the aircraft in a congested ramp area.
[A/C = Aircraft ATC = Air traffi c control CA = Captain FMC = Flight management computer FO = First offi cer SOP = Standard operating procedure TOD = Top of descent]
Overall Flight
Narrative This narrative should include your overall impressions of the crew.
Overall, the crew did a marginal job with planning and review/modify plans during predeparture. However, during the descent/approach/land phase, it was excellent. Their execution behaviors were marginal to good for the entire flight.
While the takeoff brief was marginal, the CA made an outstanding approach brief. Open communication was not a problem. Good flow of information when the flight’s complexity increased with the late runway change. They really stepped it up.
During predeparture, the CA introduced an unnecessary element of being rushed, which compromised workload management. However, his decisiveness and coordination in the descent/approach/land phase kept his leadership from being marked “marginal.”
The big knock against this crew involved checklists, cross verifications, and all monitoring in general. They were a little too complacent during low workload periods (e.g., No altitude verifications during climb). The CA set a poor example in this regard. When the workload increased, the crew did a good job.
[CA = Captain]
14 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • FEBRUARY 2005 LOSA PROVIDES DATA
Appendix University of Texas Line Operations Safety Audit (LOSA) Observation Form With Sample Observations (continued)
Threat Management Worksheet
Threat Description Threat Management
Threat Phase of Linked to Type Flight flight crew 1 Predepart/Taxi error? How did the crew manage or Describe the threat 2 Takeoff/Climb mismanage the threat?
Threat ID 3 Cruise 4 Des/App/Land (Yes/No) 5 Taxi-in Runway and taxiway Threat mismanaged — CA failed to include T1 construction on their departing 103 1 No the construction and closures in his brief. No runway (final 2000’). plans were made in the event of a rejected takeoff, which is required by airline SOP. Late ATC runway change — Threat managed — CA reprogrammed the changed runway to 24R from T2 101 4 Yes FMC, handled the radios, and placed 25L due to a slow moving emphasis on the FO to fly the aircraft. aircraft on 25L. After a late runway change, ATC Threat managed — CA asked for the FO’s preference. They mutually decided to T3 called back and told the crew 101 4 Yes that it was at their discretion to continue the approach into 24R because it land on 24R or 25L. was already in the FMC. On taxi-in, there were no wing Threat managed — The crew called ground 204 5 Yes T4 walkers meeting the aircraft in a ops and wing walkers were dispatched to the congested ramp area. airplane.
T5
T6
Threat Codes Environmental Threats Airline Threats
100 Adverse Weather 103 Airport Conditions 200 Airline Operational Pressure 204 Ground/Ramp 101 ATC 104 Heavy Traffic (air or ground) 201 Cabin 205 Dispatch/Paperwork 102 Terrain 199 Other Environmental Threats 202 Aircraft Malfunctions/MEL Items 206 Manuals/Charts 203 Ground Maintenance 299 Other Airline Threats
[ATC = Air traffi c control CA = Captain FMC = Flight management computer FO = First offi cer ID = Identifi cation MEL = Minimum equipment list SOP = Standard operating procedure]
FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • FEBRUARY 2005 15 LOSA PROVIDES DATA
Appendix University of Texas Line Operations Safety Audit (LOSA) Observation Form With Sample Observations (continued)
Error Management Worksheet
Error Description Error Response/Outcome Error Management Phase of Linked to Crew Error Error Flight Threat? Response Outcome Error How did the crew (If Yes, 1 Detected 1 Inconsequential Describe the crew error 1 Predepart/Taxi manage or 2 Takeoff/Climb enter the Type 2 No response 2 Undesired state
Error ID mismanage the error? 3 Cruise Threat ID) 3 Additional error 4 Des/App/Land 5 Taxi-in CA failed to brief a rejected takeoff for shortened E1 1 T1 403 2 1 No error management. departing runway due to construction. FO failed to set his 1 304 2 3 E2 airspeed bugs. Linked to error #3.
In running the Before Takeoff Checklist, the FO E3 1 401 2 2 Linked to UAS #1. skipped the takeoff data item. At FL200, the crew was cleared to FL270. They Error managed — 2 302 1 1 E4 accepted and the FO dialed Captain caught the error 230 instead of 270 in the on cross-verification. Mode Control Panel. FO, hand flying, let the 4 E5 airplane slip a little to the 300 2 2 Linked to UAS #2. left during the final approach. Error Type Codes Aircraft Handling Procedural Communication
300 Manual Flying 400 SOP Cross-verification 500 Crew to External Communication 301 Flight Control 401 Checklist 501 Crew to Crew Communication 302 Automation 402 Callout 599 Other Communication 303 Ground Handling 403 Briefing 304 Systems/Instruments/Radios 404 Documentation 399 Other Aircraft Handling 499 Other Procedural
[CA = Captain FL = Flight level FO = First offi cer ID = Identifi cation SOP = Standard operating procedure UAS = Undesired aircraft state]
16 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • FEBRUARY 2005 LOSA PROVIDES DATA
Appendix University of Texas Line Operations Safety Audit (LOSA) Observation Form With Sample Observations (continued)
Undesired Aircraft State (UAS) Management Worksheet
UAS Description UAS Response/Outcome UAS Management
Linking UAS Crew UAS Error? Undesired aircraft Code Response UAS Outcome How did the crew manage or
UAS ID state description mismanage the undesired (Enter the 1 Detected 1 Inconsequential aircraft state? Error ID) 2 No response 2 Additional error Errors mismanaged — The bug error should have been caught UAS E2 Wrong airspeed bugs on 1 1 1 with the Before Takeoff Checklist, 1 takeoff roll. but the FO missed the item. The FO detected and corrected the error on the roll. Error mismanaged — FO tried to correct but still landed left of the UAS FO landed left of the 86 1 1 centerline. Approach was stable 2 centerline. and made the first high-speed taxiway.
UAS 3
Undesired Aircraft State Type Codes
Configuration States Ground States Aircraft Handling States — All Phases Approach/Landing States 1 Incorrect A/C configuration — 20 Proceeding toward wrong 40 Vertical deviation 80 Crew induced deviation above flight controls, brakes, thrust runway 41 Lateral deviation G/S or FMS path reversers, landing gear 21 Runway incursion 42 Unnecessary WX penetration 81 Crew induced deviation below 2 Incorrect A/C configuration — G/S or FMS path 22 Proceeding toward wrong 43 Unauthorized airspace penetration systems (fuel, electrical, taxiway/ramp 82 Unstable approach hydraulics, pneumatics, air- 44 Speed too high conditioning, pressurization, 23 Taxiway/ramp incursion 83 Continued landing — unstable 45 Speed too low instrumentation) 24 Wrong gate approach 46 Abrupt aircraft control (attitude) 3 Incorrect A/C configuration — 25 Wrong hold spot 84 Firm landing automation 47 Excessive banking 26 Abrupt aircraft control — taxi 85 Floated landing 4 Incorrect A/C configuration — 48 Operation outside aircraft limitations 86 Landing off C/L engines 87 Long landing outside TDZ 88 Landing short of TDZ 99 Other Undesired States
[A/C = Aircraft C/L = Centerline FMS = Flight management system FO = First offi cer G/S = Glideslope ID = Identifi cation TDZ = Touchdown zone WX = Weather]
FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • FEBRUARY 2005 17 LOSA PROVIDES DATA
Appendix University of Texas Line Operations Safety Audit (LOSA) Observation Form With Sample Observations (continued)
Crew Performance Marker Worksheet
123 4 Poor Marginal Good Outstanding Observed performance had Observed performance was Observed performance Observed performance safety implications adequate but needs improvement was effective was truly noteworthy
Phase of Flight Ratings Takeoff/ Descent/Approach/ Planning Performance Markers Predeparture/ Taxi Climb Land/Taxi The required briefing was interactive and SOP BRIEFING operationally thorough. 2 4
Operational plans and decisions were PLANS STATED communicated and acknowledged. 3 4 Crew members developed effective strategies to CONTINGENCY MANAGEMENT manage threats to safety. 1 3 Execution Performance Markers Crew members actively monitored and cross- MONITOR/CROSS-CHECK checked systems and other crew members. 1 1 2 Operational tasks were prioritized and properly WORKLOAD MANAGEMENT managed to handle primary flight duties. 2 3 3 Crew members remained alert to the environment VIGILANCE and position of the aircraft. 3 3 3 Automation was properly managed to balance AUTOMATION MANAGEMENT situational and/or workload requirements. 3
TAXIWAY/RUNWAY Crew members used caution and kept watch MANAGEMENT outside when navigating taxiways and runways. 3 4
Review/Modify Performance Markers Existing plans were reviewed and modified when EVALUATION OF PLANS necessary. 4 Crew members not afraid to ask questions to INQUIRY investigate and/or clarify current plans of action. 3 3
Overall Performance Markers Ratings Environment for open communication was COMMUNICATION ENVIRONMENT established and maintained. 3
Captain showed leadership and coordinated flight LEADERSHIP deck activities. 3
[SOP = Standard operating procedure]
18 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • FEBRUARY 2005 AVIATION STATISTICS
Clear Air Turbulence, Downdraft Cited Most Often in U.S. Weather Turbulence Accidents, 1992–2001
No fatalities occurred as a result of weather turbulence in air carrier operations during the study period. Eight fatalities occurred in weather turbulence accidents in commuter and on-demand operations.
— FSF EDITORIAL STAFF
rom 1992 through 2001, 4,326 Turbulence and clear air turbulence weather-related accidents oc- were the types cited most often in curred in civil aviation in the weather turbulence accidents involv- FUnited States. Of those acci- ing aircraft operated under U.S. Federal dents, 509 (11.8 percent) were categorized Aviation Regulations (FARs) Part 121 as weather turbulence accidents. The U.S. (air carriers). Downdraft was the type National Transportation Safety Board cited most often in weather turbulence (NTSB) cited clear air turbulence most often accidents involving aircraft operated as the cause or a causal factor in the weather under FARs Part 135 (commuter and turbulence accidents involving air carriers. on-demand). Downdraft was cited most often in general aviation weather turbulence accidents. Those data, and the data that follow, are from a report of a study by analysts at the NTSB reports of weather turbulence acci- National Aviation Safety Data Analysis dents included codes for various types of Center (NASDAC), part of the U.S. Federal turbulence: downdraft; mountain wave; Aviation Administration (FAA) Offi ce of turbulence;1 turbulence, clear air; turbu- System Safety. Data were extracted from lence, in clouds; turbulence, thunderstorms; the NTSB Aviation Accident/Incident updraft; turbulence, terrain-induced; and Data System. Causes and causal factors turbulence, convection-induced. were those cited in fi nal reports.
FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • FEBRUARY 2005 19 S TATISTICS
Accidents Involving Some weather turbulence events were not in- Turbulence: Part 121 cluded in this portion of the study because of the search criteria and data source used, the re- The FARs Part 121 operations in the data are those port said. Many of the Part 121 events in which of scheduled U.S.-based airlines and cargo carriers a passenger or crewmember experienced minor that fl y large transport category aircraft.2 Part 121 injuries (such as a broken nose or a broken fi n- operations accounted for 72 (14 percent) of the ger) in weather turbulence were not included 509 weather turbulence accidents. Variation by because they did not meet the NTSB defi nition year is shown in Figure 1 and Table 1. of an accident.3
Figure 1 Part 121 Weather Turbulence Accidents, by Year, 1992–2001 14
12
10
8
6 Number of Accidents 4
2
0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 Year
Source: U.S. Federal Aviation Administration National Safety Data Analysis Center; U.S. National Transportation Safety Board
Table 1 Part 121 Weather Turbulence Accidents, by Percentage, 1992–2001
Year Number of Accidents Percentage of Part 121 Weather Turbulence Accidents 1992 4 5.56% 1993 5 6.94% 1994 3 4.17% 1995 8 11.11% 1996 7 9.72% 1997 10 13.89% 1998 7 9.72% 1999 8 11.11% 2000 12 16.67% 2001 8 11.11% Total 72 100.00% Source: U.S. Federal Aviation Administration National Safety Data Analysis Center; U.S. National Transportation Safety Board
20 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • FEBRUARY 2005 S TATISTICS
Table 2 and Figure 2 show the numbers and per- Turbulence and clear air turbulence accounted centages of weather turbulence accident causes and for the majority of the serious injuries. Table 3 causal factors cited by the accident investigator. shows the number of injuries sustained by the passengers and/or crewmembers aboard the Table 2 aircraft by the type of turbulence. Part 121 Weather Turbulence Accidents, By Type of Turbulence, 1992–2001 Seventy-one (98.6 percent) of the 72 weather tur- bulence accidents involving Part 121 operations Type of Turbulence Number of Citations from 1992 through 2001 and investigated by NTSB Turbulence 24 resulted in serious injuries to passengers and/or crewmembers aboard the aircraft. Clear Air Turbulence 23 Turbulence in Clouds 14 Georgia was the U.S. state with the most weather Thunderstorm Turbulence 9 turbulence accidents involving Part 121 opera- Convection-induced 1 tions during the study period, with nine accidents. Mountain Wave 1 These weather turbulence accidents are listed by Total 72 state in Table 4.
Source: U.S. Federal Aviation Administration National Safety Data Analysis Center; U.S. National Transportation Safety Board Table 4 Part 121 Weather Turbulence Accidents, By State, 1992–2001 Figure 2 State Number of Accidents Part 121 Weather Turbulence Accidents, by Type of Georgia 9 Turbulence, 1992–2001 Florida 6 Mountain Illinois 5 Convention- Wave California 5 Thunderstorm induced 1.39% Wisconsin 4 Turbulence 1.39% 12.50% Turbulence New Jersey 4 33.33% Colorado 4 Texas 3 Indiana 3 Turbulence in Oregon 3 Clouds New York 3 19.44% Clear Air Turbulence Michigan 3 31.94% Alaska 2 Source: U.S. Federal Aviation Administration National Safety Data Analysis Center; U.S. National Missouri 2 Transportation Safety Board North Carolina 2 Louisiana 2 Nevada 2 Table 3 New Mexico 2 Part 121 Total Weather Turbulence Injuries, by Type of North Dakota 1 Turbulence, 1992–2001 Massachusetts 1 Hawaii 1 Type of Turbulence Serious Injuries Minor Injuries Total Injuries Pennsylvania 1 Turbulence 29 35 64 South Carolina 1 Clear Air Turbulence 27 25 52 Tennessee 1 Turbulence in Clouds 19 29 48 Kansas 1 Thunderstorm Turbulence 12 27 39 Virginia 1 Convection-induced 1 0 1 Total 72 Mountain Wave 1 0 1 Note: States not listed had no Part 121 weather turbulence Total 89 116 205 accidents during the study period. Source: U.S. Federal Aviation Administration National Safety Data Analysis Center; U.S. National Source: U.S. Federal Aviation Administration National Safety Transportation Safety Board Data Analysis Center; U.S. National Transportation Safety Board
FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • FEBRUARY 2005 21 S TATISTICS
Accidents Involving According to NTSB fi nal reports, weather turbu- Turbulence: Part 135 lence during Part 135 operations accounted for 26 (5.1 percent) of the 509 total weather turbulence The FARs Part 135 operations in the data are those accidents (5.1 percent). Variation by year is shown of scheduled (commuter) fl ights or nonscheduled in Figure 3 and Table 5. (on demand/air taxi) fl ights. Scheduled Part 135 operations involve aircraft carrying nine or fewer Figure 4 and Table 6 (page 23) show Part 135 passengers.2 The data for nonscheduled operations weather turbulence accidents by type of turbu- also include cargo airplanes with payload capacities lence and by injury severity. A single accident of 7,500 pounds (3,400 kilograms) or less. could have more than one turbulence-related
Figure 3 Part 135 Weather Turbulence Accidents, by Year, 1992–2001 7
6
5
4
3
Number of Accidents 2
1
0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 Year
Source: U.S. Federal Aviation Administration National Safety Data Analysis Center; U.S. National Transportation Safety Board
Table 5 Figure 4 Part 135 Weather Turbulence Accidents, Part 135 Weather Turbulence Accidents, by By Percentage, 1991–2001 Type of Turbulence, 1992–2001 Percentage of Number of Part 135 Weather Turbulence in Clouds Thunderstorm Turbulence Year Accidents Turbulence Accidents 6.90% 3.45% 1992 3 11.54% Clear Air Turbulence 1993 2 7.69% 6.90% 1994 2 7.69% 1995 2 7.69% Turbulence 10.34% 1996 1 3.85% Downdraft 1997 6 23.08% 55.17% 1998 2 7.69% 1999 3 11.54% Terrain-induced 2000 3 11.54% 17.24% 2001 2 7.69% Note: A single weather turbulence accident could have more than one turbulence cause or Total 26 100.00% factor cited. Source: U.S. Federal Aviation Administration National Safety Source: U.S. Federal Aviation Administration National Safety Data Analysis Center; U.S. National Data Analysis Center; U.S. National Transportation Safety Board Transportation Safety Board
22 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • FEBRUARY 2005 S TATISTICS
Table 6 Part 135 Total Weather Turbulence Injuries, by Type of Turbulence, 1992–2001
Type of Turbulence Fatal Injuries Serious injuries Minor Injuries None Total Downdraft 2 1 4 9 16 Terrain-induced 2 1 1 1 5 Turbulence 0 0 1 2 3 Clear Air Turbulence 1 1 0 0 2 Turbulence in Clouds 2 0 0 0 2 Thunderstorm Turbulence 1 0 0 0 1 Total 8 3 6 12 29 Note: A single weather turbulence accident could have more than one turbulence cause or factor cited. Source: U.S. Federal Aviation Administration National Safety Data Analysis Center; U.S. National Transportation Safety Board
cause or causal factor. For the 26 Part 135 air- [This article is based on “Review of Aviation craft involved in weather turbulence accidents, Accidents Involving Weather Turbulence in the there were 29 turbulence-related causes and/or United States, 1992–2001,” dated August 2004, causal factors cited. Downdraft was the major by FAA NASDAC. The report is available on the weather turbulence factor in these Part 135 ac- Internet at
More than 50 percent of the Part 135 weather 1. “Turbulence” was coded when the investigator did not provide any further specifi cs. turbulence accidents occurred in the U.S. state of Alaska. These weather turbulence accidents are 2. Since March 20, 1997, aircraft with 10 or more seats listed by state in Table 7. ■ used in scheduled passenger service have operated under FARs Part 121. Prior to that date, some of those fl ights operated under FARs Part 135.
Table 7 3. An accident is defi ned by NTSB as an event associ- Part 135 Weather Turbulence Accidents, ated with the operation of an aircraft that takes place By State, 1992–2001 between the time any person boards the aircraft with the intention of fl ight and all such persons have State Number of Accidents disembarked, and in which any person suffers death Alaska 14 or serious injury, or in which the aircraft receives Colorado 2 substantial damage. Idaho 2 A serious injury is defi ned by NTSB as any injury that Utah 2 (1) requires hospitalization for more than 48 hours, Arizona 1 commencing within seven days from the date the Arkansas 1 injury was received; (2) results in a fracture of any bone (except simple fracture of fi ngers, toes or nose); California 1 (3) causes severe hemorrhages, nerve, muscle or Hawaii 1 tendon damage; (4) involves any internal organ; or (5) South Carolina 1 involves second[-degree] or third-degree burns affect- Texas 1 ing more than 5 percent of the body surface. Total 26 Substantial damage is defi ned by NTSB as damage or Note: States not listed had no Part 135 weather turbulence failure that adversely affects the structural strength, accidents during the study period. performance or fl ight characteristics of the aircraft, Source: U.S. Federal Aviation Administration National Safety Data Analysis Center; U.S. National Transportation Safety Board and would normally require major repair or replace- ment of the affected component.
FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • FEBRUARY 2005 23 PUBLICATIONS RECEIVED AT FSF JERRY LEDERER AVIATION SAFETY LIBRARY
Simplifying Processes and Tools Aids Project Risk Management
A qualitative methodology, such as posing and answering key questions, is often the best framework for project risk management; nevertheless, say the authors, quantitative analysis has its place as well.
— FSF LIBRARY STAFF
Books simple approaches are often suffi cient for making sound decisions. A large part of this book is based on simple qualitative approaches to project risk.” Project Risk Management Guidelines: Managing Risk in Large Projects and Complex The goal of risk management is to identify and Procurements. Cooper, Dale F.; Grey, Stephen; manage significant risks. The process can be Raymond, Geoffrey; Walker, Phil. Chichester, conceived, the authors say, in terms of steps that West Sussex, England: John Wiley & Sons, 2005. involve answering relevant questions: 384 pp. Figure, tables, glossary, references, index. • Establish the context: “What are we trying to ne of the main lessons I learned from the achieve?” “Ofi nance sector, an industry that is often perceived as notoriously risky, is this: If something • Identify the risks: “What might happen?” is too complex to understand and explain, then it is probably too risky to undertake, as you won’t be • Analyze the risks: “What might that mean for able to design and implement the right kinds of the project’s key criteria?” operational processes, controls and monitoring to manage the risks effectively,” says co-author Dale • Evaluate the risks: “What are the most impor- Cooper. “That insight … has led me to simplify tant things?” many of the processes and tools I use for risk management. When complexity is needed, then • Treat the risks: “What are we going to do it is really needed and it must be done properly, but about them?”
24 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • FEBRUARY 2005 R ESOURCES
• Monitor and review: “How do we keep them achievement in aeronautical engineering, design- under control?” and, ing and manufacturing.” During test fl ights, with its Orenda Iroquois engines, the aircraft reached • Communicate and consult: “Who should be a maximum speed of Mach 1.98. involved in the process?” The Arrow’s fi rst production model was rolled The fi rst part of the book discusses in detail each out in 1957. Its sponsor, the Canadian govern- of those steps, and is followed by consideration ment, canceled the project in 1959. The five of related issues such as public-private part- Arrows in airworthy condition, as well as others nerships, outsourcing and environmental-risk on the assembly line that were almost ready for management. A chapter on “technical tools and fl ight, were ordered destroyed, as were engineer- techniques” describes such principles as hazard ing drawings and photographs — a decision that and operability studies, fault-tree analysis and remains controversial. rapid risk ranking and the inputs, outputs and documentation needed for each tool. The politics of the Arrow have been written about many times, the authors say, and their goal in this To illustrate the concept of a fault tree, the au- book was to document the aircraft’s engineering, thors include a fi gure that illustrates the logical technical and fl ight-testing aspects before the ab- progression in troubleshooting an uncommanded sence of aircraft and scarcity of records cause it to cold shower using conceptual “gates” of either/or fade from aviation history. choices: “no hot water” vs. “mixer-tap fault”; “hot water [has been] consumed” vs. “water did not “We will attempt to unravel some of the mysteries heat”; “no power” vs. “heater-element failure”; about the Arrow and expose the reader to some etc. of its lesser-known facets,” say the authors. “We will take you from the Arrow’s inception and early The authors conclude with a chapter on the design studies to roll-out, and from fl ight test to quantifi cation of project risks. “Quantitative risk the advanced proposals for the development of assessments extend the process described earlier to future versions. We will describe and show by more detailed numerical analysis of uncertainty, pictures some of the action behind the scenes. … usually in the context of a model of the project We have gathered together what we feel is a good being examined,” say the authors. Quantitative historical record of many previously unpublished analysis is particularly appropriate for tasks such photos and information.” as setting targets, evaluating the realism of esti- mates, selling a project proposal on the basis of The book includes cut-away drawings of the confi dence in the forecast outcome and choosing Arrow’s interior structure and components, in- between alternative technologies with different cluding its weapons system (Sparrow 2 missiles). risk profi les. A technical illustration of the cockpit is labeled with numbered callouts that identify avionics. Avro Arrow: The Story of the Avro Arrow Photographs show the Arrow from many angles From Its Evolution to Its Extinction. on the ground and in fl ight, and color photographs Revised edition. The Arrowheads (Organ, and diagrams indicate the various paint schemes Richard; Page, Ron; Watson, Don; Wilkinson, applied to the aircraft. Les). Erin, Ontario, Canada: Boston Mills Press, 2004. 180 pp. Photographs, figures, Reports bibliography, index. Measures of Information Complexity and the he authors, who call themselves the Implications for Automation Design. Xing, Arrowheads, describe the Avro CF-105 T Jing. U.S. Federal Aviation Administration Arrow — a long-range, twin-engine, all-weather (FAA) Offi ce of Aerospace Medicine. DOT/ jet interceptor — as “a plane without equal and FAA/AM-04/17. October 2004. 15 pp. Figures, considered by many to be 20 years ahead of tables, references. Available on the Internet at its time.” Donald H. Rogers says in his fore-
FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • FEBRUARY 2005 25 R ESOURCES
odern air traffic control (ATC) automa- metrics that can be used to assess the complex- Mtion tools are designed to help controllers ity of ATC automation displays, to evaluate new identify potential conflicts between aircraft in systems and to serve as guidelines for interface a complex airspace structure and to provide design. controllers with decision-support tools. ATC automation tools are intended to ensure safety, to increase controllers’ functional capacities and Regulatory Materials to relieve controllers from some tasks. In so do- ing, these tools can create new tasks associated Radiotelephony Manual. U.K. Civil Aviation with acquiring and integrating information Authority (CAA) Safety Regulation Group from displays. (SRG). Civil Aviation Paper (CAP) 413, Edition 15, including amendment 1/04. Dec. “The use of new tools requires that controllers 17, 2004. 177 pp. Table, diagrams, appendix, integrate information from displays into their glossary, bibliography, index. Available on own methods of managing their cognitive the Internet at
• How is complexity of visual displays • General procedures in RTF (transmitting quantified? techniques);
The report presents a framework for developing • Airport control service (aircraft takeoff clear- metrics for information complexity in automa- ance and movement instructions to vehicle tion displays. It also describes a specifi c set of drivers);
26 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • FEBRUARY 2005 R ESOURCES
• Radar (vectoring); U.S. Airworthiness Certifi cates and Authorizations for Operation of Domestic • Approach (instrument flight rules and Foreign Aircraft. U.S. Federal Aviation departure); Administration (FAA) Advisory Circular (AC) 20-65A. July 8, 2004. Table, references. • Area control service (position reporting); 6 pp. Available from FAA via the Internet at and,
CAP 413 contains useful information for those ** Documedia Solutions 37 Windsor St. studying for the U.K. flight RFT operator’s Cheltenham, Gloucester GL52 2DG U.K. license examination. Candidates for European Internet:
LIBRARY
FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • FEBRUARY 2005 27 ACCIDENT/INCIDENT BRIEFS
Overfl owing Sink Blamed for Short Circuit, Fumes in B-717
The accident report said that an electrical odor in the cabin during a domestic flight in Australia led to an unscheduled landing.
— FSF EDITORIAL STAFF
he following information provides an interphone near the aft left lavatory was hot, that the awareness of problems through which electrical odor was becoming stronger and that the such occurrences may be prevented in aft cabin interphone handset fl exible-wiring loom Tthe future. Accident/incident briefs are was “melting,” the accident report said. based on preliminary information from govern- ment agencies, aviation organizations, press infor- The fl ight crew conducted the quick reference mation and other sources. This information may handbook “Non-normal” checklist for “Electrical not be entirely accurate. Smoke/Fumes of Unknown Origin,” donned oxygen masks and selected emergency electrical power. They declared pan-pan, an urgent condi- tion, and diverted to an en route airport, where Accident Drew Attention to aircraft rescue and fi re fi ghting personnel met Training Anomaly the airplane. The odor had dissipated, the in- Boeing 717. Minor damage. terphone was no longer hot, and there was no Eight minor injuries. smoke. The airplane was taxied to the terminal, AIR CARRIER where passengers deplaned through the forward s the crew was preparing for a domestic fl ight door. Eight people in the airplane were treated for Ain Australia, cabin crewmembers observed smoke/fumes inhalation. water spilling from a sink in the aft left lavatory. They told the fl ight crew, the spill was cleaned An investigation revealed that the “miscellaneous up, and the lavatory was locked and placarded to cabin and lavatory-occupied aft” electrical circuit prevent its use. breaker had been activated (tripped) and could not be reset because of a short circuit in a connecter During cruise at Flight Level 320 (approximately plug under the lavatory sink. 32,000 feet), the cabin crew smelled a faint electrical odor in the rear of the passenger cabin. They told “Water from the overfl owing basin had seeped the fl ight crew about the odor. Soon afterward, they into the connector plug,” the report said. “The told the fl ight crew that the handset on the cabin short circuit within the connector plug resulted in
28 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • FEBRUARY 2005 A CCIDENTS/INCIDENTS several pins within the plug becoming welded to- arriving from France and notifi ed authorities at gether. As a consequence, the aft cabin interphone the departure airport. handset fl exible-wiring loom was overheated from [an] overcurrent within the loom and resulted in The report said that causes of the incident were the in-fl ight electrical smell and overheating of “the incorrect positioning of a deicing vehicle the handset.” left without its driver” and “the [fl ight] crew’s incorrect perception of the dimensions of the After the damaged components were replaced, the obstacle in a diffi cult environment in terms of airplane was returned to service. lighting.”
After the incident, the fl ight crew said that the Contributing factors were “the positioning of the landing gear “DOWN” indication in the airplane [deicing vehicle’s] control cabin in the high posi- was different than the indication in the fl ight tion; the fact that the deicing vehicle’s fl ashing light simulator that had been used during training was not at the highest point on the vehicle, whereas for fl ight using emergency electrical power. The the crew thought this to be the case, leading the operator’s investigation determined that the simu- pilots to estimate that the wing would not collide lator indication was incorrect; the manufacturer with the obstacle; the … undefi ned procedure for subsequently ordered software changes in B-717 pre-positioning the deicing vehicles; incomplete fl ight simulators to correct the problem. and imprecise documentation on the deicing zones; [and] the absence of checks on the posi- The manufacturer also was reviewing “failure con- tioning of vehicles in the procedures for setting ditions that can affect lavatory hand-basin water- up the deicing areas.” shutoff mechanisms; design, panel assembly and installation of B-717 aft cabin interphones; elec- trical installations associated with B-717 aircraft Windshield Wiper Fails During lavatory modules; [and] lavatory faucet reliability data,” the report said. Approach in Heavy Rain McDonnell Douglas MD-83. Substantial damage. No injuries. Collision With Deicing Vehicle Unnoticed by Crew ighttime instrument meteorological con- Nditions prevailed for the approach to an Boeing 747. Minor damage. No injuries. airport in Northern Ireland following a char- AIR TAXI/COMMUTER ter flight from Portugal. After the flight crew ighttime instrument meteorological condi- established the airplane on the instrument Ntions, including dense fog, prevailed during landing system (ILS) approach to Runway 26, preparations for the fl ight from France to United a controller in the airport air traffic control Arab Emirates. The fl ight crew taxied the airplane tower told them that heavy rain was falling along a taxiway toward the departure runway. The at the airport and thunderstorms were in the taxiway was adjacent to a deicing area, and the area. crew taxied into the area “without any intention to deice,” the accident report said. About 50 feet above the decision height of 400 feet, the crew observed the runway approach lights The airplane’s right wing struck a deicing vehicle. and switched on the aircraft’s windshield (wind- The fl ight crew did not realize what had happened screen) wipers. After a few strokes, the wiper blade and continued taxiing; they fl ew the airplane to its on the captain’s side loosened, and the wiper was destination without further incident. no longer usable.
About 90 minutes after takeoff, deicing personnel The crew continued the approach and, between observed damage to the deicing vehicle and noti- 30 feet above ground level (AGL) and 60 feet fi ed the air traffi c control tower. Several hours later, AGL, “the pilots were surprised by the aircraft the operator’s personnel at the airport in United suddenly drifting to the right,” the report said. Arab Emirates observed damage on an airplane The airplane touched down right of the runway
FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • FEBRUARY 2005 29 A CCIDENTS/INCIDENTS
centerline, and the right main landing gear and Hydraulic-system Contamination nose landing gear rolled off the edge of the run- Found After Uncommanded way. The captain steered the airplane back onto Spoiler Extension the runway and taxied to the station area, where passengers deplaned normally. De Havilland DHC-7 Dash 7. No damage. No injuries. The investigation revealed that weather informa- he airplane was being fl own on a domestic tion available to the pilots was four hours old and fl ight in Liberia and was in a left turn onto the that they had not been told about deteriorating T fi nal approach course when there was an uncom- weather conditions until about nine minutes manded extension of the right roll spoilers. The before landing. Had they been told earlier, they fl ight crew applied power, retracted the spoilers “would probably have been better prepared for a and completed the approach and landing. possibly diffi cult landing in darkness with heavy rain, thunder and poor extraneous visual refer- During a preliminary investigation, the operator ences,” the report said. found contamination in the no. 2 hydraulic system. A preliminary report said that the contamination Visibility just before touchdown probably was might have resulted from the failure of the no. 2 hy- about 1.5 kilometers (0.9 statute mile), and high- draulic pump about two weeks before the incident. intensity approach lights and runway lights were set to 3 percent of their intensity, so “it is reason- Maintenance personnel replaced the right roll spoiler able to assume that the pilots’ visual references for and sent the removed spoiler to the manufacturer the landing were compromised,” the report said. for further examination. The airplane’s hydraulic fi lters were replaced and its hydraulic systems were “When the windscreen wiper on the pilot-in- fl ushed before the airplane was returned to service. command’s side stopped working, the situation became further aggravated. He was forced to de- cide quickly whether he should [reject the landing] or complete the landing, or have the copilot take Change in Refueling Pattern control and land the aircraft. In the situation then Preceded In-fl ight Loss of prevailing, however, it was probably too late to Engine Power hand over control to the copilot.” Piper PA-24-250 Comanche. Substantial damage. One serious injury. The report said that the cause of the accident was the “degree of diffi culty to perform the landing aytime visual meteorological conditions pre- increasing at a rate that the pilots did not fully vailed for the departure from an airport in the realize in time.” Contributing factors were that D
United States on the second leg of a round-trip fl ight. CORPORATE/BUSINESS “the pilots were not prepared for the prevailing The pilot said that he selected the left main fuel tank weather situation; the landing took place in dark- for the takeoff and that about 200 feet above ground ness with a low cloud base, in poor visibility, in level, the engine stopped producing power. heavy rain, with few extraneous visual references; the pilot-in-command’s windscreen wiper did The pilot verifi ed that the electric fuel pump was not function; the high-intensity approach and on and that the mixture was rich, then switched to runway lights were set to the standard setting of the right main fuel tank and back to the left main low intensity; at approximately the time of dis- fuel tank. He conducted an emergency landing in a connection of the autopilot, the aircraft suffered a fi eld about 0.5 nautical mile (0.9 kilometer) south roll disturbance; [and] there may have been local of the airport in a residential area. The airplane turbulence or wind shear.” struck trees and then struck terrain.
The report recommended international harmo- A preliminary report said that earlier in the day, nization of light-setting standards for high-inten- before the fi rst leg of the fl ight, the pilot had sity approach lights and runway lights and that asked airport personnel to pull the airplane from periodic functional checks of aircraft windshield its hangar and to add fuel so that the fuel tanks wipers be conducted “under load.” were full.
30 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • FEBRUARY 2005 A CCIDENTS/INCIDENTS
“Upon arriving at [the airplane], the pilot realized air traffi c control (ATC) and said that he wanted the airplane had not been refueled,” the report to divert to a nearby airport because of a possible said. “The pilot stated that he was running late and fuel shortage. ATC said that the airport he had elected to have [airport refueling personnel] fi ll only suggested was closed but that another nearby the left [auxiliary fuel tank] and right auxiliary fuel airport was open. [tank]. After refueling, he noted that the right main fuel tank and left [auxiliary fuel tank] and right The fi nal accident report said that the pilot altered auxiliary fuel [tank] were full and there were ‘only his course, radioed the airport air traffi c control a few gallons’ in the left wing fuel tank.” tower that he was fl ying the airplane on an ap- proach to landing “due to low fuel, because of The pilot selected the right auxiliary fuel tank for minimum fuel” and received clearance to fl y the the fi rst leg of the round-trip fl ight and selected airplane over a populated area at 1,500 feet. The the left main fuel tank before landing. Before de- engine then stopped, and the pilot “realized that parture on the second leg of the fl ight, the pilot he was too low to reach the runway and reported (who said that when he refueled the airplane, he ‘running out of fuel present time.’” He landed the always ensured that both main fuel tanks were full) airplane in a fi eld about two minutes later — about “subconsciously thought the left man fuel tank was one hour and 55 minutes after takeoff. full,” the report said. The pilot said that the fuel tanks, which held 110 The company that recovered the airplane said that liters (29 U.S. gallons), had been full at takeoff. The about four tablespoons (59 milliliters) of fuel had report said that 110 liters should have been enough been drained from the left fuel tank. for a three-hour fl ight and that the investigation did not determine why the fuel tanks were empty Unoccupied Ground Vehicle within two hours. Strikes Parked Airplane “It could not be determined if the ‘FUEL LOW’ Raytheon Beechjet 400A. Substantial warning system had generated an indication damage. One minor injury. in the cockpit when 25 liters [seven gallons] Daytime visual meteorological conditions pre- remained in the tank,” the report said. “It was vailed when the airplane, which was parked at also not possible to prove that the tank was full an airport in the United States, was struck by a at departure.” ground service vehicle. Nosewheel Collapses The operator of the vehicle said that he was driv- During Test-fl ight Landing ing toward the airplane, after the pilots started the engines, to unplug a ground power unit. A tow bar Van’s RV-6A. Minor damage. No injuries. that had been placed on the vehicle began to slide off, and the operator tried to “grab the tow bar and he pilot conducted a 95-minute test fl ight on steer the vehicle at the same time but fell off the Tthe experimental airplane before returning vehicle onto the ground,” a preliminary accident to land the airplane at an airport in England. The report said. “The unoccupied vehicle continued fl ight was the second fl ight of the day; the land- towards the airplane, striking the right wing.” ing was the ninth landing since the airplane was fi rst fl own. OTHER GENERAL AVIATION The pilot said that he considered the landing a Fuel Exhaustion Prompts “good landing” and that as he adjusted the throttle Emergency Landing for full power to conduct a touch-and-go, he heard Robin DR 400. Substantial damage. a “grating” sound and rejected the takeoff. After he One minor injury. exited the airplane he observed that the nose leg was bent and that “the yoke carrying the nosewheel isual meteorological conditions prevailed for had ‘tucked under’ (rotating rearwards) so that the Vthe fl ight from Germany to the Netherlands. nose of the aircraft was resting on this yoke,” the About 90 minutes after takeoff, the pilot radioed accident report said.
FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • FEBRUARY 2005 31 A CCIDENTS/INCIDENTS
The RV-6A is a nosewheel airplane that was de- Weather at an airport 15 nautical miles (28 kilo- veloped from the RV-6, a tailwheel airplane. The meters) northwest of the accident site included nosewheel consists of a “steel leg attached to the visibility of 0.8 statute mile (1.3 kilometers) and engine mount and protruding forward to a free- a 200-foot overcast. castoring yoke and nosewheel,” the report said. Metallurgical tests showed that the nose leg met Pilot Blames Lack of Markings the design specifi cation. For Wire Strike After Takeoff “It is likely that the leg was defl ected by a vertical Bell 47G. Destroyed. One minor injury. load at some point along the runway,” the report said. “Reports from a number of eyewitnesses sug- aytime visual meteorological conditions gest that the nose leg may have been subjected Dprevailed during preparations for a locust- to a higher vertical load during the attempted spraying fl ight in Australia. As the pilot reposi- touch-and-go sequence than the pilot appreciated, tioned his helicopter for prefl ight loading, he causing defl ection so that the yoke contacted the conducted an air taxi around another helicopter runway surface.” that was ready for departure.
Two similar airplanes were involved in previous The pilot said that he observed a pole about 300 accidents in which the nose leg collapsed, the meters (984 feet) away but that he had forgotten report said. about power cables located 50 meters (164 feet) away and at treetop level. The helicopter struck the power cables. Gusty Wind Flips Taxiing Airplane The pilot said later that if the power cables had Cessna 182D. Substantial damage. been marked, he would have seen them and would No injuries. have avoided them. After the accident, the power company installed overhead markers to the re- s the pilot taxied the airplane at an airport in paired power cables. ACanada, the wind fl ipped the airplane onto its back. Helicopter Strikes Mountain After Rejected Landing A preliminary report said that the wind velocity was 39 knots, gusting to 52 knots. The report did Eurocopter SA 315B Lama. Substantial. Five minor injuries. not mention wind direction. he helicopter was being fl own on a heli-skiing Tfl ight in India, transporting four passengers to Pilot Becomes ‘Disoriented’ a hilltop. About one nautical mile (1.9 kilometers) While Wearing Night Vision before landing, the pilot felt a gust of wind; during Goggles in IMC the fi nal pre-landing check, he rejected the landing because he was using more power than required,
ROTORCRAFT Eurocopter AS 350B3. Destroyed. the accident report said. No injuries. As he fl ew the helicopter over a ridge to the south, ighttime instrument meteorological condi- the helicopter descended and struck a mountain. Ntions (IMC) prevailed for the fl ight in the The report said that the cause of the accident was United States. A preliminary report said that about “the decision of the pilot to [reject the] landing 25 minutes after takeoff, the pilot, who was wearing while in the shallow approach, and turning to the night vision goggles, became disoriented. After he right caused stalling of the rotor blades, resulting removed the goggles, the helicopter struck a mesa in sinking of the helicopter and impacting … the (a hill with steep walls and a relatively fl at top). mountain.” ■
32 FLIGHT SAFETY FOUNDATION • FLIGHT SAFETY DIGEST • FEBRUARY 2005 Now you have Flight Safety Foundation the safety tools
Approach-and-landing Accident Reduction to make a difference. Tool Kit
The Flight Safety Foundation is a comprehensive and practical resource on compact disc to help you prevent the leading causes of fatalities in com mer cial aviation: approach-and-landing ac ci dents (ALAs), including those involving controlled fl ight into ter rain (CFIT).
Put the FSF to work for you TODAY! • Separate lifesaving facts from fi ction among the data that confi rm ALAs and CFIT are the leading killers in avi a tion. Use FSF data-driven studies to reveal eye-opening facts that are the nuts and bolts of the FSF ALAR Tool Kit. • Volunteer specialists on FSF task forces from the international aviation industry studied the facts and de veloped data-based con clu sions and recommendations to help pilots, air traffi c controllers and others prevent ALAs and CFIT. You can apply the results of this work — NOW! • Review an industrywide consensus of best practices included in 34 FSF ALAR Briefi ng Notes. They provide practical in for ma tion that every pilot should know … but the FSF data confi rm that many pilots didn’t know — or ignored — this information. Use these benchmarks to build new standard operating pro ce dures and to im prove current ones. • Related reading provides a library of more than 2,600 pages of factual information: sometimes chilling, but always useful. A versatile search engine will help you explore these pages and the other components of the FSF ALAR Tool Kit. (This collection of FSF publications would cost more than US$3,300 if purchased individually!) • Print in six different languages the widely acclaimed FSF CFIT Checklist, which has been adapted by users for ev ery thing from checking routes to evaluating airports. This proven tool will enhance CFIT awareness in any fl ight department. • Five ready-to-use slide presentations — with speakers’ notes — can help spread the safety message to a group, and enhance self-development. They cover ATC communication, fl ight op er ations, CFIT prevention, ALA data and ATC/aircraft equipment. Customize them with your own notes. • An approach and landing accident: It could happen to you! This 19-minute video can help enhance safety for every pilot — from student to professional — in the approach-and-landing environment. • CFIT Awareness and Prevention: This 33-minute video includes a sobering description of ALAs/CFIT. And listening to the crews’ words and watching the accidents unfold with graphic depictions will imprint an un for get table lesson for every pilot and every air traffi c controller who sees this video. • Many more tools — including posters, the FSF Approach-and-landing Risk Awareness Tool and the FSF Approach-and-landing Risk Reduction Guide — are among the more than 590 mega bytes of in for ma tion in the FSF ALAR Tool Kit. An easy-to-navigate menu and book marks make the FSF ALAR Tool Kit user- friendly. Applications to view the slide pre sen ta tions, videos and pub lica tions are included on the CD, which is designed to operate with Microsoft Windows or Apple Macintosh operating systems. Order the FSF : Member price: US$40 Recommended System Requirements: Nonmember price: $160 Windows® Mac® OS Quantity discounts available! • A Pentium®-based PC or compatible computer • A 400 MHz PowerPC G3 or faster Macintosh computer • At least 128MB of RAM • At least 128MB of RAM • Windows 98/ME/2000/XP system software Contact: Ahlam Wahdan, • Mac OS 8.6/9, Mac OS X v10.2.6–v10.3x Mac OS and Macintosh are trademarks of Apple Computer Inc. registered in the United States and other countries. Microsoft and Windows are either registered trademarks or trademarks membership services coordinator, of Microsoft Corp. in the United States and/or other countries. +1 (703) 739-6700, ext. 102. The FSF ALAR Tool Kit is not endorsed or sponsored by Apple Computer Inc. or Microsoft Corp. Flight Safety Foundation
PRESENT THE 50th annual corporate aviation safety seminar CASS AAVIATIONVIATION SSAFETYAFETY – CCONTEMPORARYONTEMPORARY CCHALLENGESHALLENGES
To receive agenda and registration information, contact Ahlam Wahdan, tel: +1(703) 739-6700, ext. 102; e-mail: wahdan@fl ightsafety.org. To sponsor an event, or to exhibit at the seminar, contact Ann Hill, tel: +1(703) 739-6700, ext. 105; e-mail: hill@fl ightsafety.org. april 26–28, 2005 OORLANDORLANDO, FFLORIDALORIDA
Want more information about Flight Safety Foundation? Contact Ann Hill, director, membership and development by e-mail:
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We Encourage Reprints Articles in this publication, in the interest of aviation safety, may be reprinted in whole or in part, but may not be offered for sale directly or indirectly, used commercially or distributed electronically on the Internet or on any other electronic media without the express written permission of Flight Safety Foundation’s director of publications. All uses must credit Flight Safety Foun da tion, Flight Safety Digest, the specifi c article(s) and the author(s). Please send two copies of the reprinted material to the director of pub li ca tions. These restrictions apply to all Flight Safety Foundation publications. Reprints must be ordered from the Foundation. For more information, contact the director of publications by telephone: +1 (703) 739-6700, ext. 116; or by e-mail: