AeroSafety world
LATE GO-AROUNDS What simulations show FIGHTING FATIGUE FRMS in maintenance TU-154 AT SMOLENSK FATAL FUEL IMBALANCE New report from Poland JUST POLICY TIPPING POINT Fair play in investigations
The Journal of Flight Safety Foundation SEPTEMBER 2011 The Foundation would like to give special recognition to our Benefactor, Patron and Contributor members. We value your membership and your high levels of commitment to the world of safety. Without your support, the Foundation’s mission of the continuous improvement of global aviation safety would not be possible.
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just left a big meeting at the International work rules. Or, a poorly protected system could Civil Aviation Organization (ICAO) about the allow a lot of very personal information to be realities of implementing fatigue risk manage- disclosed in court in a way that could damage ment systems (FRMS). First, I have to say that both the airline and its employees. I continue to be amazed at ICAO’s new sense of So here are some not-so-simple pre-conditions openness. I found myself surrounded by a mixture for a successful FRMS: First, there must be a of industry leaders, regulators and scientists that real commitment to the program on the part never would have been allowed through those hal- of the company and the employees. They have lowed doors a few years ago. In addition, we had in to agree that they are going to do this thing in our hands excellent guidance material that walked a way that makes life better, the company more both the operator and the regulator through the efficient and operations safer; second, there has process of FRMS implementation. It was especially to be a regulator involved that is smart enough exciting to see that the material carried the logos to know the difference between an FRMS and a of ICAO, the International Air Transport Associa- fancy PowerPointtm presentation and confident tion and the International Federation of Air Line enough to act on that knowledge; third, the effort Pilots’ Associations. must involve all the parties — if a union doesn’t But this was not a party to celebrate a roll-out; exist, there still must be a way to fully involve this meeting addressed real implementation issues. the crews, and every layer of management has to It included a frank discussion about what could understand the program, including scheduling, go wrong and where FRMS should not even be human resources and any other concerned de- attempted. It is important to remember that FRMS partment; finally, there must be a plan to protect is optional. It can be used as an airline’s primary all this amazing data so it doesn’t end up in the scheduling tool or as a tool to tweak existing newspaper after the first operational incident or flight-time and duty-time rules, or it can be left worker’s disability claim. on the shelf. FRMS rests on a foundation of flight Missing a few of those conditions? That isn’t time and duty time rules. It does not replace them. a shock. Conduct a frank and honest assessment There are plenty of good reasons to implement and see what can be salvaged. Keep in mind this an FRMS. It is a once-in-a-generation gift from sci- is not an “all or nothing” exercise. And remember ence. When done right, FRMS relieves the company to read the directions first. from arbitrary restrictions and gives crews the right Here’s a link to the program description: rest at the right time. Pilots who have flown for
contentsSeptember 2011 Vol 6 Issue 7 features
14 CoverStory | Tipping Point for a Pilatus PC-12
20 HumanFactors | FAA Fatigue Rule Delay
20 23 MaintenanceMatters | Slow Pace of FRMS
28 SafetyCulture | Just Policy at American Airlines
34 CausalFactors | Another Look at Smolensk
36 FlightOps | Go-Arounds After Touchdown
42 FlightOps | Dusty and Gusty 23 48 SafetyCulture | The Need to Notice Hazards departments
1 Executive’sMessage | FRMS and You
5 EditorialPage | How’s It Going?
8 AirMail | Letters From Our Readers 28 9 SafetyCalendar | Industry Events 10 InBrief | Safety News
2 | flight safety foundation | AeroSafetyWorld | September 2011 36 48
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AeroSafetyWORLD telephone: +1 703.739.6700 54 DataLink | Runway Excursions a Continuing Threat William R. Voss, publisher, FSF president and CEO voss@flightsafety.org 58 InfoScan | Before and After J.A. Donoghue, editor-in-chief, FSF director of publications 64 OnRecord | Ice Blocks A330 Pitot Probes donoghue@flightsafety.org, ext. 116 Mark Lacagnina, senior editor lacagnina@flightsafety.org, ext. 114 72 SmokeFireFumes | U.S. and Canadian Events Wayne Rosenkrans, senior editor rosenkrans@flightsafety.org, ext. 115 Linda Werfelman, senior editor werfelman@flightsafety.org, ext. 122 Rick Darby, associate editor darby@flightsafety.org, ext. 113 Karen K. Ehrlich, webmaster and production coordinator ehrlich@flightsafety.org, ext. 117 Ann L. Mullikin, art director and designer About the Cover mullikin@flightsafety.org, ext. 120 Ice blocked fuel flow from Pilatus PC-12’s left wing tanks. Susan D. Reed, production specialist © Chris Sorensen Photography reed@flightsafety.org, ext. 123
Editorial Advisory Board David North, EAB chairman, consultant We Encourage Reprints (For permissions, go to
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How’s it Going?
ccording to the responses to a activities?, a very vigorous 81.1 percent of has become less helpful. Some 13.8 per- survey we recently conducted, it is subscribers said yes, and an even happier cent of subscribers believed this, while going pretty good, with some areas 86.6 percent of the member list agreed. 23.5 percent of FSF members said this of concern. By “it,” I mean the state However, 9.7 percent of subscribers told is true. I can only guess why these num- Aof safety culture in the aviation industry. us fewer people are involved; only 3.4 bers broke down this way by pointing The survey was intended primarily to percent of the FSF member list agreed out that 18.4 percent of FSF member gather information about what our read- with that notion. responses came from executive-level ers like and don’t like about AeroSafety We asked if there were more cross- people, a much larger number than the World so that we can (a), improve the functional safety committees. Some 42 8.4 percent of executive-level subscribers. publication; and (b), show prospective percent of the subscribers said yes, but Perhaps — and this is just a guess — more advertisers that this is a credible, widely 52.9 percent of the FSF members agreed, interaction between regulators and ex- read safety publication. That last part showing that someone has been paying ecutives produces a less-rosy outlook on — our hope going into the exercise — attention. However, 13.1 percent of sub- the process. happily was confirmed; it seems as if scribers and 9.2 percent of members said I think we can take comfort in the most of you are very positive about what that recently more safety decisions are fact that there is growth in the kinds of we are doing, with, as always, room for being made by a single person, a fairly attitudes and practices that have been improvement. If you are a prospective disturbing statistic. found to help reduce the risk of accidents, advertiser, we’ll gladly share the survey It is easier to report safety problems but we must also remain concerned that results with you. and deviations for 52.6 percent of our despite overwhelming evidence, some However, we also tossed in a couple of subscribers and an even better 65 percent people and institutions are backsliding safety culture questions seeking opinions of FSF members, but more difficult for into old and counterproductive ways. about changes over the past few years, 6.8 percent of subscribers and 4 percent Safety, it is said, is not a destination but and sent the survey to two groups — to of FSF members. a journey, and some have decided to take our digital edition subscribers, more An interesting switch in tone was a disturbingly different route. than 11,000, and to people on our FSF revealed by responses to the question: members contact list, a bit over 3,000. Has regulator involvement recently been We got more than 1,000 responses; not more helpful or less helpful? Among the every question was answered by every subscribers, 30.4 percent said regulators respondent, explaining why you won’t be have been more helpful, while only 24.4 able to add numbers to make 100 percent. percent of FSF members agreed. This J.A. Donoghue When we asked, are more people in approval gap widened even further when Editor-in-Chief your company actively involved in safety the question was if regulator involvement AeroSafety World www.flightsafety.org | AeroSafetyWorld | September 2011 | 5 Serving Aviation Safety Interests for More Than 60 Years
Officers and Staff light Safety Foundation is an international membership organization dedicated to Chairman, Board of Governors Lynn Brubaker the continuous improvement of aviation safety. Nonprofit and independent, the Foundation was launched officially in 1947 in response to the aviation industry’s need President and CEO William R. Voss F for a neutral clearinghouse to disseminate objective safety information, and for a credible Chief Operating Officer Capt. Kevin L. Hiatt and knowledgeable body that would identify threats to safety, analyze the problems and General Counsel and Secretary Kenneth P. Quinn, Esq. recommend practical solutions to them. Since its beginning, the Foundation has acted in the public interest to produce positive influence on aviation safety. Today, the Foundation provides Treasurer David J. Barger leadership to more than 1,075 individuals and member organizations in 130 countries. Administrative
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Pre-Eminence time. Also, the transformation of pleasure to work with on just finished your editorial [ASW, the magazine has been excellent and numerous occasions, has 7/11, p. 5] and must commend its presentation is surely bound to at- that rare ability to make statistics- I you on your exceptional leader- tract further advertising, which I have filled accident reports an interesting ship of ASW the past five years. Your learned through Professional Pilot is read. editorial staff is excellent, and I can always a publication’s lifeblood, and Thank you for allowing me to con- assure you — from my viewpoint as a the daily battle to retain it month after tribute and work with the Foundation reader — that the publishing expertise month never-ending. and ASW; it is by far my most reward- is excellent as well. No apologies are ASW remains the pre-eminent ing effort expended in this business. necessary for a printing schedule that magazine for aviation safety, and your relies partly on safety-related events, efforts are to be commended. Like- David M. Bjellos which never occur at a convenient wise, your staff, which I have had the Aviation Manager, Florida Crystals
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8 | flight safety foundation | AerosafetyWorld | September 2011 ➤ safetycalendar
SEPT. 12–15 ➤ ISASI 2011 Annual Seminar. SEPT. 26 ➤ Aircraft Composite Repair OCT. 4–5 ➤ Staying in Control: Loss-of- International Society of Air Safety Investigators. Management Forum. Aviation Week. Madrid, Control Prevention. European Aviation Safety Salt Lake City.
xygen mask hoses in airliner cockpits should be made “The captain stated that, as he moved toward the fire longer to ensure that pilots have full access to emergency extinguisher, his oxygen mask and smoke goggles were ‘torn Oequipment located in the cockpit, the U.S. National Trans- off’ because he had reached the end of the hose attached to the portation Safety Board (NTSB) says. oxygen mask,” the NTSB said. In a safety recommendation letter to the U.S. Federal Aviation He put the mask and goggles back on, discharged the fire Administration (FAA), the NTSB cited the circumstances sur- extinguisher and moved toward the cockpit door to pick up a rounding the May 16, 2010, fire in the windshield heat terminal second fire extinguisher from a flight attendant. As he did, the connection in the cockpit of a United Airlines Boeing 757-200 dur- mask and goggles came off again. ing a flight from New York to Los Angeles. The flight crew diverted The NTSB said that it “is concerned that the length of the to Washington Dulles International Airport in Chantilly, Virginia. hose attached to the captain’s oxygen mask was insufficient to None of the 112 people in the airplane was injured. allow him access to needed emergency equipment located in The NTSB said that the probable cause was the ignition of the cockpit without having the mask inadvertently removed a power terminal on the captain’s windshield because of a loose from his face. As a result, the captain was needlessly exposed to electrical connection. The captain told NTSB accident investi- smoke and fumes.” gators that he had donned his oxygen mask and smoke goggles The Air Line Pilots Association, International (ALPA) had because of the acrid odor in the cockpit; soon afterward, he left made a similar suggestion to the FAA in 2007. ALPA noted that his seat “because the flames were in front of him and he needed the response from the FAA Seattle Aircraft Certification Office to immediately reach the fire extinguisher” on the back wall of was that oxygen masks were intended primarily for use during the cockpit, the NTSB said. a decompression, not while fighting an in-flight fire. © Lvco99/Flickr The NTSB recognized the need for portable breathing equipment in fighting a cabin fire but added that it might be “of limited use while fighting an in-cockpit fire when the oxygen masks are available and likely already donned.” In its safety recommendation letter, the NTSB also called on the FAA to “provide clear guidance … concerning the type of breathing equipment to wear when combating a cockpit fire” — that is, whether oxygen masks or portable protective breath- ing equipment would be preferred. A third recommendation asked the FAA to amend advisory circulars to specify that cockpit fire extinguishers must be within the reach of at least one flight crewmember while oxy- gen masks are in use.
Tiger Suspension Ends
iger Airways Australia has re- Other conditions involved the sumed operations after a suspen- currency and revision of operations Tsion of more than one month by manuals, appointment of personnel to the Civil Aviation Safety Authority of key positions and amendments Australia (CASA), which said it would to the airline’s safety management continue monitoring the airline’s system. operations. “Tiger Airways Australia was CASA suspended Tiger Airways’ required to demonstrate it had complied operations July 2, citing a “serious and with the necessary safety requirements
imminent risk to air safety,” and lifted the before it was permitted to resume opera- Jimmy Harris/Wikimedia suspension Aug. 10, with the condition tions,” CASA said. that Tiger Airways comply with CASA re- CASA Director of Aviation Safety with the conditions for its air operator’s quirements for pilot training, proficiency, John McCormick said that Tiger Air- certificate and “meet the necessary safety rostering and fatigue management. ways had shown that it could comply requirements.”
10 | flight safety foundation | AeroSafetyWorld | September 2011 inBrief
Fuel Findings New Rules
he practice of some low-cost ew regulations are in effect carriers of consistently avoiding throughout Europe for the licens- Tthe carriage of extra fuel could N ing and medical certification of air create situations that limit a captain’s traffic controllers. decision-making options and lead to The regulations, developed by the the impression among pilots that the European Aviation Safety Agency (EASA), use of marginal fuel is normal, the establish uniform requirements for control- International Federation of Air Line lers and require continent-wide recognition Pilots’ Associations (IFALPA) says. © Pixel_Pig/iStockphoto of controller licenses, ratings, language The organization said its survey of 132 airline pilots about their employ- endorsements and medical certificates. ers’ fuel-planning policies found that 40 percent of the pilots wanted more Controllers with licenses issued in authority in determining how much fuel to load for specific flights. accordance with the new regulations will About one-third of the respondents said that they were aware of landings by be qualified to work in all EASA member their company’s pilots with fuel that amounted to less than the “final reserve.” states. “Landing with astonishingly small amounts of fuel occurs on long-range EASA Executive Director Patrick Gou- flights, as well as on short-haul flights,” IFALPA said in a briefing leaflet on dou said that the implementation of a single its survey. Despite such “extreme examples,” the leaflet said, “overwhelmingly, set of regulations for controller licensing the practice of good airmanship is widespread.” “will make an important contribution to the The leaflet noted “tremendous differences” in operators’ policies and achievement of a high and uniform level of speculated that a number of fuel incidents might go unreported, however. safety across Europe.”
New Warnings on Fuel Additives
he U.S. National Transportation Safety Board (NTSB), In related action, the accident prompted the FAA to publish citing the 2009 crash of a Pilatus PC-12/45 that killed the a proposed clarification of its seat belt and seating requirements Tpilot and all 13 passengers, is asking regulators to require for U.S. Federal Aviation Regulations Part 91 general aviation more stringent warnings to pilots about the need for fuel addi- aircraft to specify that a seat belt and/or seat may be used by tives, including fuel system icing inhibitors (p. 14). more than one person only if the seat belt is approved for such Recommendations to the European Aviation Safety Agency use, the “structural strength requirements for the seat are not (EASA) and the U.S. Federal Aviation Administration (FAA) exceeded” and the seat usage is in compliance with the airplane call for the two regulators to amend certification require- flight manual. ments for aircraft that require fuel system icing inhibitors and The accident airplane’s 13 passengers — six adults and other fuel additives “so that those limitations are highlighted seven children — shared nine seats, and the NTSB said that by a warning in the limitations section of the airplane flight evidence indicated that four of the children were either unre- manual.” Other recommendations would apply that require- strained or improperly restrained. ment to aircraft that already are in service. Sbscottw/Wikipedia The NTSB also called on the regulators to require that the same warnings be placed on a fuel filler placard. An additional recommendation, issued only to the FAA, called on the agency to “issue guidance on fuel system icing prevention that includes pilot precautions and procedures to avoid fuel system icing problems aboard turbine engine– powered aircraft and describes the possible consequences of failing to use a fuel system icing inhibitor, if required by the airplane flight manual, especially during operations at high altitudes and in cold temperatures.” The airplane had been en route from Oroville, Califor- nia, U.S., to Bozeman, Montana, when the pilot diverted to Butte, Montana. The airplane crashed west of Runway 33 in Butte.
www.flightsafety.org | AeroSafetyWorld | September 2011 | 11 inBrief
Battery Policy Called Unacceptable
he International Federation of Air shipment of batteries.” Other tests have risk of a fire caused or made worse by Line Pilots’ Associations (IFALPA) determined that the Halon fire sup- the shipment of lithium batteries as Thas denounced policies that con- pression systems used in many aircraft cargo.” tinue to exempt air cargo shipments of cargo holds are unable to control a lithium batteries from most provisions lithium metal battery fire, IFALPA regulating the handling of dangerous said. goods. IFALPA noted that when lithium The batteries have been linked to batteries are shipped as air cargo, they more than 40 reported incidents of are not subject to many of the technical “smoke, fire, extreme heat or explosion instructions developed by the Inter- in air transport,” IFALPA said. national Civil Aviation Organization There are two major types of (ICAO) for dangerous goods shipments, lithium batteries: lithium ion batteries, including requirements for a dangerous which usually are rechargeable and used goods label to be placed on the pack- in such devices as laptop computers, age. The ICAO instructions also include cell phones and portable music players; a call for the pilot-in-command to be and lithium metal batteries, non- informed of the presence of the battery rechargeable batteries used in cameras, shipment in the aircraft and for shippers flashlights and automatic external to receive training in dangerous goods defibrillators. regulations. Testing has shown that a fire The instructions should be revised, involving lithium ion batteries “will IFALPA said, “to protect passengers, easily propagate through the entire flight crew and the aircraft from the © Yury Shirokov/Dreamstime.com
Antonov An-12s Grounded In Other News …
ostrans- he International Civil Aviation nadzor, the Organization has signed an agree- RRussian T ment with the International Federa- agency supervis- tion of Freight Forwarders Associations ing transportation, to conduct a joint training program on has suspended the transportation of dangerous goods flights by the 12 by air. … Deborah A.P. Hersman has Antonov An-12 been sworn in for a second term as chair- airplanes oper- man of the U.S. National Transportation ated by six airlines Safety Board. … The Civil Aviation Safety within the Russian Authority of Australia has updated its
Federation. Juergen Lehle/Wikimedia guidelines for aviation operations during The agency volcanic ash events. The guidance, said the suspension would remain in effect until the airlines reduce the risks based on updated material from the of operating the An-12s through actions taken in accordance with safety International Civil Aviation Organization, management systems. says aircraft should not operate in areas The suspension followed the Aug. 9 fatal crash of an Avis-Amur An-12 of medium or high ash contamination — described as the oldest airplane in the Russian commercial fleet — as the but operations may be permitted in crew attempted to return to Magadan, Russia, because of a fuel leak and an areas of low-level contamination, as engine fire. All 11 people in the airplane for the cargo flight were killed and long as a safety risk assessment is con- the airplane was destroyed in the crash. ducted first.
Compiled and edited by Linda Werfelman.
12 | flight safety foundation | AeroSafetyWorld | September 2011 ESCO-ZA_ASW_0911Out.pdf 8/25/2011 2:44:26 PM
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Tipping PoinAn icing-induced fuel imbalancet BY MARK LACAGNINA triggered a loss of control.
he outside air was cold enough to cause water dissolved in the Pilatus PC-12/45’s Jet-A fuel to form ice crystals that accumulated on the main fuel filter and built up sufficiently on components in the left wing tanks to block the flow of fuel from the tanks. The airplane became increasingly left-wing-heavy as excess fuel returned by the engine was addedT to the fuel trapped in the left tanks while the right tanks continued feeding the engine. The pilot pressed ahead toward the planned destination until he apparently realized that his efforts to balance the fuel and to correct the low-fuel-pressure condition were not working. He diverted the flight to an alternate airport but lost control of the airplane while maneuvering to land. The PC-12 crashed near the runway, killing all 14 people aboard. In its final report on the March 22, 2009, accident, the U.S. National Transportation Safety Board (NTSB) said that the probable causes were “the pilot’s failure to ensure that a fuel system
14 | flight safety foundation | AeroSafetyWorld | September 2011 coverStory
icing inhibitor was added to the fuel [and] his wing tanks to the engine. By design, more fuel failure to take appropriate remedial actions is supplied to the engine than is necessary for after a low-fuel-pressure state (resulting from combustion, and excess fuel is sent back to the icing within the fuel system) and a later fuel tanks via return lines. imbalance developed.” Electric boost pumps are activated automati- The accident airplane was operated by cally or manually to correct a low-fuel-pressure a company owned by three partners. Media condition, typically caused by filter blockage reports said that the passengers on the ac- or the failure of an ejector pump or the engine- cident flight were family members en route to driven fuel pump, or to balance the fuel in the a resort near Bozeman, Montana, U.S., for a wing tanks. week of skiing. Fuel quantity is indicated by two vertical The company’s contract pilot, 65, held an arcs, each comprising 28 “bars,” or liquid crystal airline transport pilot license and had 8,840 display segments. Each bar represents about flight hours, including 1,760 hours in PC-12s. 48 lb (22 kg) of fuel. The PC-12 airplane flight He had retired from the U.S. Air Force as a manual (AFM) states that if an imbalance of transport and instructor pilot in 1972, and had three bars is indicated and cannot be corrected, flown for several airlines and as a PC-12 pilot the pilot should “land as soon as practical.” for an air ambulance operator before being hired Of particular note is that the AFM requires by the company in 2002. an icing inhibitor to be blended with the fuel A former chief pilot for the air ambulance operator told in- vestigators that the pilot was “extremely PC-12/45 Fuel System
knowledgeable” about Right wing the airplane. A PC-12 training center in- Quantity Float structor said that the sensors (x4) switch Main tank pilot had demonstrat- CAWS ed “superb” judgment R fuel low Transfer ejector and a “very high level” FUEL QTY Fuel pump F F boost of competence. pump 3 3 Delivery 2 2 ejector pump 1 1 Collector tank
PC-12 Fuel System L 0 0 R x1/4 Check valves Low fuel A brief description pressure switch CAWS of the airplane’s fuel fuel press
system might aid in Low-pressure engine-driven understanding the fuel pump Filter To Fuel supply line circumstances that led engine fuel to the accident. system Filter bypass The system holds valve
a maximum of 2,704 Fuel return line lb (1,227 kg) of usable To left wing fuel in a main tank
and a collector tank CAWS = central advisory and warning system
in each wing (Figure Source: U.S. National Transportation Safety Board 1). Ejector pumps
© Damian Leśniak/Airliners.net transfer fuel from the Figure 1 www.flightsafety.org | AeroSafetyWorld | September 2011 | 15 Coverstory
The report noted, however, that refueling Pilatus PC-12/45 records for the accident airplane indicated that the pilot did not always ensure that an icing inhibitor was added. He did not request an ic- ing inhibitor when the airplane was refueled at its home base in Redlands, California, the day before the accident.
Too Many People The accident flight from Redlands to Bozeman comprised three legs, with stops in Vacaville, California, and Oroville, California, to pick up passengers. The pilot departed from Redlands at 0742
© Jerry Search/Airliners.net local time. The average outside temperature recorded by the engine trend-monitoring system wiss aircraft manufacturer Pilatus announced plans to develop a was minus 24 degrees C (minus 11 degrees F) at pressurized, single-turboprop utility airplane in 1989. A prototype SPC-12 flew two years later. The PC-12/45, so designated for its the cruise altitudes, Flight Level (FL) 260 (ap- increased maximum takeoff/landing weight of 4.5 tonnes (4,500 kg, proximately 26,000 ft) and FL 220. 9,900 lb), was introduced in 1996 and received U.S. Federal Aviation After arriving in Vacaville at 0930, the Administration approval for commercial operation under instrument pilot used the airport’s self-service facility flight rules the next year. to refuel the PC-12. Investigators found no The airplane has two pilot seats and eight passenger seats in evidence that an icing inhibitor was blended standard configuration; certification for single-pilot operation allows a ninth passenger to occupy the copilot’s seat. The Pratt & Whitney with the fuel. Canada PT6A-67B engine is flat-rated at 895 kW (1,200 shp) for takeoff The instrument flight rules (IFR) flight plan and 746 kW (1,000 shp) for climb, and drives an aluminum four-blade filed by the pilot for the next leg of the trip listed Hartzell propeller. five occupants. However, there were 10 people Maximum rate of climb at sea level is 1,680 fpm. Maximum operat- aboard when the airplane departed from Vaca ing altitude is 30,000 ft. Maximum cruise speed is 270 kt at 25,000 ft. ville at 1020. The average outside air tempera- Maximum range is 2,261 nm (4,187 km). Stall speeds are 65 kt in land- ing configuration and 92 kt clean. ture at the cruise altitude, 6,000 ft, was minus 4 The PC-12/45 was replaced in 2006 by the PC-12/47, which has a degrees C (25 degrees F). higher maximum takeoff weight (4,740 kg, 10,450 lb) and winglet and Four more passengers boarded the airplane aileron modifications designed to improve handling. at Oroville. Although the pilot’s IFR flight plan Source: Jane’s All the World’s Aircraft listed nine people, seven adults and seven chil- dren ranging in age from 1 to 9 were aboard the 10-seat airplane when it departed for the flight for all operations in ambient temperatures to Bozeman at 1210 local time. below freezing.1 “At least four of the seven children on board “On a standard day, the temperature is 0 the airplane were not restrained or were im- degrees C [32 degrees F] at 7,500 ft, so most properly restrained,” the report said. “After the PC-12 flights would require the use of an [icing accident, one of the owners of the airplane (who inhibitor],” the report said. “All jet fuels contain organized the flights) stated that the airplane trace amounts of water, and a fuel system icing had carried the same number of adult and child inhibitor lowers the freezing point of water to passengers on previous flights.” minus 46 degrees C [minus 51 degrees F] to The limitations section of the PC-12 AFM prevent the water from turning into ice crystals, specifies that the maximum number of pas- which can block a fuel line or filter.” sengers is nine. The report noted, however,
16 | flight safety foundation | AeroSafetyWorld | September 2011 coverStory
that the U.S. Federal Aviation Administration Self-Induced Pressure (FAA) allows a child under age 2 to be held The pilot had told a training center instructor on an adult’s lap. The FAA also permits two that he never felt company pressure to fly in people to occupy one seat in a noncommercial unsafe conditions. NTSB concluded that his deci- airplane if their total weight does not exceed sion to continue toward Bozeman rather than to 170 lb (77 kg) and they can be secured properly land at one of several suitable alternate airports by the seat belt. that were available as the fuel imbalance wors- There was no evidence that the pilot per- ened likely was influenced by self-induced pres- formed weight-and-balance computations for sure to avoid inconvenience to his passengers. any leg of the trip. Investigators estimated that However, about two hours into the flight, the airplane was within center-of-gravity limits the pilot likely “recognized the magnitude of the for all three legs but was over the maximum situation” and requested clearance from ATC to takeoff weight by 432 lb (196 kg) on departure divert to Butte, Montana (Figure 2). He did not from Vacaville and by 572 lb (259 kg) on depar- provide a reason for the request, and ATC did ture from Oroville. not question it. The flight plan showed an estimated time Investigators were unable to determine why en route of 2.5 hours with 3.5 hours of fuel the pilot chose to land at Butte, rather than at a aboard for the leg from Oroville to Bozeman. closer alternate airport. Moreover, at this point, Shortly after departure, the pilot was cleared the distances to Bozeman and to Butte were by air traffic control (ATC) to navigate di- similar, and the weather conditions were nearly rectly to Bozeman. identical, with 10 mi (16 km) visibility, a broken The average outside air temperature at the ceiling at about 6,000 ft and winds from the cruise altitude, FL 250, was minus 40 degrees C. northwest at 8 kt. Data recorded by the PC-12’s central advisory and warning system (CAWS) showed that the boost pump in the left collector tank operated Flight Path nearly continuously beginning about an hour after departure, a sign that ice was restricting Montana the flow of fuel from the left tanks, causing a Bozeman fuel imbalance and contributing to the low-fuel- (planned pressure condition. Butte destination) (alternate The boost pump in the right collector tank airport) also operated intermittently in response to the low-fuel-pressure condition caused by the par- Oregon tial blockage of the filter and by the decreasing flow of fuel from the left tanks. Idaho At 1335, or about an hour and 15 minutes after departure, the fuel quantity indicator Oroville showed a three-bar differential. “About 1 hour (departure 21 minutes into the flight, the fuel supplied to airport) the airplane’s engine was being drawn solely Nevada from the right fuel tanks by the right fuel boost pump, and the left-wing-heavy fuel imbalance
continued to increase,” the report said. Map © Cartographer/Fotolia.com California
Despite the low-fuel-pressure condition, Source: U.S. National Transportation Safety Board however, the engine operated normally through- out the flight. Figure 2 www.flightsafety.org | AeroSafetyWorld | September 2011 | 17 Coverstory
Soon after ATC approved the request to km] southwest of the Runway 33 threshold,” the divert to Butte, the pilot asked for clearance to de- report said. scend. The controller issued the altimeter setting A witness said that as the airplane neared for Butte and cleared the pilot to descend at his the runway, it appeared to be much too high discretion to 14,000 ft. The report noted that the to land. The witness said that the airplane then minimum IFR altitude for the area was 13,100 ft.2 flew northwest, away from the runway, entered About 10 minutes later, at 1422, the pilot a steep left turn about 300 ft above the ground, was cleared to descend to 13,000 ft and to report pitched nose-down and descended rapidly. when he had the airport in sight. The pilot The PC-12 crashed and burned in a acknowledged the instruction, requested a lower cemetery about 2,100 ft (640 m) west of the altitude and was cleared to descend to 12,200 ft, approach end of the runway. CAWS data the minimum IFR altitude. indicated that the left wing tanks were filled to capacity and that the right wings tanks con- ‘Extreme’ Imbalance tained only 66 lb (30 kg) of fuel on impact. Shortly thereafter, however, the airplane Investigators were unable to identify the descended below the assigned altitude. At this source of the restriction to the flow of fuel point, the fuel quantity indicator showed a 22- from the left tanks. “Ice accumulation in the bar differential, which was characterized by the fuel system … could degrade the performance report as an “extreme” imbalance (Figure 3). of many fuel system components, including the At 1427, the controller advised the pilot fuel boost pumps and valves,” the report said. that the airport was 12 nm (22 km) ahead and “If the pilot had added [an ice inhibitor] asked if he had the field in sight. The pilot to the fuel for the flights on the day of the responded, “Yeah, as soon as we get past one accident, as required, the ice accumulation in more cloud.” the fuel system would have been avoided, and Recorded ATC radar data showed that the a left-wing-heavy fuel imbalance would not PC-12 was at 11,100 ft and 8 nm (15 km) south- have developed.” west of the airport when the pilot reported that The accident investigation generated he had the field in several recommendations (see p. 11). Among Fuel Indication on Approach sight and canceled his them was that the FAA and the European IFR clearance. Aviation Safety Agency should raise pilot FUEL QTY The Butte airport awareness about manufacturers’ require- is an uncontrolled ments to blend an icing inhibitor with jet F F field located in a fuel and about the potential consequences of valley at 5,550 ft in noncompliance.
mountainous terrain. This article is based on NTSB Accident Report NTSB/ 3 3 The pilot reported on AAR-11/05, “Loss of Control While Maneuvering; Pilatus the common traffic PC-12/45, N128CM; Butte, Montana; March 22, 2009.” 2 2 advisory frequency The report is available at
18 | flight safety foundation | AeroSafetyWorld | September 2011 DEDICATED TO HELPING BUSINESS ACHIEVE ITS HIGHEST GOALS.
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ssuance of a new package of flight than to say that the rule is “still under aircraft rest facilities. In most cases, and duty time limitations and rest executive review.” however, maximum flight and duty requirements for U.S. airline flight Under the proposed rule, U.S. Fed- times would be shorter than the cur- crewmembers — years in the mak- eral Aviation Regulations Part 121 air rently allowable periods. Iing — has been delayed again. The carrier pilots would be required to have The Air Line Pilots Association, In- projected date for release of the final a minimum of nine hours of rest before ternational (ALPA) said that the delay rule describing the new requirements is reporting for duty — in most cases, in issuing new regulations endangers now Nov. 22. one more hour than currently required airline safety. The U.S. Federal Aviation Admin- (Table 1, p. 22). Maximum allowable “The White House has stalled a istration (FAA) previously had planned duty times and flight times would vary historic, safety-based regulatory ef- to issue the final rule in early August. — depending on the number of pilots fort to create modern duty and rest An FAA spokeswoman offered no de- in the crew, the start time, number of regulations for U.S. airline pilots,” said tails on the reasons for the delay, other flight segments and the existence of Lee Moak, an airline captain and the
Waiting BY LINDA WERFELMAN
FAA postpones a final rule on duty time limits and rest requirements for airline pilots. © trekandshoot/Dreamstime.com
20 | flight safety foundation | AeroSafetyWorld | September 2011 “Fabulous aircraft...the whole experience was just great.” FAA postpones a final rule on duty time limits and rest Mike, Singapore requirements for airline pilots.
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Publication of the new proposed rule in the Proposed Flight Duty Periods Federal Register on Sept. 14, 2010, generated Maximum Flight Duty Period (Hours) similar objections, voiced in many of the 2,000 Based on Number of Flight Segments2 public comments submitted before the comment Start Time1 1 2 3 4 5 6 7+ period ended six weeks later. 0000-0359 9 9 9 9 9 9 9 Opposition came from the airline industry 0400-0459 10 10 9 9 9 9 9 in general, and cargo and charter operators — 0500-0559 11 11 11 11 10 9.5 9 including charter operators that carry military 0600-0659 12 12 12 12 11.5 11 10.5 troops and military cargo — in particular. 0700-1259 13 13 13 13 12.5 12 11 The Air Transport Association (ATA) said 1300-1659 12 12 12 12 11.5 11 10.5 that, although it supports the establishment of 1700-2159 11 11 10 10.0 9.5 9 9 duty and rest requirements that are developed 2200-2259 10.5 10.5 9.5 9.5 9 9 9 2300-2359 9.5 9.5 9 9 9 9 9 from science-based safety and operational data, it opposes the proposed rule because, in Notes 1. Local time at the flight crewmember’s home base or at a location in another time zone to drafting it, the FAA “went well beyond what which the crewmember has become acclimated. The maximum flight periods are reduced current scientific research and operational by 30 minutes for a crewmember who has not become acclimated to the time zone. data can support and added many other 2. Applies to unaugmented flight crews. measures and requirements that … are based Source: U.S. Federal Aviation Administration on individual judgments driven by extrane- Table 1 ous considerations, including perceptions about the political environment and what is president of ALPA. “With each hour of delay acceptable.” beyond the deadline, airline passengers and These measures include strict limits on daily crews are needlessly put at risk when we know flight times and limits on any extension of the that the solution to addressing pilot fatigue lies flight duty periods, the ATA said. in science-based regulations that apply to all The ATA also said that its calculations indi- types of flying.” cated that implementation of the proposed rule In a mid-August speech to the ALPA Air would cost nearly $20 billion over 10 years, well Safety Forum, Deborah A.P. Hersman, chairman above the FAA’s “incomplete” estimate of $1.3 of the U.S. National Transportation Safety Board billion over the same time period. (NTSB), agreed, voicing frustration with the The National Air Carrier Association, which “slow rolling” of the publication of the final rule. represents charter operators, said, in its 2010 The NTSB has for years included the mitiga- response to the proposed rule, that the FAA tion of pilot fatigue on its Most Wanted List of had “failed to consider the unique nature of the transportation safety improvements. operations of nonscheduled carriers” and that When the notice of proposed rule making the proposal would have a “disproportionately was published in September 2010, the FAA said large, if not disastrous” effect on its members’ the proposed changes would “sufficiently ac- small businesses. commodate the vast majority” of flight opera- The Cargo Airline Association had similar tions while also “reducing the risk of pilot error complaints, citing the FAA’s disregard of “sub- from fatigue leading to accidents.” stantial operating differences between industry The rule-making effort was begun in June segments that require different methods of 2009 — about 15 years after a previous FAA mitigating fatigue.” The agency’s proposal would attempt to introduce new requirements was met “seriously impede the operating flexibility of the with opposition from the airlines because of the all-cargo carriers and, even where operations associated cost and the scarcity of supporting remain feasible, will dramatically increase costs,” data, and ultimately shelved. the association said.
22 | flight safety foundation | AeroSafetyWorld | September 2011 MAINTENANCEMATTERS
FRMS has not yet made major inroads in aviation maintenance. Finding a Foothold BY LINDA WERFELMAN
viation maintenance organizations have work hours and fewer opportunities for sleep for been slow to implement formal fatigue many maintenance technicians, some of whom risk management systems (FRMS), have taken second jobs. despite their unique opportunities to Quevedo, who began his career as a me- Aemploy some of the most effective types of fa- chanic for Eastern Airlines, said that at times, tigue countermeasures, according to a report by his shift extended for 24 hours or longer, and the U.S. Federal Aviation Administration (FAA) that, when necessary, he and his colleagues took Civil Aerospace Medical Institute.1 short naps, although the company had no of- Aviation maintenance personnel work in ficial napping policy. conditions that are conducive to fatigue, often The FAA report noted that many main- at night and with unregulated duty hours, the tenance tasks — “especially those involving report said. intense visual attention, communication or a Rudy Quevedo, Flight Safety Foundation dep- heavy reliance on memory” — are especially uty director of technical programs and a member susceptible to fatigue’s effects. of the FAA Maintenance Fatigue Working Group, FRMS usually addresses the threat of falling said airline mergers and general economic asleep during a “continuous-control task” such
upheaval have resulted in increased stress, longer as piloting an aircraft. However, falling asleep is © Chris Photography Sorensen
www.flightsafety.org | AeroSafetyWorld | September 2011 | 23 MAINTENANCEMATTERS
not the primary hazard facing aviation main- ‘52 Days Straight’ tenance personnel, the report said. Instead, the Methods of reducing fatigue include limiting an greatest threat involves fatigue-impaired mental employee’s hours of service (HOS). U.S. Federal functioning and the possibility that it will lead Aviation Regulations say only that maintenance to maintenance errors. technicians working on Part 121 air carrier “This distinction, while seemingly trivial, has aircraft must be off duty for “at least 24 con- important implications for fatigue risk manage- secutive hours during any seven consecutive ment in aviation maintenance,” the report said, days, or the equivalent thereof, within any one adding that it follows that the methods and goals calendar month.” of a maintenance-oriented FRMS will differ from “In effect,” the report said, “a person could those of a flight crew FRMS. work up to 52 days straight, in a period of two For example, because maintenance tasks consecutive months, and still be in compliance typically are “self-paced rather than externally with the regulation.” paced,” a maintenance technician who recog- Only a few countries apply specific limits, nizes that he or she is fatigued “may be able to the report said. For example: pause a task, trade speed for accuracy or repeat Falling asleep • The New Zealand Civil Aviation Author- a step, as necessary,” the report said. ity says that maintenance personnel must is not the Maintenance personnel also may, in some have had at least eight hours off duty be- cases, have opportunities to modify task perfor- primary hazard fore performing work and at least four 24- mance, perhaps by introducing the use of task hour periods off in the preceding month. facing aviation cards or operational/functional checks or per- forming demanding tasks at times of day when • The Civil Aviation Administration of maintenance fatigue is less likely, the report said. China says maintenance personnel may In addition, the report said, maintenance work no more than eight hours a day and personnel. personnel usually do not travel across time 40 hours a week. Under special circum- zones and therefore do not experience jet lag stances, they may work as long as 11 hours and travel-related disruption of their circadian a day, but monthly overtime may not rhythms — two problems that often plague exceed 36 hours. pilots and flight attendants. The Civil Aviation Safety Authority of Australia, As a result, the report added, maintenance under regulations that took effect in June, does not organizations may be able to employ a greater limit work hours but instead “makes it an offense number of solutions to their fatigue problems. for a maintenance organization to permit a main- The report cited three objectives of fatigue tainer who is significantly impaired by fatigue or a risk management: reducing fatigue, reducing the psychoactive substance to carry out maintenance number of fatigue-related errors or identifying on an airline aircraft,” the report said. the errors and correcting them, and limiting the Best practices guidelines developed for harm caused by errors. the U.K. Civil Aviation Authority (U.K. CAA) Flexibility is crucial, Quevedo said, adding — which does not itself prescribe work limits that an absolute limit on the number of hours — call for 12-hour shifts that, with overtime, worked might not be the best option for either should be extended to no longer than a total of an employer that has extra maintenance work 13 hours, with a work break every four hours. that must be completed on time or employees Technicians should have at least 11 hours off who understand how to adjust their task perfor- between shifts, and they should be informed of mance to compensate for fatigue. their work schedules a month in advance.2 “Eventually, there’ll have to be FRMS,” he said, While not incorporated into U.K. CAA adding that it would be especially useful “when regulations, the guidelines were included in it’s not business as usual.” an agency advisory document for Part 145
24 | flight safety foundation | AeroSafetyWorld | September 2011 MAINTENANCEMATTERS
operators and in guidance issued by the Interna- employees to reduce fatigue that results from tional Civil Aviation Organization. lifestyle choices. The European Aviation Safety Agency Scientific Scheduling includes fatigue among the topics that should be Another method of reducing fatigue is scientific covered in maintenance human factors training, scheduling, which incorporates a software mod- and some civil aviation authorities, including eling system to estimate the level of fatigue likely Transport Canada, the U.K. CAA and the FAA, to result from a specific scheduling pattern. have published educational material on fatigue “Software models … can take into account — some of it aimed not only at maintenance circadian variations in alertness and sleep personnel but also at their supervisors, non- obtained, to produce an estimate of the fatigue maintenance co-workers, and family members. level that may result from a particular shift pat- Some FRMS guidelines call for workers to take tern,” the report said. “When used as scheduling “fatigue leave” if they believe they are too fatigued tools, software models have the advantage of to perform their duties, but the report conceded offering greater flexibility than HOS limits.” that the concept may not be readily accepted. The report cited the Fatigue Audit InterDyne “Organizations need to weigh the potential (FAID) model as an example, noting that it disruption caused by an unplanned absence with considers employee work and break times for a the potential harm that could result when an em- seven-day period and assigns a fatigue score of ployee reports for duty impaired,” the report said. between zero and 140. Typically, employees who score less than 80 are “generally safe” to perform A ‘Second Line of Defense’ their jobs, the report said, but scores of more Because fatigue cannot be eliminated, the report than 80 may indicate an “unsafe condition.” recommended “a second line of defense, with The report added, however, that research by the objective of reducing the probability of error the U.S. Federal Railroad Administration has among fatigued workers.” indicated that scores as low as 60 may indicate First, workers are taught to monitor their level fatigue-related risks. of fatigue, overcoming the inherent inaccuracy of Fatigue models generally have been used in self-perception by using a fatigue rating scale (Ta- flight crew scheduling, but one airline, which ble 1) or psychomotor performance tests that can the report did not name, also has used FAID to be installed on hand-held devices or smartphones. evaluate maintenance work schedules and to The report noted that various alertness monitoring help in schedule design. devices now being used in the trucking industry The report also cited planned naps of 20 may eventually be incorporated into an FRMS. to 40 minutes as a key mitigation for fighting To reduce levels of fatigue, work breaks — fatigue but acknowledged that “napping as a fa- especially those that include a brief walk — can tigue countermeasure in maintenance may face provide temporary relief, as can exposure to resistance from airlines and regulators.” fresh air or cool, dry air, the report said, citing In addition, the report suggested that Karolinska Sleepiness Scale providing employees with educational mate- rial about fatigue and 1 2 3 4 5 6 7 8 9 Very alert Alert, Neither Sleepy, but Very sleepy, acceptable counter- normal level alert or no effort to great effort to measures is one of sleepy keep awake keep awake only a few methods Source: Akerstedt, T.; Gillberg, M. “Subjective and Objective Sleepiness in the Active Individual.” International Journal of Neuroscience, Volume 52 (1990): 29–37. by which an organi- zation can influence Table 1 www.flightsafety.org | AeroSafetyWorld | September 2011 | 25 MAINTENANCEMATTERS
several earlier studies. Bright light also is critical, therefore, that such person- “Harm minimization in the context of can reduce fatigue and fatigue-related nel have an awareness of the effects of maintenance fatigue involves keeping the errors, and caffeine, if used according to fatigue on human performance.” most safety-critical tasks out of the hands a precise schedule, can reduce fatigue for Some tasks can be “fatigue-proofed,” of the most fatigued people.” about two hours, studies have shown. or modified to reduce the likelihood The report said that, for example, of fatigue-related errors or to increase work on flight control systems would Task-Based Action the likelihood that such an error will be not be assigned to maintenance person- Other efforts to reduce fatigue-related detected,” the report said, noting that nel during their circadian low point, errors emphasize changing some aspect Transport Canada has recommended but they would instead be given other, of the assigned task — an area that has that the following fatigue-proofing strat- less critical tasks. “This approach does received relatively little attention. egies be used when performing tasks not prevent maintainers from making “Task-based approaches are based that are susceptible to fatigue: a fatigue-related error on whatever task on the idea that maintenance tasks vary they are assigned but reduces the likely • Work under close supervision; along a continuum, from tasks that are consequences of that error.” highly susceptible to fatigue to those • Work in pairs or teams; The report said that although, in that are less susceptible,” the report • Rotate tasks; many cases, HOS limits and scientific said. “Task-based approaches … can software scheduling models have been • Use checklists; involve two complementary strategies: used separately and viewed as competing changing when the task is performed • Use experienced personnel to methods of addressing workplace fatigue, and changing how it is performed.” provide support for new person- they can be incorporated into a single Research has identified the types nel; and, program. HOS limits can establish the of tasks most prone to fatigue-related • Conduct briefings when shifts “outer bounds” of duty times while scien- errors, including tasks that are monoto- turn over. tific scheduling models form the basis of nous or very familiar. Others that are specific schedules within the bounds. highly susceptible are inspection tasks, Recommendations from other sources “In addition to HOS limits, an FRMS tasks that require “intense, continuous call for formalized self-checks, opera- for maintenance will include a range concentration,” those performed in a tional or functional checks, or inde- of interventions addressing the task, darkened environment and those in pendent inspections for tasks that are the work environment and the fitness which “incorrect performance is not im- especially susceptible to fatigue or those for duty of personnel,” the report said. mediately obvious,” the report said. that have been performed incorrectly “Whatever approach to fatigue risk man- Most maintenance organizations do in the past because of fatigue. Other agement is applied, commitment from not consider the fatigue-susceptibility of research calls for rested personnel to all levels of the organization is essential. a task when they develop work sched- check work that has been performed Upper management has a responsibility ules, but individual maintenance techni- during the window of circadian low — to state a clear policy on fatigue, includ- cians sometimes have “informal norms between 0300 and 0600 local time. ing how fatigue-related incidents will be concerning the time of day at which dealt with under a just culture.” tasks are performed,” the report said, Minimizing the Harm Notes noting that their procedures may involve Recognizing that fatigue-related errors performing the most challenging tasks at occur despite efforts to prevent them, 1. Hobbs, Alan; Avers, Katrina Bedell; Hiles, the beginning of a work shift. the report said that a “final line of John J. Fatigue Risk Management in Aviation “In most large organizations, [main- defense” should limit the damage that Maintenance: Current Best Practices and Potential Future Countermeasures. DOT/ tenance personnel] have limited control results from these errors. FAA/AM-11/10. June 2011. over the timing of tasks throughout their “Harm minimization differs from the 2. Folkard, Simon. U.K. CAA Paper 2002/06, shift, yet crew leads, foremen or plan- interventions described in the preceding Work Hours of Aircraft Maintenance ning personnel may have some influ- sections, as the focus is on the severity Personnel. West Sussex, U.K.: Research ence on the time of day at which certain of the error’s consequences, rather than Management Department, Safety tasks are performed,” the report said. “It the probability of error,” the report said. Regulation Group. 2003.
26 | flight safety foundation | AeroSafetyWorld | September 2011 China Airlines, your first impression of Taiwan.
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With its people-oriented culture, China Airlines is dedicated to providing all passengers with quality personalized service to ensure that they enjoy maximum comfort when flying with us. As Taiwan’s largest airline and one of Asia’s leading carriers, China Airlines operates a fleet of modern aircraft to over 98 destinations in 29 countries around the world. China Airlines is your most convenient and trustworthy choice. safetyculture
n June 15, the American Airlines document is titled Just Policy for Maintenance Maintenance and Engineering Organi- Errors and Violations. zation (known as M&E) implemented The greatest benefit that we expected al- a new policy designed to enhance the ready is becoming a reality: preventing rash de- Ocompany’s ability to learn from errors and cisions by managers after a costly outcome that, violations in the workplace, and to identify the in the past, would have focused their attention most effective actions we can take to prevent on “disciplining the last person who touched their reoccurrence. Basically, our approach the airplane.” We also are now setting up, as applies just culture philosophy and tools, and quickly as possible, a method of communicat- standardizes previously diverse investigative ing internally the high-impact lessons we are processes into one cooperative investigation learning. We expect this innovation to strongly that considers errors and violations as learning complement, and even enhance, the tools in
By Brad Brugger and Pete Sirucek opportunities for everyone, not just our avia- our aviation safety action partnership (ASAP) tion maintenance technicians. The resulting program for M&E personnel.
American Airlines prioritizes fairness while investigating errors and violations by maintenance and engineering employees. Just Policy
28 | flight safety foundation | AeroSafetyWorld | September 2011 safetyculture
responsible for making good choices and for reporting safety concerns, near-misses or errors/ violations when they are identified. Writing the policy led us to reconsider M&E values, rejecting the past punitive approach in which judgments could take place too quickly, and instead fostering a fair and consistent process that stresses learning. Our goal is to truly understand why something happened and to share the accountability. For example, we no longer want any M&E manager to become hung up on the bad outcome — the U.S. Federal Avia- tion Administration (FAA) finding, the damage or whatever it was. Neither management nor the union can sit back if that occurs, only to realize later that known errors or violations, or a bigger systemic The authors say The Just Policy first lays out our organiza- problem, were not being reported or were being that implementing tion’s commitment to four core principles: the tacitly approved. It’s especially unfair in such their Just Policy; recognition that not every system is perfect, to cases to treat one unlucky mechanic — the communicating err is human, to drift from what we know to one who got caught — as a scapegoat when we the benefits of be safe or compliant is human, and that risk is should have identified the bigger problem. its principles and everywhere; we are most interested in learning If the system is the issue, the first task is to tools; and, in the as much as possible after an error or event to fix the relevant process. If the mechanic made a future, sharing understand risk at the individual level and the poor choice but the process is fine, the mechanic lessons learned are organizational level; we are willing to investi- likely just drifted away from what he or she was opportunities to gate, to learn from our mistakes and to share taught. But, in reality, what we most often find is give back to other what we have learned; and we are determined to that an error, violation or event involved a little airlines that have balance accountability with justice. bit of both aspects. been generous with This philosophy encourages our employees to As in the past two years of the M&E ASAP best practices. be open, forthright and honest and, psychologi- program, at-risk behaviors remain the most cally, to “get to a place of comfort” where they common issue while reckless behaviors are rare. are willing to talk about what happened or what So addressing at-risk behaviors provides us the they did; to help identify the root causes and all best opportunity for making good systemic the contributing factors; and to learn from the changes and focusing on coaching, mentoring factors. The policy also establishes clear personal and role modeling. accountability for at-risk behavior and reckless Technically, the policy only guides M&E behavior (see “Just Policy Definitions,” p. 30). management. It does not require anything new The Just Policy requires a strong sense of of non-management personnel: They are still “shared accountability” at all levels of M&E. responsible for reporting hazards and safety This means that M&E management is responsi- concerns when they see them. The major dif- ble for designing a reliable system — processes, ference has been the safe avenue for the reports procedures, resources, facilities and incentives of an error, violation or event — especially necessary to produce the desired outcomes (for one not submitted voluntarily to the ASAP example, quality, safety and regulatory compli- program by the employee — to be received, ac- ance) — and for managing employees in a fair cepted and acted upon by management in our
Photos: © Byron Totty, American Airlines photography Totty, © Byron Photos: and just manner. In turn, each employee is just culture environment.
www.flightsafety.org | AeroSafetyWorld | September 2011 | 29 safetyculture
Writing the Just Policy also opened an op- towards, and achieving, desired quality results portunity to standardize and consolidate sever- that enhance a robust safety culture and align al investigative processes. Disjointed processes M&E with the American Airlines safety man- and poor results previously had inhibited M&E agement system (SMS). efforts to learn from them, incorporate sound fixes to the system, and respond consistently. Safety Champions Now, the initial (preliminary) investiga- The role of Outcome Engineering, our consultant tions are conducted by representatives of M&E in this evolving field of aviation safety, has been management; the initial investigations are then to transform theoretical principles of just culture forwarded to our maintenance event assess- into practical guidance and tools that also draw ment aid (MEAA) investigation group. The principles from safety engineering, human fac- MEAA investigation group then coordinates tors and law. Their trademarked tool, called the the investigation with the ASAP event review Just Culture Algorithm, enables neutral M&E committee if an associated ASAP report has employees trained and certified in its use (called been filed. Standardized processes that have safety champions) to easily identify system defi- been designed to improve their cooperation ciencies and to objectively assess the quality of ensure that the representatives are all working choices made by individuals. The algorithm, associated definitions and training previously had been used and tested for Just Policy Definitions effectiveness within our four ASAP programs as part of an 18-month coordinated study for At-risk behavior: A behavioral choice that increases risk where this risk the FAA Aviation Flight Standards Division for either is not recognized, or is mistakenly believed to be justified. Voluntary Reporting (AFS-230). Human error/error: An inadvertent action; unintentionally doing some- The study provided a unique opportunity thing other than what should have been done; a slip, lapse or mistake. to address the U.S. airline industry’s concern Just culture: The American Airlines Maintenance and Engineering about undefined or inadequately defined report- Organization’s (M&E’s) philosophical mindset and management method, rejection criteria in ASAP programs. When focused at all levels on learning, fairness and consistency, safe system design, and making/managing quality choices. the study concluded, leaders of all our airline’s ASAP programs agreed to indefinitely continue Just Culture Algorithm: A trademarked algorithm developed by Outcome Engineering, applied during the consistent process of using this tool, which clearly defines “where the investigating an error or violation, to assess the quality of behavioral line is drawn” and limits the range of allowable choices and duty breaches. actions to be taken by M&E and the FAA. Just Policy for Maintenance Errors and Violations: The document that With respect to errors, our intent is to states the M&E’s commitment to enhance safety culture and speci- support the erring employee by conducting a fies company management actions to respond to errors, violations “learning conversation” about why the error and events (i.e., accidents, incidents or other reportable actions/ occurred and what can be done to prevent a re- occurrences). occurrence. Resulting nonpunitive actions also Maintenance event assessment aid (MEAA): The M&E process used as a focus on correcting system deficiencies to meet nonpunitive, system-focused investigative tool that identifies the root causes and contributing factors of an error, violation or event. this objective. Reckless behavior: An employee’s behavioral choice to consciously With respect to at-risk behaviors, our intent disregard a substantial and unjustifiable risk. is to coach the employee about the behavior dur- Safety management system: The M&E-wide approach to managing ing a supportive discussion that reinforces safe safety risk and assuring the effectiveness of safety risk controls. behavioral choices. The MEAA process identifies Violation: An infraction or breach of a work-related regulation, com- for managers the typical reasons why employees pany policy/procedure/rule, professional standard or training. engage in at-risk behavior, and frames nonpuni- — BB and PS tive solutions that balance positive and nega- tive incentives that influence employees. Often,
30 | flight safety foundation | AeroSafetyWorld | September 2011 safetyculture
at-risk behaviors evolve into “norms.” In these cases, the investigation expands to identify and coach employees and management regarding at- risk behaviors at the system level (maintenance crew, maintenance station, region, etc.).
ASAP Tool Refinement In the context of the FAA’s forthcoming regula- tion on SMS in aviation maintenance, M&E had envisioned the Just Policy as an opportunity to expand just culture beyond our ASAP. We hoped this would ensure a strong foundation before implementing the SMS. Safety engineering and human factors aspects of just culture had been incorporated into American Airlines operating departments © Byron Totty, American Airlines photography Totty, © Byron since the 1990s. Prior to writing the Just Policy, just culture had been applied in the “vacuum” of action by the company — that is, measures be- Plans call for the M&E ASAP process. So the “legal” aspects of yond nondisciplinary remedial action per guide- developing an just culture — shared accountability and defined lines of American Airlines’ Peak Performance investigation training behaviors — are new. The successful, formal Through Commitment policy — is appropriate package, designed to incorporation of just culture into ASAP in 2009 to cause an individual to refrain from undesir- enhance the quality therefore brought a deeper awareness of the ben- able behavioral choices. of that process, efits of applying these principles to the manage- including root- ment of risk. Decision Algorithm cause analysis. In practice, except for refining tools, the Just The purpose of the algorithm in our ASAP and Policy has not changed significantly our ASAP non-ASAP processes is to objectively allocate program. The prime example of refinement the responsibility — to identify what role the orga- policy has brought about has been application of nization played in system design and to assess the Outcome Engineering definition of reckless the quality of choices made by individuals behavior to better understand the ASAP term working within that system. Then the process “intentional disregard for safety” as the rejec- clearly defines when it is appropriate to support tion criterion — that is, the reason that an event the employee, to coach the employee or, in the rare review committee would decline to accept an cases typically indicated, to take disciplinary action employee’s voluntarily submitted report of an against the employee. error or violation for nonpunitive consideration The Just Policy specifies use of the MEAA, under the ASAP process. our version of Boeing Commercial Airplanes’ Moreover, adapting the Just Culture Algo- Maintenance Error Decision Aid (MEDA) and rithm to the M&E ASAP has ensured standard the Just Culture Algorithm as the tools for in- and consistent criteria for determining the vestigating human factors and root causes. The specific behaviors involved in any event, error or policy also places the ownership (i.e., responsi- violation. This became a means to more accu- bility for the MEAA and just culture processes rately assess, and effectively respond to, behav- and tools) on a small group of neutral, trained ioral choices that may increase risk, and to more and qualified personnel. clearly identify system design flaws. If this group concludes that an error or The Just Policy states that, for identified violation involved reckless behavior, the policy reckless behaviors, some level of corrective requires a joint ratification of the conclusion by www.flightsafety.org | AeroSafetyWorld | September 2011 | 31 safetyculture
say they agree with the policy, but some union personnel are skeptical that the company will remain committed to it and apply it consistently. In fact, one initial response from M&E management personnel has been that, even without the policy, a “good manager” already should have been treating employees according to its ba- sic principles. At the organization level, however, management had struggled to fairly and consistently apply — re- gardless of the severity of the outcome involved (costs of injuries, damage, © Byron Totty, American Airlines photography Totty, © Byron delays, production time, rework, etc.) the company’s director of maintenance just trying to get the job done with — just culture principles to all cases of and the safety of flight and compliance limited time or resources. The coach- errors and violations. coordinator of the Transport Workers ing leads to improving the system by We are optimistic that gaining Union of America. The director of main- removing the incentives that drive the acceptance of the policy will not be tenance also has been designated as the at-risk behavior. as difficult once everyone affected responsible person for directing training M&E also recognizes from experi- understands the personal implications and communications activities for all ence that it is rare for an employee to and sees the policy in practice. Union aspects of M&E. act recklessly. We therefore believe that personnel have said they appreciate the Training covers preliminary steps disciplinary action is only appropriate in policy’s commitment that they will be that local managers or supervisors must the case of a reckless choice, to discour- treated fairly if they ever face these cir- take when they become aware of a main- age the reckless choice. M&E, through cumstances. So far, the implementation tenance-related error or violation. The our Just Policy and sharing lessons of the Just Policy has met M&E values steps were designed to ensure that all learned, identifies and clearly commu- and expectations. subsequent fact-gathering is conducive nicates the difference between an at-risk As of September, the Just Policy to learning as much as possible about behavior and a reckless act. implementation team is pushing into the error or violation and preventing re- the field detailed training on roles and occurrence, to improving system design Front Line Challenges responsibilities of management and and to managing employees fairly. “Road show” presentations about the labor union leaders across the system. The insidious aspect of at-risk policy to M&E personnel, which began Upcoming reinforcement training for behavior is that past success in deviat- before it was finalized, and our later all other M&E employees will focus on ing from a rule with no bad outcomes training discussions have been invalu- basic principles, risk recognition and — or, more typically, with apparently able. Discussions and questions from especially the individual employee’s role positive incentives or reinforcements the management and union personnel and responsibility for reporting hazards — leads to false confidence about the who attended the road shows allowed within the M&E SMS. safety of the behavior. us to fine-tune the Just Policy before it Brad Brugger
32 | flight safety foundation | AeroSafetyWorld | September 2011 Whatever it Takes
Pilot Larry Erd, Falcon 7X Captain, lands at London Luton, with an inboard slat fault alert. He quickly checks the aircraft system and then confirms he is AOG – and his next flight is on the following day. He calls Dassault’s Technical Center in Paris and gets Insy Houang – Customer Service Engineer and an on duty 7X specialist. Together they access the aircraft on-board Central Maintenance Computer to identify the fault code. Insy coordinates assistance and parts shipment Whatvia Eurostar,ev fromer Paris-Le it Bourget Take to Luton.s Go Team technicians from Dassault’s Luton Satellite installAnoka, aMinnesota. new flight A Falcon control 50EX PCB customer the next morning andhas anLarry AOG e-mails that calls back for alater new toElectr Dassaultonic Falcon: “TheContr olairplane Unit (ECU). performs really well and Customer Service“Can we ishave doing it fixed an byincredible 10:00 a.m. job too.” tomorrow?” Falcon Rep. Andy Townshend drives up from St. Paul, MN. Parts are flown in from Teterboro, NJ. Duncan technician R.J. Ridel flies in from Battle Creek, MI. Andy coordinates everything – even hand delivering the ECU to the plane by 1:00 a.m. so the job can get done overnight. At 10:00 a.m., the Falcon is ready to fly and the customer’s e-mail reads: “Thank you all. I’d say that’s going the extra mile.”
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AeroSafety World Trim: 8.5 in x 11 in Bleed: .25 in CAUSALfactors
Another Look at
Smolensk BY MARK LACAGNINA
Polish report says that a radar malfunction was involved in the Tu-154 crash.
rroneous on-track, on-glide-path callouts that the Tu-154 was not within flight-path de- by an air traffic controller during a radar- viation limits and concluded that the controller’s assisted nonprecision approach likely guidance errors were caused by a malfunction encouraged the flight crew to continue or mistuning of the radar system at Smolensk Ethe approach despite the presence of thick fog, Severny Airdrome. according to an independent report by Polish The aircraft struck terrain short of the run- authorities on the April 10, 2010, crash of a way, killing all 96 people aboard. Tupolev 154M at Smolensk, Russia. Similar to the report published last year by the The report by the Polish Committee for In- Interstate Aviation Committee (IAC), the Polish vestigation of National Aviation Accidents said committee’s report primarily faults the flight crew
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for the accident, saying, “The immedi- The commander told an aide to interference with the radar signals ate cause of the accident was the descent Polish President Lech Kaczinsky, who by trees that had grown beyond the below the minimum descent altitude at was among the passengers, that they permissible height along the final ap- an excessive rate of descent in weather would not be able to land and asked for proach path or errors in the manual conditions which prevented visual con- a “decision as to what we are going to tuning of the system. tact with the ground, as well as a delayed do.” The aide later returned to the flight Early in the approach, the copilot execution of the go-around procedure.” deck and said that a decision had not reacted to a terrain awareness and The IAC report said that the im- been made. warning system (TAWS) “TERRAIN mediate cause of the accident was the The only instrument approach AHEAD” warning by adjusting the flight crew’s failure to proceed to an available was based on two nondi- altimeter setting to increase the indi- alternate airport after being told repeat- rectional beacons supplemented with cated altitude and “fool the TAWS,” the edly that the weather conditions at radiolocators used by a landing zone report said. The crew did not respond Smolensk were significantly lower than controller to inform pilots about their to “PULL UP” warnings generated later the nonprecision approach minimums position relative to the threshold of in the approach. (ASW, 2/11, p. 20). Runway 26, the 2.7-degree glide path The Tu-154 was at a radar altitude The findings of the investigation and the extended runway centerline. of 91 m (299 ft) and 698 m (2,290 ft) committees appear to differ mainly in The published minimum descent alti- from the runway threshold when the the extent to which air traffic control tude was 100 m (328 ft). commander announced that he was (ATC) and the presence on the flight The air force CIC came to the initiating a go-around. He pulled the deck of the commander-in-chief (CIC) flight deck as the crew was being control column back and increased of the Polish air force contributed to the vectored to the final approach course. thrust, but the aircraft continued losing accident. Compared to the IAC report, Although he did not don a headset and height due to inertia. A section of the the 328-page Polish report gives greater spoke only twice, making an altitude left wing struck a tree and separated. weight to the former and less to the callout at 100 m and a comment about The aircraft rolled inverted and struck latter. It provides the following details “nil visibility” later in the approach, rising terrain. about the accident flight: the report said that his (and the aide’s) Among the “contributing circum- The Tu-154 and a Yakovlev 40 presence on the flight deck was “unac- stances” cited by the report were the operated by the 36th Special Airlift ceptable” and “could have distracted crew’s failure to monitor altitude and Another Look at Regiment of the Polish air force were the crew and drawn their attention respond to the TAWS “PULL UP” assigned to transport VIPs to Smolensk away from core duties.” warnings, and the controller’s on-track, for a commemoration of the 70th an- The landing zone controller ad- on-path callouts, “which might have niversary of the Katyn Massacre during vised the crew several times of their affirmed the crew’s belief that the ap- Smolensk World War II. distance from the runway threshold, proach was proceeding correctly.” Weather conditions at Smolensk saying each time that they were “on The report also is highly critical deteriorated rapidly after the aircraft track and path” although the aircraft of the 36th Special Airlift Regiment, departed from Warsaw. The crew of the was above the acceptable glide path describing the flight crew’s training Yak-40, which was about 20 minutes deviation limit and left of the extended and preparation for the flight as “hasty ahead, was able to land at Smolensk but centerline limit. The controller made [and] haphazard.” According to media later told the Tu-154 crew that visibility the same callout when the Tu-154 later reports, the regiment was disbanded in had decreased to 400 m (1/4 mi). descended 20 m (66 ft) below the glide August, and government flights were As the Tu-154 neared Smolensk, path and was 80 m (262 ft) left of the reassigned to Poland’s commercial car- the aerodrome controller told the extended centerline. rier, LOT Airlines. crew that the airport had “unsuitable The report concluded that the This article is based on the English translation of landing conditions.” The commander “absence of reaction” by ATC to the the Polish committee’s final report, 192/2010/11, replied, “If possible, we shall attempt Tu-154’s flight path deviations was available from the Polish Ministry of Internal approach, and if the weather is too the consequence of a malfunction of Affairs and Administration at © Jan Ostrowski/Airliners.net bad, we will go around.” the radar system’s gain adjustment, ter-poland.pl/FinalReportTu-154M.pdf>. www.flightsafety.org | AeroSafetyWorld | September 2011 | 35 flightops nowledge of the deceleration/ If communicated via graphs and His perspective of when an acceleration forces and human diagrams in training, aircraft flight overrun becomes preferable to a factors involved in rejecting manuals and approach briefings, and go-around2 comes from study of the a landing after touchdown — via aural and graphical alerts from July 2008 Hawker 800A accident at especiallyK on a contaminated runway avionics (ASW, 11/09, p. 26, and 8/10, the neighboring Minnesota airport with significant crosswind — should p. 30), imperceptible risks become in Owatonna (ASW, 4/11, p. 16) inform flight crews’ risk assess- readily apparent, according to Nihad and hypothetical commit-to-stop ments before arrival in a regional jet Daidzic, a professor in the Depart- scenarios involving typical business or other turbine-powered airplane, ment of Aviation at Minnesota State jet speeds and accelerations. These says a U.S. academic researcher. University, Mankato.1 scenarios were analyzed that year Computer simulations validate risks involved if airline pilots consider a go-around after touchdown. Point of NoBY Wa Returnyne Rosenkrans FROM Orlando | © Chris Photography Sorensen 36 | flight safety foundation | AeroSafetyWorld | September 2011 flightOPS said. “This point on the run- Simulating a Go-Around After Touchdown way, defined in the model by airspeed,” with its as- Main gear Nose gear Commit-to-stop sociated minimum takeoff/ Final approach touchdown touchdown point Lifto go-around action speed and TOGA thrust maximum safe elapsed time, Threshold Flare Con guration change crossing height “is the dynamic location of height Derotation Deceleration Acceleration the last-chance go-around attempt after actual touch- TOGA = takeoff/go-around Notes: Mathematical submodels for each landing phase shown were designed to enable the landing model and a flight down and landing roll. The simulation program to calculate operational landing distances, including a basis for designating a commit-to-stop point, exact point in flight opera- and to realistically analyze variations in pilot techniques. For educational purposes, the submodels account for effects of a stabilized or unstabilized final approach; variation from main gear threshold crossing height of 35-50 ft; variation from a tions could depend on any proper height at flare and touchdown point; variation from 3-second derotation; maximum safe elapsed decision time before of many factors — airspeed, decelerating to minimum TOGA action speed; an assumed 1,000 ft (305 m) for configuration change with or without thrust reversers; and no assumed provision for engine failure or departure obstacles while accelerating to safe liftoff speed by the end wind, distance, touchdown of the runway. location, deployment of Source: Adapted from Nihad Daidzic thrust reversers, runway Figure 1 contamination condition, engine failure in attempted with a computer simulation that he de- objective has been to understand some go-around, and so forth.” Certainty veloped for studies of runway overruns of the dynamics in pilot response about the exact point — absent a head- on contaminated runways (for which when the airplane has already touched up display/head-up guidance system or the Boeing 737-800 was modeled as down and the crew is trying to execute other equivalent capability in a primary an example applicable to large com- a go-around [Figure 1].” flight display/multifunction display — mercial jets),3 and of runway veer-offs As recently as 2010, a non-U.S. fatal may not be possible, he indicated, but (for which a Bombardier CRJ700 was accident with this element reminded early recognition of risk factors can be modeled as an example applicable to government and industry safety special- trained (Figure 2, p. 38). regional jets). He discussed results at ists of the continued importance of Factors modeled in the various the World Aviation Training Confer- related academic research, policies and simulations have included the pilot ence and Tradeshow (WATS 2011), pilot education (see “Committed to indecision time, airplane height and April 19–21, in Orlando, Florida. Stop,” p. 39).4 speed above the runway threshold Overruns and veer-offs have oc- “Operators need to have standard (kinetic energy state/inertia), flare tech- curred with “stubborn frequency” operating procedures [SOPs] and a clear nique, touchdown point (air distance despite industry initiatives throughout policy on if, how and when to execute from threshold), friction generated by at least 20 years, such as the 2000 and a go-around after touchdown,” he said. brake systems, runway surface condi- 2010 versions of the Flight Safety Foun- “For regionals or majors, this scenario tion, speed-dependent rolling friction dation Approach-and-Landing Accident can be much more hazardous than a V1 coefficient, stages of ground spoiler Reduction Tool Kit, Daidzic said. cut (action speed),” that is, practicing deployment/lift dump, thrust-reverser “Go-around safety is actually a complete loss of power from one engine deployment, duration of configura- problem for every airplane, although at the maximum airspeed in the takeoff tion changes, drag, density altitude and at WATS 2011 I am talking specifically at which the pilot must take the first the gravitational effects of an uphill about regional airline operations,” action (for example, apply brakes, reduce or downhill runway. Slopes of lines he said. “In 2008, I called this a point thrust, deploy speed brakes) to stop on resulting graphs — representing of no return [also called a commit- the airplane within the accelerate-stop deceleration rates and elapsed time — to-stop point] on the runway, refer- distance (ASW, 7-8/11, p. 23). emphasize the critical importance of a ring then to the lowest speed that “After the point of no return, it is stabilized approach to a safe landing. the airplane can slow down to before far better to accept the possible overrun “Many experts who studied veer- the crew initiates the go-around. My than to attempt a go-around,” Daidzic offs in the past recommended that www.flightsafety.org | AeroSafetyWorld | September 2011 | 37 flightops devices, complicating pilot assessments of go- Typical Factors Affecting Landing Distance around feasibility. These simulations used the CRJ700 perfor- 50 ft Increase in typical landing distance mance data set and a 5,500-ft (1,676-m) runway Decelerate Stop due to improper landing techniques while varying other factors, such as nose-gear Improper landing technique touchdown at 1,500, 2,500 and 3,500 ft [457, 762 High approach speed (+10 kt) and 1,067 m] from the threshold; liftoff speed of 170–310 ft (50–95 m) 120, 130 and 140 kt; and headwind or tailwind. Overextended flare (3-second float after flare) The model calculated minimum safe go-around 515–775 ft (155–235 m) speed and the elapsed time to decelerate to that Speedbrakes not extended 420–825 ft (130–250 m) speed, in scenarios with and without thrust High over threshold (100 ft altitude) reverser deployment, at a given runway length. 950 ft (290 m) These are a function of the touchdown/lift-off Speedbrakes not extended and thrust reversers not deployed speeds and touchdown point — an air distance 640–1,165 ft (195–355 m) from the threshold plus the distance computed One-half of full brake pedal pressure with a 3-second derotation factor. 600–1,530 ft (185–465 m) The graph generated by one CRJ700 veer- Notes: These data from the Boeing 737 NG Flight Crew Training Manual were published by off simulation represented a case involving a the India Ministry of Civil Aviation Court of Inquiry following its investigation of the May 2010 landing accident in which the flight crew attempted a go-around at Mangalore. slippery surface (ice-like friction coefficient of Distances shown vary with wet or dry runway condition; the data exclude contaminated 0.08), a 30-kt direct crosswind and no thrust runway considerations. reverser deployment. With the nose gear on the Source: Boeing Commercial Airplanes centerline, the downwind main gear normally Figure 2 would be positioned 40 to 65 ft (12 to 20 m) from the runway edge. After about 10 seconds pilots get out of reverse thrust and put back in without corrective action, however, the CRJ700 forward thrust,” Daidzic said. “Sometimes pilots wound up about 13 ft (4 m) from the runway do not have time to do that. Then they would be centerline, he said. between a ‘hammer and a hard place’ because, “Either the left or right main gear then if they get out of reverse thrust on a slippery would be about 30 to 50 ft [9 to 15 m] from one runway, they are going to overrun. So they have runway edge or the other, but this is not the to choose between one of these two — it’s going worst-case scenario,” Daidzic said. “If we look at to be an overrun or a veer-off. But with better, a case with thrust reversers, the airplane turns accurate models in flight simulation training into the wind due to directional stability. Unless devices, pilots easily could practice corrective the pilot uses some aerodynamic controls — actions in many landing scenarios — slippery such as turning into the skid, which puts the runways with crosswind, and so forth.” Effects of airplane nose downwind with the thrust revers- unstabilized approaches and the “excessive pen- ers then counteracting the wind — after landing alty” imposed by failure to use thrust reversers in on the runway centerline, after 10 seconds, the slippery or hydroplaning conditions also could be airplane would be about 50 ft off or more and demonstrated. thus already in a ditch.” His own veer-off simulations represented If these scenarios had been compounded by forces acting on a Bombardier CRJ700 with inadequate crosswind control during the approach General Electric CF34-8C5 engines landing on — creating airborne lateral drift of 3 fps (1 mps), a slippery runway in a crosswind, he said. The for example — the airplane already would have crosswind force tends to make the airplane slide been displaced from the centerline by about 10 ft sideways, and the effect of this lateral force also (3 m) by the time of nose gear touchdown. “In a changes depending on the use of deceleration matter of 10 seconds, this pilot already would have 38 | flight safety foundation | AeroSafetyWorld | September 2011 flightOPS experienced a veer-off, and the speed Go-Around Window the opportunity can be to initiate the would be very high,” Daidzic said. “Be- An example from one table in his go-around. The assumptions were a cause of the slippery runway, the airplane commit-to-stop simulation results 1,000-ft (305-m) indecision and con- would not be slowing as quickly, so the for a typical business jet, but appli- figuration change distance, hydro- speed generally would be about 100 kt, cable to any airplane given suitable planing surface and maximum thrust and that can be fatal.” runway length, showed how brief after thrust reverser deployment. “Say Committed to Stop esults of a U.S. National Trans- Regarding on-board tools, possibly Among the ALAR Tool Kit Update’s portation Safety Board (NTSB) including decision support for go- warnings originating a decade ago, a Rperformance study during the inves- arounds, the NTSB also recommended video says, “A key factor in making the tigation of the Hawker 800A accident in that the FAA, “Actively pursue with go-around decision is to constantly July 2008 have rekindled concerns about aircraft and avionics manufacturers the reassess your decision to land during procedures and training regarding development of technology to reduce the approach. Note that there is a time go-arounds after touchdown in turbine- or prevent runway excursions and, when it is no longer appropriate to go powered airplanes (ASW, 4/11, p. 16). once it becomes available, require that around — for example, when spoil- “Establishing a committed-to-stop point the technology be installed.” ers and thrust reversers have been in the landing sequence beyond which a The report also discussed the opera- deployed. Your operational procedures go-around should not be attempted for tor’s inadequate policy, procedures and should have appropriate information turbine-powered aircraft would elimi- training, noting, “None of the guidance regarding these situations, and you nate ambiguity for pilots making deci- explicitly states that a go-around should should follow those procedures.” sions during time-critical events,” said only be conducted before landing or Other examples of expert ad- the NTSB’s final report. “If the [accident] identifies a committed-to-stop point vice appear in “Reducing the Risk of captain had continued the landing and (that is, a point in the landing sequence Runway Excursions: Report of the accepted the possibility of overrunning beyond which a go-around should not Runway Safety Initiative,” published by the runway instead of attempting to be attempted). … The NTSB notes that Flight Safety Foundation, which says, execute a go-around late in the landing other recent overrun accidents have not “Operators should define and train roll, the accident most likely would have been as catastrophic because the flight procedures for go-around, including been prevented or the severity reduced crews did not attempt to go around during flare and after touchdown.” and because the airplane would have come after landing. … [Two other recent U.S. the Runway Excursion Risk Reduction to rest within the runway safety area.” accidents]1 might have been prevented Toolkit, First Edition 2009, which says, “A The most closely related safety if the pilots had committed to the land- go-around should be conducted at any recommendation to the U.S. Federal ings or better understood where the time significant deviations are recog- Aviation Administration (FAA) in the committed-to-stop point was rather nized during the flare and touchdown.” NTSB’s March 2011 report said, “Require than attempting to go around with — WR manufacturers of newly certificated insufficient runway available to lift off Note and in-service turbine-powered aircraft and clear obstacles.” 1. The NTSB could not be certain that to incorporate in their aircraft flight Preventing these situations was an these accidents would have been manuals a committed-to-stop point objective of international specialists in- prevented. The board said, “On Oct. in the landing sequence (for example, volved in the 2006–2009 runway safety 5, 2005, [the pilot of] a Beechcraft 58 overran the runway in Jacksonville, in the case of the Hawker Beechcraft initiative facilitated by Flight Safety Florida, after attempting a go-around 125-800A airplane, once lift dump is Foundation and the International Air late in the landing roll on a wet, deployed) beyond which a go-around Transport Association. Best prac- ungrooved runway. … On July 15, should not be attempted.” A compan- tices are on the compact disc titled 2005, a Cessna 525A collided with a ion recommendation said that, upon FSF Approach-and-Landing Accident localizer antenna in Newnan, Georgia, after the pilot conducted a go-around completion of this manual revision, Reduction (ALAR) Tool Kit Update, late in the landing roll on a wet, specific categories of operators and evidence that the “committed-to-stop” ungrooved runway. … As a result of the flight training schools should be re- aspect of go-around decisions had pilot’s delayed decision to go around, quired to incorporate that information received industry attention before the the airplane became airborne only 300 into their manuals and training. Hawker 800A crash. ft [91 m] from the runway end.” www.flightsafety.org | AeroSafetyWorld | September 2011 | 39 flightOPS the groundspeed on Every Second Counts After Touchdown on a Contaminated Runway touchdown is 120 kt and the nose gear Spoilers Friction braking is on the ground by deployment duration Friction 1,500 ft” beyond the braking delay threshold with thrust reversers deployed Spoilers delay Thrust immediately, he reversers Derotation delay said. “Theoretically, this pilot could slow Total elapsed time since main gear touchdown down to 77 kt in Thrust reversers deployment approximately 11 Main gear Nose gear Thrust reversers Full seconds,” then select touchdown touchdown at reverse ground idle stop takeoff/go-around Notes: A mathematical simulation model was designed to capture time factors, including those imperceptible or difficult thrust and reconfig- to judge for pilots, that cumulatively determine from data the likelihood of stopping on a runway under conditions set by the researcher. Typical landing rollouts for large commercial jets took about 30 seconds on a dry or wet runway and 40 to 50 ure the aircraft, “and seconds on an extremely slippery runway, simulations showed. Thrust reversers delay includes time for mechanical interlock still lift off in the actuation and turbine engine spool-up from idle thrust. If required, reverse thrust may continue to full stop. 4,000 ft (1,219 m) Source: Adapted from Daidzic, Nihad E.; Shrestha, Juna. “Airplane Landing Performance on Contaminated Runways,” Journal of Aircraft, November-December 2008. of runway available Figure 3 after touchdown [Figure 3]. For pilots long in this case, you have less than be overrunning at 30, 40 or 50 kt,” he who do not have an accelerometer 3 seconds to make a decision to go said. Visually judging the deceleration telling them their deceleration, around,” Daidzic said. “If you pass the rate in darkness also would increase however, it is very difficult — espe- point of no return, you have to accept the difficulty in this case. cially at high speed in a couple of an overrun that can result in an ac- seconds — to gauge how fast they are cident because if you try to lift off, the Notes slowing down.” result will be catastrophic.” 1. Daidzic also is an adjunct professor of Moreover, if the pilot touched Essentially, the simulations show mechanical engineering, with a doctorate down long at the same speed — for that a go-around, theoretically, can in fluid mechanics, and holds an airline example, more than 3,000 ft from the be safely attempted after touchdown transport pilot certificate and a certified threshold or beyond the first third only if initiated before the known flight instructor–instrument rating, among of the available runway — he or she point of no return, he said. Favor- other pilot qualifications. could only decelerate about 12 kt in able conditions for a safe outcome 2. Daidzic, Nihad; Peterson, Thomas. “When approximately 3 seconds. In the same ideally would include controllable go-around is impossible — defining the "generic" business jet scenario with deceleration-acceleration, a runway point of no return.” Professional Pilot, December 2008, p. 110. no thrust reversers, the simulation far longer than landing calculations showed that the minimum ground require, landing on an appropri- 3. Daidzic, Nihad E.; Shrestha, Juna. speed for a safe go-around would be ate touchdown marker, no obstacles “Airplane Landing Performance on about 107 kt and the maximum safe in the departure flight path, a go- Contaminated Runways in Adverse Conditions.” Journal of Aircraft, Volume 45 elapsed time to initiate the go-around around decision before (or not more (November–December 2008), p. 2131. would be 14 seconds. Landing long than three seconds after) main-gear The captain of a Boeing 737-800 attempted without thrust reversers might reduce touchdown and at least the calculated 4. that time to 4 or 5 seconds. minimum go-around speed. “On a to conduct a go-around at Mangalore, India, in May 2010, after touching down The above scenario with maxi- contaminated runway — or especially about 5,200 ft (1,585 m) from the landing mum reverse thrust reinforces calls when hydroplaning — the pilots may- runway threshold and deploying thrust re- for specific SOPs, training and dis- be would not know that the airplane versers, resulting in a fatal accident (ASW, cipline. “If you touch down fast and has no chance of stopping and would 5/11, p. 12). www.flightsafety.org | AeroSafetyWorld | September 2011 | 41 flightops and BY ED BROTAKDusty Gusty t was a typical early summer evening in south- visibility, they also are associated with very ern Arizona, U.S., this past July 5. At 1751 strong winds that can seriously affect an local time, the Phoenix Sky Harbor Interna- aircraft in flight. Engines can be damaged by tional Airport was reporting 10 mi (16 km) ingesting the dust. Ivisibility with winds of 7 kt. But all that changed Strong winds associated with a dust storm in a matter of minutes. were believed to be the cause of the May 26, A 1 mi (1.6 km)-high, 100-mi (1610 km)- 2011, crash of an air ambulance just outside wide wall of dust roared in from the southeast, Delhi, India. Seven people in the airplane and moving at 30–40 mph (48–64 kph). At the air- three on the ground were killed when the port, the leading edge of the dust cloud moved Pilatus PC-12 turboprop fell from the sky into through at 1847. Within minutes, a full-blown a residential neighborhood. Officials there said dust storm or haboob — Arabic for “strong the airplane hit a “wall of air” and was “unable wind” — was well under way. At its worst, the to move due to the strong winds.” At the time visibility dropped to 1/8 mi (200 m) and the of the crash, surface winds at the airport were winds gusted to 46 kt. The airport was closed for gusting to 40 mph. 45 minutes. The reduced visibilities and strong Even large airplanes can encounter dif- winds lasted for hours. ficulties. On March 11, 2005, an Airbus Dust storms pose a significant hazard for A321-200 operated by British Mediterranean aviation. Not only do they drastically reduce Airways encountered a dust storm while © Alan Stark/Flickr 42 | flight safety foundation | AeroSafetyWorld | September 2011 flightOPS Dust storms, including high winds, and can occur anywhere there is lots of dry soil. Dusty Gusty trying to land at Khartoum Airport, Sudan dust must be removed from runways and other (ASW, 3/08, p. 29). After two aborted ap- critical areas. proaches, a third approach was attempted. To explain the workings of dust storms, This approach also became unstable when the we start by clarifying the difference between airplane descended too quickly as it neared dust storms and sandstorms. True sand- the runway. With visibilities below acceptable storms only occur when there is actual sand minimums, the pilot initiated a go-around. in the air and therefore are usually confined The airplane was within 121 ft (37 m) of the to the sandy desert regions of the world and ground before the crew pulled up. The event their immediate surroundings. Sand grains was officially described as a “serious incident.” are larger and heavier than dust and gener- Three years later at the same airport, a Sudan ally cannot be carried as high into the air. Airways Airbus crashed on landing in a dust Dust storms comprise smaller soil particles storm. Twenty-eight people lost their lives. which can be carried much higher into the Ground operations at air terminals can be atmosphere, sometimes thousands of feet. brought to a standstill by dust storms. Outside Dust storms are much more common than workers can be extremely hampered in, if not sandstorms. They occur in arid regions, but prohibited from, doing their jobs. And in the can also occur in other places and with other aftermath of the storm, there is the cleanup soil types, as long as the soil is dry. Drought to deal with. Just as in a snowstorm, the sand/ conditions are often a prerequisite. www.flightsafety.org | AeroSafetyWorld | September 2011 | 43 flightops Besides loose, dry soil, significant wind by moist, tropical air from the south. The is necessary for dust storm formation. Strong “summer monsoons” usually begin in June but winds are needed to mix the dust from the occasionally are delayed until July. The Phoe- surface into the air and then keep it suspended nix area usually gets one to three dust storms for a significant time. The wind, of course, will each summer. Convective dust storms are also transport the dust particles and make the dust common in other parts of the world, such as the storm move. Fortunately, strong winds without Sahara region. precipitation are fairly unusual outside desert “Convective dust storms” cannot be regions. Atmospheric instability can also play forecast in advance, and that makes them a role. The more instability, the more vertical extremely dangerous. In August 2000, a Bel- mixing can occur. It is this vertical mixing that lanca 17-30 single-engine airplane crashed into can allow the dust to be carried to great heights, the mountains outside of Scottsdale, Arizona, as high as 20,000 ft. killing two. The situation was similar to the As would be expected, dust storms are com- Phoenix event — a thunderstorm-generated mon in and around the arid and desert regions dust storm. of the world. The lack of vegetation leaves the The best forecast that meteorologists can soil exposed, with nothing to slow the wind near make is to warn when conditions favor con- the surface. However, even the more humid vective development. It is impossible to know climates are not immune from dust storms. exactly where the convective cells will develop Droughts can dry topsoils and make them more and if they will produce a dust storm. Convec- prone to blowing. A weather system associated tive dust storms are fairly small — usually tens with strong winds but no precipitation can lead of miles across. After a dust storm has formed, to significant blowing dust. the U.S. National Weather Service issues either The strong winds associated with dust an “advisory” or a full-fledged “warning.” A storms are produced by a variety of weather “blowing dust advisory” is issued if the visibility systems. In the desert Southwest of the United is forecast to temporarily decrease to between States, they are usually convective. Strong 1/4 mi (0.4 km) and 1 mi due to wind-borne downdrafts from thunderstorms produce most sand or dust with winds of 25 mph (40 kph) of the dust storms. At times, the precipitation or greater. A “dust storm warning” is issued if from the storm evaporates in the dry air before the visibility is expected to drop below 1/4 mi reaching the surface. Only the strong winds frequently, with winds of 25 mph or greater. make it to the ground. Even when rain reaches The criterion of 25 mph is a minimum; winds the ground under the main convective column, frequently range from 40 to 60 mph (65 to 95 the outflow from the storm’s downdrafts has kph) in a dust storm. spread out, well ahead of the main storm. The In the more poleward arid regions and outflow boundary or gust front will be the in other drier areas in the mid-latitudes, the leading edge of the dust storm. In time, the strong winds that produce dust storms usually rain shaft may follow, turning the dust to mud. are associated with larger weather systems. To In the Phoenix dust storm, thunderstorms first further the discussion, we need to discuss how developed over 100 mi away, just east of Tuc- wind is actually produced. Wind, or hori- son, in the afternoon. This complex of strong zontal air movement, is the result of pressure to severe storms moved northwest, with its differences. Air tries to move from higher outflow boundary, the leading edge of the dust to lower pressure. The greater the pressure storm, reaching Phoenix by evening. difference, the stronger the winds. Standard Thunderstorms and the dust storms they surface weather maps use isobars, lines of produce occur in the summer in the Southwest. equal pressure, to illustrate the pressure field. It is then that the usually dry region is invaded When the isobars are closer together, there is 44 | flight safety foundation | AeroSafetyWorld | September 2011 flightops a stronger pressure gradient and the winds are accompanied by steep temperature lapse rates, stronger. The laws of physics confirm what we which increase instability and the vertical depth see in real-world high-pressure areas that have of any dust storm. On Feb. 24, 2007, a major weaker pressure gradients and light winds, low-pressure area moved out of the U.S. Rocky whereas lows with tighter pressure gradients Mountains and into the central Great Plains. have stronger winds. Fronts, associated with With a tight pressure gradient, the system was lower pressure, can also be accompanied by producing strong winds throughout much of the strong winds. central part of the United States. Of particular Low-pressure areas, or cyclones, produce concern was a strong, dry cold front extending winds that rotate counterclockwise in the north- southward from the low and moving through ern hemisphere, clockwise below the equator. Texas. At the Dallas/Fort Worth International Stronger cyclones, with lower pressures, produce Airport, strong southerly winds ahead of the stronger winds. Winds over 50 mph (80 kph) front gusted over 20 kt. But the air was moist can be expected with these storms. The winds with dew points near 60 degrees F (16 degrees occur regardless of precipitation. If a source of C). A wind shift to west-southwest near 0900 moisture is available, then as the air is lifted into local time accompanied the frontal passage. the low-pressure centers, clouds and precipita- Although a few rain showers had preceded tion usually form. If moisture is not available, the front, the air quickly dried behind it. Dew the low only produces wind and the potential points dropped precipitously, reaching as low for dust storms. as 9 degrees F (minus 13 degrees C). Winds Dust storms associated with these larger, increased and at times gusted to nearly 50 kt. “synoptic-scale” systems are much more By 1500, dust and sand moved in from the west. widespread than those associated with thun- Horizontal visibility plummeted, dropping at derstorms, often affecting hundreds or even times below 1 mi with the vertical visibility thousands of square miles. On April 4, 2009, a below 1,000 ft (305 m). The combination of low strong low-pressure area to the north gener- visibility and strong winds persisted for hours. ated a dust storm that affected all of central Much of Texas dealt with similar conditions. Texas. Lubbock reported wind gusts to 41 kt Even with these larger weather systems, and reduced visibilities due to blowing dust. At dust storms are difficult to predict. It takes just Amarillo, it was even worse, with winds gust- the right combination of wind and dry soil. ing to 55 kt and visibilities as low as 3 mi (5 And dust storms are becoming more common km) in blowing dust. around the world. In the United States, the In May 2004, dust storms were generated in Colorado Plateau region saw a record 14 large five different countries on the Arabian penin- dust storms in 2009. Northern China now aver- sula by the same weather system. On Sept. 23, ages 30 dust storms a year. Iran is reporting 2009, a dust storm 300 mi (483 km) wide and an ever-increasing number of events. In some 600 mi (965 km) long affected two states in regions, dust storms can be linked to poor Australia. It was the worst dust storm in Syd- agricultural practices. In other areas, drier ney in 70 years. Air traffic was halted at Sydney conditions and more drought occurrences are Airport, where the visibility dropped to 1/4 mi significant factors. Some believe that global cli- with gale-force winds. An intense cyclone and mate change is tied into this. Regardless of the frontal system produced the strong winds. causes, dust storms will continue to be a major Besides low-pressure areas themselves, aviation hazard in many parts of the world. fronts associated with some lows can also cause Edward Brotak, Ph.D., retired in 2007 after 25 years as problems. Dry cold fronts are the worst. Again, a professor and program director in the Department of the lack of a moisture source prohibits precipita- Atmospheric Sciences at the University of North Carolina, tion formation. Dry cold fronts are also often Asheville. 46 | flight safety foundation | AeroSafetyWorld | September 2011 safetyculture here has been a great deal of dis- A previous article (ASW, 3/11, p. In this context, Huh? (I wonder what cussion lately about organizational 30)1 discussed the unspoken language that is?) is the most important word in responsibility versus individual of threat and error management TEM’s unspoken language because it responsibility for aviation mishaps. (TEM), which comprises three words: represents the recognition that some- AlthoughT the main body of research for Huh?, Whoa! and Phew! The central thing is not right. The question comes the last 30 years has shown that aviation theme was that each of us builds up unbidden from the lessons stored in accidents mainly are organizational ac- a valuable library of lessons based on our subconscious. When the question cidents, the role of the individual — the our training and experience. Some arises while performing an operational pilot, maintenance technician, dispatch- lessons are easily recalled as they are aviation task, it may signal an important er, etc. — cannot be discounted. The stored in our conscious minds. Other recognition of a hazard and should not answer to the organization/individual lessons have been partially forgotten be ignored. dilemma might lie in the role of percep- and exist primarily in our subcon- The other two words of TEM’s unspo- tion in hazard identification. scious minds. ken language — Whoa! and Phew! — are the need to By Thomas Anthony with Chris Nutter NoticeHazards can evade identification when not clearly perceived. 48 | flight safety foundation | AeroSafetyWorld | September 2011 safetyculture the result of not recognizing the significance of involuntary act of cognition much like the invol- Huh? in identifying a hazard. untary recognition in Huh? Two related processes of perception — no- In his book Blink: The Power of Thinking ticing and not noticing — have a direct bearing Without Thinking, Malcolm Gladwell cites upon hazard identification. As with TEM’s an even more dramatic example of the sub- unspoken language, they are deceptively simple conscious processes of noticing.2 An ancient but may provide valuable insight into hazard marble sculpture of a Greek youth purchased identification. for $10 million by a museum came with sub- stantial documentation of authenticity. The Noticing (The Mini) director of the museum proudly showed the An example of noticing is the experience that a new treasure to Thomas Hoving, former direc- proud couple (Tom Anthony and his wife) had tor of the Metropolitan Museum of Art in New while trying to decide what kind of car to buy York. After looking over the sculpture, Hoving for their daughter, who was returning home asked, “Have you paid for this?” He added this ? after two years of service with the Peace Corps advice: “If you haven’t, don’t. If you have, try to in Honduras. Their discussions led to the Mini get your money back.” Cooper as possibly the best choice. There wasn’t a single element of the sculpture They were surprised when Minis began to that appeared false to Hoving; but, as a whole, the appear everywhere — in the hardware store sculpture did not ring true. It ultimately proved parking lot, alongside at a traffic light … here to be a forgery produced in the 1980s. and there … everywhere. Was there a sud- What can this example from the world of art den explosion in the number of Minis in their teach us about aviation safety? It is further evi- neighborhood? No. They simply experienced dence that, through our experience and training, the phenomenon of noticing. we build up a library of lessons, some of which They were not consciously looking for we “just can’t put our finger on” but are none- Minis, but they were noticing them. It was an theless real, valuable and not to be ignored. www.flightsafety.org | AeroSafetyWorld | September 2011 | 49 safetyculture Not Noticing (The Gorilla) research on motorcycle accidents. For example, In their book, The Invisible Gorilla: And Other Harry Hurt, a professor at the University Ways Our Intuitions Deceive Us, Christopher Cha- of Southern California (USC), in landmark bris and Daniel Simons recount an experiment research conducted for the U.S. Department of that they conducted in the Harvard University Transportation and published in 1981, found psychology department in the 1980s.3 A video of that “the failure of motorists to detect and rec- the experiment on YouTube shows two commin- ognize motorcycles in traffic is the predominat- gled teams passing basketballs among themselves. ing cause of motorcycle accidents.” One team is dressed in black uniforms and the Hurt explained that “the driver of the other other team is dressed in white uniforms. vehicle involved in the collision with the mo- The viewer is directed to count the number torcycle did not see the motorcycle before the of times the white team members pass the ball to collision, or did not see the motorcycle until too each other. (The correct number is 34.) However, late to avoid the collision.” during the one-minute video, a person dressed in Similar findings resulted from the Motorcycle a gorilla suit walks into the middle of the game, Accident In-Depth Study, conducted in five Euro- thumps its chest, walks about and leaves. The pean countries in 1999 and 2000. The researchers gorilla is on camera about nine seconds. concluded that the lack of evidence of emergency After watching the video, the viewer is asked braking or avoidance maneuvers by the drivers of if he or she noticed a gorilla. Invariably, about half vehicles that struck motorcycles confirmed that of first-time viewers say that they did not see the the drivers did not see the motorcycles. gorilla. They did not notice the gorilla because they were looking for something else. They were How Much Is Unseen? focused on counting the number of times the The “invisible gorilla” experiment and the mo- white-team members passed the ball to each other. torcycle safety study underscore a fundamental fact: Although light reflected by the gorilla or Fatal Not Noticing (Motorcycles) the motorcycle passes through the lens of the Analogous findings of a more critical and eye and strikes the retina inside the eye, there is safety-related nature have been generated from no cognition — the objects are not seen. This raises a compound question: Structure of the Retina How much are we not seeing, and is any of it important? Cer- tainly, the images of Light the motorcycles were critically important. As aviation pro- fessionals, we want Retina Light to notice hazards and avoid not noticing them. Gregg Bendrick Ganglion Amacrine Horizontal Rod Pigment of the U.S. National cell cell cell epithelium Aeronautics and Optic Bipolar Cone fiber layer cell Space Administra- Sources: Rhcastilhos/Wikimedia and Susan Reed tion and the USC Aviation Safety Pro- Figure 1 gram describes the 50 | flight safety foundation | AeroSafetyWorld | September 2011 safetyculture hazard-identification functions of the retina as First, although the retina is located within follows: “The retina of the eye has very specific the eye, it is actually part of the brain. Second, structures within it which function as opti- while for years scientists have identified rods cal hazard-identification and risk-assessment and cones as the only significant light-sensing mechanisms. These are the cones and the rods mechanisms within the eye, recent research has of the retina. The cones (so named because of identified a third type of light-sensing neurons their conical shape) are concentrated in the in the retina: the intrinsically photosensitive center of the retina. The rods (so also named retinal ganglion cells, which transmit signals to because of their shape) are dispersed over the control our circadian rhythms and other photo- wider area of the retina with a much lower level periodic functions (Figure 1). of concentration. Circadian rhythms have a direct bearing As aviation “The cones process visual information for upon our levels of mental awareness and our professionals, our central vision. The central vision is what abilities to notice and identify hazards, and our we see and are consciously aware of. It is what tendency to not notice. we want to notice we are ‘looking at.’ On the other hand, the rods So, unlike our earlier conception of the eye process information of the peripheral vision. In (retina) as simply a remote camera that trans- hazards and avoid effect, the rods, which feed our peripheral vi- mits raw data to the brain, where it is processed sion, act as light and motion detectors, as well as and analyzed, research has found evidence that not noticing them. a basic horizon indicator. the retina also performs the traditional brain “We can ‘see’ things via this peripheral vi- functions of processing and storage. sion but not be consciously aware of them. The peripheral vision helps with our overall spatial Sigmund Says orientation, and when a light or relevant motion Sigmund Freud, in The Psychopathology of ‘catches our eye,’ our brain redirects the eyes to Everyday Life, points out that “no person forgets focus the central (cone) vision onto the item of to carry out actions that seem important to interest. That is, the item is now brought to our himself.”4 Using himself as an example, he conscious level of awareness. claimed an excellent memory but admitted that “This duality of vision also allows us to he sometimes forgot appointments with patients focus on something, like reading a newspaper that he was treating at no charge. or viewing an iPod while we are walking. We Freud underscored this observation with can do these two things at once, and we may not the comment: “What one forgets once, he will be conscious of the walking function, nor the forget again.” general surface of the walkway ahead, though it He also provided a personal insight into is being subconsciously processed.” peripheral noticing: “Both irritating and The rods, then, provide a very important laughable is a lapse in reading to which I am Huh?-like function. They sense movement and frequently subject when I walk through the environmental differences, and they act auto- streets of a strange city during my vacation. matically to direct the central vision to focus on I then read ‘antiquities’ on every shop sign the item identified to be of further interest. In a that shows the slightest resemblance to the sense, it is a physiological TEM function. word; this displaying the questing spirit of the collector.” More Than a ‘Camera’ Noticing is the opposite of forgetting. It is un- In a recent discussion of the retina as a hazard- commanded remembering. As Freud pointed out, identification mechanism, Bendrick provided we notice what we are interested in or value; we two additional insights that have powerful safety forget (or do not notice) those things that we see implications and bear upon the question of as unimportant or do not value. Our interests organizational/individual responsibility. reflect our values — those things that we see as www.flightsafety.org | AeroSafetyWorld | September 2011 | 51 safetyculture important, those things that we see as treat them with respect. What is simple, though, and can be unimportant. The English poet and artist William universally expected to produce a true What role does the organization Blake said, “A fool sees not the same tree and accurate answer with regard to the have in creating the values, and there- that a wise man sees.” Organizations are world of aviation mishaps is the universal fore the interests, of its employees? better served by wise men than by fools, question: Why? This question is a tool George S. Patton might have provid- but wisdom is the result of learning, that, with dedication and application, can ed the answer when he took command rather than birth. Organizations can produce the most honest and complete of the U.S. Third Army and addressed create their own “wise men” by valuing explanation of any mishap, whether in its 90th Division as it prepared to go learning, sharing and communication. the aviation environment or in any other back to the front during World War II. Wisdom is the fruit of understanding, complex technological environment. The troops had experienced some rough not of rote repetition or blind obedience. Why? is the tool that leads us from going prior to Patton assuming com- The responsibilities of the individ- impression to answer, from incomplete to mand, and their performance had been ual are significant as well. The primary complete. It is a tool for correcting under- not wholly successful. Nevertheless, the responsibility of individuals is to per- lying causes rather than for satisfying the general let them know that they were the form their jobs to the full extent of their superficial demands of the moment. best damned troops in this man’s army. abilities and training, with honesty and The Mini Cooper, the invisible Later, he was asked by an aide if without reservation. Individuals must gorilla, motorcycles, Sigmund Freud, he really thought they were the best. act and communicate in the interest of George Patton and the physiology of Patton replied that it was not important the organization that employs them. the eye are diverse sources upon which that they were the best, it was important Inherent in the responsibility to to draw insights into aviation safety. that they thought they were. communicate is the recognition that each However, we believe that the insights individual has a valuable role in hazard are valid and valuable. They underscore Values Affect Perception identification. Without the full participa- the complexities of individual percep- These examples demonstrate the role of tion of employees at all levels in hazard tion and the role of organizational cul- values in influencing individual percep- identification, an organization cannot ture in creating the values and beliefs tion and performance. Where have we operate safely and productively. that direct and shape our perception of seen the word values before? It is in The willingness of the individual the outside world. our definition of organizational culture: to communicate and report honestly Thomas Anthony is director of the Aviation the values, beliefs, roles and behaviors reflects directly upon the culture of the Safety and Security Program at the Viterbi School that define the identity of a particular organization. The organization must of Engineering, University of Southern California. organization and the individuals that have practices and procedures that Chris Nutter is a staff instructor at the USC function within it. value communication and reporting. It Aviation Safety and Security Program, and a An organizational culture reflects must have a reporting culture as part of a captain for a major airline. the values, beliefs and roles expected learning culture that enables long-term from employees. It must be established organizational growth and viability. Notes and maintained in a tangible, organized 1. The article is available at 52 | flight safety foundation | AeroSafetyWorld | September 2011 SAA magzineAd215.9x279.4FA.pdf 1 8/12/11 1:50 PM Developing Talent for Global Aviation C M Y CM MY CY CMY K 34th ICAO Edward Warner Award 1996 Flight International An internationally-recognised institute Aerospace Industry Award with 4 specialised schools delivering more than100 programmes annually. To-date, it has trained over 52,000 participants from190 countries. Tel: (65) 65406209 / 65430433 Fax: (65) 65429890 / 65432778 Email: [email protected] www.saa.com.sg A Division of the Civil Aviation Authority of Singapore Copyright © 2011 Civil Aviation Authority of Singapore. All rights reserved. DataLink BY RICK DARBY Runway Excursions a Continuing Threat Safety gains in the excursion accident record were reversed in 2010. orldwide commercial jet compared with four of eight in 2009. principally differences in accidents aviation resulted in fewer ac- The 26 approach and landing accidents since commercial jet aviation began in cidents in 2010 than in 2009, accounted for 65 percent of the total significant numbers in 1959, and dur- according to data released by accidents, compared with 60 percent in ing 10-year study periods. WBoeing Commercial Airplanes.1,2 That 2009 and 58 percent in 2008. Viewed in a wider time frame, some was the best news in the year-over-year One of the 13 runway excursion improvement is seen. In the 2001–2010 comparisons. However, on-board fatali- accidents was fatal — the overrun at period, there were 4,707 on-board fa- ties jumped from 413 in 2009 to 555 in Mangalore, India, on May 22, which talities in scheduled passenger service, 2010. The number of runway excursions cost 158 lives (ASW, 5/11, p. 12). compared with 4,938 in 2000–2009, — veer-offs and overruns — increased Excursion accidents represented 33 a decrease of 5 percent (Table 2, p. by one, and runway excursions as a per- percent of total accidents, compared 56). The number of fatal accidents in centage of all accidents were higher. with 19 percent in 2009 and 30 percent scheduled passenger service dropped A total of 40 accidents occurred in in 2008. from 69 in 2000–2009 to 67 in the more 2010 (Table 1). That represented a 35 A single accident — a fatal one — recent 10-year span. There was one percent decrease from 62 the previous occurred during cruise flight in 2010. fewer charter operations fatal accident year and a 25 percent decrease from 53 Seven accidents, of the total of 62, were in 2001–2010 than in 2000–2009. in 2008. Eleven accidents were classi- in the cruise phase the prior year. Cargo flights were involved in 15 fied as “major” in 2010, compared with Changes from one year to the next fatal accidents in the most recent 10 13 in 2009.3 can suggest possible trends but are years compared with 14 in the prior 10 Nine of the 2010 accidents were subject to “confounding” factors; for years, resulting in 46 on-board fatalities fatal, including one that occurred while example, the number of fatalities in compared with 42. The number of acci- the aircraft was stopped on the runway; an accident may be influenced by the dents in cargo operations was down in a passenger later died from injuries number of passengers who happen the latest 10-year span, from 81 to 80. sustained during the evacuation. to be on the flight. Boeing’s annual Considering all accidents in the Six of the eight in-flight fatal ac- accident summaries provide longer worldwide commercial jet fleet, no cidents in 2010 occurred during the timelines where the data compari- change in recent trends appeared in approach and landing phases of flight, sons are likely to be more meaningful, the latest summary. Fatal accidents 54 | flight safety foundation | AeroSafetyWorld | September 2011 DataLink 2010 Airplane Accidents, Worldwide Jet Fleet Onboard Fatalities Phase of Damage (External Major Date Airline Model Accident Location Flight Description Category Fatalities) Accident? Jan. 2 Compagnie Africaine 727 Kinshasa, Congo D.R. Landing Runway veer-off Destroyed d’Aviation Jan. 15 Iran Air F-100 Isfahan, Iran Landing Hard landing Substantial Jan. 16 Utair 737-500 Moscow Taxi Nose landing gear collapse Substantial Jan. 19 Mexicana Airlines A318 Cancun, Mexico Takeoff Fan cowling torn off Substantial Jan. 25 Ethiopian Airlines 737-800 Near Beirut, Lebanon Climb Struck Mediterranean Sea after Destroyed 90 (0) takeoff Jan. 30 Spring Airlines A320 Shenyang, China Landing Tail strike Substantial Feb. 6 SAS MD-82 Grenoble, France Landing Tail strike Substantial Feb. 11 Click Mexicana F-100 Monterrey, Mexico Landing Runway veer-off Substantial Feb. 13 Southwest Airlines 737-700 Near Santa Clarita, Approach TCAS avoidance maneuver California, U.S. injured flight attendant March 1 ACT Airlines A300-B4 Bagram, Afghanistan Landing Landing gear collapse Substantial March 1 Air Tanzania 737-200 Mwanza, Tanzania Landing Runway veer-off Substantial March 4 China Airlines 747-400 Anchorage, Alaska, U.S. Takeoff Tail strike Substantial March 4 Cobham Aviation 717 Ayers Rock, Australia Parked Flight attendant fell from airplane Australia April 2 EgyptAir A330 Cairo, Egypt Taxi Struck two light poles Substantial April 2 Southwest Airlines 737-300 Los Angeles Pushback Struck baggage cart Substantial April 13 Merpati Nusantara 737-300 Manokwari, Indonesia Landing Runway overrun Destroyed Airlines April 13 AeroUnion A300-B4 Near Monterrey, Mexico Approach Struck ground Destroyed 5 (1) May 12 Afriqiyah Airways A330 Near Tripoli, Libya Approach Struck ground Destroyed 103 (0) May 22 Air India Express 737-800 Mangalore, India Landing Runway overrun Destroyed 158 (0) June 5 US Airways A321 Charlotte, North Carolina, U.S. Parked Struck by another taxiing airplane Substantial June 6 Royal Air Maroc 737-400 Near Amsterdam, Netherlands Initial climb Bird strike Substantial June 21 Hewa Bora Airways MD-82 Kinshasa, Congo D.R. Takeoff Runway veer-off Substantial July 27 Lufthansa Cargo MD-11 Riyadh, Saudi Arabia Landing Runway veer-off Destroyed July 28 AirBlue A321 Near Islamabad, Pakistan Approach Struck hillside Destroyed 152 (0) July 28 Mauritania Airways 737-700 Conakry, Guinea Landing Runway overrun Substantial Aug. 12 Azerbaijan Airlines A319 Istanbul, Turkey Landing Runway overrun Substantial Aug. 16 Aires Colombia 737-700 San Andres Island, Colombia Landing Landing short Destroyed 2 (0) Aug. 20 Chanchangi Airlines 737-200 Kaduna, Nigeria Landing Landing short Substantial Aug. 24 Henan Airlines EMB-190 Yichun, China Final Landing short Destroyed 42 (0) approach Aug. 26 Iran Aseman Airlines F-100 Tabriz, Iran Landing Runway overrun Substantial Sept. 3 UPS 747-400 Near Dubai, United Arab Cruise In-flight fire Destroyed 2 (0) Emirates Sept. 6 easyJet A320 London Parked Struck by truck Substantial Sept. 24 Wind Jet A319 Palermo, Italy Landing Runway veer-off Substantial Sept. 25 Atlantic Southeast Airlines CRJ-900 New York Landing Gear failed to extend Substantial Oct. 3 Thomsonfly 767 Bristol, England Landing Hard landing Substantial Oct. 31 Turkish Airlines A310 Casablanca, Morocco Landing Runway veer-off Substantial Nov. 2 Lion Air 737-400 Pontianak, Indonesia Landing Runway overrun Substantial Nov. 4 Global Air 737-200 Puerto Vallarta, Mexico Landing Nose landing gear retracted Substantial Nov. 4 Qantas Airways A380 Near Batam Island, Indonesia Climb Uncontained engine failure Substantial Nov. 10 Kuwait Airways A300-600 Kuwait City Parked Evacuation — 1 (0) Total accidents: 40 Totals 555 (1) 11 TCAS = traffic-alert and collision avoidance system Source: Boeing Commercial Airplanes Table 1 www.flightsafety.org | AeroSafetyWorld | September 2011 | 55 DataLink were reduced from 89 in 2000–2009 to 87 in 1999–2008 and 1998–2007, 25 percent each. 2001–2010. All accidents increased from 393 to From 1959 through 2010, 34 percent of acci- 399, respectively. dents were fatal. In accidents from 2001 through 2010, 87, The most recent 10-year period included 180 or 22 percent, were fatal (Figure 1). For 2000– substantial damage accidents with no fatalities, 2009, the equivalent figure was 23 percent; for representing 45 percent of all accidents. Among non-fatal accidents, Accidents, Worldwide Commercial Jet Fleet, by Type of Operation 4.5 percent involved no substantial damage On-board Fatalities All Accidents Fatal Accidents (External Fatalities)* but serious injuries Type of operation 1959–2010 2001–2010 1959–2010 2001–2010 1959–2010 2001–2010 in 2001–2010. In the Passenger 1,390 308 481 69 28,381 (777) 4,711 (157) 1959–2010 stretch, Scheduled 1,276 287 436 67 24,267 4,707 the corresponding Charter 114 21 45 2 4,114 4 percentage was 4.9 Cargo 250 80 75 15 262 (330) 46 (74) percent. Maintenance test, ferry, 117 11 44 3 208 (66) 17 (0) For 1959 through positioning, training and demonstration 2010, 88 fatal acci- Totals 1,757 399 600 87 28,851 (1,173) 4,774 (231) dents — 15 percent of U.S. and Canadian operators 541 75 178 12 6,158 (381) 265 (15) fatal accidents — oc- Rest of the world 1,216 324 422 75 22,693 (792) 4,509 (216) curred in the absence Totals 1,757 399 600 87 28,851 (1,173) 4,774 (231) of substantial damage. *External fatalities include ground fatalities and fatalities on other aircraft involved, such as helicopters or small general For 2001 through aviation airplanes, that are excluded. 2010, the percentage Source: Boeing Commercial Airplanes was the same. Table 2 Scheduled com- mercial passenger Accidents, by Injury and Damage, Worldwide Commercial Jet Fleet operations had a fatal accident rate of 0.40 1959 through 2010 Total 1,757 600 fatal accidents 1,157 non-fatal accidents per million depar- (34% of total) (66% of total) tures in 2001–2010. 487 accidents with hull loss 424 hull loss accidents All other operations, 25 accidents with including categories substantial damage 676 substantial damage 88 accidents without 57 accidents without substantial such as charter pas- substantial damage damage (but with serious injuries) senger, charter cargo, 0 100 200 300 400 500 600 700 800 900 1,000 1,100 1,200 1,300 1,400 1,500 1,600 1,700 1,800 maintenance test and Number of accidents training, had a fatal ac- 2001 through 2010 Total 399 cident rate of 0.67 per 87 fatal accidents 312 non-fatal accidents (22% of total) (78% of total) million departures. 72 accidents hull loss 118 hull loss without fatalities Boeing has ad- 2 fatal accidents with opted the practice of 180 substantial damage without fatalities substantial damage tabulating fatalities 13 accidents without 14 accidents without substantial substantial damage damage (but with serious injuries) according to the stan- dardized taxonomy of 0 100 200 300 400 Number of accidents the U.S. Commercial Aviation Safety Team/ Source: Boeing Commercial Airplanes International Civil Figure 1 Aviation Organization 56 | flight safety foundation | AeroSafetyWorld | September 2011 DataLink (CAST/ICAO).4 For the most recent Fatalities by CAST/ICAO Taxonomy Accident Category, Worldwide Commercial Jet Fleet, 2001–2010 10-year study period, “loss of control in 2,000 , | On-board fatalities [Total 4,774] flight” (LOC-I) and 1,800 External fatalities [Total 231] “controlled flight into 1,600 terrain” (CFIT) were 1,400 1,200 the categories with , | 1,000 the greatest number | Fatalities 800 of on-board fatali- 600 ties (Figure 2). The 400 | 156|69 | | 200 | | | LOC-I on-board | | | | | 0 fatalities, numbering LOC-I CFIT RE UNK MAC SCF-NP RE OTHR RI-VAP WSTRW FUEL RAMP SCF-PP F-NI EVAC 1,756, were almost (Landing) + (Takeo ) ARC + USOS unchanged from Number of fatal accidents 2000–2009. The on- (87 total) 20 17 17 3 2 1 5 4 1 1 1 9 3 2 1 board loss of life from CAST = U.S. Commercial Aviation Safety Team; ICAO = International Civil Aviation Organization; ARC = abnormal runway CFIT accidents, how- contact; CFIT = controlled flight into terrain; EVAC = evacuation; F-NI = fire/smoke (non-impact); FUEL = fuel related; LOC-I = ever, which totaled loss of control – in flight; MAC = midair/near midair collision; OTHR = other; RAMP = ground handling; RE = runway excursion; RI-VAP = runway incursion – vehicle, aircraft or person; SCF-NP = system/component failure or malfunction (non-powerplant); 961 in 2000–2009, was SCF-PP = system/component failure or malfunction (powerplant); UNK = unknown or undetermined; USOS = undershoot/ greater in the latest overshoot; WSTRW = wind shear or thunderstorm. period at 1,007. No accidents were noted in the following principal categories: aerodrome, abrupt maneuver, air traffic management/ communications, navigation, surveillance, bird strikes, cabin safety events, fire/smoke (post-impact), ground collision, icing, The third greatest low altitude operations, loss of control – ground, runway incursion – animal, security related or turbulence encounter. number of on-board Note: Principal categories are as assigned by CAST. Airplanes manufactured in the Russian Federation or the Soviet Union are excluded because of lack of operational data. Commercial airplanes used in military service are also excluded. fatalities in 2001–2010 Source: Boeing Commercial Airplanes was amalgamated by Boeing as “run- Figure 2 way excursion (RE) Airplanes manufactured in the Soviet Union or landing” combined Commonwealth of Independent States are excluded with “abnormal runway contact” (ARC) and because of the lack of operational data. “undershoot/overshoot” (USOS). The on-board An airplane accident is defined as “an occurrence fatalities, 766, in the latest 10-year time frame associated with the operation of an airplane that were higher than those in the previous 10-year takes place between the time any person boards tally, 606. The equivalent number in 1999–2008 the airplane with the intention of flight and such was 408. time as all such persons have disembarked, in There was no increase in on-board fatalities which death or serious injury results from being from runway excursions on takeoff between in the airplane; direct contact with the airplane or anything attached thereto; or direct exposure to jet 2001–2010 and 2000–2009: 154 on-board fatali- blast; the airplane sustains substantial damage; or ties, 38 external fatalities. the airplane is missing or completely inaccessible.” Occurrences involving test flights or hostile action Notes such as sabotage or hijacking are excluded. 1. Boeing Commercial Airplanes. Statistical Summary 3. Boeing defines a major accident as one meeting of Commercial Jet Airplane Accidents: Worldwide any of three conditions: the airplane was destroyed; Operations 1959–2010. June 2011. 2. The data are limited to commercial jet airplanes 4. The taxonomy is described at Before and After Fatigue-inducing pilot stress does not occur only in the cockpit. BY RICK DARBY BOOKS Bennett, who conducted the study and ‘Tired All the Time’ analyzed the responses, says, “In 2010, the British The Pilot Lifestyle: A Sociological Study of the Air Line Pilots’ Association’s members perceived Commercial Pilot’s Work and Home Life a need to document the pilot lifestyle. Sociology, Bennett, Simon. Leicester, England: University of Leicester Institute of with its ability to ‘get behind the story,’ seemed the Lifelong Learning, 2011. 228 pp. ideal investigative tool. … In essence, this report is idn’t get to sleep until 2300. Woke at an oral history of the modern pilot experience.” 0100 and stayed awake until 0400. Then Bennett used three research instruments to “D slept until 0800. [At] work by 0900 to understand and analyze the commercial pilot pick up taxi to LBA [Leeds-Bradford Airport, lifestyle. The first was a sleep/activity log, or England]. Ninety-minute ride. Flight delayed SLOG, kept for 21 days by pilots in the study. one hour due to late inbound. Operated “More textured than a simple sleep log, it LBA-PMI-MAN [Leeds-Bradford–Palma de recorded pilots’ lived reality of work and home,” Mallorca, Spain–Manchester, England]. Flight he says. Completed SLOGs, which ranged in delayed PMI by one hour due to flow-control length from about 2,000 to 9,000 words, were restrictions. No meal on return flight — oven confidential and de-identified. The study began unserviceable — so starving. Two hours late in mid-2010 and ended in 2011. into MAN. Drove home. Quick chat to wife, Interviews and a Web-based questionnaire then bed at 2230 with sleeping tablet — I need supplemented the SLOGs. In addition, “useful to get some sleep.” data emerged via an unexpected route: Many of Many corporate managers work long hours the diarists provided information in emails and and travel often. It is hard to imagine a com- letters,” Bennett says. pany, however, that would expect a high-level Each published diary is followed by Bennett’s executive to keep a schedule like the one above analysis, often including findings from other regularly, every working day and/or night. researchers, which are keyed to end notes. For But it was a manager with a great deal of the sake of brevity, details of the citations are responsibility, an airline captain, who wrote that omitted in the following examples. description of his workday. It is quoted from the From the diary of another captain on long- diary he kept during the busy summer charter- haul flights: flight period, as one of about 130 pilots who re- Day 1. “Woke at 0610. [All times in this corded in detail their experiences in the cockpit, and other diary excerpts are coordinated at airports, at hotels and at home. universal time to clarify the durations in the 58 | flight safety foundation | AEROSafetyWorld | September 2011 InfoScan sequences.] Preflight sleep 1130–1245. Felt of falling asleep if you are driving while tired or well rested. Departed by car for base at 1400. sleep-deprived.’” Arrived 1630. (Drive to work took 2.5 hours.) “Generally, the diarist seemed able to Pushed 1930 for LHR-EWR [London Heathrow obtain preflight and in-flight sleep. The Up- to Newark, New Jersey, U.S.]. In-seat sleep for per Class seat episode on Day 9 illustrates the 45 minutes.” importance of undisturbed, stress-free sleep Day 2. “[I was] pilot flying for arrival. On opportunities. This was manifestly not a stress- blocks 0330. Felt absolutely whacked by the time free sleep opportunity. The [U.S.] Federal I boarded the crew bus. Crew bus to Manhat- Aviation Administration comments: ‘Sleep tan hotel accommodation. Checked in by 0530. should not be fragmented with interruptions. Asleep by 0630. Slept until 1025, then restless In addition, environmental conditions, such sleep until 1330.” as temperature, noise and turbulence, impact Day 7. London Heathrow to HGK (Hong how beneficial sleep is, and how performance Kong). “No Upper Class seat available for in- is restored.’” flight sleep, so resorted to bunk. Three-and-a- A first officer preparing for duty on a long- half-hour rest break. There was an extra duvet haul flight — Munich, Germany (MUC) to Los available, so I slept unusually well.” Angeles (LAX) to MUC — wrote in his diary: Day 9. “Pushed 1130 for HGK-SYD [Syd- Day 3. “Leave day. Kids woke me up at ney, Australia]. Two-and-a-half-hour rest break 0445. Felt all right. Usual morning tasks. Get taken in Upper Class seat. The flight service kids ready, breakfast. Went to town [Düsseldorf; manager warned me she would need the seat if DUS]. Packed suitcase and prepared for the we hit turbulence, as one of the passenger seat trip until lunchtime. The wife was angry at me belts was defective. Aware of this prospect, I leaving — had a little fight about that. Family never slept at all, really. I kept waking up when took me to the airport at 1400. Flight from DUS we hit turbulence, anticipating a seat-swap. My to MUC. Arrive 1700. Rented a car and drove to eyes were stinging as the sun started to come up the hotel. Arrived 0815. Had dinner at 1900. Did during our approach into Sydney.” some preparation/reading for the trip. Went to Day 12. “Woke at 0500 after a good sleep bed at 2045 and fell asleep around 2100.” (eight hours). Socialized, then retired at 1830. I Day 13. “I slept from 2400 to 0300 [in the slept well at first, but an incoming crew decided aircraft on a flight to São Paulo, Brazil]. I felt to hold a party in the room above mine.” tired afterwards — but well enough to fly the Excerpts from Bennett’s analysis: last four hours of the flight. I landed the aircraft. “The diarist seems to have benefited from We landed well ahead of schedule and were ‘Sleep should not quiet and relaxing hotel accommodations, with on blocks at 0750. We drove to the hotel and I the exception of the room party incident in finally got to bed at 1000. I slept until 1200. I did be fragmented with HKG. Hotel life [has] its irritations. Hotels can not feel rested afterwards. … Since [fellow crew- interruptions.’ be noisy during the day: rooms are cleaned, members] wanted to meet for dinner, I decided goods are delivered, guests are dispatched and to take a nap from 1800 to 2000 and slept from maintenance is done. Unfortunately, the noise 1830 to 2000. I did not feel well afterwards. I starts just when pilots are getting ready for bed.” went to the bar where we had arranged to meet “The diarist lived roughly a two-and-a-half- and had my first drink of the evening, bought by hour drive from LHR, his base. On landing, he my captain — so I couldn’t say no. I didn’t really would drive home. … Transport Canada says, want to drink alcohol, though. We spent the rest ‘Driving to and from work when fatigued should of the evening (2200–0030) in a steak restaurant. be considered a hazard. This is increasing in I couldn’t eat much because of the time of day. It importance as commute times continue to grow was too late for me.” significantly longer. You will always be at risk Excerpts from Bennett’s analysis: www.flightsafety.org | AEROSafetyWorld | September 2011 | 59 InfoScan “There is strong evidence here of how completing a night flight, stop-start coach travel offspring impose routine on parents. The diarist is very unpleasant.” (and his partner, of course) were locked into a The captain sent an email to Bennett along routine of going to bed around 2100 and get- with his SLOG: “Thank you for undertaking what ting up at between 0500 and 0600. There is also I view to be a critical piece of research. There strong evidence of this being a tight-knit family has been a change in many airlines from a faintly unit with lots of time spent together when the paternalistic ethos to hard-nosed commercial- diarist was at home. Young families are demand- ism. This is reflected in their short-term behavior, ing. Perhaps it was the prospect of having to which is only to the detriment of flight safety. cope alone that caused the minor spat prior to Fatiguing rosters are far more prevalent now the MUC-LAX-MUC trip.” than at any time I can remember. It has become “The diarist had a time-consuming and a major topic of conversation in our [flight crew] potentially arduous commute to work. For community. This is the first year in my career of example, his Day 3 commute to the pre-LAX 16 years that I have filed a fatigue report. hotel accommodation by family car, aircraft and “I have noticed an increase in the use of sleep- rented car took over four hours. After returning ing tablets among crew (I don’t use them). These from São Paulo, the diarist spent five and a half are not necessarily prescribed, as they are avail- hours commuting by aircraft, train and bus to able in some of our more esoteric destinations.” his home. … The greater the number of trans- In Bennett’s analysis, he cites his own study port interfaces — for example, between an air of the sleeping habits of “back of the clock” service and a train or bus service — the greater cargo flight crews, in which he found that the chance of missing a connection and of being “although the majority tried to get pre-report, late for report. Short, single-mode commutes top-up sleep, they were often thwarted by their enhance operational resilience.” body clock or other factors, like noise.” “In their paper ‘The Mental Health of Pilots: The fatigue issue arises in report after Hassles with preflight An Overview,’ Bor, Field and Scragg investigate report in the pilot lifestyle book. Here is a typi- and post-flight the link between social or peer pressure and cal example, from a first officer working for a alcohol consumption amongst commercial pilots: German carrier: “Right now many pilots in my transportation are ‘Pilots experience high levels of stress in their jobs company are flying overtime and many say that and have to endure considerable disruption to it can’t go on. We usually fly five days in a row, a running thread their personal lives. Intermittent absences from have two days off, flying again for five days, etc. family and social support, periods of time relax- Many times we have four or five legs a day, and through the diaries. ing and recuperating, sometimes accompanied by to top it off, in Frankfurt we have many aircraft boredom and social pressure to consume alcohol changes — meaning we arrive in Frankfurt, have with fellow crewmembers, may be the root cause to hurry to finish up the paperwork, shut down of alcohol misuse and dependency.’” the aircraft, lug our baggage out of the aircraft, Hassles with preflight and post-flight hop on a crew bus which takes us to another air- transportation are a running thread through craft, lug our baggage to the new aircraft, do all the diaries. Here is a captain for a charter airline the checks to turn the aircraft on again, etc. All after a flight from Cuba to Manchester: this leads to many of us being tired all the time.” “Into the [hotel] for a sleep of five hours The overall impression obtained from read- and then back to LGW [London Gatwick] by ing many of the 21-day diaries is that the pilots coach at 1515. The coach is 30 minutes late and — perhaps encouraged by being asked to report is going via Birmingham Airport, which means their experience — were aware of their physi- we don’t get back to LGW until 2130, and after a ological and psychological states. They were not 20-minute walk and transit ride to my car I get supermen or superwomen. They were affected home at 2230, tired and with a headache. After by the same problems, anxieties and irritants 60 | flight safety foundation | AEROSafetyWorld | September 2011 InfoScan as people in more “routine” occupations, plus SMS as Seen by Practitioners additional ones related to frequent long-haul fly- Implementing Safety Management Systems in Aviation ing, such as the disorientation caused by being Stolzer, Alan J.; Halford, Carl D.; Goglia, John J. (editors). Farnham, unsynchronized with local times. Surrey, England, and Burlington, Vermont, U.S.: Ashgate, 2011. 464 pp. Figures, tables, index. But it is equally clear that the pilots made a disciplined effort to do whatever it took to com- he editors’ earlier book, Safety Management pensate for stress and find their balance. They Systems in Aviation, was largely concerned phoned home, found ways to amuse themselves Twith explaining safety management system and relax as much as possible under the circum- (SMS) concepts (ASW, 12/08, p. 54). This time, stances, and above all tried — albeit not always their book differs in emphasis and format. It is successfully — to get enough sleep. concerned above all with practical SMS imple- According to Bennett’s Web-based ques- mentation. And whereas the earlier work was tionnaire, 74.4 percent of the respondents written by the present editors, here they have answered “yes” to the question, “Have you ever assembled stand-alone chapters by industry commenced a duty [period] knowing you were specialists who have put SMS into practice. fatigued?” A larger percentage, 86.1 percent, “While the editors are involved in industry, acknowledged flying a sector knowing they were consulting and academia, we thought that turning fatigued. to the day-to-day practitioners of SMS provides The questionnaire asked, “What is the lon- yet another perspective for the student of SMS,” gest period of continuous wakefulness (in hours, the editors say. “Our authors are among the most from waking up to setting the brakes at the experienced practitioners in the industry today.” end of the last sector) you have experienced at SMS is still evolving as it translates from the- work?” Replies were “up to 17” hours from 13.9 ory to practice. The authors of the 14 chapters percent of the pilots; “18–22” from 32.6 percent; write from their own viewpoints, and the editors “23–27” from 33.3 percent; and “28 or more” say they are more concerned with conveying the from 20.3 percent. breadth of the subject than reconciling the indi- Although some pilots criticized company viduals’ outlooks into a systematic treatment. scheduling policies, 84.3 percent said they had The book begins with a prologue about a failed to get adequate rest at home before report- fictional fatal runway collision between a corpo- ing for duty. The most frequent reasons given rate jet and a “Quest Airlines” aircraft, as both were family-related stress, work-related stress, companies’ management teams review their household noise and extraneous noise. SMS and its prior implementation. Bennett concludes, “Although subjective, Subsequent chapters examine SMS from pilots’ responses to questions about fatigue and various angles. Some headings are “Perspec- stress should give cause for concern. … One tives on Information Sharing”; “Top Manage- remarked: ‘I don’t want to [quit] flying particu- ment Support”; “Safety Culture in Your Safety larly. But I wake up some days and I ask, “For Management System”; “Integrating SMS Into how much longer can I do this when I feel this Emergency Planning and Incident Command”; tired?”’ Such sentiments do not bode well for and “Safety Promotion.” the industry. An airline’s safety performance is The chapter titled “Practical Risk Manage- influenced in part by its organizational memory, ment,” by Kent Lewis, offers an example of the the sum of employees’ wisdom and experience. book’s material. Lewis says, “The goal of SMS Inevitably, airlines with a high pilot turnover is to prevent loss of life and property while have a weaker organizational memory in terms conducting daily operations, and this is ac- of flying operations than those with a low complished by the detection and mitigation of turnover. Airlines allow the experience pool to hazards. Risk management forms the founda- evaporate at their peril.” tion for an effective SMS, regardless of size, www.flightsafety.org | AEROSafetyWorld | September 2011 | 61 InfoScan mission or resources of the organization, team out the evening’s festivities, the air traffic control or individual.” tower was closed and braking action reports After outlining several operational risk would have to be relayed to the inbound aircraft reduction models, Lewis looks at case studies of by airport operations personnel.” hazards and actual incidents and accidents. All of those hazards were known before the For example, in a near midair collision be- accident, Lewis notes. tween a U.S. Navy T-34C training aircraft and a “With all of this information in hand, a civilian aircraft, “the identified hazard was the lack time-critical risk assessment could be conducted ‘With [the Navy’s] of a radio [in the military airplane] that operated and most likely it would score in a category that on civilian frequencies. … With [the Navy’s] risk- required actions be taken to reduce the level of risk,” risk-management management model, when a severe hazard was he says. “There are many examples of risk-assess- discovered, a report had to be generated to notify ment matrices and personal minimum checklists model, when a the appropriate-level risk managers within 24 available for use.” [The FSF Approach and Landing severe hazard was hours. This report also included recommendations Accident Reduction Tool Kit Update 62 | flight safety foundation | AEROSafetyWorld | September 2011 InfoScan pursuing targeted and continuous improve- industry where it is ments in systems, culture, processes and currently lacking.” capability.” Continuing The plan’s initiatives are of two types. airworthiness. First, “we are taking action to address the “Improve the CAA’s factors behind the most significant worldwide capability to ex- accident types involving large airliners — we call tract intelligence these the ‘Significant Seven’ — as well as actions from all sources of for other sectors, such as business aviation, large airworthiness-related public transport helicopters and general aviation.” safety data, so that Second, “we are taking action to address the associated risks ‘capability issues.’ We believe that enhancing our are better understood and the most effective safety risk management systems and adoption of actions to mitigate them can be identified and a performance-based regulatory approach will implemented.” improve the way the CAA regulates and will result Strategy for human factors (HF). “A better in safety improvements of benefit to aviation and understanding of human performance, limitations, the public at large by focusing on the right risks.” attitudes and behaviors to drive the practical ap- The Significant Seven factors are loss of con- plication of human factors principles in reducing trol, runway excursions, controlled flight into risk within the aviation safety system.” terrain, runway incursions, airborne conflict Performance-based oversight. “Deliver and ground handling. Some findings of a CAA effective regulation in a manner and at times task force report on the status of the seven was which have the greatest impact on preventing described in ASW (4/11, p. 50). significant aviation losses. Facilitation of pro- The report says, “One of the target outcomes portionate, targeted and consistent regulation.” from the CAA Strategic Plan is that ‘the U.K. Fatigue risk management systems aviation industry and the CAA will have mea- (FRMS). “Deliver effective regulatory oversight surably increased capability and performance of fatigue management using FRMS techniques in safety management, human factors and just and metrics, proportionate to the size and culture, and demonstrated the benefits in terms complexity of the operational environment. To of risk reduction.’” ensure that safety-critical workers are able to Key capability issues’ intended outcomes are operate at an effective level of alertness for all discussed under the following headings. normal and abnormal circumstances.” Integrated safety risk management The report also notes “total system threats” process. “Develop a new integrated safety risk such as the volcanic ash crisis of 2010 — an management process to allow more effective example of an improbable event whose knock- monitoring and management of aviation safety on effects can temporarily cripple the entire risk by the CAA and industry.” aviation system. Reviewing lessons learned from Safety management systems (SMS). the ash cloud debacle revealed that “one of the “Improve the safety performance of organizations CAA’s strengths … was its ability to draw upon through the implementation of effective SMS and internal expertise based on a long involvement the CAA’s capability to assess the effectiveness in relevant issues and previous incidents. The and safety performance of an organization’s SMS.” need to retain such capability is reflected in the Just culture. “To achieve a balance between CAA Strategic Plan, together with the need for the interests of safety (e.g., protection of safety continued improvement in the CAA’s expertise, information) whilst not tolerating reckless- plans and processes for crisis management, and ness, and to achieve improvements in the open the ability to better identify and prevent or pre- reporting of safety occurrences in parts of the pare for rare but high-impact events.” www.flightsafety.org | AEROSafetyWorld | September 2011 | 63 OnRecord Ice Blocks A330 Pitot Probes Airspeed data discrepancies triggered disengagement of the autoflight systems in two airplanes. BY MARK LACAGNINA The following information provides an aware- and altitude were lost, the autopilot and auto- ness of problems that might be avoided in the throttle disengaged, and the fly-by-wire system future. The information is based on final reports reverted from normal control law to alternate by official investigative authorities on aircraft control law, which provides fewer protections accidents and incidents. against exceeding performance limitations. “The flight crew continued using backup in- JETS struments,” the report said. “After approximately five minutes, primary data was restored. … The Fly-by-Wire Protections Degraded crew determined they could not restore normal Airbus A330s. No damage. No injuries. law and continued the flight under the appropri- ce crystals blocked the pitot probes on two ate procedures.” The airplane was landed in São Airbus A330s that were cruising at high Paulo without further incident. Ialtitudes in the vicinity of convective weather In the second incident, the crew of the U.S. activity, causing erroneous airspeed indica- airplane was using the on-board weather radar tions and reduced autoflight systems operation, system to avoid thunderstorms while flying according to a report issued in June by the U.S. over Japan at FL 390. However, “just prior to National Transportation Safety Board (NTSB). the event, the airplane entered an area of cirrus The incidents reported by NTSB involved an clouds with light turbulence and moderate rain, A330-200 of Brazilian registry that was en route with a brief period of intense rain and hail aloft,” with 176 people aboard from Miami to São Paulo, the report said. Brazil, on May 21, 2009, and an A330-300 of U.S. The autopilot and autothrottle disengaged, registry that was en route with 217 people from fluctuating airspeed indications were displayed, Hong Kong to Tokyo on June 23, 2009. and a stall warning was generated. The crew “Crew statements and recorded data for both “reported that the airspeed fluctuations and flights did not indicate any airplane anomalies warnings lasted about one minute, and they con- prior to the events,” the report said. trolled the airplane by pitch and power reference, The Brazilian airplane was at Flight Level per applicable checklist procedures, until normal (FL) 370 (approximately 37,000 ft) over Haiti airspeed indications returned,” the report said. when the flight crew noticed an abrupt decrease Airspeed fluctuations occurred again briefly in outside air temperature and observed St. as the crew turned the airplane farther away Elmo’s fire, a coronal discharge of plasma that from the convective activity. After about two produces a faint flame-like glow on an aircraft minutes, “the airspeed indicators returned to flying through an electrically charged atmo- normal, and the crew re-engaged the autopilot sphere. The airplane’s air data reference system and completed the flight in alternate [control] ceased operating, primary displays of airspeed law,” the report said. 64 | flight safety foundation | AEROSafetyWorld | September 2011 OnRecord Investigators determined that the incidents occurred on June 1, 2009, when an A330-200 — were initiated when at least two of the three Air France Flight 447 — equipped with Thales pitot probes on each airplane were blocked by AA probes descended into the Atlantic Ocean an accretion of ice crystals. during a flight from Rio de Janeiro, Brazil, to The electrically heated pitot probes mea- Paris. All 228 people aboard the airplane were sure total air pressure, which is converted by killed. Based on preliminary findings, the BEA three air data modules (ADMs) into electronic has called on EASA to review icing-certification signals that are used — along with static pres- standards for pitot probes. sure measured by the airplane’s static ports — by EASA in August proposed an airworthiness three associated air data inertial reference units directive that would require A330/340 flight to calculate airspeed. The data generated by the control computer software changes to prevent ADMs are compared by independent flight con- re-engagement of autoflight systems with unreli- trol computers that disengage autoflight systems able airspeed data. and adjust the flight control law if discrepancies The incident cited by the NTSB report exceed programmed limits. involved an A330, equipped with Goodrich A330s originally were equipped with 0851HL pitot probes, near Guam on Oct. 28, Goodrich 0851GR pitot probes. “In 2001, 2009. The incident was investigated by the following some inconsistent speed problems, Australian Transport Safety Bureau (ATSB), Airbus replaced the original 0851GR probes which reported in January 2011 that the flight with either Goodrich 0851HL probes or Thales crew had been maneuvering at FL 390 to avoid [C16195QAA] probes,” the report said. “Op- cumulus buildups during a flight from Japan to erators had the option to install either of those Australia with 214 people aboard. probes in any location and could have any mix Shortly after the A330-200 entered an area St. Elmo’s fire of both types on the same airplane.” of light precipitation, St. Elmo’s fire appeared appeared on the The Thales “AA” probes have been found to on the windshield, and “there was a brief period be more susceptible to high-altitude ice crystal of disagreement between the aircraft’s three windshield, and ‘there icing than other approved probe designs. In sources of airspeed information,” the ATSB 2007 and 2008, Airbus recommended that A330 report said. The autopilot and autothrottle was a brief period operators replace any AA-series probes with disengaged, the flight control system reverted to Thales C16195BA (“BA”) probes. Tests per- alternate law, and several warning and caution- of disagreement formed by Thales in an icing wind tunnel have ary messages were generated. between the aircraft’s shown that the BA probes are more resistant “The airspeed disagreement was due to a than the AA probes to blockage. temporary [about five-second] obstruction of three sources of The European Aviation Safety Agency the captain’s and [the] standby pitot probes, (EASA) and the U.S. Federal Aviation Admin- probably due to ice crystals,” the report said, airspeed information.’ istration in August 2009 issued airworthiness noting that the aircraft had experienced a directives requiring the replacement of all AA similar incident eight months earlier. “Both of probes on A330s and A340s. The directives the events occurred in environmental condi- required Goodrich 0851HL probes at the no. 1 tions outside those specified in the certification (captain’s) and no. 3 (standby) positions, and requirements for the pitot probes.” either a 0851HL probe or a Thales BA probe at the no. 2 (first officer’s) position. Faulty Coupling Leaks Fuel Boeing 757-28A. No damage. No injuries. The NTSB report discussed two other occurrences — an accident and an incident — he 757 was at FL 360, en route from Turkey involving “unreliable airspeed events” in A330s. to London Gatwick Airport with 226 pas- The accident, which is being investigated by the Tsengers and eight crewmembers aboard French Bureau d’Enquêtes et d’Analyses (BEA), the morning of June 12, 2010, when a “FUEL www.flightsafety.org | AEROSafetyWorld | September 2011 | 65 OnRecord CONFIG” warning appeared on the engine indi- Gust Launches Jet Bridge cating and crew alerting system. The flight crew Embraer 135KL. Minor damage. No injuries. noticed a fuel imbalance, with 800 kg (1,764 lb) he airplane was at a gate at Dubuque more fuel in the right wing tanks than in the left (Iowa, U.S.) Regional Airport, being pre- wing tanks. Tpared for takeoff with 44 passengers and While performing the quick reference hand- three crewmembers the morning of April 3, book procedure for the fuel imbalance, the com- 2011, when a strong gust pushed the jet bridge mander found a discrepancy of 800 kg between about 25 ft (8 m) into the Embraer’s forward the fuel-consumed and the fuel-remaining in- fuselage, creating a 20-in (51-cm) gash below dications. This discrepancy indicated a fuel leak the captain’s side window. because “fuel flow indications remained equal “The airport had deactivated the brake sys- for both engines,” said the report by the U.K. Air tem on the jet bridge during the winter months Accidents Investigation Branch (AAIB). since the brakes would routinely freeze,” the The commander considered diverting NTSB report said. “The gate agents who were the flight to Paris but decided to continue to operating the jet bridge attempted to keep it London because the aircraft was nearing the from being blown into the airplane, but, with beginning-of-descent point to Gatwick. “He the brake system deactivated, they were unable made a PAN call [a declaration of an urgency] to do so.” to London ATC [air traffic control], who cleared A further complication was that the emer- the aircraft for an immediate approach to Run- gency stop button inside the jet bridge not only way 26L with no speed or altitude constraints,” was ineffective in applying the brakes, it also the report said. isolated power to the control panel, rendering The crew shut down The crew shut down the left engine during the steering system inoperative. the landing roll as a precaution against fire and The report noted that the day before the in- the left engine parked and secured the aircraft on Runway 08L, cident, a technician had encountered problems during the landing where it was inspected by airfield fire and rescue while trying to reactivate the jet bridge’s brake services personnel. A substantial amount of fuel system. Repairs to complete the scheduled reac- roll as a precaution had spilled from the left wing, but there was no tivation of the system had not been performed fire. The aircraft then was towed to a remote when the incident occurred. against fire. stand, where the passengers and crew disem- barked normally. Unstable Approach Leads to Overrun A total of 3,800 kg (8,378 lb) of fuel re- Cessna Citation CJ2. Minor damage. No injuries. mained in the aircraft’s tanks. The commander xcessive airspeed throughout the descent, estimated that 1,300 kg (2,866 lb) of fuel had approach and landing was a factor in the leaked from the left wing. ECJ2’s runway excursion at Kassel, Germany, A company maintenance engineer traced the afternoon of March 24, 2010, said a report the leak to a sealing ring in a coupling between on the serious incident by the German Federal the left engine’s high-pressure fuel pump and Bureau of Aircraft Accident Investigation. fuel governor overspill return tube. The seal- The aircraft was inbound with a passenger ing rings in both engines were replaced, and and two pilots from Stuttgart. The second-in- ground runs at maximum power revealed no command was flying from the left seat. Both further leakage. pilots were familiar with Kassel-Calden Airport, “Further detailed investigation into the fuel having flown there several times. The weather leak was not possible, as the seals removed from at the airport was clear, and surface winds were the aircraft were discarded, rather than being re- from 160 degrees at 10 kt. tained as is required by the operator’s engineer- Nearing the airport from the southwest, the ing organization’s procedures,” the report said. crew established the CJ2 on a left downwind 66 | flight safety foundation | AEROSafetyWorld | September 2011 OnRecord leg to land on Runway 22, which was 1,500 m the aircraft], and the assisting cabin crewmem- (4,921 ft) long and 30 m (98 ft) wide. ber fell through the open door onto the apron, From recorded ATC radar data, investigators [sustaining] a fractured left arm, a sprained right estimated that indicated airspeed had averaged wrist and some other minor injuries.” 295 kt during the descent and 210 kt during the The marshaler and the operator of the initial approach. On final approach, indicated portable stairs had not been able to see the door airspeed was 190 kt. from their positions. The report said that after the “The crew subsequently reported that accident, the ground handling services provider the aircraft crossed the Runway 22 threshold adopted a requirement for one ground crewmem- at about 130 kt, with the flaps set at the first ber to remain at the top of the portable stairs and position (15 degrees),” the report said, noting observe the door being closed and locked before that the recommended procedure was to use signaling for the stairs to be removed. a reference landing speed (VREF) of 103 kt and full flaps (35 degrees). “Throughout, the speed TURBOPROPS was too high for a stable and well-controlled ap- proach, even under visual flight conditions.” Turbine Blades Shed Neither pilot called for a go-around. The CJ2 Cessna 208 Caravan. Destroyed. No injuries. touched down at about 120 kt and 572 m (1,877 he Caravan had been chartered to transport ft) from the runway threshold, “from which five employees of an industrial services com- point continual wheel/brake marks were left by Tpany and a cargo of hazardous material — both main landing gear,” the report said. including blasting detonators, ammonium nitrate Realizing that the aircraft could not be stopped and nitromethane — the afternoon of Sept. 15, on the runway, the crew intentionally steered it off 2009. The airplane was climbing through 8,500 ft the left side. This action “prevented a collision with when a catastrophic engine failure occurred. the Runway 04 approach lights and possibly also The pilot declared an emergency and pre- the localizer antenna, which are all mounted on pared to land the 208 in a field near Sheffield, concrete plinths [pedestals],” the report said. “The Massachusetts, U.S. The right wing struck a tree decision to guide the aircraft toward open space and separated on approach to the field, but the avoided serious damage to the aircraft.” airplane came to a stop upright, the NTSB report The CJ2 came to a stop, with the wheels and said. The passengers and the pilot were able to tires on the main landing gear sunk deeply in soft exit the Caravan before it was engulfed in flames. ground, 53 m (174 ft) from the runway edge. The ammonium nitrate and nitromethane were consumed by the fire, but none of the detonators, Crewmember Falls From Door which were stored in a metal box, ignited. Boeing 717-200. No damage. One serious injury. Investigators determined that the engine’s hile preparing the 717 for departure first-stage sun gear splines had failed, causing from Ayers Rock, Northern Terri- the power turbine disk to overspeed and release Wtory, Australia, the afternoon of March turbine blades. The engine had accumulated 4, 2010, a cabin crewmember had difficulty 7,620 hours, including 65 hours since it was unlatching the open left forward door from the overhauled 19 months before the accident. fuselage. Another cabin crewmember, who had Maintenance records showed that “the sun shut the right forward door, came to help. gear found on the accident engine was previ- “The assisting cabin crewmember placed one ously removed from another engine due to foot outside the aircraft onto the portable stairs ‘spalled gear teeth’ about seven years prior to the to assist with closing the door,” the ATSB report accident,” the report said. “The condition of the said. “At this point, ground personnel com- sun gear when installed on the accident engine menced moving the portable stairs [away from could not be determined.” www.flightsafety.org | AEROSafetyWorld | September 2011 | 67 OnRecord Control Lost in Crosswind made the decision to divert to the nearest suit- CASA 212-200. Substantial damage. No injuries. able airfield and, with ATC assistance, diverted he flight crew was conducting a cargo flight the to Bristol, which was 25 nm [46 km] ahead of the afternoon of Sept. 18, 2009, from Nome, Alaska, aircraft.” The Dash 8 was landed at Bristol Interna- TU.S., to Savoonga, which had surface winds tional Airport without further incident. from 010 degrees at 26 kt, gusting to 34 kt, 5 mi (8 “The oil leaks were traced to damaged O-ring km) visibility in light rain and an overcast at 800 ft. seals within the oil cooler fittings on both en- The captain used full flaps for the approach gines,” the report said. “Both oil coolers had been to Runway 05, which was 4,400 ft (1,341 m) long removed and refitted during the base maintenance and 100 ft (30 m) wide, and constructed of gravel. check at Exeter. It was probably during reinstalla- “The captain reported that during the landing roll, tion that the O-ring seals were damaged,” in part despite the use of differential power and other con- by overtightening and misalignment of the fittings. trol adjustments, he could not maintain directional The technician who had reinstalled the oil control,” the NTSB report said. The CASA veered coolers told investigators that he was under off the right side of the runway and struck a ditch. some time pressure to complete the job, which The report noted that the maximum demon- was difficult because of the small space in which strated crosswind component for the airplane is the components are located. “He needed two 20 kt. The operating manual recommends reduc- hands to install each pipe and used a torch ing the crosswind component by 25 to 75 percent [flashlight], held in his mouth, to illuminate the for landing on a slippery runway and limiting flap pipe and oil cooler fitting,” the report said. extension to 15 degrees in a strong crosswind. When the maintenance inspection was com- pleted, engine ground runs were performed per Oil Leaks Traced to Damaged Seals the aircraft maintenance manual to test systems Bombardier DHC-8-102. Minor damage. No injuries. and check for oil leaks, the report said. “How- fter a maintenance inspection at Exeter, ever, a leak check of the oil cooler fittings was England, the Dash 8, which was of Greek not specifically called for.” Aregistry, was flown to East Midlands for repainting on April 16, 2010. The flight was Parking Brake Set Improperly uneventful; but, after the aircraft was parked, an Beech King Air E90. Substantial damage. No injuries. engineer observed oil spots beneath both engine fter landing at Colorado Springs, Colorado, nacelles. The engineer tightened oil-system elbow U.S., the night of Sept. 4, 2010, the pilot joints on both engines and observed no leaks Ataxied the King Air to the ramp and was during a brief ground run following repainting. marshaled by ground personnel to a parking spot. During the positioning flight back to Exeter He then set the parking brake and continued con- ‘The copilot went eight days later, a master warning was gener- ducting a checklist with the engines running. into the cabin and ated about 10 minutes after takeoff, and the crew “Unbeknownst to the pilot, the airplane noticed a loss of oil pressure in the right engine. began to roll forward until it impacted a tug and observed what “The copilot went into the cabin and observed ground power unit located approximately 25 ft what appeared to be a major oil leak coming from [8 m] across the ramp,” the NTSB report said. appeared to be a the right engine, with oil flowing down the right The nose landing gear collapsed, and the nose of side of the aircraft fuselage,” said the AAIB report. the airplane came to rest atop the tug. The pilot major oil leak The crew shut down the right engine, declared shut down the engines, and he and his three pas- coming from the an urgency and requested ATC vectors directly to sengers exited the King Air without assistance. Exeter. Five minutes later, left-engine oil pressure NTSB determined that the probable cause right engine.’ began to fluctuate. “The copilot again entered the of the accident was “the pilot’s failure to ensure cabin and, this time, observed an oil leak from that the airplane’s parking brake was properly the left engine,” the report said. “The commander set before diverting his attention to other tasks.” 68 | flight safety foundation | AEROSafetyWorld | September 2011 OnRecord PISTON AIRPLANES than 100 ft above ground level, and indicated airspeed was at, or a few knots below, the Duke’s Upside-Down in a Thunderstorm minimum single-engine control speed (VMC), Cessna 421C. Destroyed. Five fatalities. according to the NTSB report. he pilot was aware of convective activity on his “The pilot attempted to advance the throttles route from McKinney, Texas, U.S., to Tampa, but was unable [to] since the flight instructor’s TFlorida, and planned to use the airplane’s hand was already on the throttles,” the report weather radar system and lightning detector, pilot said. “The airplane veered sharply to the left and reports and ATC assistance to avoid the thunder- rolled. The pilot was able to level the wings just storms during the July 8, 2009, afternoon flight. prior to the airplane colliding with trees and The 421 was over the Gulf of Mexico when terrain.” The pilot sustained serious injuries, and the pilot requested assistance from ATC to exit an the flight instructor was killed. area of turbulence. The Jacksonville Center con- The pilot told investigators that before troller told the pilot that if he continued straight beginning the proficiency check, the flight in- ahead for about two minutes, he should be clear structor had not briefed him on procedures for of the weather, according to the NTSB report. simulating an engine failure and had mentioned A few seconds later, the pilot reported signifi- that he had not flown a Duke “in a while.” cant turbulence and downdrafts of 2,000 fpm. “He then requested a course reversal to exit the weather On Auxiliary Tanks Too Long before he declared an emergency and advised ATC Cessna 401. Substantial damage. Three serious injuries. that the airplane was upside-down,” the report fter a three-hour aerial mapping flight the said. “There were no further transmissions from the afternoon of June 18, 2010, the 401 was on a pilot, and radar contact with the airplane was lost.” A3-nm (6-km) final to land at Plymouth, Mas- Recorded ATC radar data showed that the sachusetts, U.S., when both engines lost power. 421 had entered rapidly developing cumulo- While trying unsuccessfully to restart the nimbus and an area of radar echoes indicating engines, the pilot noticed that the fuel quantity extreme precipitation intensities. Investiga- indicators showed about 25 gal (95 L) remaining tors concluded that the pilot lost control of the in the main tanks and 2–5 gal (8–19 L) remain- airplane, which subsequently broke up and ing in the auxiliary tanks. descended into the gulf about 25 nm (46 km) “The pilot then selected a forced-landing site northwest of Port Richey, Florida. between two large trees and landed the airplane “The airplane’s airborne weather radar may in heavily wooded terrain,” the NTSB report said. have been unable to provide an accurate repre- Investigators determined that the pilot had not sentation of the radar echoes along the aircraft’s ensured that the fuel selectors were positioned to flight path” due to attenuation, or the weakening the main tanks, which is the first task on the “Be- and scattering of the transmitted radar energy fore Landing” checklist. The 401’s auxiliary tanks by the intense precipitation, the report said. are designed for use only in cruise flight. “Therefore, the final penetration of the intense portion of the storm was likely unintentional.” Fuel-Fed Fire Erupts on Departure Piper Chieftain. Destroyed. One fatality, one minor injury. Engine-Out Simulation at VMC xtensive maintenance, including the instal- Beech 60 Duke. Destroyed. One fatality, one serious injury. lation of four extra fuel tanks, had been per- hortly after takeoff from Edenton, North Eformed to prepare the Chieftain to be ferried Carolina, U.S., for an instrument profi- from the United States to Korea. Shortly after the Sciency check the evening of June 7, 2010, airplane departed from Las Vegas for the first leg the flight instructor retarded the left throttle to of the flight the afternoon of Aug. 28, 2008, a fire simulate an engine failure. The airplane was less erupted in the right engine compartment. www.flightsafety.org | AEROSafetyWorld | September 2011 | 69 OnRecord The airplane, a Colemill Panther conver- relied on the fuel gauge reading, without using sion, was about 7 nm (13 km) from North Las an independent method to cross-check that Vegas Airport when the pilot reversed course reading against the actual fuel tank quantity,” the and declared an emergency. He feathered the report said. right propeller but did not accelerate to best single-engine rate of climb speed or complete Downdraft Causes Hard Landing other actions required to configure the airplane Aerospatiale AS 355F-1. Substantial damage. One serious injury, three minor injuries. for single-engine flight, said a report issued by NTSB in July 2011. As a result, the pilot was un- he pilot was maneuvering the helicopter to able to arrest the descent rate. film an automobile participating in a hill The Chieftain struck trees and power lines, Tclimb at Pikes Peak, Colorado, U.S., on Sept. and came to a stop upside-down next to a house 17, 2010. A sharp turn in the racecourse near about 1.25 nm (2.3 km) from the runway. The the top of the peak required the pilot to fly away pilot was killed, and one of the five people in the from the mountain and then perform a 180- house received minor injuries. degree turn back toward the peak. The report said that the fire had originated “After turning 180 degrees and on the in the vicinity of the engine-driven fuel pump inbound leg toward the mountain, the helicop- and its fittings. Although extensive damage pre- ter encountered a downdraft and was pushed cluded a definitive conclusion about the cause of toward rising terrain,” the NTSB report said. the fire, the report said that it likely had been fed “Helicopter performance at that altitude did by fuel leaking from either a supply line “B” nut, not provide the pilot with a power margin great a broken fuel line or the fuel pump itself. enough to arrest the descent.” The pilot attempted to land on a road, where HELICOPTERS the helicopter touched down hard and rolled over. The pilot sustained serious injuries. Fuel Cross-Check Neglected Bell 206B. Substantial damage. Two serious injuries. Fatigue Cited in Rotor Blade Failure he JetRanger was about 15 minutes into a Bell 206L-1. Destroyed. Three fatalities. 20-minute sightseeing flight along the coast he emergency medical services crew was Tnear Coomera, Queensland, Australia, the returning from a fund-raising event in Bur- afternoon of June 10, 2009, when the “FUEL Tney, Indiana, U.S., to their base in Rushville, PUMP” warning light illuminated, indicat- Indiana, the afternoon of Aug. 31, 2008, when ing low fuel pressure. “The pilot believed he an 8-ft (2-m) section of a main rotor blade sepa- had sufficient fuel on board and continued the rated, rendering the LongRanger uncontrollable. flight,” said the ATSB report. The helicopter crashed in a corn field, killing the The helicopter was descending to land at the pilot, flight nurse and paramedic. Coomera helipad when the engine lost power “Metallurgical examination determined that due to fuel exhaustion. “During the final stages the blade failed as a result of fatigue cracking,” of the autorotative landing, the pilot was unable the NTSB report said. “The origin of the fatigue to arrest the helicopter’s descent rate, and the crack coincided with a large void between the helicopter struck the ground heavily,” the report blade spar and an internal lead weight. said. Two of the four passengers sustained seri- “Further investigation determined that the ous injuries. presence of residual stress in the spar from the Examination of the JetRanger showed that manufacturing process, in combination with the fuel gauge may have been over-reading. excessive voids between the spar and the lead “The operator’s practice when calculating the weight, likely resulted in the fatigue failure of quantity of fuel to be added during refueling the blade.” 70 | flight safety foundation | AEROSafetyWorld | September 2011 OnRecord Preliminary Reports, July 2011 Date Location Aircraft Type Loss Type Injuries July 4 Pukatawagan, Manitoba, Canada Cessna 208 Caravan total 1 fatal, 8 minor/none One passenger was killed when the Caravan overran the runway and went down an embankment during a rejected takeoff. July 4 Eidfjord, Norway Eurocopter AS 350 total 5 fatal The helicopter crashed and burned in mountainous terrain while transporting passengers to a remote area. July 5 Rackla, Yukon, Canada Shorts SC-7 Skyvan major 2 minor/none The Skyvan touched down near the right side of the gravel runway, veered off and struck a ditch while landing on a cargo flight. July 6 Bagram, Afghanistan Ilyushin 76 total 9 fatal The cargo airplane struck a mountain about 25 km (13 nm) southwest of the airport during a night approach. July 8 Kisangani, Democratic Republic of Congo Boeing 727 total 83 fatal, 35 minor/none The 727 crashed about 300 m (984 ft) from the runway during an approach in heavy rain and low visibility. July 8 Chimaltenango, Guatemala Bell 206 total 2 fatal, 1 serious Witnesses said adverse weather conditions prevailed when the helicopter struck power lines and crashed on high terrain during a charter flight to Guatemala City. July 11 San Fernando, Mexico Beech King Air 90 major 9 minor/none The King Air was substantially damaged during a forced landing on open ground after both engines flamed out due to fuel exhaustion. July 11 Andaman Sea, Myanmar Sikorsky S-76 total 3 fatal, 8 minor/none The helicopter crashed in the sea after an apparent engine failure during departure from an oil platform. July 11 Strezhevoy, Russia Antonov 24 total 6 fatal, 4 serious, 27 minor/none The flight crew ditched the An-24 in the Ob River after an uncontained fire erupted in the left engine nacelle. July 13 Recife, Brazil Let L-410 Turbolet total 16 fatal The airplane crashed near a beach shortly after the pilot reported an engine problem on takeoff. July 14 Warsaw, Poland ATR 72 major 1 serious The airplane was parked at a stand with the engines running in darkness and heavy rain when a baggage vehicle struck the right propeller. The vehicle driver was seriously injured, and propeller debris struck the ATR’s wing and fuselage. July 21 Wadeye, Northern Territory, Australia Eurocopter Super Puma major 1 minor The helicopter was being taxied on a ramp when the main rotor struck a light pole. Debris struck one person on the ground and a parked Swearingen Metro. July 23 Kei Mouth, South Africa Cessna 208 Caravan total 1 minor/none The Caravan overran the runway during landing and traveled down a steep slope. July 26 Goulmima, Morocco Lockheed C-130 total 80 fatal The C-130 crashed on high ground about 10 km (5 nm) northeast of the airport during an approach in fog. July 28 Jeju Island, South Korea Boeing 747 total 2 fatal The airplane was on a cargo flight from Seoul to Shanghai, China, when the crew reported a fire and that they were diverting to Jeju. The crew subsequently reported control problems shortly before the 747 crashed in the East China Sea. July 29 Cairo, Egypt Boeing 777 major 291 minor/none The 777 was parked at a stand when a fire erupted on the flight deck. All 291 passengers were evacuated via jet bridges. The fire extensively damaged the cockpit and burned through the fuselage below the copilot’s side window. July 29 Ife Odan, Nigeria Eurocopter AS 350 total 3 fatal The helicopter struck a hill in fog during a flight from Lagos to Ilorin. July 30 Georgetown, Guayana Boeing 737NG total 2 serious, 161 minor/none The 737 overran the 7,448-ft (2,270-m) runway while landing in darkness and heavy rain, and traveled down a slope and through a fence before coming to a stop on the airport perimeter road. This information is subject to change as the investigations of the accidents and incidents are completed. Source: Ascend www.flightsafety.org | AEROSafetyWorld | September 2011 | 71 smokeFirefumes Selected Smoke, Fire and Fumes Events in the United States, June–July 2011 Date Flight Phase Airport Classification Subclassification Aircraft Operator 6/1/2011 Climb Milwaukee (MKE) Smoke Unscheduled landing Embraer ERJ-190 Not stated The flight crew reported a strong odor in the cabin after takeoff, declared an emergency and returned to MKE. The aircraft was landed without incident. Maintenance troubleshot, performing high-power engine runs. They were unable to duplicate any odors. All functions were normal in an operational check. McDonnell 6/3/2011 Climb Not stated Smoke Continued for landing Douglas MD-88 Delta Air Lines The flight crew noticed that the left air conditioning pack indicator read 45 pounds per square inch (psi); the acceptable maximum was 28 psi. The crew turned off the air conditioning pack. The indicator then read 20 psi. The crew also noticed a faint, hot burning oil smell on climbout. Maintenance replaced the left air conditioning supply pressure transmitter. They were unable to duplicate the smell. The crew said that there was no smell during cruise or approach. McDonnell 6/4/2011 Climb Not stated Smoke/Fumes Unscheduled landing Douglas MD-80 Delta Air Lines A flight attendant reported a burning odor after takeoff. The right air conditioning pack was immediately secured and the smell dissipated. The flight crew found the right pack temperature valve at “full hot” and repositioned to it to the midrange. They reactivated the right pack and the odor returned. They secured the high-pressure bleed valve and the pack then operated normally. The auxiliary power unit (APU) inlets and the APU were found oil-soaked, but the leakage source was not identified. Maintenance ran the engines and APU in all configurations and did not produce any further odors. They performed a duct burnout according to the aircraft maintenance manual. Harrisburg, 6/5/2011 Climb Pennsylvania (MDT) Smoke in cockpit Emergency Diversion Embraer ERJ-170 Not stated The flight crew reported smoke in the cockpit during the climb. The crew declared an emergency, diverted to MDT and landed without incident. Maintenance troubleshot and found the first officer’s lighting control panel at fault. Maintenance removed and replaced the lighting control panel. 6/12/2011 Ground operations Not stated Smoke, fluid loss Returned to gate ATR 72 Executive Aircraft Charter The crew reported that the no. 3 brake assembly was leaking fluid, as well as smoking due to foreign object debris hitting the brake line. The aircraft was removed from service. Maintenance replaced the no. 3 main brake assembly. 6/16/2011 Cruise Atlanta (ATL) Smoke in cockpit and cabin Continued with flight Boeing 717 AirTran Airways In level flight at 28,000 ft, flight attendants reported a burning odor in the vent. The first officer detected it as well. At the gate in ATL, the electric smell was very evident after the cockpit door was opened. Maintenance removed and replaced both coalescer bags. Dallas/ McDonnell 6/19/2011 Taxi/ground operations Fort Worth (DFW) Smoke, warning indication Returned to gate Douglas MD-82 American Airlines During taxi at DFW, the lavatory smoke alarm began to chime and there was a strong electrical odor in the vicinity of the aft left lavatory. No circuit breakers tripped and the odor disappeared. Maintenance replaced a malfunctioning overhead ballast and the aft left lavatory smoke detector. 6/22/2011 Cruise Not stated Odor in cabin Emergency landing Boeing 737 Southwest Airlines A strong odor was reported in mid-cabin during cruise flight. An emergency was declared and the flight was diverted. The recirculation and gasper fans were turned off. Maintenance removed and replaced the gasper fan. 6/24/2011 Cruise Los Angeles (LAX) Smoke, warning indication Unscheduled landing Boeing 767 American Airlines The crew reported a strong burning odor in the cockpit, accompanied by a status message: “FORWARD EQUIPMENT EXHAUST FAN.” The equipment cooling switch was moved to standby and the odor seemed to dissipate. The utility buses were turned off as a precaution. The forward exhaust equipment cooling fan circuit breaker tripped. Maintenance replaced the forward rack exhaust fan. 6/25/2011 Cruise Not stated Fumes in cabin and cockpit Unscheduled landing Boeing 767 American Airlines The flight crew reported a strong odor of burning rubber in the cabin and cockpit. An emergency was declared and the flight was diverted. Landing was without incident. Maintenance replaced the seal and tightened a nut on the hot air supply tube. 7/4/2011 Landing Not stated Smoke in cockpit Continued landing Boeing 737 US Airways The crew reported smoke at the connector on first officer’s sliding window during the landing roll. They turned off the window heating and the smoke stopped. Maintenance found a broken wire leading to the connector and re-pinned the connector. Manchester, New 7/5/2011 Approach Hampshire (MHT) Odor/fumes in cabin Continued flight Embraer ERJ-190 US Airways While en route to MHT, flight attendants and passengers reported an odor from the air conditioning packs that caused them to cough, beginning during the approach approximately 15 nm (28 km) from touchdown. The odor persisted until engine shutdown. Maintenance operated the engine bleed system with the packs operating and verified that the right pack bypass trim valve was bypassing hot air. They removed and replaced the pack bypass trim and the fault was corrected. Electrical odor/ 7/13/2011 Cruise Not stated fumes in cabin Continued flight Boeing 777 American Airlines The flight crew reported that a recirculation fan status message was displayed. An electrical smell was reported in the cabin simultaneously. The flight was landed without incident. Maintenance deferred work on the upper aft recirculation fan according to the minimum equipment list. The fan was later replaced. Source: Safety Operating Systems and Inflight Warning Systems 72 | flight safety foundation | AEROSafetyWorld | September 2011 help us make flying safer. Your tax-deductible contribution to the Flight Safety Foundation endowment through the Combined Federal Campaign (CFC) supports the work of aviation safety professionals worldwide. Flight Safety Foundation (flightsafety.org) is the only non-profit organization whose sole purpose is to provide independent, impartial, expert safety guidance and resources for the commercial and business aviation industry. 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