AeroSafety WORLD AIRSPACE INTEGRATION Making way for UAS PATHOLOGICAL STARTLE Researchers probe pilot reactions UNLIMITED CROSSWINDS Study challenges airline practices
BRAKING ACTION ON WET RUNWAYS SLIP-SLIDING AWAY
THE JOURNAL OF FLIGHT SAFETY FOUNDATION MAY 2013 e Foundation would like to give special recognition to our BARS Benefactors, Benefactor and Patron 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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SETBACK IN Nigeria
y now you may have heard that Harold De- safety challenges in the African region. The Foun- muren, director general of the Nigerian Civil dation has experience in gathering operational Aviation Authority, has been fired. Demuren, flight data from this region through our Basic who sits on the Foundation’s Board of Gov- Aviation Risk Standard (BARS) program. We also ernors,B had been director general since 2005 and were at the forefront of the issues through our as- made significant progress in advancing aviation and sociation with Demuren. aviation safety in Nigeria. The Foundation has been As I mentioned above, there has been safety actively involved with public and private support and operational progress in Nigeria and throughout for Demuren, and we are saddened by his removal. Africa in recent years. New control towers have been It has been reported that Nigerian President built, low level wind shear detection equipment and Goodluck Jonathan removed Demuren from office runway visual range monitors have been installed because of two fatal commercial aviation accidents at some airports, and 24 new flight operations in- that occurred in Nigeria last year — reasoning that spectors and 54 airworthiness inspectors have been we find incomprehensible. No amount of govern- hired. Thirteen African countries now exceed the ment oversight could have prevented those tragedies. International Civil Aviation Organization’s standards Demuren actively spoke out for reform and infra- and recommended practices as determined by the structure improvements and set higher operational Universal Safety Oversight Audit Program. standards in Nigeria. He constantly advocated best Much of this positive momentum can be attrib- practices for operators and worked for the devel- uted to Demuren’s tireless efforts. He was a strong opment of adequate standards for better and safer leader who helped to bring safety issues to the fore- service for the people of Nigeria and all of Africa. front and promote action on them. He was able to Last July, on the occasion of the African form alliances with many entities to effect change Union Ministerial Conference on Aviation Safety and make progress. That type of dedication and in Abuja, Nigeria, the country’s vice president, talent will be missed. Jonathan’s use of Demuren as Namadi Sambo, on behalf of Jonathan, said the a scapegoat is a major setback for Nigeria and for Nigerian federal government had the political aviation safety in that country and in Africa overall. will to implement all resolutions contained in the then-anticipated Abuja Declaration, the document ultimately adopted at the conference, to ensure a safe and secure aviation industry. In addition, he called on all member nations to cooperate and collaborate to achieve safer skies for Africa. A delegation from Flight Safety Foundation Capt. Kevin L. Hiatt participated in the conference and presented a President and CEO working paper on regulatory and operational Flight Safety Foundation
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MAY 2013 | 1 AeroSafetyWORLD
contents May 2013 Vol 8 Issue 4 12 features
12 CoverStory | FOQA Demystifies Wet Runways
18 AirportOps | Grasping Wetness of Snow
23 FlightOps | States Compete for UAS Sites
28 FlightTraining | Startle, Freezing and Denial
34 CausalFactors | R22 Crash Invokes Certification
39 ThreatAnalysis | Strong Gusty Crosswinds
18 departments 23 1 President’sMessage | Setback in Nigeria
5 EditorialPage | Focus on the Journey
7 LeadersLog | Reflections
8 SafetyCalendar | Industry Events
9 InBrief | Safety News
2 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MAY 2013 28 34 39
AeroSafetyWORLD telephone: +1 703.739.6700 45 DataLink | Canadian Runway Incursions Capt. Kevin L. Hiatt, publisher, FSF president and CEO 48 InfoScan | Proceed With Caution [email protected] Frank Jackman, editor-in-chief, FSF director of publications 53 OnRecord | ‘Hazardous Proximity’ [email protected], ext. 116
Wayne Rosenkrans, senior editor [email protected], ext. 115
Linda Werfelman, senior editor [email protected], ext. 122
Rick Darby, associate editor [email protected], ext. 113
Jennifer Moore, art director [email protected]
About the Cover Protected flight recorder data reveal unprecedented Susan D. Reed, production specialist insights on wet-runway braking action to a U.S. airline. [email protected], ext. 123 © Ismael Jorda/AirTeamImages Photo illustration: Jennifer Moore Editorial Advisory Board
David North, EAB chairman, consultant
We Encourage Reprints (For permissions, go to
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MAY 2013 | 3 Select the Integrated Air Safety Management Software Solution... SMS IAMS FAA Airline Quality JSA IOSA Flight Control Safety Audits Risk Matrix Safety Integrated JSA Aviation Security IAMS SMS IOSA Environmental JSA FAA Risk Management IAMS SMS SMS IATA Operational Safety Audit Flight Control Job Safety Analysis IATA Risk Matrix Safety Management System Job Safety Analysis FAA IOSA Risk Assessment JSA Integrated Airline Management System IATA JSA Environmental Federal Aviation Administration IOSA IOSA Reporting Airline Industry IAMS Aviation Risk Assessment FAA Airline Safety JSA SMS Safety Audits Aerosafety Risk Management Flight Control Flight Control Safety Audits Safety Audits Reporting JSA Risk Matrix SMS Airline IOSA FAA SMS Airline IAMS IAMS Air Safety IATA Quality Integrated Airline Safety IOSA Reporting Flight Control Job Safety Analysis Aerosafety Safety Audits Risk Management IATA Airline Industry FAA SMS SMS JSA Aviation FAA
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FOCUS ON THE Journey
ext month, I am scheduled to give 58th annual Business Aviation Safety Of course, that’s true of commercial a presentation at the Internation- Seminar (BASS), the same stellar ac- aviation, as well. That perception is al Union of Aerospace Insurers’ cident rate isn’t found in all geographic a positive when your accident rate is (IUAI) annual general meeting. regions or across all aviation sectors. improving, but could be a negative in NThe topic is “2012: Blip or Step-Change.” The commercial aviation accident rate some sectors, such as emergency medi- This speaking engagement is signifi- is significantly worse in Africa than in cal services, which have seen a spate of cant on a number of fronts. First of North America; there were more ac- accidents recently. all, the IUAI meeting is being held in cidents involving turboprops last year Merlin Preuss, vice president of gov- Bermuda and, as most of you prob- than involving commercial jets; and it’s ernment and regulatory affairs at the ably are aware, there are worse places to tough to compare commercial aviation Canadian Business Aviation Association, spend a few days in early June. Secondly, to corporate aviation because it’s difficult said, “It’s getting harder to avoid the big I recently marked my one-year anni- to come up with accurate exposure data one.” He pointed to demographics and versary at Flight Safety Foundation, so such as number of flights or departures said that business aviation is seeing de- I’m interpreting Foundation President in the business aviation sector. creasing experience levels in operations and CEO Kevin Hiatt’s approval to My presentation still is in the prepa- personnel and increasing complexity and take on this engagement as a vote of ration phase, and I will depend on Kevin sophistication in the aircraft being used. confidence. and others here at the Foundation to vet And George Ferito, outgoing chair- Most important, however, is the everything before I actually step onto the man of the Foundation’s Business Ad- subject. Was the much-ballyhooed saf- podium in Bermuda, so I’m not yet ready visory Committee and an executive at est year since the dawn of time, or least to answer the “blip or step-change” FlightSafety International, said that it since the dawn of aviation, a blip on the question. But I bring up the speech be- is inevitable that there will be accidents continuum or does it mark a permanent cause with it looming, I find myself very and that “safety is not a destination. It’s change? Has the industry achieved an attuned to what others are saying about a journey.” unmatched, sustainable level of safety the industry’s accident rate and aviation So, where are we in our journey? excellence? safety prospects, and because I recently As we all know by now, the data show returned from BASS, where, of course, that 2012 was the safest year on record the topic was much discussed. for commercial aviation, particularly if At BASS, Steve Brown, chief operat- you just look at Western-built equip- ing officer for the National Business ment. But as we have mentioned in Aero- Aviation Association, said, “Safety is Frank Jackman Safety World, and as was pointed out in what defines the public perception of Editor-in-Chief April in Montreal at the Foundation’s business aviation.” AeroSafety World
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MAY 2013 | 5 Serving Aviation Safety Interests for More Than 65 Years OFFICERS AND STAFF light Safety Foundation is an international membership organization dedicated to Chairman Board of Governors David McMillan the continuous improvement of aviation safety. Nonprofit and independent, the President and CEO Capt. Kevin L. Hiatt FFoundation was launched officially in 1947 in response to the aviation industry’s need General Counsel for a neutral clearinghouse to disseminate objective safety information, and for a credible and Secretary Kenneth P. Quinn, Esq. and knowledgeable body that would identify threats to safety, analyze the problems and Treasurer David J. Barger recommend practical solutions to them. Since its beginning, the Foundation has acted in the
ADMINISTRATIVE public interest to produce positive influence on aviation safety. Today, the Foundation provides Manager of leadership to more than 1,000 individuals and member organizations in 150 countries. Support Services and Executive Assistant Stephanie Mack MemberGuide FINANCIAL Flight Safety Foundation Financial Operations 801 N. Fairfax St., Suite 400, Alexandria VA 22314-1774 USA Manager Jaime Northington tel +1 703.739.6700 fax +1 703.739.6708 flightsafety.org Member enrollment ext. 102 MEMBERSHIP AND BUSINESS DEVELOPMENT Ahlam Wahdan, membership services coordinator [email protected] Senior Director of Seminar registration ext. 101 Membership and Namratha Apparao, seminar and exhibit coordinator [email protected] Business Development Susan M. Lausch Seminar sponsorships/Exhibitor opportunities ext. 105 Director of Events Kelcey Mitchell, director of events and seminars [email protected] and Seminars Kelcey Mitchell Donations/Endowments ext. 112 Seminar and Susan M. Lausch, senior director of membership and development [email protected] Exhibit Coordinator Namratha Apparao FSF awards programs ext. 105 Membership Kelcey Mitchell, director of events and seminars [email protected] Services Coordinator Ahlam Wahdan Technical product orders ext. 101 Consultant, Student Namratha Apparao, seminar and exhibit coordinator [email protected] Chapters and Projects Caren Waddell Seminar proceedings ext. 101 Namratha Apparao, seminar and exhibit coordinator [email protected] COMMUNICATIONS Website ext. 126 Director of Emily McGee, director of communications [email protected] Communications Emily McGee Basic Aviation Risk Standard Greg Marshall, BARS managing director [email protected] GLOBAL PROGRAMS BARS Program Office: Level 6, 278 Collins Street, Melbourne, Victoria 3000 Australia Director of tel +61 1300.557.162 fax +61 1300.557.182 Global Programs Rudy Quevedo Foundation Fellow James M. Burin
BASIC AVIATION RISK STANDARD BARS Managing Director Greg Marshall
facebook.com/flightsafetyfoundation Past President William R. Voss @flightsafety Founder Jerome Lederer 1902–2004 www.linkedin.com/groups?gid=1804478
FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MAY 2013 LEADERSLOG
ReflectionsBY WILLIAM R. VOSS Wayne Rosenkrans Wayne
few months ago I left Flight Safety you back. Every day I woke up and found myself Foundation to return to a job in the U.S. among selfless, dedicated and talented people federal government. I left with some re- who couldn’t wait to share their passions and grets, but I had to give in to some practi- insights. For me, that was an incredible honor, Acal considerations. After more than 1,000 days and when you receive that sort of honor, the jet on the road and nearly 2 million miles in the lag and frustrations fade into the background. air, I realized I needed to be home more often to Perhaps the greatest lesson I learned is that, get to know my family. In addition, I needed to above all else, the aviation safety system needs to spend just a few more years in the government function as a community. Our strength is in our so that when I retire, I receive the full value of a ability to learn from each other. Our resilience is pension that I had paid into for 26 years. I will in our ability to support one another and over- still be working in the safety business, but I will come common threats. Aviation safety is not a not be as visible for a little while. business that generates easy-to-calculate financial I have written scores of AeroSafety World returns, or makes heroes out of its leaders. Our editorials and have been given credit for un- business, on a good day, makes itself appear to covering more than a few pearls of wisdom be unnecessary. You can spend a career selflessly through these columns. As my parting insight, dedicating yourself to driving out risk and saving let me disclose the source of that “wisdom.” The lives, only to have the world turn on you when greatest wisdom in this business has been, and something goes wrong. We all know that, but will remain, the people who read this column. carry on anyway. No one acting alone can last To appear wise, all I ever had to do was offer long in such an environment. We need each other a colleague in one part of the world the solu- to survive, and we need each other to succeed. tions developed by someone I had met a few That is the central purpose of this noble days before in another corner of the globe. For Foundation. It is our communication network, the last few years, I have been little more than a it is our support system, it is our community. I mirror that reflected the insights generated in hope all of you support Kevin Hiatt as he leads one corner to another. the Foundation forward. I have learned to appreciate the power, ca- I thank all of you for an extraordinary six pability and resilience of the people who work years. I have been overwhelmed by your kind- in aviation safety. It was my job to spend every ness and hospitality. I have been humbled by waking hour understanding what you were do- your expertise and dedication. ing, what was working, and what was holding Until we meet again …
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MAY 2013 | 7 ➤ SAFETYCALENDAR
MAY 13–17 ➤ SMS Theory and Principles. JUNE 4–6 ➤ Advanced Commercial Aviation JULY 23–24 ➤ Aviation Human Factors and MITRE Aviation Institute. McLean, Virginia, U.S. Accident Investigation. U.S. Department of SMS Wings Seminar. Signal Charlie. Dallas. Mary Beth Wigger,
MAY 20–24 ➤ Unmanned Aircraft Systems. JUNE 21 ➤ Dangerous Goods Training SEPT. 29–OCT. 1 ➤ SMS/QA Symposium. DTI Southern California Safety Institute. Prague, Course for Safety Assessment of Foreign Training Consortium. Disney World, Florida, U.S. Czech Republic. Denise Davalloo,
8 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MAY 2013 INBRIEF Safety News
‘Monitoring Matters’
he aviation industry should recognize the importance of improved cockpit Tmonitoring by flight crewmembers as a tool in reducing safety incidents, the U.K. Civil Aviation Authority (CAA) says. The CAA said its new Monitoring Mat- ters safety package — consisting of guid- ance material and five video re-enactments of actual incidents in which poor moni- toring compromised safety — is aimed primarily at flight training instructors and will be of interest to all commercial pilots in multicrew operations. “Effective monitoring really does matter on the flight deck,” said Gretchen Haskins, director of the CAA Safety Regu- © ad_doward/istockphoto lation Group. “Pilot monitoring skills play an absolutely vital role in ensuring the safety of aircraft opera- cross-checking each other’s actions and diligent observation of tions. However, we do see significant variations in the quality of the flight path, aircraft system and automation modes.” this monitoring. If we are to maintain the U.K.’s excellent safety The CAA said effective monitoring is a “key safety net” in record, we need to ensure all operators are focusing the relevant preventing — and recovering from — loss of control events, components of their ab initio and recurrent training on high which the agency cited as one of the “significant seven” risks to quality cockpit monitoring.” aviation safety. Many loss of control events can be traced to the The CAA described monitoring as “the behaviour and failure of pilot training to keep pace with advances in cockpit skills used by pilots to maintain their own ‘big picture’ by technology, the CAA said.
Call for Action Risks of Corrosion Inhibitors he Canadian aviation community should “step up and find solutions on their own” to some of the most persistent safety problems plaguing the industry, Wendy Tad- ircraft operators and main- Tros, chairwoman of the Transportation Safety Board of Canada (TSB), says. tenance personnel should In a column written for The Hill Times, a weekly publication covering the Canadian Ause caution in applying government, Tadros noted that the TSB has “talked repeatedly about what needs to be corrosion-inhibiting compounds done to improve safety — and by extension, save lives.” to many structural joints, the However, she added, “when it comes to implementation, progress can easily get Australian Civil Aviation Safety bogged down in layer upon layer of ‘consultation’ and ‘process,’ leaving the regulatory Authority (CASA) says. system so slow it’s almost broken.” CASA issued an airworthi- She referred specifically to recent events involving controlled flight into terrain ness bulletin describing a recent (CFIT), runway overruns and runway incursions — three items that have been empha- study that found that, when ap- sized for several years on TSB’s Safety Watchlist, a document in which the agency identi- plied to highly loaded or fatigue- fies the greatest risks to transportation safety in Canada. critical joints, the compounds “Now is the time for Transport Canada to take concrete action,” Tadros said, adding that can reduce fatigue life by as much industry also should act by “being proactive and adopting stricter safety measures, and no lon- as half and accelerate the growth ger waiting for government to eventually legislate what best practices should be implemented.” of fatigue cracks. She suggested that the industry improve approach procedures and fully utilize When used appropriately, the technology to help prevent CFIT accidents; extend runway end safety areas and provide corrosion-inhibiting compounds pilots with timely information about runway conditions to help curtail runway overruns; can provide substantial benefits, and ensure that pilots are given warnings of collision risks to prevent runway incursions. CASA said.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MAY 2013 | 9 INBRIEF
Tower Closures
ome 149 airport air traffic control towers in the United States will close June 15 because Sof legislative requirements that the Federal Aviation Administration (FAA) cut $637 million from its budget. The FAA originally had planned to close the facilities in April, but the agency said more time was needed to resolve legal challenges to the closure decisions. “Safety is our top priority,” said Transporta- tion Secretary Ray LaHood. “We will use this additional time to make sure communities and pilots understand the changes at their local Epolk/Wikimedia Commons airports.” Operators of about 50 of the airports have said that they may attempt to finance tower operations themselves, and the extra time will aid in the transition, the FAA said. Tower operations at the other airports will cease.
New Fatigue Rules in Australia Plotting Progress in India
ustralia’s Civil Aviation Safety Authority (CASA) has adopted new rules for he International Air Transport fatigue management for flight crewmembers, along with a timetable that calls Association (IATA) is urging the Afor a three-year transition to the new rule set. TIndian government and industry The new approach is designed as a three-tier system, designed in recognition to cooperate on projects that IATA that “fatigue is a complex aviation safety issue, that there is no one-size-fits-all says will enhance aviation safety, solution,” CASA said. security and efficiency throughout the The first tier is a basic prescriptive system, with “relatively restrictive flight and country. duty time limitations,” designed for use by operators that “do not have the capacity IATA Director General and CEO or experience to integrate additional risk management concepts,” CASA said. Tony Tyler praised as “a step in the The first tier rules include requirements that a flight duty period be no longer right direction” the Indian govern- than nine hours in any one day, with no more than seven hours of flight time; ment’s plan to replace the Directorate under certain circumstances, the duty period may be extended by one hour and the General of Civil Aviation with a civil flight time, by 30 minutes. Flight crewmembers also must have at least 12 con- aviation authority (CAA). secutive hours off during any 24-hour period and at least two days off during any He said the new CAA should seven-day period. consider incorporating the standards The second tier is a fatigue management system, with more flexible flight of the IATA Operational Safety Audit and duty time limits for pilots, and requirements for operators to identify fatigue (IOSA) into the national safety over- hazards and set appropriate flight and duty time limits after taking those hazards sight framework for airlines. into account. “Safety is the industry’s number The third tier is a fatigue risk management system (FRMS), intended for op- one priority,” Tyler said, noting that erators that “seek to demonstrate an alternative approach to fatigue management,” IOSA has played a significant role with requirements for operators to develop appropriate policies for risk manage- in establishing voluntary global ment, safety assurance and safety promotion processes. safety standards. In its discussion of the final rule set, CASA said that data from the Australian “India is the great potential Transport Safety Bureau indicates that human fatigue was a possible contributory factor market of the future, and the in- in about 78 aviation accidents or incidents in Australia between 2002 and 2012. dustry here has only just begun to “Fatigue can undermine the crew’s capacity to deal effectively with threats realize its tremendous promise,” he and errors,” CASA said. “Crews must be adequately alert to perform competently said. “If we are to realize that future, in normal and abnormal operations, and this capacity needs to be protected at all we must successfully overcome times, regardless of how benign a flight appears to be.” some major issues.”
10 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MAY 2013 INBRIEF
© Reuters
A Lion Air Boeing 737-800 sits in shallow waters of the Indian Ocean after an April 13 crash on approach to Denpasar- Ngurah Rai Bali International airport in Indonesia. All 108 people in the airplane survived the accident, but the airplane was destroyed. Rain and wind shifts were reported at the time of the approach.
Loss of Separation In Other News …
he number of reported operational errors by air traffic controllers resulting Certification tests have been completed in air traffic losses of separation increased more than 50 percent from 2009 for the new battery system for Boeing Tto 2010, according to a report by the U.S. Department of Transportation’s 787s. Boeing next must analyze test- Office of Inspector General (OIG). related data and submit materials to the The report said the U.S. Federal Aviation Administration attributes the U.S. Federal Aviation Administration, increase primarily to increased reporting through voluntary programs such as which grounded the 787s in January the air traffic safety action program and the automated traffic analysis and review because of battery problems. … The program. Port Authority of New York and New The OIG report, however, said the increase in reported errors “was linked, Jersey will pay a $3.5 million fine in part, to a rise in actual errors. … For example, FAA’s air route traffic control under a settlement agreement with centers, which have had an automated system in place for years to detect and the U.S. Federal Aviation Administra- investigate reported errors, had a 39 percent increase in operational errors during tion (FAA) stemming from the FAA’s the same period.” allegations of aircraft rescue and fire The report also said that nearly 25 percent of the increase stemmed from a fighting violations at four Port Author- procedural change at one terminal radar approach control that resulted in the re- ity airports. The affected airports were classification of a number of routine approach and landings as operational errors. John F. Kennedy International Airport, The FAA has adopted new policies and procedures to reduce the number of LaGuardia airport, Newark (New Jer- loss of separation events and to improve reporting, “but their effectiveness is lim- sey) Liberty International Airport and ited by incomplete data and implementation challenges,” the OIG report said. Teterboro Airport.
Compiled and edited by Linda Werfelman.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MAY 2013 | 11 12 Illustration by Susan Reed | Is Showing Is Slip Your likely tobeslipperyandhelppilotscompensate. FOQA datacandetectairportswhere runwaysare COVERSTORY BYJOEVIZZONI a test program related to aircraft braking action. runway. form They of part pilot the feedback in responses upon landing inrain contaminated runways. are, These rather, pilot P be associated withbe stopping on winter- ablebe to stop intime” would normally as grease”pery and “I thought Iwouldn’t ilot statements such as “it was as slip- and on awet
has been mergedhas been with United Airlines, and in 2010at Continental legacy Airlines, which The braking actiontest program came about Program The than snow- or ice-covered runways. runways have or equal worse braking action In test the fact, program that revealed some wet FLIGHT FOUNDATION SAFETY |
WORLD AEROSAFETY | MAY 2013 COVERSTORY
was based on using the aircraft itself and flight that qualified as being within the deter- data to better assess braking action. In coopera- mined runway slipperiness threshold. tion with Kongsberg Aeronautical, which pos- sessed an algorithm developed for the purpose • Landings found to be within the runway that it could easily be adapted and downloaded slipperiness threshold were then tested into the aircraft, the airline’s flight operational against the weather conditions prevailing quality assurance (FOQA) group saw this as an at the time of landing. By using METARs exciting safety project and subsequently initiated (the international standard code format the test program. Due to the inherent sensitiv- for hourly surface weather observations) ity of FOQA data and its use, representatives of for the airport, the FOQA group could pilots as well as operational management were easily assess whether the landing informa- summoned to take part in decisions and approve tion likely represented a slippery runway the framework for the test program. landing. • To ensure the anonymity of the crew and Sensitive Issues avoid potential traceability, only a de- When it came to sensitivity in the use of flight identified METAR eliminating the date data, one factor proved essential and favorable. was used to match the flight. The algorithm and the subsequent program loaded onto the aircraft fleet did not require • In the next phase, the FOQA group ap- flight data downloading from the aircraft or proached the ALPA gatekeeper with the any other distribution of flight data. The pro- landing details. He contacted the crew to gram was designed to obtain braking action in- receive their feedback. formation purely through onboard calculation processes. Only the resulting braking action • The ALPA gatekeeper relayed the feedback information was transmitted by a downlink. and comments to the FOQA group. The braking action information generated The system comprising detection, verification by the system on the aircraft was not influenced and the final validation by the pilot worked by the pilot. The information did not reflect on well, and the pilot statements referred to earlier the skill and airmanship of the pilot. represent some of the feedback results. According to established practices, the FOQA group did not have direct contact or ‘Friction-Limited’ Braking Action communication with pilots. All crew contact Setup of the on-board algorithm and pro- was through the Air Line Pilots Association, gram is, in broad terms, targeted to detect International (ALPA) as a gatekeeper. when aircraft encounter “friction-limited” With a clear understanding of the frame- braking situations. Detecting when an air- work for the test program, the next step was to craft encounters friction-limited braking is set up a system to assess, receive and evaluate a key constituent in determining maximum feedback from pilots. braking capability for an aircraft. The test program defined braking action as “dry,” Management of Test Data and Pilot Feedback “good,” “medium” (fair) or “poor” and as- Braking action data were processed, handled signed numerical equivalents of the airplane and communicated for feedback from pilots braking coefficient. (Figure 1, p. 14). The following steps and For practical purposes throughout the phases further detail the procedure: test program and in pilot contact, the feed- back process was focused solely on landing • The FOQA group checked daily incoming situations in which braking action was clas- data from flights and looked for landings sified as being less than “good.” This was to
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MAY 2013 | 13 14 | COVERSTORY Figure 1 Joe Vizzoni Source: METAR =international standard code weather format observations for surface hourly ALPA =Air LinePilots Association, International; FOQA =flight operationalassurance; quality FOQA for Wet Runways andSlippery Test Program Friction-limited FOQA data landings winter operations and winter contaminants. runways traditionally associated has with been runways may slippery, be issue the of slippery Although it is common knowledge that wet A Pilot’s Dilemma occasions. difficult landings, test the when to on was designed focus avoid adding to pilots’ workload for routine crew feedback between data, and METAR occurrence Validation METAR for of match data gatekeeper ALPA FOQA Flight crew feedback supports findings. the The photograph shows consistency and further leave most of stopping the to brakes. wheel the ic drag have less impact on deceleration the and engine when reverse andrun thrust aerodynam- than 70kt. is phase the of This also stopping the only shows encounters at groundspeeds less ations. For illustration the purposes, practical where aircraft encounter situ friction-limited - 15) shows (p. an example of one of airports the awareness of problem. the The photograph on maps of runways the to enhance situational system tool, number the of landings slippery FOQA group plotted, positioning using aglobal risk. at higher being airports of these to aperception added ther fur accidents of overrun Ahistory crowned. nor grooved neither typically are runways the where America, Central in located primarily airports, these from originate quoted earlier statements pilot were Some of slippery. the conditions that finding the supported also feedback Pilot and/or wet runways. rain be to conditions confirmed analysis METAR The conditions. presented slippery rently recur afew airports that finding the was program outcome test of the One unexpected Test Findings Program is of utmost importance for pilot. the knowledge of, and access to, information crucial safely given prevailing the conditions. Therefore to make right the decisions and land aircraft the substantialrevealed variations. Apilot’s jobis isthis not always and case, the test the program programs to ensure proper In friction. reality, tain proper runway and design maintenance problem.the oftypes deposits on runways the compounded wet. risk of when higher Various slippery being nor crowned for water drainage had increasingly whereairports runways were neither grooved Early test, inthis program data showed that ceived increased attention, and for reason. good However, recently wet the runway issue has re- To conduct in-depth analysis, further the Ideally, management airport should ascer FLIGHT FOUNDATION SAFETY |
WORLD AEROSAFETY | MAY 2013 - - -
© Tim de Groot/AirTeamImages of multipleflights. enabling comparison positioning system, defined bytheglobal These positionswere limited braking. indicated friction- program recurrently where theon-board indicate positions Magenta areas Guatemala Airport. Satellite photoof the meeting, the ALPA the meeting, the gatekeeper presented the ALPA, managers, fleet safety the group, etc. At meeting normally involves participants from to bringwas decided up issue. the The safety of company’s the monthly safety meetings, it parent that issue hadpursued. to be In one same the viewpoint,virtually it ap became - addressed problem the and approached it from conditions involved rain and/or wet runways. at risk with when such airports apolicy certain with test this program was potential increased beginning ofbeginning landing the roll. usage was more appropriate, at especially the many pilots relied on brakes reverser when pricesfuel were on It rise. the that seemed too reverser usage for savings fuel years ago when companythe recommended, to an extent, idle reversers. Although never compromising safety, feedback. crew for recommendations inaddition to their pilot feedback, ALPA the gatekeeper asked the In response landing to aslippery that needed Alert FOQA FLIGHTSAFETY.ORG Finding that asignificant number of pilots A frequent issue was emphasis the on idle |
WORLD AEROSAFETY | MAY 2013 1 What surfaced cost-conscious environment, it shows also that and indesign maintenance.ideal Second, ina pilots operating that inairports are less than ing results. tool for as auseful First, it serves maximum of use reverser thrust. wet conditions was about 80percent, is which standardthe inrainy used engine speed or rainy or wet. After introduction of 10-7, the “idle,”is virtually conditions evenwhen were about engineto speed see 40percent, which varied. Prior to 10-7era,it the was normal increasing engine the revolution has speed line with policy, of use the reverse by thrust ers upon landing is normal procedure, but in morebeen selective. Deployment of revers- significant changes. reverser Thrust usage has and after 10-7implementation the and showed ings, reverser their usage was analyzed before rain and/or wet runway conditions inland- an analysis.run Where METAR data indicated and of use reversers, idle FOQA the group has to 10-7. the than grease” for that airports were those subject reduction inpilot statements such as “slipperier implementation, there asubstantial has been tent. Alittle more than two years after 10-7 the increasing and according scale to its in- original The braking action test program continues at an The 10-7/FOQA Era Alert test program. at to revealed be airports the risk inthe higher more permanent form and for was used some of on other the hand, represented information ina likely forgotten be within sixmonths. The 10-7, was considered less appropriate it because would seriousnessthe of issue, the pilot the bulletin pilots’the approach plate for to an Due airport. problem and recommends aresponse —into FOQA —anotification alert a that describes were to issue apilot or a10-7/ bulletin insert group. an then This became action item. datathe and in-depth analysis from FOQA the supportedcase by pilot the recommendations, This action item demonstrates encourag- To into look further impact the of 10-7 the In considering action item, the options the COVERSTORY |
15 Google Maps COVERSTORY
The Future Selections From a 10-7 Issued for a Runway Although there has been an increasing focus on rain and wet runways, the braking action • The runway is not grooved and standing water is likely to be test program was not specifically set up to present when raining. find runways prone to higher risk in rain. It • Braking action is likely to be fair–poor when the runway is wet. was part of a general move to better and more • Select and use the maximum autobrake setting. accurately assess the braking capability of air- • Make every attempt to touch down at the 1,000-ft point. craft, in particular during challenging winter conditions. • Use maximum reverse thrust. —JV The on-board system developed is now downloaded onto all United’s Boeing 737NGs, representing a significant network. Today, rather than issuing generalized notifications and this aircraft network furnishes braking action procedures, proper use of technology and coop- information daily, albeit not yet for operational eration by pilots can enable a clinical approach purposes but only for FOQA group analysis. and more detailed procedures, better balancing United’s pilots will continue to serve a safety with economic considerations. pivotal role in the system verification by providing valuable feedback. A print function Safety Culture and Environment has been programmed on the flight deck and Continental Airlines had a long history of us- activated for response, thereby simplifying ing flight/FOQA data to proactively enhance participation by pilots. The test program will safety and efficiency, which has continued continue to be focused on runway conditions after the merger with United. Although the where braking action is assessed to be less braking action test program and the initial than good by the numerical scale of airplane 10-7 FOQA alert may seem ordinary, the braking coefficient. process epitomized what is needed to build a In terms of the future viability of the sys- platform of understanding, trust and coopera- tem, the algorithm and program have proved tion to create the right culture and environ- stable and reliable. Currently the system is un- ment for working with sensitive information dergoing a validation in cooperation with the such as FOQA data. U.S. Federal Aviation Administration. Access For all parties in this test project, the focus to and availability of FOQA data provide new has always been on safety. Nevertheless, it has opportunities to improve safety and efficiency been important to safeguard the corporate safe- of airline operations. By the same token, it is ty culture and environment by having proper important that the necessary framework be in systems, routines and procedures. When place to pursue desired results, such as those this test program surfaced, the operational that have been evident in this project. management took a keen interest, provided Joe Vizzoni has been a part of this test program and all the the “green light,” and then supported the test processes described from its start. He is a first officer with program. This was important and provided the United Airlines on the Boeing 757 and 767 and also has proper framework for the project’s more active experience as an aerospace engineer, of which nine of 14 participants. years were with Boeing. ALPA and the FOQA groups have had a long relationship and developed good rap- Note port through many years of cooperation. The 1. Thrust reversers are most efficient at higher speed, so intriguing part was to have a third party work- to reduce the kinetic energy of a landing aircraft, it ing within the traditional format of the FOQA is best to apply them at once, thus carrying forward group and ALPA. It has been a success. less energy toward the end of the runway.
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BY REINHARD MOOK
Aircraft braking coefficient is affected by liquid water in frozen runway contamination.
18 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MAY 2013 AIRPORTOPS
ingering uncertainty associated with temperature range near freezing or when there is measured and estimated runway friction wet, compacted frozen contamination. The pres- and aircraft braking coefficients can lead ent study draws attention to wetness in frozen to landing distances or maximum landing contamination. Though interrelated, wetness and Lweights that also are uncertain or inaccurate. surface temperature, together with the three-kel- “This has contributed to accidents and inci- vin-spread-rule (which indicates that a difference dents where aircraft departed runways because between dew point and METAR, the current the surface was more slippery than expected,” aviation meteorological report, air temperature [2 according to the executive summary of a study m or 6.6 ft above the runway surface] of 3 three released in 2011 by the Accident Investigation kelvins or less indicates that the humidity is 80 Board Norway (AIBN).1 percent or more; a kelvin [K] is 3 degrees C or 5.4 In 30 investigated occurrences, the AIBN degrees F), might prove to be essential indicators found that “aircraft braking coefficient (ABC) for braking action to be expected.1,2 was not in accordance with the measured/ Recent snow may contain a large propor- estimated runway friction coefficients (FC).” tion of liquid water. When such snow is com- In its study, the AIBN identified a number pacted, its surface becomes coated with a film of common factors that have reduced safety of liquid water, hence the ability to transfer margins, and factors that explain the differ- shear force (that is, braking) at the microscopic ences between ABC and FC. “These factors are level between tire and runway surface materi- related to meteorological conditions and friction als is reduced. Similar conditions happen when measurement uncertainty, runway treatment, compacted snow or ice is thawing at its upper operational aspects and regulatory conditions,” surface. Compressed snow transformed to ice the AIBN study said. disintegrates gradually when the melting point Among the factors is the wetness of snow, or temperature is approached as the surfaces of the volume percentage of liquid water in frozen frozen particles are enveloped by liquid water. runway contamination. The author carried out The static stability of the ice decreases and rein- a study of wetness in frozen contamination at forces the lubricating effect of free liquid water Svalbard Airport, Spitsbergen, Norway, from in contact with a decelerating tire. 2009 through 2012 under the auspices of AIBN in Additional liquid water is generated in the order to better understand aircraft winter opera- footprint of tires due to the flash melting of ice tions following the board’s comprehensive report. caused by tire dynamics. Experience shows that Results of the author’s study show that wet- the total outcome of braking as described by the ness in falling snow, or recently fallen snow, de- ABC is partially related to the portion of liquid creases with surface air temperature, except for water in the frozen contamination. That portion specific cases related to temperature inversions. might be relevant for runway management. Recently fallen snow that is not exposed to fur- ther precipitation or thawing partially dries up Moisture Measurement Challenges in the course of hours, thus improving braking To determine wetness in snow or ice, the differ- conditions. In such situations, estimated aircraft ence in permittivity (the dielectric constant3) braking performance based on the ABC value of frozen versus liquid water often is used by closely correlates with contemporary observed micrometeorologists in this area and has turned wetness in samples of frozen contamination. out to be useful in snow and ice research. The Denoth Dielectric Moisture Meter4 is based on Essential Indicators that difference and allows the proportion of As shown by the 2011 AIBN study, measure- liquid water to be determined when the density
© Jorgen Syversen/AirTeamImages © Jorgen ments of braking action by conventional devices of the snow is known. A flat capacitive sensor are difficult to rely on, particularly in the critical was used in the author’s research, with one side
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MAY 2013 | 19 AIRPORTOPS
The challenge of attaining close contact Number of Cases for Classes of Wetness and Air Temperature at 2 m between sensor and contaminating material was Air Temperature (oC) met by scraping together superficial snow or Wetness Volume (%) ≤ –15 –14 to –10 –09 to –05 –04 to 00 ≥ 00 Total bars (studs) of snow or ice, and filling a freez- ≤ 4 6 7 1 — — 14 ing box to a depth of 6 cm (2.36 in). Thus the 5–9 1 2 2 — — 5 measurements of wetness were done at that 10–14 2 5 6 5 — 18 6-cm deep probe. The density was determined 15–19 4 3 11 14 6 38 from the weight of the known volume, avoiding 20–24 — — 5 6 11 22 caverns of air. The readings were obtained in an ≥ 25 — — — 2 2 4 area sheltered from wind. Total 13 17 25 27 19 101 Sample Readings Note: Volume percent in recent snow. There is a relationship between air temperatures Source: Reinhard Mook observed 2 m above ground (per the METAR) Table 1 and wetness of snow. Compacted snow not older than one hour after precipitation, or cases placed atop the frozen contamination and the with snowfall continuing at the time of wetness other side left exposed to the air. The effective measurement, but after compression by traffic, area covered by the sensor was about 160 cm2 were considered. Cases of blowing snow together (25 in2), and the operating frequency was 20 with precipitation were excluded, as older, dried MHz. The sensitivity decreases strongly with up snow might influence the results. The sample distance inside the probe. This tool measures of 101 readings was the outcome of occasional a layer of 1.0 cm (0.39 in) of compacted snow observations, without equal probability for any or ice. Ideally, there should be no caverns of air combination of temperature and wetness. between the sensor and the frozen material. Table 1 shows low temperatures — less than The permittivity of a frozen layer can be or equal to 9 degrees C (48 degrees F) — and calculated as a function of the voltage read when the dichotomy in wetness observed. There are the sensor is placed upon the frozen contami- both cases of low wetness (less than or equal to nation; the device works by comparing this to 4 volume percent), as one would expect, and the voltage when the sensor is exposed to air, as rather large figures of wetness (10 to 19 volume the point of reference.To calculate liquid water percent). When temperatures aloft at the 850 content, the density of snow or ice is needed. hPa (25.1 in Hg) pressure level were checked, it In field work at a runway, exposed to turned out that comparatively wet snow in low freezing temperatures, wind and often poor ground level temperatures was due to tempera- illumination, some uncontrolled errors in the ture inversions and advection or transfer of measurements cannot be avoided. Compressed warm air above. Other cases were due to snow snow or ice rarely presents a smooth surface to showers in an Arctic maritime air mass with a make good contact with the sensor. In addition, near moist adiabatic gradient of air temperature. grains of sand applied to a runway cannot be Therefore, as a rule, measuring wetness of snow, eliminated from the area to be measured, much which is not yet accepted as a standard practice less removed when enclosed in the frozen mate- in runway management, should not be done rial. Sand affects the readings of wetness as well from ground air temperatures only. Tempera- as the measurement of density. The depth of the tures aloft should be considered as well. contaminating layer is not constant and may in- Otherwise, wetness increases with ground clude different horizons. Therefore the dielectric level air temperature. Figures for temperatures reading may be influenced by the permittivity of greater than or equal to 0 degrees C (32 de- asphalt or concrete. grees F) cover all the cases of very wet snow or
20 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MAY 2013 AIRPORTOPS
snow and rain accumulating frozen material in water in compacted snow is relevant for braking airport ground operations. Frequently, rain only conditions. There are interrelations among the is observed when the air temperature exceeds mechanics of ice crystals, liquid water enclosed about 3 degrees C (37 degrees F). The maximum in ice aggregates, temperature and the frozen wetness observed from 26 to 27 volume percent material’s ability to transfer shear forces. is limited by the ability of the frozen material to retain liquid water. Wetness and Braking Coefficient The relationship between ABC and wetness is Wetness in Snow Over Time essential for runway management involving When snowfall ends, sweeping may result in frozen contaminants. Figures on deceleration compacted snow, probably on top of older experienced by aircraft were not available for contamination. Over time, the snow will dry up the author’s study. Therefore, such figures had due to internal freezing and crystal growth, ice to be estimated, as described previously by the bonding to material at the bottom and evapora- author.5 The method can easily be criticized for tion. All these processes depend on gradients some subjectivity, so the given ABC should be of internal and external temperatures, together treated as an indicator only. with ventilation (wind). Frequently, when The ABC derived represents cases when the precipitation has stopped and the cloud cover mean headwind component was less than 8 kt. has dissipated, the temperature falls and the dew Otherwise, different kinds and structures of fro- point to frost point spread increases. Every case zen contamination are represented in the sample is different, but the drying up in the course of of 62 cases. In Table 3, the independent variable time may be of interest for defined conditions, as braking action might improve. Decrease in Percent of Wetness From The 17 cases considered had, at the end of the End of Snowfall Through Time snowfall, wetness between 24 and 10 volume Time from start (hours) 0 2 4 6 8 percent. That starting wetness was assumed as Percent of wetness at start (%) 100 87 51 33 24 100 percent in all cases, as it turned out that Mean surface snow temperature (°C) –4 –7 –8 –10 –11 drying up could be described in terms of the Mean frostpoint spread (K) 1 3 5 6 5 percent of the actual starting wetness. The development in weather terms meant scattered Note: Actually observed liquid water volume percent put to 100. Sample cases = 17. clouds to clear sky after precipitation and de- Source: Reinhard Mook creasing snow surface temperature as measured Table 2 by an infrared sensor. Table 2 shows as a mean value that wetness Wetness in Surface Snow Related to Estimated ABC of snow was reduced by 75 percent after eight Surface Air hours. In the cases observed, mean surface Wetness Temperature Temperature temperature had dropped from minus 4 degrees Volume (%) ABC (oC) (oC) Spread (K) Number C (25 degrees F) to minus 11 degrees C (12 de- ≥ 25 0.05 0 3 1 1 24–20 0.04 0 2 2 3 grees F), and the spread of METAR air tempera- 19–15 0.06 –1 –1 3 6 ture and frost point temperature (defined for ice 14–10 0.07 –4 –3 3 13 instead of dew point defined for liquid water) 9–5 0.11 –8 –6 5 24 had increased to 5 K. ≤ 4 0.14 –10 –9 6 15 The general experience of pilots that friction ABC = aircraft braking coefficient may be poor on recent snow, but that it improves Note: Total number of cases = 62. over the course of hours, is consistent with the Source: Reinhard Mook observed drying up and decrease of surface temperature. It may be concluded that liquid Table 3
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MAY 2013 | 21 AIRPORTOPS © Mathieu Pouliot/AirTeamImages
is wetness in terms of liquid water occur together with decreasing tem- Notes volume percent. Mean surface tem- peratures and increasing spread. As 1. AIBN (2011) Winter Operations, Friction perature (measured by infrared sensor) shown in a previous study, ABC usually Measurements and Conditions for Friction and mean air temperature (as reported improves with decreasing surface tem- Predictions. Accident Investigation Board in the METAR), together with spread perature and increasing spread (except of Norway (Statens Havarikommisjon for related to dew point temperature, are for polishing effects). Wetness and sur- Transport), Lillestrøm, Norway. given. The ABC is expressed for Boeing face temperature turn out to be good 2. Mook, R. “Valuable Intelligence.” 737-800 aircraft. As a rule, the contami- indicators for ABC due to meteorologi- AeroSafety World Volume 6 (November nated runway was sanded, from prior cal feedback interdependencies. 2011):16–19. or recent application, or both. Fre- It should be noted that case studies 3. The velocity of the propagation of electro- quently, warm sand was applied. could offer more details worth consid- magnetic waves relative to the velocity in a Though observations were made ering, although they represent unique vacuum, depends on that constant. It is spe- preferably when wetness was large, there situations. But each case study, by cific for any substance, except ferromagnet- ic material not propagating electromagnetic was a bias toward more observations eliminating distracting details, might waves. The constant respective velocity when wetness actually was small. Thaw- reveal insights not seen in statistical for ice is significantly different from liquid ing or very wet precipitation are not analysis alone. water, a property applied. Velocity and frequent occasions, as compared to all Reinhard Mook, Ph.D, who retired in 2006 as a refraction are linked together, as is well the days with “dry” conditions. Flights professor at the University of Tromsø in Norway, known from the spectral colors of sunlight are canceled or diverted when expected is an independent consultant and researcher. He in ice crystals due to refraction. has conducted micrometeorological field work braking action is reported as poor. 4. Denoth, A. (1994) “An electronic device as an independent researcher at Norway’s Sval- Table 3 shows increasing ABC with for long-term snow wetness recording.” bard Airport Longyear and analyses of slippery Annals of Glaciology, 19, 104–106. decreasing wetness, notably when it runway incidents for the AIBN, SAS Scandina- gets less than 10 volume percent. These vian Airlines and the former Norwegian airline 5. Mook, R. “Treacherous Thawing.” AeroSafety rather dry conditions in the sample Braathens SAFE. World Volume 3 (October 2008):14–19.
22 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MAY 2013 © Draganfly Innovations C fully integrated into shared airspace will soon be be soon will airspace shared into integrated fully Plan tion Safety aircraft or remotely piloted aircraft systems (RPAS). sion (EC)have remotely them calling begun piloted Organization (ICAO) and European the Commis- asthem UAS, International the while Aviation Civil U.S. Federal Aviation Administration (FAA) refers to known as vehicles unmanned aerial or drones, the has them changed. to describe used Previouslyogy and examining safety and concerns. privacy sites where permitted vehicles the to be operate will FLIGHTSAFETY.ORG FLIGHTSAFETY.ORG Global Avia ICAO, 2013 of Global its the in revision As systems the have advanced, terminol the - civil airspace,civil preparing to designate research of unmanned aircraft systems (UAS) into are mapping strategies for integrating asurge aviationivil authorities on three continents | AEROSAFETY , says the notion of having RPAS notion of having the , says WORLD WORLD | MAY 2013 MAY - Place Their Finding Finding unmanned aircraft intoshared airspace. Governments andtheaviationindustry Governments
are findingwaystoincorporate
BY LINDAWERFELMAN
FLIGHTOPS
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23 FLIGHTOPS
a reality and that related information process preclude the FAA from disclos- the behavior of birds and other airborne and data will evolve rapidly. ing details of the applications, but the animals — a technology that might An earlier ICAO document predict- agency has said that its goal is to select eventually help prevent bird strikes. ed that the integration process would six sites that will enable the study of Ohio, which joined with Indiana in be “a long-term activity with many UAS operations under all types of applying for an FAA test site designation, stakeholders adding their expertise on conditions — in a wide variety of geo- in 2012 established the Ohio UAS Center such diverse topics as licensing and graphical locations and climate condi- and Test Complex, described by James medical qualification of … crew, tech- tions, for example — and in areas with Leftwich, the state’s special adviser for nologies for detect-and-avoid systems, varying air traffic density and ground UAS initiatives, as “a problem-solver and frequency spectrum (including its pro- infrastructure. Varying research needs door-opener for anyone who needs air- tection from unintentional or unlawful also will be considered. space, access to ground facilities, research interference), separation standards Site selections are expected to be and analytic support and everything else from other aircraft and development of announced late this year. it takes to move the UAS frontier forward a robust regulatory framework.”1 Meanwhile, state officials and others safely, successfully and steadily.”3 representing UAS concerns have outlined 50 Site Applications their proposals. UAS Markets In the United States, current activity For example, Oklahoma, which A study released in March by the Asso- centers on the FAA’s preparations to vowed to “compete aggressively” to host ciation for Unmanned Vehicle Systems select six UAS test ranges — required one of the FAA UAS test sites, said in International (AUVSI) estimated that, by a 2012 law — that will be used to a 2012 report by the Oklahoma UAS in the first three years after the planned “develop a body of data and operational Systems Council that it already had at 2015 integration of UAS into U.S. experiences to inform integration and least 15 private companies “involved in all airspace, the industry will create 70,000 the safe operation of these [UAS] aircraft facets of UAS,” along with related research new jobs. By 2025, the number will top in the National Airspace System.” At the and development programs, education 100,000, according to projections.4 same time, the FAA has set a late April and training, and a detailed plan to de- The study projected the largest mar- deadline for receiving public comment velop the UAS industry in the state.2 ket for UAS in the United States would on its proposed methods of addressing Among the UAS projects under be the precision agriculture industry, privacy concerns associated with UAS consideration in Oklahoma are those which would use UAS to monitor crops operations within the test site program. involving oil and gas pipeline inspection, and apply pesticides. Another major The FAA says it received 50 applica- weather monitoring and several areas market would be in public safety. tions for test sites in 37 states (map). of radar development, including radar Some public safety uses, including Rules governing the site selection aeroecology, which uses radar to detect surveillance, have prompted objections from critics who cite privacy concerns, including the American Civil Liber- ties Union (ACLU), which warns that “routine aerial surveillance would pro- foundly change the character of public life in America. “Rules must be put in place to ensure that we can enjoy the benefits of this new technology without bringing us closer to a ‘surveillance society’ in which our every move is monitored, tracked, recorded and scrutinized by the government.”5 Some state legislatures are consider- States with applicants ing action to regulate the use of UAS in
Base: © User:Tubs/Wikimedia Commons CC-SA-BY 3.0 CC-SA-BY Commons Base: © User:Tubs/Wikimedia surveillance, and at least one — Virginia,
24 | FLIGHTFLIGHT SAFETY SAFETY FOUNDATIONFOUNDATION || AEROSAFETYWORLD || MAY 2013 © Scheibel additional lives at risk.” ous situations remotely, without putting fires, hazardous spills and other danger canoped help assess “natural disasters, lightweight systems now devel being - misunderstood” and that small, the public safety of uses UAS are “greatly said the tions and services, technology designs and builds UAS-related opera- which president Services, Global of Bosh ofbenefits UAS. nomic development and public safety to promote what it considers- eco the Alliance for Publicogy Safety formed earlier year, this Virginia the Technol- other research organizations. UAS inresearch used by universities and tions. The legislation not does apply to exceptions for search-and-rescue opera- torium on law enforcement use, with legislation for calling atwo-year mora- site designation —already has passed another of states the aUAS seeking test FLIGHTSAFETY.ORG FLIGHTSAFETY.ORG developed bycies to be “the public’s ACLU for called written usage- poli investigation or trial.” In addition, the ora crime are relevant to an ongoing suspicion that contain they of evidence images unless “there is reasonable to prohibit retention of UAS-derived cies and situations, other specific and enforcement of use UAS to emergen - guards should inplace to be limit law Alliance member Robert Fitzgerald,Alliance member Robert As legislation the was debated being Nevertheless, ACLU the said, safe- | AEROSAFETY WORLD WORLD 6 | MAY 2013 MAY - the FAAthe said, and “are not intended are for intended test the specifically sites, may end its operational authority. have violated laws, privacy FAA the protections; ifan operator is found to and other laws on individual privacy erators must comply with federal, state includingactivities, UAS operations. able exist policies privacy to cover site all operators to ensure that publicly avail- requirementsprivacy would direct site operatewill test the sites. The proposed conditionsprivacy —under they which termsthe and conditions —including ter into an agreement with FAA the on forcalls operators of test the sites to en- held anagency also online session. written comments from public, the the with public.” the In addition to accepting “through engagement and collaboration issues,privacy it which plans to address tegration of UAS into U.S. airspace raises phones.”cell positioninging GPS[global systems] or aircraft, manned aircraft, imag thermal of technology, “whether it is unmanned by use the law enforcement of any type framework already inplace” to regulate opposes any misuse of UAS technology.” individual privacy. …AUVSI strongly duct explicitly directing users to respect year, AUVSI published of acode con- U.S. Senate Judiciary Committee. “Last said intestimony inMarch before the portant to my as well,” industry Toscano is concernedalso about issues. privacy CEO of AUVSI, said UAS the industry to oversight,ject including open audits. authorities, and for UAS sub to use be - representatives,” not law enforcement The proposed requirements privacy Another proposal says that site op- The FAA’s proposal privacy initial The FAA acknowledged that in- the Toscano noted “robust the legal “Safeguarding people’s is privacy im- Michael Toscano, president and - sales demonstrationssales or crew training. in research and development, and flight cate; most active UAS civil are involved - certifi an airworthiness experimental large urban areas, FAA the said. controlled conditions,” usually not in research and environmental monitoring. der patrol, training, scientific military search and rescue, law enforcement, bor included fire fighting, disaster relief, in1990.Typical use their have uses numbers since FAA the first authorized UAS have inU.S. been skies inlimited Controlled Conditions Joint Undertaking (SJU) is planning to Traffic Management Research (SESAR) In Europe, Single the European Sky Air Demonstration Projects from other users,” FAA the said. operating outside airspace restricted with UAS the as its ‘eyes’ and serve when plane [that] must maintain contact visual bypanied “a or …chase observer visual and-avoid must they accom rules, be - aircraftthese cannot comply with see- with an control air traffic facility. Because a transponder and/or incoordination ments such as only during daylight, with operate under mission-specific require- of waiver or authorization and typically ment agencies, must have acertificate respond issues to those long inthe run.” and practices should industry the policy by UAS operations and how law, public about issues privacy which are raised to engage stakeholders all indiscussion with UASed test site operations inorder transparency of associat policies privacy - Rather, aim to they assure maximum commercial UASs would operate. and regulatory framework under which to pre-determine long-term the policy Public UAS, operated by govern - Operators of UAS civil must obtain Today, operate they “under very FLIGHTOPS - |
25 FLIGHTOPS
© Boeing
authorize 10 demonstration projects natural resources monitoring, media “This means ensuring the safety aimed at exploring how remotely pi- and entertainment, digital mapping, of any other airspace user, as well as loted aircraft systems will be integrated land and wildlife management, [and] the safety of persons and property on into the aviation community by 2016.7 air quality control and management.” the ground,” he said. “Development The SJU has established a May 31 of the complete regulatory framework deadline for demonstration project ‘Less Onerous’ for remotely piloted aircraft will be a proposals, including “integrated pre- In Australia, the Civil Aviation Safety lengthy effort. This is not a knee-jerk operational flight trials activities.” The Authority (CASA) is planning the reaction, it is an evolutionary pro- projects, which will involve various gradual implementation of regulations cess, with regulations being added or types and sizes of remotely piloted air for remotely piloted aircraft. amended gradually.” systems, must be performed in Europe- Regulations will be proposed for an Union or Eurocontrol member states different categories of remotely piloted Notes
between October 2013 and March 2015. aircraft, and authorities are considering 1. ICAO. Unmanned Aircraft Systems (UAS), The EC said the development of simplifying the certification process for Cir 328. 2011. remotely piloted aircraft systems has those that will be used in less complex 2. Oklahoma Governor’s Unmanned “opened a promising new chapter in the and less risky operations. In many Aerial Systems Council. A Strategic Plan history of aerospace.” instances, non-binding guidance mate- for the Development of an Unmanned Civil aviation has yet to follow the rial will be introduced first, followed by Aerial Systems Enterprise in the State of military in its widespread use of un- adoption of regulations, CASA said. Oklahoma. 2012. manned aircraft, the EC said. In a February speech to the Asso- 3. Governor’s Communications Office. When it does, the EC added, un- ciation for Unmanned Vehicle Systems “Ohio Launches One-Stop Shop for manned aircraft “can offer a wide range Australia, Director of Aviation Safety Unmanned Aircraft Efforts.”
[The aircraft] can perform tasks that operated in Australia weigh less than 4. Jenkins, Darryl; Vasigh, Bijan. The manned systems cannot perform, either 7 kg (15 lb) and because of their many Economic Impact of Unmanned Aircraft for safety or for economic reasons.” capabilities — “it is impossible for CASA Systems Integration in the United States. A Among those tasks are long- to effectively regulate all of them.” special report prepared at the request of duration monitoring, crisis manage- Instead, McCormick said, “we have AUVSI. March 2013. ment, border control, fire fighting and to address the current reality. There is 5. ACLU. Blog of Rights: Domestic Drones. operations in clouds of volcanic ash, no point in CASA writing regulations
26 | FLIGHTFLIGHT SAFETY SAFETY FOUNDATIONFOUNDATION || AEROSAFETYWORLD || MAY 2013 I work hard to convince our business aviation passengers that I’m one in a million.
Truth is, I’m one in 1.2 million. Dorette Kerr Manager, Flight Administration John Deere
John Deere competes in the global marketplace from its headquarters in Moline, Illinois. To stay nimble and connected, the company relies on business airplanes and people such as Dorette Kerr — one of more than 1.2 million people employed in the business aviation industry. What she and the rest of John Deere’s flight staff enable their company to do is just one more way that business aviation works for America. Noplanenogain.org
PAID FOR BY THE NATIONAL BUSINESS AVIATION ASSOCIATION 28 | FLIGHTTRAINING F ous incidents, and aliterature including review reports onselected airline accidents- and seri pilots, simulator aflight experiment, analysis of a timely manner. inappropriately —or to evenfailed react at in all pilotssome these cases, reacted ineffectively or bysuddenly surprised situations. critical In airline pilots when to failed reactas expected Recent interviews with AustralianRecent interviews airline profile accidents over last the few years, transport safety. However, insome high- continual improvement incommercial air or world the decades, has from benefited BY WAYNE PATRICK MARTIN, MURRAY ANDPAUL BATES during unexpectedcriticalevents. from severe startle,freezing anddenial Researchers explore pilotimpairment concludes research that further —especially by article’s this author primary (Wayne Martin) serious incidents or accidents. thesis Adoctoral possibly resulting inundesired aircraft states, has on significanttially aviation effects safety, startle as strongstartle label extremerealizes. Some subject specialists morecur often than aviation the community freezing reactions called —orsevere startle by consequent acute stress suggest that pathological reactions induced by insights from neuroscience and psychology Any such behavior inaction-type poten- FLIGHT FOUNDATION SAFETY serious. serious. or and denial oc and —may |
WORLD AEROSAFETY | MAY 2013 -
© Duncan Walker/iStockphoto FLIGHTTRAINING
development of interventions suitable such movement would have helped incident more often are peppered with for future training — is warranted. them survive. human failings involving the pilots. In Such additional work could validate Inaction in the face of imminent some relatively recent fatal accidents, the assumption that by exposing pilots threat especially raises concern from the findings showed that flight crews in the simulator to unusual critical the aviation safety perspective. Airline mishandled critical events and failed events, they are likely to develop both passenger behavior during aircraft acci- to recover the aircraft [ASW, 8/12, p. specific and generic strategies for deal- dents, for example, has followed similar 14; ASW, 6/10, p. 32; ASW, 3/10, p. 20; ing with them. Ideally, such exposure patterns, with some researchers4,5 ASW, 4/11, p. 46]. Typically, there was also would engender a greater sense finding that even in simulated evacu- some delay in acting, or incorrect action of self-efficacy, in turn making pilots ation trials, behavioral inaction was taken, which exacerbated the problem. significantly less likely to experience displayed by a number of the passen- Although airline pilots routinely acute stress reactions after real-world gers. One study suggests that 10 to 15 practice engine failures, engine fires, severe startle. percent of people typically display such depressurizations and major system Humans are particularly susceptible pathological behavior when faced with malfunctions, the types of critical events to acute stress reactions, and unex- life-threatening situations,3 and real-life that prevail in recent accident data are pected, threatening and critical events examples exist such as a fatal aircraft commonly regarded as “black swan” often present circumstances in which fire6 after a rejected takeoff known to events, that is, highly unusual.16 They some individuals fail to cope well. The have involved passive inaction among involved unexpected situations in which physiological stress reaction has been passengers. pilots became very surprised and/or shown to have severe effects on work- This inaction, which is most likely an overwhelmed. Moreover, the response ing memory and other cognitive func- acute stress reaction to an overwhelm- to severe startle — or subsequent acute tions, with constructive thoughts being ingly threatening stimulus, may be due stress reactions of freeze or denial — is replaced by task-irrelevant, anxious to an elementary freezing mechanism sometimes exacerbated by the flight thoughts. Acute stress reaction, which within the brain7,8 or indeed to a coping/ crew’s conditioned expectation for is associated with an appraisal of threat, defense mechanism that seeks to deny things never going wrong. This uninten- can create situations in some people the existence or severity of the threat.9,10 tional sense of complacency is born of in which they are overwhelmed and Inaction also may be the result of the the ubiquitous normality in line opera- freeze, or institute a coping mechanism severe startle, and experiments by other tions, week-in and week-out for long such as freezing or denial. researchers have shown that cogni- periods of time. tive and dexterous (that is, hand/foot Paralyzed With Fear dexterity) impairments could last for up Reaction Process Acute stress reactions are common to 30 seconds following this degree of Central to the acute stress reaction is the during life’s emergencies. One only has startle.11,12,13,14 person’s appraisal that some particular to see human behavior shown on the While these reactions could be stimulus is threatening. Some research- six o’clock evening news as a disaster considered typical among a small frac- ers17 have described appraisal as “an unfolds somewhere around the world. tion of the “innocent” participants in an evaluative process that determines why Earthquakes, floods, fires, ship sink- unfolding non-aviation disaster, people and to what extent a particular transac- ings, oil rig disasters or train wrecks expect that professional pilots — who tion or series of transactions between the often turn up a mixture of behaviors. are generally well trained, very experi- person and the environment is stress- Studies by several researchers,1,2,3 enced and presumably endowed with ful.” They further have suggested that through eyewitness accounts and the “right stuff”15 — will nonchalantly, appraisal involves two distinct processes: interviews with survivors, have looked competently and flawlessly deal with primary appraisal, which determines at why some people survived a disaster critical emergencies to avoid disaster. level of threat, and secondary ap- and others did not. The survivors often Unfortunately, this may not be the case. praisal, which determines an appropriate have reported seeing people who were Extremely high aircraft reliability method of coping. This process is very apparently paralyzed with fear and has become the norm, so official find- rapid and appears to precede conscious- incapable of movement, even when ings after an aircraft accident or serious thought processing in the cortex of the
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Conceptual Model of Threat, Appraisal and Information Processing
Environmental Event
Primary Appraisal
Benign Positive Loss/Harm or Irrelevant Threat/ Challenge
Secondary Appraisal
Defense or Coping Mechanism Employed Reappraisal
Assign Attentional Ignore OR Resources Problem Focused Emotion Focused
Perception Attentional Channeling
Normal Information Processing Perception
Degraded Information Processing
Note: When pilots appraise a situation as overwhelmingly threatening, there is a possibility that an emotion-focused coping method — largely negative/ pathological in its effect — will interfere severely with their information processing, problem solving and decision making.
Source: Wayne Martin, Patrick Murray and Paul Bates
Figure 1
brain.18,19 This fact is clearly advanta- denial, self-deception or reality distor- The startle reflex invokes a pattern geous in situations when immediate tion.17,20,21 These coping mechanisms can of aversive movement (that is, away action is required but may induce a have severe effects on the constructive from the stimulus) and aligns atten- pathological acute stress reaction that is processing of information, problem solv- tional resources to the source of the unwarranted. ing and decision making. In the aviation stimulus. This process is remarkably If they appraise their situation as context, this is very problematic in critical fast, with first signs of reaction oc- threatening, humans involuntarily situations. One useful conceptual model curring in as little as 14 milliseconds will apply some form of unconscious (Figure 1) illustrates this flow of threat, (ms) in some tests on humans.26,27 emotional homeostatic (stress- appraisal and information processing.22 Given that cognitive processing of relieving) coping or conscious defense new stimuli takes more than 500 mechanism. This may take the form Startle ms,28 that “quick and dirty” reflexive of trying to fix the problem. That is an The startle reflex is a normal and reaction is clearly an innate process entirely appropriate method, which universal human response to some un- for avoiding harm. is employed by most pilots in most expected/surprising stimulus. When a The brain’s amygdala region, which situations. If no immediate fix is at person appraises the stimulus as threat- is strongly associated with emotional hand, however, or the situation is ap- ening, activation of the sympathetic memory of fear, appears to be where praised as being overwhelming, then nervous system triggers widespread and initial appraisal of threat is made. Pro- the possibility exists that some form of rapid changes in the body. This arousal, jections from the amygdala then initiate emotionally focused coping mecha- which is also associated with the acute the startle reflex and, if the threat nism will be employed. stress reaction, is generally known as persists, the full startle or surprise reac- Emotionally focused coping, how- the fight or flight response and has been tion.7,8 Essentially, this is still the fight ever, is largely pathological and may shown to have significant effects on or flight response, the same process include elements such as avoidance, cognitive and psychomotor processes. invoked during acute stress reactions.
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The rapid changes in the body’s the three approaches that had become Freezing also has been described systems result from arousal of the unstable and had continued below as a response to overwhelming threat sympathetic nervous system. Changes 100 ft AGL. While this was a relatively in which, at the rudimentary sub- include increasing heart and respiration small sample size, the results were both conscious level, the brain is unable to rates, routing more blood flow to vital statistically and qualitatively significant, cope with the complexity and danger organs, and introducing hormones such with the majority of pilots admitting to presented by sudden circumstances. as adrenaline (epinephrine) into the having experienced physiological and Reports from survivors3 of an oil rig bloodstream.29,30 Other characteristic cognitive effects following the startle. fire and a ship sinking, for example, changes are blinking and contraction of described people who were simply arm and leg muscles. Freezing frozen or paralyzed and unable to save As noted, other research11,12,13,14 Freezing is an acute stress reaction that themselves, despite encouragement or has shown that cognitive and dexterous may be a conscious or subconscious abuse from other passengers. impairment can last for up to 30 sec- method of dealing with an overwhelm- Similarly, the known aviation cases onds during reaction to severe startle. ing stressor. One study3 defined it as include pilots who have simply frozen This has significant implications for “a stress coping mechanism entailing during critical events. In one accident, aviation because sudden, unexpected a subconscious mechanism for stress the captain apparently experienced and critical events are typical of aircraft relief, or a conscious disbelief that the freezing after commencing a rejected emergencies. A significant number phenomenon is actually occurring.” takeoff.24,25 He closed the thrust levers, of accidents and serious incidents Freezing is generally a major breakdown but failed to brake or select reverse reviewed for the thesis — in which in the normally integrated cognitive pro- thrust, simply staring straight ahead. pilots performed less than optimally cesses within the brain. Sometimes the The aircraft ran off the end of the run- during critical events but startle/acute people affected remain aware of what is way at 70 kt, killing two people. stress reaction was not an official cause going on around them, but are incapable During part of the data collec- — were cases in which startle may have of taking any participative behavioral tion for the thesis — interviews with a contributed to a poor outcome. and/or cognitive action. sample of pilots who had experienced The simulator experiment involved This reaction has been relatively critical events/emergencies during an airline’s large commercial jet simula- common during non-aviation disas- airline operations — one pilot recalled tor flown by a sample of 18 type-rated ters and also has been noted in real- an actual event in which the captain pilots. This part of the study found that life and simulated aircraft accidents froze during an approach, having set up seven of the 18 performed very poorly and evacuations. It appears that in a high rate of descent. The aircraft con- during a critical event when startled freezing, the cognitive processes re- tinued to descend well below glide path (Figure 2, p. 32). In the experiment, a quired to initiate action are overcome until becoming visual at very low level startling stimulus was introduced 40 by an acute sense of dread, with the on a collision course with an apartment ft above decision altitude on an ap- working memory being consumed by building. Fortunately, once visual, the proach where the cloud base was 100 irrelevant thoughts of fearful out- captain recovered, and a last-minute ft below the minima. While five pilots come. “Paralyzed” or “petrified with evasive maneuver narrowly avoided the performed nominally and six displayed fear” have been common recollections building. The first officer, who repeat- some slight reactionary delay, the seven from some people who have survived edly had tried to alert the captain to the showed either impulsive behavior such critical situations. glide path deviation, also tried several (immediate go-around) or significant Unlike denial, which is quite diffi- times to take over control and even delays in reactions. cult to quantify, most people are famil- resorted unsuccessfully to hitting the Three pilots continued descent to iar with the concept of freezing under captain to gain control. below 100 ft above ground level (AGL), conditions of acute stress. Like “a deer Another of these interviewees and two pilots continued to land despite caught in the headlights,” a popular described a situation in which a military severely unstable approaches. Enhanced analogous phrase for this phenomenon, pilot under instruction, while practic- ground proximity warning system freezing is not uncommon in aviation ing spins with high rotation rate, simply “PULL UP” warnings resulted on two of accident and incident data. froze during recovery from a spin. The
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Results of Startle Experiment in Boeing 737 Simulator denial could have severe implications in airborne critical events because of Stimulus Altitude Approach 1 Approach 2 (AGL) Lowest Alt During Go-Around Lowest Alt During Go-Around the careful analysis and logical problem With Stimulus Without Stimulus solving required. 240 ft 170 170 The airline pilot interviews for 240 ft 170 140 the thesis revealed that short-term 240 ft 170 190 denial was relatively prevalent during 240 ft 160 110 these events, with participants report- 240 ft 160 170 ing that some level of denial had been 240 ft 150 180 experienced in 15 of the 45 events they 240 ft 150 160 recalled. This was generally short-term 240 ft 150 170 denial, and it did not turn out to be of 240 ft 150 170 catastrophic consequence. However, it 240 ft 140 170 raises the question of how many fatal 240 ft 140 160 accidents have involved denial, with the 240 ft 200 170 pilots never achieving recovery or with 240 ft 220 160 recovery being delayed too long. 240 ft 86 140 The pilots’ interview responses also 240 ft 66 150 indicated that such brief periods of 240 ft 56 180 denial were not unusual, although in all 240 ft 0 (landed) 150 of the situations that interviewees dis- 240 ft 0 (landed) 190 cussed, denial was quickly overcome as Alt = altitude, AGL = above ground level rational processing kicked in. Dynamic Note: The 18 participating type-rated pilots descended 36.1 ft on average during their delayed reaction denial, if it had persisted, could have to the startle stimulus induced by the researchers on their first approach. been particularly detrimental to the Source: Wayne Martin, Patrick Murray and Paul Bates outcome of the situation, although it Figure 2 is impossible to tell from accident data whether denial was involved. However, student became unresponsive, and the Many would ignore the symptoms for there are several examples of instances instructor pilot had to physically hit the some time rather than confront the in which pilots took no action at a time student to get him to release his iron grip stressful issue of their mortality. when intervention was required, indi- on the controls. A successful recovery Denying the threat’s existence can cating that dynamic denial is at least a was finally made close to bailout altitude. be very effective in relieving stress; possibility. Further research in this area however, continual reappraisal and is required. Denial dynamic denial are required for this One subject specialist23 even has Denial also is an emotionally focused coping mechanism to persist. Dy- described a pathological taxonomy coping mechanism, and, like freezing, namic denial occurs when the flow of of seven different stages: denial of a very rudimentary human process. critical information is not continually personal relevance, denial of urgency, If a person appraises the stimulus as processed as part of this pathological, denial of vulnerability, denial of affect, being particularly threatening, and acute-stress coping mechanism. denial of affect relevance, denial of this mechanism is implicitly invoked, While this could be problematic threatening information and denial of then the stressful stimulus may simply when situations such as deteriorat- information. While the early stages are be ignored. ing weather or aircraft status com- mildly concerning in the aviation con- Denial also appears to have a pound the threat, the more immediate text, the latter stages — when threaten- subconscious strategic purpose. This stressors — those conducive to dy- ing information or all information is is remarkably common, particularly in namic denial — generally are of greater denied — are particularly worrisome in people with life-threatening illnesses. concern in critical events. So dynamic the aviation safety context.
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In summary, if a critical situation 6. U.K. Air Accidents Investigation Branch. 19. Zajonc, R.B. 1980. “Feeling and thinking: arises during flight operations but an in- 1988. “Report on the accident to Boeing Preferences need no inferences.” American dividual pilot’s brain unconsciously and 737-236 Series 1, G-BGJL at Manchester Psychologist 35 (2): 151–175. International Airport on 22 August 1985 involuntarily ignores the cues for threats 20. Lazarus, R.S. 1966. Psychological Stress and presented, then the chances of recover- (Aircraft Accident Report 8/88).” London: the Coping Process. New York: McGraw-Hill. ing are substantially reduced. Her Majesty’s Stationery Office. 21. Monat, A., and R.S. Lazarus. 1991. Wayne L. Martin, a Boeing 777 first officer for 7. Le Doux, J.E. 1996. The Emotional Brain. Stress and Coping. New York: Columbia Virgin Australia Airlines, has submitted a doc- New York: Simon and Schuster. University Press. toral thesis on this subject to Griffith University, 8. Le Doux, J.E. 2000. “Emotion circuits in Brisbane, Australia. His career includes work in 22. Martin, W.L., P.S. Murray, and P.R. the brain.” Annual Review of Neuroscience human factors and airline pilot training, and he Bates. 2010. “The effects of stress on 23: 155–184. is a member of the International Pilot Training pilot reactions to unexpected, novel, and Consortium Working Group on Training 9. Carver, C.S., M.F. Scheier, and J.K. emergency events.” In Proceedings of the Practices. Patrick S. Murray, an associate Weintraub. 1989. “Assessing coping 9th Symposium of the Australian Aviation professor and director of the Griffith University strategies: A theoretically based ap- Psychology Association, Sydney, 19–22 Aerospace Strategic Study Centre, is a member proach.” Journal of Personality and Social April, 2010. of the Line Operations Safety Audit Collaborative Psychology 56 (2): 267-283. 23. Breznitz, S. 1983. “The seven kinds of currently conducting research on regional 10. Folkman, S., R.S. Lazarus, C. Dunkel- denial.” In S. Breznitz (Ed.). The Denial airline safety. His career includes experience as Schetter, A. DeLongis, and R.J. Gruen. of Stress. New York: International a military pilot and airline pilot, and in a senior 1986. “Dynamics of a stressful encounter: Universities Press. position at the Australian Civil Aviation Safety Cognitive appraisal, coping, and encoun- Authority. Paul R. Bates, an associate professor 24. Heaslip, T.W., N. Hull, R.K. McLeod, ter outcomes.” Journal of Personality and and head of aviation at Griffith University, chairs and R.K. Vermil. 1991. “The frozen pilot Social Psychology 50 (5): 992–1003. the Outreach Committee of the International syndrome.” In Proceedings of the 6th Civil Aviation Organization Next Generation of 11. Thackray, R.I., and R.M. Touchstone. International Symposium on Aviation Aviation Professionals Task Force. 1983. “Rate of recovery and subsequent Psychology, Columbus, Ohio: 782–787. radar monitoring performance following 25. Stokes, A.F., and K. Kite. 1994. Flight a simulated emergency involving startle.” Notes Stress: Stress, Fatigue, and Performance in U.S. Federal Aviation Administration Aviation. Aldershot, UK: Ashgate. 1. Fritz, C.E., and E.S. Marks. 1974. “The Office of Aviation Medicine, Report no. NORC studies of human behaviour in FAA-AM-83-13. 26. Simons, R.C. 1996. Boo!: Culture, experi- disaster.” Journal of Social Issues 10 (3): ence, and the startle reflex. U.S.: Oxford 12. Vlasek, M. 1969. “Effect of startle stimuli 26–41. University Press. on performance.” Aerospace Medicine 40: 2. Glass, A.J. 1959. “Psychological aspects of 124-128. 27. Yeomans, J.S., and P.W. Frankland. 1996. disaster.” JAMA 171: 222–225. 13. Woodhead, M.M. 1959. “Effect of brief “The acoustic startle reflex: Neurons and connections.” Brain Research Reviews 21: 3. Leach, J. 2004. ‘“Why People ‘Freeze’ in noise on decision making.” Journal of The 301-314. an Emergency: Temporal and Cognitive Acoustic Society of America 31: 1329–1331. Constraints on Survival Responses.” 14. Woodhead. 1969. “Performing a visual task 28. Asli, O., and M.A. Flaten. 2012. “In the Aviation, Space, and Environmental in the vicinity of reproduced sonic bangs.” blink of an eye: Investigating the role of Medicine 75 (6): 539–542. Journal of Sound Vibration 9: 121–125. awareness in fear responding by measur- ing the latency of startle potentiation.” 4. Muir, H.C., C. Marrison, and A. Evans. 15. Wolfe, T. 2001. The Right Stuff. New York: Brain Science 2: 61–84. 1989. “Aircraft evacuations: The effect Bantam Books. of passenger motivation and cabin con- 29. Jansen, A.S.P., X. Van Nguyen, V. Karpitsky, figuration adjacent to the exit.” London, 16. Taleb, N.N. 2010. The Black Swan. New T.C. Mettenleiter, and A.D. Loewy. 1995. U.K.: Civil Aviation Authority, CAA York: Random House Publishing. “Central command neurons of the sympa- Paper 89019. 17. Lazarus, R.S., and S. Folkman. 1984. Stress, thetic nervous system: Basis of the fight or Appraisal, and Coping. New York: Springer. flight response.” Science 270 (5236): 644–646. 5. Muir, H.C., D.M. Bottomley, and C. Marrison. 1996. “Effects of cabin configu- 18. Duckworth, K.L., J.A. Bargh, M. Garcia, 30. Stratakis, C.A., and G.P. Chrousos. 1995. ration and motivation on evacuation be- and S. Chaiken. 2002. “The automatic “Neuroendocrinology and Pathophysiology haviour and rates of egress.” International evaluation of novel stimuli.” Psychological of the Stress System.” Annals of the New Journal of Aviation Psychology 6 (1) 57–77. Science 13: 513–519. York Academy of Sciences 771: 1–18.
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BY LINDA WERFELMAN
A fatal accident involving a Robinson R22 has prompted a call for revised certification requirements for light helicopters. © Ryan Hothersall/Jetphotos.net
egulatory authorities should alter the cer- 5,000 flight hours who was trying to increase tification requirements for light helicopter his 58 hours in helicopters so that he could earn designs to reduce the risk of accidents in- a commercial helicopter license and a license volving loss of main rotor control, the U.K. to instruct in helicopters. The helicopter was RAir Accidents Investigation Branch (AAIB) says. destroyed. The AAIB included its recommendations to The AAIB report said the cause of the ac- the European Aviation Safety Agency (EASA) cident was “main rotor divergence resulting and the U.S. Federal Aviation Administration in mast bumping” — a condition in which the (FAA) in its final report on the Jan. 6, 2012, main rotor hub contacts the main rotor mast. As crash of a Robinson R22 Beta near Ely, Cam- the rotor blades continue to “flap,” each contact bridgeshire, England. becomes more violent, and the result can be The accident killed the 50-year-old pilot damage to the rotor mast or separation of the — a flight instructor in airplanes with nearly main rotor system from the helicopter.
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The accident flight began at 0958 local time, not considered strong enough to have gener- when the helicopter left Manston Airport for a ated low-level turbulence. They said either wake flight to Fenland Airfield, about 240 km (130 turbulence or a need for a sudden maneuver to nm) northwest. avoid another aircraft was highly unlikely. The pilot told air traffic control, as the R22 The accident helicopter was manufactured passed east of Cambridge Airport at 1118, that in 1988; at the time of the accident, the airframe the helicopter was flying at 1,400 ft. That was the had been in operation for 6,407 hours and the last radio transmission received from the pilot. engine, for 1,595 hours. The last maintenance A fatal accident involving a Robinson R22 The helicopter continued northwest, toward Fen- check was a 50-hour check completed Dec. 6, has prompted a call for revised certification land, and disappeared from radar about 1125. 2011 — 28 flight hours before the accident. No Witnesses on the ground southwest of the significant defects were found, the report said. requirements for light helicopters. accident site said they saw the helicopter rapidly Maintenance records included no mention pitch and roll left and heard a “pop, as if it was a of any disturbance of the pitch control links paper bag you banged in your hands,” the report during the year before the accident and showed said. Two witnesses also said that they saw ob- that the last “known disturbance” of the rotor jects separate from the helicopter before it fell, system occurred in April 2010, when the main inverted, to the ground. rotor blades were removed for replacement of The wreckage was found in a field 2 nm (4 the spindle bearings. km) southwest of Ely. The helicopter was invert- Examination of the wreckage found damage ed and there were few ground marks, indicating to the main rotor that showed that the main that the helicopter had little horizontal speed rotor blades had “flapped to extreme up and just before the impact. Both main rotor blades down angles prior to separation,” the accident had separated from the hub and were found sev- report said. eral hundred meters from the main wreckage. This condition — known as main rotor diver- The teeter stops, One tail rotor blade also had separated and was gence — has several causes in helicopters such as shown in the not found, but the other was still attached. There R22s, which have “teetering, two-bladed rotors,” photographs below, was no indication that the main rotor had struck the report said, citing low-g maneuvers, low-rotor had split because the tail boom, the accident report said, noting rpm, turbulence and “large abrupt control inputs.” of mast bumping, that “tail boom separation following main rotor The report said it was “possible that a com- which occurs when contact has been a characteristic of a number of bination of low rpm, an abrupt control input rotor blades “flap R22 in-flight structural failures.” and low-g caused the main rotor divergence. downwards to an Accident investigators said that weather … If carburetor ice caused a loss of rotor rpm, extreme angle and conditions at the time of the accident included this would have triggered the low rpm audio strike the mast,” visibility of 30 km (19 mi), few clouds below warning, and this warning sounds like the stall the AAIB says. 25,000 ft and a light, westerly wind that was warning in some light fixed-wing aircraft. The response of a fixed-wing pilot to a stall warning is often to push forward on the controls to un- stall the wing. This would be an inappropriate response from the pilot in these circumstances but understandable given that the vast majority of his flying was in fixed-wing aircraft.” The report said that low rotor rpm “could explain why the pitch link failed in the way that was observed” — with the separation of the no. 1 pitch link and indications that the attached bolts had failed because of overload resulting
U.K. Air Accidents Investigation Branch Investigation Air Accidents U.K. from the application of considerable force.
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In addition, the report said, “the forward of power by lowering the collective in less than deflection of the cyclic, leading to a low-g flight about 1.5 seconds in the cruise, or one second in condition, could explain the rapid roll, but only the climb, to prevent rotor stall.” if the witnesses were mistaken and the roll was, As a result, EASA has begun a study of the in fact, to the right.” effect of increasing the required reaction times, The report also cited previous studies, the report said. including a 1996 study by the U.S. National Transportation Safety Board (NTSB), that linked Handling Qualities “large, abrupt control inputs” to mast bumping.1 The report said that handling qualities are another probable factor in a number of R22 NTSB Study crashes involving loss of main rotor control. The report noted the NTSB’s 1996 recommen- “Only light control forces are required to dation calling on the FAA to require helicopter apply full cyclic deflection in the R22, making manufacturers to “provide data on the response it easy inadvertently to enter a low-g situation of helicopters to large, abrupt cyclic inputs as a or to make an abrupt and rapid control input part of the certification process.” leading to rotor stall and mast bumping,” the The FAA implemented part of the recom- report said. mendation by modifying Advisory Circular FAA and EASA certification requirements, (AC) 27.661, Rotorblade Clearance, to require which have changed little in recent decades, are manufacturers to conduct a blade flapping less stringent than equivalent military require- survey. ments, the report said. FAA and EASA “However, the AC did not define what the The document noted that a 2005 study by control deflections should be or what the rate of the U.S. National Aeronautics and Space Ad- certification input should be,” the AAIB report said. “It speci- ministration Ames Research Center included a fied that margins should be determined, but it recommendation calling on helicopter manu- requirements … are did not specify what the margins should be.” facturers to “explore the feasibility of designing less stringent than The NTSB eventually closed out the recom- a low-cost, lightweight stability augmentation mendation and characterized the FAA’s response system, which would also provide benefits for equivalent military as “acceptable,” but the AAIB said that the NTSB the reduction of low-speed and hovering heli- action was influenced by the decline in the copter accidents.” requirements. number of accidents involving main rotor loss of In addition, the AAIB report said that a control in the mid-1990s. stability augmentation system “would provide “The NTSB attributed this to the increased some control force feedback, thereby making training and experience requirements imposed large abrupt cyclic inputs less likely, as well as by the FAA,” the report said. “However, since recovering the aircraft to a safe attitude should the 1996 NTSB study, there have been at least a the pilot release the cyclic control.” further 16 fatal R22 accidents involving loss of main rotor control.” Safety Notices Precise causes of many of these accidents Robinson Helicopters included a series of safety have been difficult to determine, the report said, notices in the R22 Pilot’s Operating Handbook “because the pilot’s control inputs leading up to that discussed, among other topics, the dangers the divergence are rarely known.” of failing to maintain rotor rpm and the impor- Nevertheless, the report added that some of tance of avoiding a rotor rpm stall. the 16 accidents probably resulted from a loss “As the rpm of the rotor gets lower, the of rotor rpm that followed a power loss “with- angle-of-attack of the rotor blades must be out the pilot lowering the collective quickly higher to generate the lift required to support enough. In the R22, the pilot must react to a loss the weight of the helicopter,” one safety notice
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says. “As with the aeroplane wing, the blade aerofoil will stall at a critical angle, resulting Robinson R22 in a sudden loss of lift and a large increase in drag. The increased drag on the blade acts like a huge rotor brake, causing the rotor rpm to rapidly decrease, further increasing the rotor stall.” The AAIB report noted that in an airplane, a pilot would react to a stall warning horn by moving the control column forward to reduce the wings’ angle-of-attack and adding power. A similar response in a helicopter, however, can result in the low-g condition associ- ated with an uncontrollable right roll and mast-bumping.
Lightweight Data Recorders The report noted that Robinson Helicopters has agreed that additional information is © Chris Hallewell/Flickr needed “to fully understand the causes of ac- cidents involving main rotor divergence.” The he Robinson R22 is a light, two-seat helicopter first flown in 1975. company was considering the installation of a The R22 Beta was certificated in 1985. small lightweight flight data recorder in its air- T It has a two-blade main rotor with a tri-hinged underslung rotor head designed to limit blade flexing and rotor vibration, and a craft to help provide more data on pilot control two-blade tail rotor. inputs in the moments preceding a main rotor The R22 has one 119-kw (160-hp) Textron Lycoming O-320-B2C divergence, the report said. piston engine, and a 72.5 L (19.2 gal) fuel tank. The empty weight is “The pilot’s control inputs leading up to the 374 kg (824 lb), and maximum takeoff and landing weight is 621 kg divergence are rarely known,” the report said. (1,370 lb). “If the helicopter manufacturer succeeds in Maximum rate of climb at sea level is 1,200 fpm; maximum level speed is 97 kt; and range at sea level with auxiliary fuel, maximum developing a lightweight flight data recorder for payload and no fuel reserves is 592 km (319 nm). the R22 that includes recordings of control posi- Source: Jane’s All the World’s Aircraft, U.K. Air Accidents Investigation Branch Report EW/C2012/01/01 tions, it is likely that there will be new insights into the causes of main rotor divergence. “The technology already exists to cre- “Therefore, the certification requirements ate a small lightweight recorder that includes for future helicopter designs should be updated solid-state three-axis gyros, three-axis accel- and improved to reduce the risk of loss of con- erometers, GPS [global positioning system] trol and loss of main rotor control accidents,” and an altitude pressure sensor, but one of the the report added. “It is desirable that the EASA challenges is to develop a lightweight and non- and FAA cooperate in this task.” invasive means of measuring control positions.” This article is based on AAIB Accident Report No. EW/ The company also plans research on the C2012/01/01, published in the February 2013 “AAIB likely effectiveness of combating carburetor Bulletin.” icing by installing a heated throttle butterfly in the carburetor, the report said. Note Other design solutions also could help re- 1. NTSB. Special Investigation Report — Robinson duce the potential for accidents involving loss Helicopter Company R22 Loss of Main Rotor Control of main rotor control, the report said. Accidents, NTSB/SIR-96/03. 1996.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MAY 2013 | 37 ICAO Regional Runway Safety Seminar - Antigua http://www.icao.int/Meetings/AntiguaRRSS/Pages/default.aspx 27-29 MAY 2013
The International Civil Aviation Organization (ICAO), in partnership with the Eastern Caribbean Civil Aviation Authority (ECCAA), the Organization of Eastern Caribbean States (OECS), Flight Safety Foundation (FSF) and the International Federation of Air Line Pilots Association (IFALPA), invites its Member States, participants, sponsors and exhibitors to the North American, Central American and Caribbean Regional Runway Safety Seminar – St John’s, Antigua and Barbuda.
ICAO and its Runway Safety Partners are committed to presenting Regional Runway Safety Seminars (RRSSs)(RR across the globe over the next two years to promote the establishment of Runway Safety Teams (RSTs) as a means of addressing runway safety issues. Be part of an important regional event that will bring together experts from diverse professional domains to promote a multidisciplinary approach to improving runway safety outcomes in North America, Central America and the Caribbean.
Learn About • the benefits of establishing Runway Safety Teams (RSTs) and how they work • identification of runway safety hazards • different mitigation strategies available • regionally relevant issues and how they have been or could be addressed • regional support for RSTs
Who Should Attend • Regulators • Aircraft operators and pilots • Air navigation service providers and ATCs • Aerodrome operators • Aircraft manufacturers • Other aviation professionals interested in SCAN ME improving runway safety FOR MORE INFO
Hosted in Collaboration With:
For more information about this event contact Elizabeth Gnehm at [email protected]. C recommendations during Flight Safety and afew of NLR’s recently developed studyfurther of factors the involved Laboratory Netherlands (NLR). and safety, flight National Aerospace senior consultant for operations flight misconceptions, says Gerard van Es, cause of systemic gaps, mismatches and control (ATC) —involve some- risk be sometimes underestimated by air traffic — never routine for crews flight and FLIGHTSAFETY.ORG FLIGHTSAFETY.ORG Crosswinds He explained impetus the for in commercial air transport approachthe and landing phase strong gusty crosswinds during hallenging encounters with | AEROSAFETY Strong Gusty Gusty Strong WORLD WORLD | MAY 2013 MAY BY WAYNE ROSENKRANS 41) that motivated German accident accident 41) German motivated that p. Analyses,” EASA and German ed Prompt 2008 Incident in (see “Serious 2008 in Germany in incident a serious was recent examples many one of the and Wright, Orville and of Wilbur flights the since pilots have confronted Aviation Safety Agency (EASA). prepared as advisers to European the a colleague, Emmanuel Isambert, to complete the report that he and WorldSafety 2012. In April, van updated Es Aero inSantiago,Seminar inOctober Chile, Foundation’s International Air Safety Difficult surface wind conditions wind surface Difficult about responses industry in airlinepracticesandflightcrew decisionmaking. Two focusedstudieschallengetoday’s variations 1 - 2
- for use, van said. industry Es regulationscertification fixed became onstrated crosswind inairworthiness- after World War IIto dem- 1978,when originated from afew years inaperiod said. Es van EASA, for study NLR to —led the decisions landing/go-around into data wind ous vari howintegrate and pilots gusts of presence near-surface the detect that systems measuring of all assessment for —calling recommendation man AGer mitigations. to update and factors causal the into deeper to dig EASA, subsequently and investigators, Crosswind-related regulations THREATANALYSIS 3 - -
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39 © Daan Krans/AirTeamImages THREATANALYSIS
NLR’s scope included querying operators do it this way.’ Others said, ‘We do, but we don’t about understanding of aircraft certification specify how to deal with the gusts.’” for crosswind and relevant policies and proce- Each type of wind information has advan- dures; a brief review of factors in crosswind- tages and limitations. “FMS [flight manage- related occurrences; a review of measurement ment system–derived] wind is something that technologies; and the salience of wind instru- you have to be very careful in using, especially ment precision. during the approach,” van Es said. “[Yet] some “First of all, we noticed that the way of arriv- operators … said use of FMS wind is encour- ing at and presenting the [crosswind] informa- aged and [indicates] good airmanship. Others tion varies between the manufacturers and even said, ‘It’s strictly prohibited because we had between the aircraft models,” van Es said. “Most incidents where we nearly lost the aircraft by [manufacturers] don’t mention any kind of using FMS winds.’” Problems in relying on this gusts, but also the way they’ve derived the [dem- source in this context include lack of system ‘Limits, real hard onstrated crosswind value] during the flight test correction for side slip, its use of an average can be very different, giving different results. value and its applicability to winds at altitude limits, are very rare, And they are allowed to, and the regulations on — not at the surface. the means of compliance [allow them] this op- Some respondents’ pilots request from ATC nor are they required portunity. Limits, real hard limits, are very rare, a series of instantaneous wind reports during nor are they required to be established. Typi- approach. “These are snapshots — the actual to be established.’ cally, it’s up to the operators to decide if they [real-time] wind that is available as measured at transfer a demonstrated value into a hard limit. the airport,” he said. “Typically, you get an aver- … This all can result in a possible mismatch age [two-minute] wind, but some airports allow [between] what the operator is using and what you to ask for an instantaneous wind [report].” the data from the manufacturer is telling [us].” Some respondents promote the use of instan- The NLR survey was sent to 115 operators taneous winds; overall, there was no common from Asia, Europe and North America, and way of determining the components either in yielded 36 operator responses. “Basically they tailwind or in crosswind. were telling a story that we were expecting, to The survey also found that 75 percent of some extent,” van Es said, especially regarding respondents use a combination of demonstrated the variability in practices. “They were very and advised crosswinds, and a number of these keen to see what others were doing and what the set maximum crosswind values lower than the issues were,” given their anecdotal knowledge of manufacturer’s demonstrated/advised cross- many crosswind-related occurrences.4 winds; 82.9 percent use the crosswind values as hard limits; 67 percent have procedures for how Wind Data Sources their pilots should calculate the crosswind com- Operators and pilots have several disadvan- ponent, with 58 percent of these specifying how tages as they integrate complex factors. “First the pilots should take gusts into account; and 33 of all, there is no common interpretation of the percent do not include gusts in their crosswind manufacturer’s crosswind,” he said. “[Respon- values. “A small number of the respondents left dents] operate similar models, and they have a the decision — to include gusts or not — up to different view of what was told to them or what the captain,” the report said. was written in the manuals provided to them. When it came to reported gust values in their Risk of Confusion operation — the wind reports, how to deal with NLR researchers usually found that in occur- gusts — some operators said, ‘We don’t take into rence reports, only the wind data reported on account the gusts when we look at the reported the automatic terminal information service wind values.’ Others said, ‘Yes, we do, and we (ATIS) had been considered by the flight crew in
40 | FLIGHTFLIGHT SAFETY SAFETY FOUNDATION FOUNDATION | | AEROSAFETY AEROSAFETYWORLD || MAY 2013 THREATANALYSIS
Serious Incident in 2008 Prompted German and EASA Analyses
reezing rain caused a two-hour delay in the Airbus A320’s The crew gained visual contact with the runway at the departure from Munich, Germany, for a scheduled flight outer marker. The copilot, the pilot flying, disengaged the Fwith 132 passengers and five crewmembers to Hamburg autopilot and autothrottles about 940 ft above the ground. the afternoon of March 1, 2008. She used the wings-level, or crabbed, crosswind-correction During cruise, the flight crew received a Hamburg auto- technique until the aircraft crossed the runway threshold matic terminal information system report of winds from 280 and then applied left rudder and right sidestick to decrab degrees at 23 kt, gusting to 37 kt. They planned for — and the aircraft — that is, to align the fuselage with the runway later received clearance for — an approach and landing on centerline while countering the right crosswind. Runway 23, which is equipped with an instrument landing The A320 was in a 4-degree left bank when it touched system (ILS) approach, said the report by the German Federal down on the left main landing gear and bounced. Although Bureau of Aircraft Accident Investigation (BFU). the copilot applied full-right sidestick and right rudder, the When the crew reported that they were established on aircraft unexpectedly rolled into a 23-degree left bank. It the ILS approach, the airport air traffic controller said that the touched down on the left main landing gear again, striking wind was from 300 degrees at 33 kt, gusting to 47 kt. the left wing tip on the runway, and bounced a second time. The report said that a decision to go around would have The crew conducted a go-around and landed the aircraft been reasonable because the controller’s report indicated without further incident on Runway 33. The left wing tip, the that the winds exceeded the maximum demonstrated cross- outboard leading-edge slat and slat rail guides were found to wind for landing, which was “33 kt, gusting up to 38 kt” and have been slightly damaged during the serious incident, the presented as an operating limitation in the A320 flight crew report said, but the ground contact was not detected by the operating manual. flight crew. The captain asked for the current “go-around rate,” and The BFU, in its final report, listed the immediate causes: the controller replied, “Fifty percent in the last 10 minutes.” “The sudden left wing down attitude was not expected by The controller offered to vector the aircraft for a localizer the crew during the landing and resulted in contact between approach to Runway 33, but the captain replied that they the wing tip and the ground. During the final approach to would attempt to land on Runway 23 first. land, the tower reported the wind as gusting up to 47 kt, and the aircraft continued the approach. In view of the maximum crosswind demonstrated for landing, a go-around would Figure 1 have been reasonable. System-level causes were: “The termi- nology maximum crosswind demonstrated for landing [italics added] was not defined in the Operating Manual (OM/A) and in the Flight Crew Operating Manual (FCOM), Vol. 3, and the description given was misleading. The recommended crosswind landing technique was not clearly described in the 323° aircraft standard documentation. The limited effect of lateral Runway 23 control was unknown.” In the relevant time period, the surface wind at Hamburg maximum was being measured by German Meteorological Service 47 kt anemometers located near the thresholds of Runways 23/33 and 15, and was logged at 10-second intervals. Air traffic con- trollers also had data on maximum veer angle and peak wind 268° speed for the preceding 10 minutes. “In the final 10 minutes prior to the occurrence, the wind direction varied between 268 degrees (minimum) and 323 degrees (maximum),” the re- port said. “In this period, the maximum gust speed recorded was 47 kt [Figure 1].” Hamburg When the controller later gave the crew clearance to land on Airport Runway 33, the information included wind from 300 degrees at 33 kt gusting to 50 kt (two-minute mean value). Four additional Continued on p. 42 German Federal Bureau of Aircraft Accident Investigation (BFU) Investigation Accident of Aircraft Bureau German Federal
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MAY 2013 | 41 THREATANALYSIS
wind reports were issued to the crew before touchdown, the as an operational limit for the aircraft. Civil air transport pilots final one for wind from 290 degrees at 27 kt gusting to 49 kt. were generally poorly informed about the effects of crosswinds “The investigation showed that wing tip contact with the in weather conditions such as these.” runway was not due to a single human error, a malfunction During this investigation, 81 pilots holding air transport of the aircraft or inadequate organisation; rather, it was due pilot licenses and employed by five different airlines provid- to a combination of several factors,” the report said, citing ed anonymous survey responses in which they were about the automatic transition from lateral flight mode to lateral evenly divided in understanding maximum demonstrated ground mode control laws when the left gear first touched crosswind as a guide versus a limit. Significant differences in down, resulting in half of full travel in response to full side understanding also were found concerning the practical ap- stick deflection. plication of maximum demonstrated crosswind. “The fact that there were no significant gusts during the The serious incident involving the Airbus A320-211 at Hamburg decrab procedure explains that the aircraft was not brought to on March 1, 2008, and related events were analyzed and safety this unusual and critical attitude by direct external influence. … recommendations about landing in strong gusty crosswind conditions The BFU is of the opinion that the captain as pilot-in-command were issued by the German Federal Bureau of Aircraft Accident did not reach his decision using … reasoning [regarding lower Investigation in Investigation Report 5X003-0/08, March 2010. crosswind component on Runway 33], because he did not re- gard the value maximum crosswind demonstrated for landing — Mark Lacagnina and Wayne Rosenkrans
preparing for an approach, while all respondents type with a wind vane, and the ultrasonic type cited control tower wind reports as their prima- (often called sonic type). Both measure data ry source. “So the reported wind that they got within 2 to 4 percent of the correct value. just before landing was not taken into account “The normal [ATIS/control tower] wind [in the occurrence reports],” van Es said. “And report that you get is an average,” van Es said. “It what happened in the 30 minutes that [elapsed is a forecast of the wind that you’re supposed to as they] were planning the approach [was that expect. Many pilots think it is an actual [real- by] the actual landing, the wind had changed. time] measurement; it is not. It is a two-minute That happens all the time; the wind encountered average, and they came up with this [to provide is completely different from what is reported. users] a good balance between the mean error They got a much stronger wind.” and the absolute error in the forecast.” Frequently in cases selected, the pilot flying The NLR report published by EASA includes used an incorrect crosswind technique, not a list of recommended mitigations for the issues following the manufacturer’s recommendation. identified, and van Es discussed some examples. Even low-velocity crosswind/gusts can be very “First of all … include gusts when decomposing difficult if the flight crew fails to correctly apply reported wind into the crosswind component the procedure. and take the gust component [as] fully perpen- Figure 1 from the NLR work gives a sense dicular to the runway,” he said. In the United of the pilots’ expectations versus the reality States in the 1950s and 1960s, this practice was they encountered in comparable models/types mandatory, NLR found. Flight crews always of large commercial jets. “For several cases — should use the most recent wind report in deci- excursions, hard landing, tail strikes, wing/pod sion making. strikes — what we see is that more than half Despite the willingness of controllers to of these occurrences [take place in crosswind provide a series of instantaneous wind reports conditions that are less than] what was demon- on request during an approach involving strong strated,” he said. gusty crosswinds, NLR researchers advise The two most prevalent wind sensors ap- against using this source. “[In] several incidents proved for airport runways with accurate gust- … the pilot was asking for … the instantaneous measurement capability are the cup/propeller wind every 10 seconds,” he said. “And [these
42 | FLIGHTFLIGHT SAFETY SAFETY FOUNDATION FOUNDATION | | AEROSAFETY AEROSAFETYWORLD || MAY 2013 THREATANALYSIS
values] went all over the place until safety magazines, a number of opera- difficulties in understanding … wind [one was] below his company limit, and tors say they will revisit their policies report [sources]. There is a lot of mis- then he said, ‘Yeah, going to land.’ He and procedures, van Es told AeroSafety conception within crews about how the went off [the runway].” World. Convincing civil aviation authori- systems work. … The best experience is As noted, applying the manufac- ties, however, is likely to take more time. the real experience, but for an average turer’s crosswind-handling technique “The regulatory [part] is always diffi- line pilot, to have a lot of these landings for the specific aircraft type/model/ cult in terms of who is taking the lead in could be quite rare.” size is the best practice in risk man- this case, especially because it’s a multi- agement. But even this cannot be 100 actor issue,” he said, and this involves the Notes percent successful, given the unique initiative of operators, manufacturers, 1. EASA. Near-Ground Wind Gust Detection. and dynamic forces in play. “The poor regulators and the aviation meteorology Research Project EASA. 2011/08 NGW. pilot … is confronted with all kinds of community. “The regulators are hesitat- Van Es, G.W.H. “Analysis of Existing confusion and issues when he has to ing to go left or right. They don’t know Practices and Issues Regarding Near- decide whether or not to land in a gusty exactly what to do.” Ground Wind Gust Information for crosswind,” van Es said. “It should be Basically, the problem they face is Flight Crews”. NLR Report no. NLR- CR-2012-143, October 2012. company policy that you can ask for some degree of mismatch in certifica- another runway or divert if you don’t tion of aircraft versus operational use 2. Citing World Meteorological Organization feel comfortable — if the wind condi- of aircraft. “What EASA has said is (WMO) WMO-No. 731, the NLR report published by EASA says, “A gust can be tions are unfavorable — because that is that they are looking to publish … a defined as the difference between the a very good defense in these cases.” sort of safety bulletin on this topic,” extreme value and the average value of Since the release of the 2010 and van Es said. “But changing regulations? the wind speed in a given time interval. 2012 reports, with further EASA–NLR I think that’s a step too far for them. A gusty wind is characterized by rapid communication through industry There are big advantages in educating fluctuations in wind direction and speed. forums and pending articles for airlines’ the pilots because they often have great At airports, gustiness is specified by the extreme values of wind direction and speed between which the wind has varied Actual Events Involving Strong Gusty during the last 10 minutes.” Crosswind Conditions vs. Guidance to Pilots 3. For example, EASA’s internationally har- monized regulation (Part 25.237, “Wind 50 Velocities”) states, “For landplanes and 45 Excursion amphibians, a 90-degree cross compo- Hard landing 40 Tail strike nent of wind velocity, demonstrated to Wing/pod strike be safe for takeoff and landing, must be 35 established for dry runways and must
30 be at least 20 kt or 0.2 VSO, whichever is greater, except that it need not exceed 25 25 kt. Note that VSO means the stall speed or 20 the minimum steady flight speed in the 15 landing configuration.” Actual crosswind (kt) 10 4. The report said, “Since 1990, there have been more than 280 approach and land- 5 ing [accidents] and 66 takeoff accidents/ 0 0 5 10 15 20 25 30 35 40 45 50 incidents investigated with [Part] 25–certified aircraft operated in com- Manufacturer advised/operator applied crosswind (kt) mercial operations worldwide in which Notes: Occurrences studied by NLR included some that happened when crosswind components crosswind or tailwind was a causal fac- exceeded the values in guidance to flight crews, and others below those values. tor. Occurrences related to gusty wind
Source: G.W.H. van Es and Emmanuel Isambert, NLR conditions are also very common in Europe. … The wind in these occur- Figure 1 rences was often very gusty.”
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MAY 2013 | 43 66th annual International Air Safety Summit IASS 2013 october 29–31, 2013
Omni Shoreham Hotel Washington, DC, USA
The 66th Annual International Air Safety Summit (IASS 2013) will be held October 29-31, 2013 at the Omni Shoreham Hotel in Washington, DC, USA. Please visit website below for hotel details and further details about the event as they become available.
flightsafety.org/IASS2013 @Flightsafety #IASS2013 DATALINK
BY RICK DARBY Canadian Sum Set Canada’s runway incursions decreased in 2012, and runway excursions decreased even more.
unway incursions at Canadian airports fatalities, were reduced year-over-year through- decreased in 2012 compared with 2011, out the study period 2010–2012. according to a report by NAV Canada, ATS deviations were reduced from 65 in the country’s air traffic services (ATS) 2011 to 40 in 2012, a 38 percent drop (Figure 1). Rprovider.1,2 The decrease included incursions Pilot deviations declined by 3 percent, from 212 attributed both to pilot deviations3 and ATS to 205. Pedestrian or vehicle deviations5 showed deviations,4 the report says. There were no “ex- almost no change from year to year. treme risk” incursions in 2012. Overall, the 2012 numbers were higher The report also indicates that runway than those for 2010. ATS deviations were 90 excursions, which are less frequent than incur- percent more frequent than in 2010, although sions but are statistically responsible for more fewer than in 2011 — when the increase from 2010 more than tripled. The decrease in pilot Canadian Runway Incursions, 2010–2012 deviations from 2010 to 2012 was 12 percent; from 2011 to 2012, 3 percent. Pedestrian or 234 vehicle deviations were nearly unchanged from 212 205 2011 to 2012, but up 34 percent from 2010.
Risk Factors 109 110 82 Not all incursions are created equal. NAV 65 Canada has four risk categories, ranging 40 Number of incursions 21 from A to D. In Category A, “extreme risk,” participants 2010 2011 2012 narrowly avoid a collision by taking instanta- ATS deviation Pilot deviation Pedestrian or vehicle deviation neous action — for example, rejecting a take-
ATS = air traffic service off or initiating a go-around while above the
Source: NAV Canada runway threshold. There were no Category A incidents in 2012, compared with three the pre- Figure 1 vious year and one two years earlier.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MAY 2013 | 45 DATALINK
Similarly, the number of Category B incur- “little or no risk,” were 20 percent fewer in 2012 sions, “high risk,” was lower in 2012 than in than in the previous year, and about the same as either of the preceding two years (Figure 2). in 2010. “High risk” is characterized as having “a sig- nificant potential for collision.” For example, Pilot Deviations action must be taken to remove an aircraft or The report categorizes numbers of incursions vehicle from a runway because of traffic taking associated with pilot deviations according to op- off or landing. erational type. Airline pilot deviations remained Category C, “some risk,” describes incursions nearly constant over the three-year study period: in which “there is ample time and distance to 78 in 2010, 76 in 2011 and 78 in 2012. There avoid a collision.” The number of Category C in- was a wider variation in civil aviation, and an cursions, 160, represented a 17 percent increase improving trend: 177 in 2010, 167 in 2011 and from the 137 in 2011. Incursions in Category D, 141 in 2012.6 In civil aviation, then, there was a 20 percent reduction in pilot-related incursions over three years. Severity of Canadian Runway Incursions, 2010–2012 Monthly Variation 239 In the absence of data, it might be assumed that 190 192 more incursions would occur in winter because 160 140 137 weather would often reduce visibility. The re- port shows no such effect. Over the 2010–2012 study period, the fewest incursions were in Number of incursions January, February and March (65, 68 and 70, 1 6 3 7 0 3 respectively). The most deviations occurred in 2010 2011 2012 June and July (123 and 124, respectively). The Extreme risk High risk Some risk Little or no risk report does not speculate about the reason for
Source: NAV Canada this counter-intuitive finding, but a varying number of flights in different seasons may have Figure 2 contributed to the effect. There was a reasonably close monthly corre- Canadian Runway Incursion Rates, 2010–2012 lation in 2010 and 2012 in the numbers of incur- sions. 2011 was the odd year out. In February, 9 for example, there were 33 incursions in 2011, 8 7 16 in 2010 and 19 in 2012. In May, the equiva- 6 lent numbers were 30, 16 and 31; in August, 29, 5 50 and 29. 4 The rate of incursions per 100,000 move- 3 2 ments — landings, takeoffs and touch-and- Number of incursions
per 100,000 movements 1 go practices — rose during the study period Runway incursion rate Linear rate 0 Jan.– April– July– Oct.– Jan.– April– July– Oct.– Jan.– April– July– Oct.– when quarterly variations were mathematically March June Sept. Dec. March June Sept. Dec. March June Sept. Dec. smoothed (Figure 3). 2010 2011 2012
Note: Rates are per 100,000 aircraft movements, which include arrivals, departures, and Excursions Reduced touch-and-go procedures at airports where NAV Canada provides control or advisory Annual numbers of runway excursions7 de- services. clined during the study period (Figure 4). Land- Source: NAV Canada ing excursions were reduced from 78 to 49, a Figure 3 37 percent drop. Takeoff excursions were down
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from 10 to 6, and “undetermined” excursions — for which it was not possible to determine from Canadian Runway Excursions, 2010–2012 reports which phase they occurred in — fell 98 from 10 to 2. In total, the number of excursions 78 76 from 2010 to 2012 decreased from 98 to 57, or 64 57 42 percent. 49 In each year, landing excursions outnum- bered takeoff excursions by a considerable Number of incursions margin.The majority of excursions — including 10 10 8 4 6 2 both takeoff and landing excursions — were classified as “loss of directional control” in each 2010 2011 2012 of the study period’s three years, but the number Landing Takeo Undetermined Total was reduced each year (Figure 5). The fewest Note: An excursion is categorized as “undetermined” when the report did not give sufficient overruns, both on takeoff and landing, occurred information to determine the phase in which the excursion took place. in 2011. Source: NAV Canada The number of excursions diminished each Figure 4 year in the Edmonton, Toronto and Montreal flight information regions.8 Canadian Runway Excursions, by Type, 2010–2012 Notes 100 1. NAV Canada. Quarterly Runway Safety Report.
2. The report defines a runway incursion as “any -oc 60 currence at an aerodrome involving the incorrect presence of an aircraft, vehicle or person on the 40 protected area of a surface designated for the landing
Number of excursions 20 and takeoff of an aircraft.” 0 3. In the report, a pilot deviation is defined as “an ac- 2010 2011 2012 2010 2011 2012 2010 2011 2012 2010 2011 2012 tion of a pilot that results in noncompliance with an Loss of Landing Takeo Undershoot ATC [air traffic control] instruction/clearance or a directional overrun overrun on landing control violation of a Canadian Aviation Regulation.” Type of runway excursion 4. The report defines an ATS deviation as “a situation Source: NAV Canada which occurs when air traffic services are being pro- vided and when a preliminary investigation indicates Figure 5 that safety may have been jeopardized, less than minimum separation may have existed, or both.” the takeoff roll if the aircraft leaves the runway other than by becoming fully airborne or if an attempted 5. A pedestrian or vehicle deviation is defined in the landing is not completed within the confines of the report as “a situation that occurs when a vehicle intended runway.” operator, a non-pilot operator of an aircraft or a pedestrian proceeds without authorization onto the 8. A flight information region (FIR) is an airspace of protected area of a surface designated for landing or defined dimensions extending upward from the takeoff. This classification includes security breaches surface of the earth, within which a flight informa- but excludes animals.” tion service and an alerting service are provided. 6. The report does not define the distinction between The Canadian Domestic Airspace is divided into civil and airline operations. the Vancouver, Edmonton, Winnipeg, Toronto, Montreal, Moncton and Gander domestic FIRs. 7. The report defines a runway excursion as occurring The regions are shown visually in the Designated “when an aircraft fails to confine its takeoff or landing Airspace Handbook
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MAY 2013 | 47 INFOSCAN
Proceed With CAUTION Is over-specification of procedures a potential safety hazard?
BY RICK DARBY
A Never-Ending Story Trapping Safety into Rules: How Desirable or Avoidable is Proceduralization? standard operating procedures, standards and Bieder, Corrine; Bourrier, Mathilde (editors). Farnham, Surrey, best practices. Accident investigation reports England and Burlington, Vermont, U.S: Ashgate, 2013. 300 pp. usually conclude with recommendations for Figures, tables, references, index. new regulations and procedures. rapping Safety into Rules — there is a title The remarkable safety record of the indus- as provocative as you are likely to see this try is due in large part to effective procedures. Tyear in books aimed at aviation safety They are the result of lessons learned from professionals. accidents and incidents, as well as research and No one needs a definition of rules. Bieder predictive analysis. and Bourrier describe “proceduralization” as But can there be too much of a good thing in “firstly, the aim of defining precise and quanti- the aviation rulebook? fied safety objectives, and secondly, the aim of The editors think so. Bieder and Bourrier defining a process, describing and prescribing say that proceduralization of safety is part of a at the same time how to achieve such objec- general trend toward “the bureaucratization of tives.” Unfortunately, “these two aspects are everyday life. … Even commonplace consump- usually not defined by the same entity. Some tion or simple emotions are rationalized and inconsistencies may even exist between the two subject to prescribed procedures, notably at types of procedures.” the workplace. In addition, the dangerous link Questioning the role of rules and proce- between bureaucratization and administrative duralization goes to the heart of commercial evil has also long been established. The key role aviation, one of the most heavily rule-bound played by technical rationality in this irresist- industries. Almost every aspect of the industry ible and sometimes dangerous push always is covered by regulations (a subset of rules), combines scientific method and procedures.
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Therefore, it requires us to stay alert and vigi- So it grew, becoming more sophisticated lant in front of constant re-engagement towards and elaborate. “Cockpit tasks have been orga- more rules and regulations.”1 nized through checklists, do lists and proce- Personnel do not have infinite attention dures,” Pélegrin says. “The philosophy behind capacity. Under a regime of excessive proce- [them] is very stringent, dictating the accurate duralization, they must devote an increas- way of configuring [and] flying the aircraft ing amount of their attention to keeping up and communicating.” with and following rules and regulations. The Next in the “never-ending story” came crew corollary is that some time and energy must be resource management (CRM). Among other debited from attention to the real-world work- principles, “CRM training emphasized that ing environment. [crewmembers] support a shared action plan Trapping Safety into Rules is a collection and shared awareness, which is essential be- of chapters examining various aspects of the cause it creates a mental image to act, synchro- theme. Part I is “Where Do We Stand on the nize action and manage time. … Procedures Bureaucratic Path Towards Safety?” Part II is also play an important role in interpersonal about “Contrasting Approaches to Safety Rules.” relationships and in conflict management Part III includes chapters under the heading because they are seen as a neutral reference: In “Practical Attempts to Reach Beyond Proce- case of disagreement, following the procedures duralization,” and Part IV is “Standing Back to is one way to solve conflict. This is taught in Move Forward.” many CRM courses.” Claire Pélegrin, in her chapter, “The Never- In due season, proceduralization became Ending Story of Proceduralization in Aviation,” generalized to the organization, encompass- traces the evolution of the phenomenon. ing flight operational quality assurance and “At the beginning of aviation, the designer, today’s widely adopted safety management the engineer and the pilot were the same person, systems (SMS). thus there was no real need for procedures,” she Pélegrin acknowledges the benefits, even the says. It was not long before specialization began, necessity, of many aspects of proceduralization. yet even then, pilots determined their own pro- But they bring drawbacks as well, she says: cedures and tried for self-enforcement. “Organizations in aviation are in a vicious World War II brought the need to train large circle with the proceduralization approach. They numbers of pilots quickly and efficiently — as started to focus on technical performance of Procedures also well as, in some cases, getting pilots ready for the technical system (safety analysis and reli- action without optimum training time. Standard ability) to become now focused on the safety of play an important operating procedures and checklists were among the socio-technical system. This is not exactly role in interpersonal the tools for achieving the goal. the same problem and not the same methodol- Commercial aviation after the war main- ogy. Liability aspects are part of the overpro- relationships and in tained and expanded the procedural approach. ceduralization. The tendency is to use written “For years, everybody shared the same idea that procedures as a legal reference in case of legal conflict management safety would be guaranteed if pilots were se- suit … and push for more procedures. This may because they are seen lected and trained to strictly apply procedures,” become counterproductive, the main difficulty Pélegrin says. Of course, safety was hardly guar- being that everybody may become lost with all as a neutral reference. anteed — for one thing, postwar commercial these safety requirements.” pilots lacked the benefits of today’s technological Airlines have to balance an inherent con- innovations such as terrain awareness and warn- tradiction. Pélegrin says, “Standard operating ing systems (TAWS), traffic-alert and collision procedures promote the idea of uniformity avoidance systems, and weather radar. But the and standardization at the risk of reducing the procedural emphasis seemed promising. human role. At the same time, pilots are seen
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as ‘far more intelligent than the procedures.’ There have been too many accidents in Pilots are considered ‘better’ than the proce- which the captain appeared to have lost situ- dure because they have a certain amount of ational awareness and the first officer failed to autonomy in their decisions, especially in case compensate. Such accidents continue (ASW, of abnormal situations and emergencies (even 3/13, p. 16). But consider the copilot’s dilemma, if, in some airlines, they have to justify that despite acting under a rule that intends to make decision afterwards).” his or her position clear. How far the experience and expertise of a pi- According to the author’s description, the lot should be allowed free exercise is a question rule applies only on approach. What if the that seems to have no absolute answer, because wrong heading has been entered for the initial there is no way to take account in advance of climb, a mountain ridge lies ahead, the TAWS is the pilot’s ability to fully know and understand warning of the collision course with terrain and the situation, the pilot’s state of mind, the pilot’s the captain appears oblivious to the risk. Is the judgment abilities, the time pressure, and other copilot authorized to take charge? variables. “There have been long discussions But that is only the first decision the copilot in many airlines and in international commit- must make. He or she is to shout two warnings tees to decide if the first officer should take a to the captain. How should they be phrased, decision/action in contradiction to the captain,” what balance struck between respect for the such as calling for a rejected takeoff or taking captain’s rank and the second-in-command’s control of the aircraft, Pélegrin says. assumed right to avoid an impending accident? Organizations are caught between encour- How much time needs to be granted for the aging individual responsibility and defining captain’s response? its limits. “If an airline promotes the idea that First, the rule says that “if the captain The implication is everyone should be engaged in safety, then there doesn’t listen,” the copilot must take charge. should be consistent policies (including train- That is unambiguous. But the rule also says that the captain is ing, procedures and practices),” Pélegrin says. the action is to happen “only in case of total “For example, you cannot promote the idea that or subtle incapacitation.” Total incapacitation, conscious and capable everyone must play a role in safety and not allow likewise, is clear and hardly needs to be embed- of communicating, them to act in safety situations.” ded in regulation — any copilot in his proper But when an organization orders a pilot to mind would take over if the captain were but speaking or take extraordinary action under some cir- suffering a medical emergency and completely cumstances, the long arm of the law reaches unable to continue command. acting irrationally, into the cockpit. Pélegrin says, “The Indian What is subtle incapacitation? The implica- endangering aviation authority has established a new rule: tion is that the captain is conscious and capable the copilot needs to shout two warnings to the of communicating, but speaking or acting the flight. commander if the aircraft is in danger dur- irrationally, endangering the flight. To put it ing its approach to the runway. If the com- paradoxically, how overt must “subtle” be? This mander doesn’t listen, then the copilot has to theme was central to the classic novel of World take charge of all operational functions. The War II, The Caine Mutiny, in which the ship’s circular2 noted the new actions would happen officers had to decide what to do about the ‘only in case of total or subtle incapacitation’ of behavior of Capt. Queeg, a crackpot whose ec- the commander and also ‘those actions must centricities might or might not have exceeded a be inducted from about 500 ft.’” captain’s authority. It would be hard to find a better example of And what is the copilot to make of “these ac- trying to have it both ways, mixing judgment tions must [emphasis added] be inducted from and initiative with proceduralization. about 500 ft”?
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The rule illustrates the negative side of pro- emerging from experience with activities by ceduralization. Undoubtedly, its intentions were those carrying them out. They are seen as good: to protect the lives of the passengers in the local and situated in the specific activity, in case of a captain unable to perform duties ad- contrast with the written rules, which are seen equately in a critical phase of flight; to stiffen the as generic, necessarily abstracted from the spine of the copilot who has to take the decision detailed situation.” to deviate from the normal authority gradient; Hale and Borys discuss many studies of and perhaps to offer the copilot legal protection both models of rulemaking. Each model has ex post facto. But it also adds a series of rules the researchers who take a stand basically for or 95 percent thought copilot must remember and analyze while deal- against them; other researchers advocate a bal- ing with a pressing safety-of-flight issue. anced position. that, if you kept to Several of the book’s chapters suggest that The authors themselves conclude, “The the rules, the work the actual effects of procedures at the “sharp review of the two models and their development end” must be studied as carefully as their ab- and use has resulted in the definition of a broad could never be stract validity. In “Working to Rule, or Work- set of concerns and dilemmas. The picture that ing Safely,” Andrew Hale and David Borys say, emerges is of a gap between the reality of work completed in time. “Rules and procedures are seen as essential to and its routines and the abstraction of the writ- allocate responsibility and to define and guide ten rules that are supposed to guide safe behav- behaviour in complex and often conflicting iour. We have described contrasting perceptions environments and processes. Behind this logical, of deviations from those written rules, either rational obviousness lies another ‘truth’ about as violations to be stamped out or as inevitable the reality of safety rules and their use.” and sometimes necessary adaptations to local They cite a study of Dutch railway work- circumstances to be used and reinforced. … ers’ attitudes to safety rules: “Only 3 percent “Model 1 is more transparent and explicit of workers surveyed used the rules book often, than the tacit knowledge and emerging set of and almost 50 percent never; 47 percent found routines characterized by model 2. This makes it them not always realistic, 29 percent thought more suitable for trainers, assessors and improv- they were used only to point the finger of ers, but at the cost of creating a gap between blame, 95 percent thought that, if you kept to work as imagined in the rule set and work as the rules, the work could never be completed carried out in practice. … Rules may be imposed in time, 79 percent that there were too many from above, but they must be at least modified rules, 70 percent that they were too compli- from below to meet the diversity of reality. … cated and 77 percent that they were sometimes “Model 2 fits best with complex, high-un- contradictory.” certainty, high-risk domains with great variety The authors present two contrasting models and need for improvisation. However, in these of safety rules. Model 1, popular among those activities, there is scope for making guidance with an engineering background or way of and protocols more explicit, usable and used, thinking, “sees rules as the embodiment of the by specifying them as process rules rather than one best way to carry out activities, covering all action rules.” contingencies. They are to be devised by experts to guard against the errors of fallible human Notes operators, who are seen as more limited in their 1. Citations of research literature contained in the competence and experience, or in the time nec- book have been omitted here for stylistic and space essary to work out that one best way.” reasons. Model 2, derived more from sociology 2. Directorate General of Civil Aviation, Republic of and psychology, perceives rules as “behaviour India. Operation circular 15, Aug. 5, 2010.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MAY 2013 | 51 Save the Date Inaugural International Aviation Safety Management InfoShare August 29–30, 2013 Singapore
CAAS brandmark with descriptor lock-up Full Colour Positive
Approved by PANTONE COATED PANTONE COATED PANTONE COATED 540 C 2925 C 227 C PANTONE UNCOATED PANTONE UNCOATED PANTONE UNCOATED 541 U 2925 U 227 U CMYK CMYK CMYK Signature/Company Stamp C:100.0 M:80.0 C:85.0 M:25.0 C:0.0 M:100.0 27 May 2009 Y:20.0 K:30.0 Y:0.0 K:0.0 Y:10.0 K:20.0 ONRECORD ‘Hazardous Proximity’ An airliner on go-around and a business jet on departure came close together in an airport hot spot.
BY MARK LACAGNINA
The following information provides an awareness of problems that might be avoided in the future. The in- formation is based on final reports by official investigative authorities on aircraft accidents and incidents.
JETS
Late Go-Around Cited Airbus A320, Bombardier Learjet 60. No damage. No injuries. were being coordinated by a controller at the “lo- cal control 1” (LC1) position; operations on Run- he absence of air traffic control (ATC) ways 19L and 19R, on the west side of the field, procedures ensuring separation between were being coordinated by a different controller Taircraft going around from one runway at the “local control 2” (LC2) position. and entering the flight path of aircraft depart- The A320 crew was conducting a visual ing from a different runway contributed to an approach to Runway 25L and had been cleared incident that placed the A320 and the Learjet in to land by the LC1 controller. Shortly thereafter, “hazardous proximity” at Las Vegas McCarran the Learjet crew was cleared for takeoff from International Airport in Nevada, said the U.S. Runway 19L by the LC2 controller. National Transportation Safety Board (NTSB). The departure thresholds of the runways are “The closest proximity of the two aircraft about 1,600 ft (488 m) apart. “The two runways was approximately 0.3 nm [0.6 km] laterally and do not physically intersect,” the report said. 100 ft [30 m] vertically,” said the NTSB’s final “However, the flight paths of the runways inter- report on the near midair collision, which oc- sect approximately 0.32 nautical miles [0.59 km] curred at 1225 local time on April 26, 2012. past the departure end of Runway 19L.” Runway The A320 was inbound to Las Vegas on a 25L is 10,526 ft (3,208 m) long, and Runway 19L scheduled passenger flight from Boston, Massa- is 9,775 ft (2,979 m) long. chusetts, and the Learjet, of Mexican registration, The A320 was about one-third of the way was departing from McCarran. The report did down Runway 25L when the crew reported that not specify the Learjet’s destination or how many they were going around. The LC1 controller people were aboard either of the two aircraft. acknowledged, saying in part: “Roger, on the Day visual meteorological conditions (VMC) go, and traffic will be at your two o’clock and prevailed, with winds from the south at 19 kt, one mile, a Learjet.” The controller also shouted gusting to 26 kt. McCarran has two sets of paral- “go around,” a normal practice to alert the other lel runways. Aircraft operations on Runways 25L controllers on duty in the tower cab that a go- and 25R, located on the south side of the airport, around was in progress.
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The Learjet was on initial climb about half- “Was that for, ah, wake turbulence or for, ah, way down Runway 19L when the LC2 controller, wind shear?” The crew replied “affirmative” and alerted by the LC1 controller’s announcement of said that they had encountered “a good gust.” the go-around, advised the crew that there was During post-incident interviews by inves- “traffic, an Airbus, ahead and to your left.” The tigators, several controllers said that there had LC2 controller also said, “You have him in sight? been similar conflicts in the hot spot between Go low.” the runways but that the conflict between the The Learjet crew replied that they had the A320 and the Learjet was the closest they could Airbus in sight but did not acknowledge the recall. They said that it likely was due in part to instruction to “go low.” This radio transmission the “late” go-around by the Airbus crew; most included the background sound of the airplane’s pilots, they said, initiate a go-around before stick shaker (stall-warning system), indicating reaching a runway’s approach threshold. that the airplane was at a high angle-of-attack. The controllers said that they had resolved Recorded radar data confirmed that the air- previous conflicts by alerting the pilots, issuing plane was in a rapid climb. The LC2 controller headings when necessary and instructing the again told the Learjet crew to “go low” and to pilots to maintain visual separation after they The controllers “maintain visual separation.” The crew did not had confirmed that the traffic was in sight. One acknowledge the instructions. controller said that “after a go-around, control- described the The LC1 controller then advised the A320 lers really don’t have any form of separation crew that the Learjet was “immediately off your and that the important thing was to just get the incident as a ‘fluke’ right. He is climbing as rapidly as he … actually, aircraft to see each other.” and as the result of I don’t know what he’s going to do for the climb, “Another ‘out’ [separation tool used by the but it looks like he’s coming right at, turning controllers] was to instruct aircraft to ‘go low’ or a ‘perfect storm’ of to your right.” At this time, the Airbus was still ‘go high,’ but this was only done during a ‘t-bone’ over Runway 25L, heading west, and the Learjet (crossing conflict) situation,” the report said. One contributing factors. was nearing the departure threshold of Runway controller told investigators that the Learjet crew 19L, heading south. apparently had not understood their instruction The A320 was nearing the departure thresh- to “go low” and had initiated a maximum-perfor- old of Runway 25L when the crew asked the LC1 mance climb after seeing the Airbus. controller if she wanted them to turn left. The The controllers described the incident as a controller replied, “Turn left now. Turn left.” She “fluke” and as the result of a “perfect storm” of then assigned a heading of 180 degrees. The Air- contributing factors. Several said they believed bus was in the turn a few seconds later when the that awareness, discussion and training had controller asked the crew if they had the Learjet prepared them to handle similar situations. in sight. The crew replied that they had the Nevertheless, NTSB concluded that the Learjet in sight and were told to maintain visual probable cause of the incident was “Federal separation with the airplane. Aviation Administration procedures that do not As the A320 completed the turn to 180 ensure separation in the event of a go-around degrees, it briefly flew parallel to the Learjet, during simultaneous independent runway which was on a heading of about 190 degrees. operations on runways that do not physically The airplanes came to their closest proximity intersect but whose flight paths intersect.” at this time. “There was no damage reported to either aircraft, or any injuries to passengers or Roller-Coaster Ride crew,” the report said. Boeing 737-700. No damage. One serious injury, one minor injury. The LC1 controller issued vectors to the he 737 was about 20 nm (37 km) northwest A320 crew for another approach, and she asked of Bob Hope Airport in Burbank, Califor- them why they had initiated the go-around: Tnia, U.S., and was descending in VMC to
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land at the airport the afternoon of Feb. (shoulder blade). Another flight at- noting that this distracted the pilots 13, 2010. The approach controller told tendant sustained unspecified minor and added to their workload. the flight crew to fly a heading of 190 injuries, and the third flight attendant The 737 was descending at 1,500 degrees and to descend to 6,000 ft. was not hurt. fpm when it reached the programmed “The captain [the pilot flying] stated The captain told investigators that final glide path. Although the pilots no- that he set a 190-degree heading in the while responding to the climb RA, the ticed indications of this, they neglected heading window and selected 6,000 feet first officer and he saw an aircraft about to change from the “LVL CHG” mode to in the altitude window of the airplane’s 2 nm (4 km) ahead and slightly higher, the “VNAV” (vertical navigation) mode, mode control panel (MCP), used to set and he made a shallow right turn to which would have caused the autopilot autopilot functions,” the NTSB report avoid the traffic. to capture the 3-degree glide path. said. The captain said that these actions “The aircraft continued to descend were confirmed by the first officer. Glide Path Distraction through the glide path until, at approxi- The approach controller then advised Boeing 737-800. No damage. No injuries. mately 1,000 ft, the EGPWS [enhanced the crew of traffic at their 11 o’clock posi- uring the flight from Shannon, ground-proximity warning system] gen- tion and about 4 nm (7 km) away. “The Ireland, with 125 passengers and six erated a terrain caution and the pilots captain said that the flight crew began Dcrewmembers the afternoon of Feb. saw the PAPIs [precision approach path scanning for the traffic and received a 7, 2012, the flight crew briefed for the in- indicators],” the report said. The pilots traffic [alert and] collision avoidance sys- strument landing system (ILS) approach later said that the haze prevented them tem (TCAS) traffic advisory (TA), which to Runway 08R at London Gatwick Air- from seeing the PAPI lights sooner. identified that the traffic was about 500 port. Later, however, ATC told the crew “ATC informed them that the feet below their airplane’s altitude,” the that the ILS approach was not available aircraft appeared slightly low and asked report said. “The captain stated that he and that they would receive radar vec- them if they were ‘visual,’” the report began to shallow the airplane’s rate of tors for a visual approach, according said. “The PF [pilot flying] discon- descent … to avoid the traffic.” to the report by the U.K. Air Accidents nected the autothrottle and autopilot, The 737, meanwhile, had deviated Investigation Branch (AAIB). reduced the rate of descent and, after about 27 degrees from the assigned VMC prevailed at Gatwick, with re-establishing the correct approach heading. The controller told the crew to visibility limited by haze. The crew angle, continued the approach. The air- check their heading. “The captain said conducted the descent with the 737’s craft landed without further incident.” that he noticed that he had inadver- autopilot and autothrottle in the “LVL tently allowed the airplane to turn to a CHG” (level change) mode, in which Unresolved Brake Warning 163-degree heading and immediately engine thrust remains at idle while Embraer Phenom 100. Minor damage. No injuries. initiated a turn back to the assigned the pitch attitude is adjusted to main- fter starting one engine in prepa- heading of 190 degrees,” the report said. tain the selected airspeed. They also ration to depart from Tucson, Ari- “During the turn, the crew received a programmed the flight management Azona, U.S., the morning of Sept. TCAS resolution advisory (RA) to de- system for a 3-degree final glide path to 10, 2010, the pilots saw a crew alert- scend at 1,500 to 2,000 feet per minute the runway. ing system (CAS) warning of a brake (fpm), followed by a command to climb ATC subsequently asked the crew failure. They attempted unsuccessfully at 2,000 fpm.” if they could accept an early turn to reset the system and decided to The report said that the captain’s onto the final approach course, and continue with their planned flight to responses to the RAs, a 2,000-fpm the crew replied that they could. As Brenham, Texas, the NTSB report said. descent followed by a 2,000-fpm climb, a result, the aircraft was turned onto The CAS message stayed on were abrupt. All 80 passengers were the final approach course at a higher throughout the flight. The pilot con- seated with their seat belts fastened, altitude than the crew had anticipated. ducted the global positioning system but the three flight attendants were “The pilots used a combination of flap (GPS) approach to Brenham’s Runway standing in the aft galley, completing and speed brake to increase the rate 16 and then transferred control to the their preparations to land. One flight of descent” to capture the 3-degree copilot for the landing on the 6,003-ft attendant suffered a broken scapula glide path from above,” the report said, (1,830-m) runway.
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“After touchdown, the copilot … discovered engines were running, the PF told the head- that the brakes did not work, and the airplane set operator to disconnect the tug and that he began skidding when he pulled the emergency would look for his hand signals on the left side parking brake handle,” the report said. “The of the aircraft.” airplane was moving about 50 to 60 kt when The headset operator was unable to remove both tires blew.” the pin securing the tow bar to the tug and The airplane veered about 120 degrees left, asked the tug driver for assistance. “Between skidded off the left side of the runway and came them, they withdrew the pin and disconnected to a stop after the right main landing gear col- the tow bar from the tug,” the report said. “The lapsed in soft ground. The pilots, alone in the headset operator then disconnected the tow bar airplane, were not injured. from the aircraft, turned his back on the aircraft “A post-accident examination of the brake and started to push the tow bar to an area control unit (BCU) revealed a fault on the forward of the aircraft, to reconnect it to the printed circuit board that led to an open circuit rear of the tug. At the same time, the tug driver for a component installed on the board,” the reversed the tug away from the aircraft before report said. “The open circuit caused the failure driving forward to pick up the tow bar.” of the BCU and the loss of normal braking.” Meanwhile, the flight crew completed the “After Start” checklist, and the PF asked the Collision With a Tug commander to request taxi clearance from ATC. Airbus A300-B4. Substantial damage. No injuries. After taxi clearance was received, the PF illumi- he scheduled cargo flight from East Midlands nated the taxi light and, without receiving the Airport in Derby, England, to Paris, the after- appropriate hand signal from the ground crew, Tnoon of April 14, 2012, also was to serve as a increased thrust to begin taxiing. “It is likely training flight. The captain-in-trainin g was to fly that the tug and ground crew were not visible to the A300 from the left seat, under the supervision the pilots when the aircraft started to taxi,” the of the training captain/commander in the right report said. seat, the AAIB report said. The headset operator said that he felt the After receiving ATC clearance to start the aircraft looming above him. He pushed the tow engines, the PF used the flight interphone to bar clear of the A300’s nosewheels and watched advise the ground crew headset operator that the aircraft pass in front of him. The tug driver the aircraft was ready to be pushed back from saw the aircraft moving and attempted unsuc- the stand. During the pushback, the flight crew cessfully to drive clear. The aircraft struck the started the no. 2 engine. left rear side of the tug and pushed it a short When the headset operator advised the distance before coming to a stop. flight crew that the pushback was complete, the The collision caused substantial damage to PF engaged the aircraft’s parking brake. “The the A300’s nose landing gear and minor damage headset operator then stood by while the no. 1 to the tug, but none of the flight crewmembers engine was started,” the report said. “When both or ground crew was hurt.
TURBOPROPS
Power Lever Jams Wisconsin, the morning of Nov. 16, 2011, Piaggio P180 Avanti. Substantial damage. Four minor injuries. when the flight crew noticed that the torque he Avanti was climbing through 22,000 ft indication for the left engine had decreased during a fractional ownership flight from to 94 percent. When the captain attempted TDetroit, Michigan, U.S., to West Bend, to move the power lever forward, he felt
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mechanical resistance. The first officer com- Control Lost During EMS Flight mented, “That’s what it was doing the other Pilatus PC-12/45. Destroyed. Ten fatalities. day, too.” wo physicians and a nurse were aboard The captain applied additional pressure to the PC-12 when the flight crew landed the power lever and heard a pop as the lever Tthe emergency medical services aircraft in moved full forward, the NTSB report said. The Patna, India, the night of May 25, 2011. After lever jammed in this position, causing engine a critically ill patient and an attendant were torque and temperature to exceed limits. boarded, the aircraft departed from Patna for The pilots shut down the left engine, de- the return trip to Delhi. clared an emergency and diverted the flight to “Weather in Delhi started deteriorating as the Bishop International Airport in Flint, Michi- flight came close to Delhi,” said the report by the gan. “After the engine shutdown, both primary Committee of Inquiry formed by the Indian Di- flight displays went blank,” the report said. rectorate General of Civil Aviation. “Widespread “The captain reset the right generator, and the thunderstorm activity was seen north-northeast flight displays regained power.” However, the of the Delhi airport [and] moving south.” displayed heading information was erroneous The PC-12 was nearing the airport and because the gyros had been reset. The report descending through 12,500 ft when ATC radar said that the crew did not check the headings showed abrupt and rapid altitude changes to against the magnetic compass. 14,100 ft, 13,100 ft and 14,600 ft before ground- The pilots … became VMC prevailed at the Flint airport, with speed decreased substantially; the aircraft then surface winds from 290 degrees at 18 kt. The entered a steep right turn and descended at rates confused about their pilots were cleared by ATC to land on Runway nearing 11,600 fpm. During this time, ATC heading and location 27 but became confused about their heading received two weak radio transmissions from the and location while circling to land. The air- crew, both indicating that the aircraft was “into bad while circling to land. port traffic controller then cleared the crew to weather.” Radar contact was lost at 1,600 ft, and at- land on any runway. The first officer replied, tempts to hail the crew by radio were unsuccessful. “We’re taking this one here. We’re turning The aircraft had struck a house in a residen- base to final.” tial area of Faridabad, about 15 nm (28 km) from The Avanti touched down long on Runway the airport. All seven people aboard the aircraft 18, which is 7,848 ft (2,392 m) long. “At the were killed, as were three people in the house. point of touchdown, there was about 5,000 feet The PC-12 was destroyed by the impact and [1,524 m] of runway remaining for the landing a subsequent fire. Examination of the wreck- roll,” the report said. age revealed that the aircraft was intact before The captain applied reverse thrust from it struck the house, and there was no sign of the right engine, and the airplane began turn- mechanical failure. ing right. He then reduced reverse thrust and “It is probable that a series of up- and down- applied full left rudder and left brake, but the drafts, turbulence (moderate to heavy) and the airplane veered off the right side of the runway dark night conditions [had] caused the crew to and flipped inverted. The pilots and the two become disoriented,” the report said. “The sub- passengers sustained minor injuries. sequent mishandling of [flight] controls caused “Examination of the left engine revealed that the aircraft to [stall and] enter a spin.” the Beta clevis pin was installed in reverse [dur- ing maintenance], which caused an interference Gear Lubrication Neglected with a fuel control unit interconnect rod,” the Beech 99. Substantial damage. No injuries. report said. “Due to the interference, the power fter dropping parachutists near Cedar- lever control linkage was jammed in the full- town, Georgia, U.S., the morning of April forward position.” A10, 2011, the pilot turned back toward the
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airport. He attempted to extend the landing way,” and the annunciator for light the left main gear, but the down-and-locked annunciator light gear did not illuminate. for the left main landing gear did not illuminate. “The pilot completed the landing on the “The pilot confirmed that he had an unsafe nose and right main landing gear, which re- gear indication on the left main landing gear,” sulted in substantial damage to the left wing and the NTSB report said. “He then actuated the test fuselage,” the report said. switch, and all three lamps illuminated, dem- Examination of the left main landing gear onstrating that he did not have a burned-out revealed that the supports for the actuator indicating lamp.” bearings lacked adequate lubrication and were The pilot cycled the gear, but the problem worn. Investigators were unable to determine persisted. He said that while subsequently us- whether the actuator had not been lubricated ing the backup manual gear-extension system, properly during installation 31 months earlier “the pressure required to pump the gear down or subsequent inspections did not detect a loss became greater and greater until something gave of lubrication.
PISTON AIRPLANES
Engine Fails on Takeoff The report also said that the engine likely Beech E18S. Destroyed. One fatality. had lost power on takeoff and that “there was no hortly after taking off from Runway 09L at evidence that the pilot attempted to perform the Opa-Locka (Florida, U.S.) Executive Airport manufacturer’s published single-engine proce- Sfor a cargo flight to the Bahamas the morn- dure, which would have allowed him to main- ing of May 2, 2011, the pilot told ATC that he tain altitude. Contrary to the procedure, the was turning downwind, rather than departing to left and right throttle control levers were in the the east, as planned. full-throttle position, the mixture control levers “According to witnesses, the airplane did were in the full-rich position, neither propeller not sound like it was developing full power,” was feathered, and the landing gear was down.” the NTSB report said. “The airplane climbed about 100 feet, banked to the left, began Parking Brake Overlooked losing altitude and impacted a tree, a fence De Havilland DHC-2 Beaver. Substantial damage. No injuries. and two vehicles before coming to rest in a fter landing the single-engine airplane at residential area.” The pilot, alone in the air- a base camp on the Tahiltna Glacier in plane, was killed, but no one on the ground AAlaska, U.S., on May 22, 2012, the pilot was hurt. raised the landing skis, placing the Beaver on its Investigators found that the pilot “had wheels, and set the parking brake to prevent the been having problems with the no. 2 [right] airplane from sliding. engine for months [but] continued to fly the Later, while preparing to depart from the airplane,” the report said, noting that the base camp, the pilot lowered the skis but forgot to Twin Beech had been parked outside in a release the parking brake, the NTSB report said. moist environment. The parking brake was still set when the Examination of the right engine revealed pilot conducted a wheel landing on a hard-sur- several discrepancies that would have caused faced runway in Talkeetna. The Beaver came “erratic and unreliable operation,” including in- to an abrupt stop and pitched nose-down; the ternal corrosion preventing both magnetos and horizontal stabilizer was substantially damaged the fuel pump from functioning properly, and when it fell back onto the runway. The pilot low compression in four of the nine cylinders. and four passengers were not hurt.
58 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MAY 2013 ONRECORD
HELICOPTERS
Control Lost During Search Distracted by Radio Call MD Helicopters MD902. Destroyed. Three serious injuries. Eurocopter AS350 B2. Substantial damage. Three minor injuries. he pilot, flight engineer and forward- he pilot, who had recently purchased the he- looking infrared radar (FLIR) operator licopter, was receiving training by a certified Taboard the state police helicopter were Tflight instructor (CFI) at Alliance Airport in searching for a missing person near En- Fort Worth, Texas, U.S., the morning of May 29, gelsbrand, Germany, in night VMC on May 2011. “During practice traffic pattern work, the 10, 2011. The helicopter was circling about helicopter’s hydraulic system was turned off to 600 ft above a hill when the radar operator simulate hydraulic failure on the flight control announced that the FLIR was showing an system,” the NTSB report said. unidentified heat source. During the subsequent approach, the CFI The pilot and flight engineer donned night and the pilot may have been distracted when vision goggles (NVGs). The pilot then maneu- an airport traffic controller advised that they vered the MD902 close to the displayed heat were using an incorrect radio frequency, the source and reduced speed to place the helicopter report said. While the instructor was setting in a hover. “Suddenly, the helicopter yawed to the correct frequency, the helicopter slowed and the right,” said the report by the German Federal entered an uncommanded left yaw. Bureau of Aircraft Accident Investigation. “He “The CFI tried to regain control by adding responded [by] actuating the left pedal up to the right pedal, trying to gain forward airspeed, and mechanical stop.” reducing power,” the report said. “The helicop- However, the helicopter continued to ter did not respond to the CFI’s control inputs, yaw right and then descended out of control descended and impacted terrain.” The pilot, CFI into the forest. All three occupants sustained and passenger sustained minor injuries. serious injuries. The radar operator exited the wreckage unaided; the pilot and flight Loose Nut Causes Power Loss engineer were rescued by police ground Bell 206B. Substantial damage. No injuries. crewmembers. fter the JetRanger’s engine lost power during The report concluded that visual restric- an aerial-application flight near Burbank, tions resulting from the use of the NVGs, AWashington, U.S., on May 30, 2012, the pilot distractions caused by the search for the miss- conducted an autorotative landing in an apple ing person, and a “loss of spatial perception” orchard. “During the landing, the rotor blades were among factors that likely contributed to impacted the trees and the tail boom separated the accident. from the main fuselage,” the NTSB report said. “It is likely that while trying to position the Maintenance records showed that the heli- helicopter as close as possible to the identified copter had been flown six hours since the en- heat source, an unnoticed loss of altitude and gine bleed air valve was replaced. Investigators backward movement of the helicopter oc- determined that maintenance personnel had not curred,” the report said. “It is highly likely that applied sufficient torque to secure a B-nut that the restricted spatial perception of the pilot due attaches the compressor discharge pressure air to the NVGs contributed to the occurrence; the tube to the engine. The B-nut had backed off the same is true for crewmembers whose attention stud during the accident flight, causing the air was focused on the search.” tube to detach and the engine to lose power.
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Preliminary Reports, March 2013
Date Location Aircraft Type Aircraft Damage Injuries March 1 Broomfield, Colorado, U.S. Aero Commander 500B substantial 2 none The pilot landed the Commander gear-up on a golf course after both engines lost power on takeoff for a test flight. March 2 Papua New Guinea Hughes 369HS substantial 1 fatal, 1 serious The pilot of the fish-spotting helicopter circled over a fishing vessel before placing the 369 in a hover to deploy a radio buoy. The helicopter was struck by the vessel and descended out of control, killing the observer. March 2 Ciales, Puerto Rico Robinson R44 destroyed 1 minor The R44 struck power lines and crashed after rotor speed decreased during cruise flight. March 4 Goma, Democratic Republic of Congo Fokker 50 destroyed 7 fatal, 3 serious The Fokker crashed in a residential area during approach in adverse weather conditions. March 4 Annemasse, France Beech Premier 1A destroyed 2 fatal, 1 serious Day visual meteorological conditions prevailed when the airplane struck a house and crashed in a field shortly after takeoff. March 5 Danville, California, U.S. Bombardier Q400 minor 51 none The Q400 was climbing through 20,000 ft when the flight crew heard a bang and received a no. 2 engine fire warning. The crew activated the fire extinguishers, but the fire warning persisted. They shut down the engine and returned to San Jose. March 6 Roskilde, Denmark Partenavia P68 Observer destroyed 2 fatal The aircraft was on a bird-control flight when it crashed under unknown circumstances on approach. March 6 Matibamba, Peru Beech King Air B200 destroyed 9 fatal The King Air struck a hillside during a charter flight to a gold-mining site. March 8 Aleknagik, Alaska, U.S. Beech 1900C destroyed 2 fatal Instrument meteorological conditions prevailed when the cargo airplane struck rising terrain shortly after the flight crew requested and received clearance to enter a holding pattern at an initial approach fix, to check on runway conditions at Dillingham. March 9 Turangi, New Zealand Robinson R66 destroyed 1 fatal The turbine helicopter crashed in mountainous terrain under unknown circumstances. March 12 Almerin, Brazil Embraer 821 Caraja destroyed 10 fatal The EMB-821, a version of the Piper Navajo, crashed under unknown circumstances during a charter flight. March 12 Katowice, Poland Boeing 737-800 none 185 none No injuries or damage occurred when the 737 overran the runway on landing. March 14 Eagle Nest, New Mexico, U.S. Robinson R44 substantial 2 none The flight instructor conducted an autorotative landing on an open field after the engine lost power during cruise flight. The main rotor blades struck and severed the tail boom on touchdown. March 15 Fort Lauderdale, Florida, U.S. Piper Cheyenne destroyed 3 fatal The Cheyenne was departing for a post-maintenance check flight when the pilot declared an emergency and attempted to return to the airport. A witness said that the airplane appeared to stall before rolling 90 degrees and descending into a parking lot. March 15 Lake Charles, Louisiana, U.S. Sikorsky S-76A substantial 3 fatal The pilot declared an emergency and said that he would conduct an off-airport landing shortly before the S-76 crashed during a post-maintenance check flight. March 17 South Bend, Indiana, U.S. Beech Premier 1A destroyed 2 fatal, 3 serious The pilot reported an electrical system problem before the airplane stalled on approach and crashed in a residential area. One person on the ground was seriously injured. March 23 Vostochnaya, Russia PZL-Mielec An-2R destroyed 1 fatal, 1 serious The aircraft crashed in a pond when the engine lost power during a test flight. March 24 Jeddah, Saudi Arabia Boeing 747-400 substantial 317 none An “explosion” and fire occurred when the no. 4 engine was started after pushback from a gate. Initial examination of the 747 revealed thermal damage to the outboard flap and jackscrew fairing.
This information, gathered from various government and media sources, is subject to change as the investigations of the accidents and incidents are completed.
60 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MAY 2013 MULTIPLE AVIATION INDUSTRY SEGMENTS. ONE MESSAGE: SAFETY.
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