AeroSafety world
2007 SAFETY REVIEW Loss of control events on the rise
MEDICATIng DEPRESSION Allowing pilots to continue flying
ASAP FOR THE CABIN Opening the door to reports CAUSAL FACTORS A340 at Toronto; 737 at Midway CLOSING SAFETY GAPS measuring your culture
TheFlight Journal Safety of FFoundationlight Safety Foundation February 2008 Serious business at the Singapore Airshow flies just as easily in smart casuals.
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rowth is good, but a consensus is forming The burden of deciding who enters the air that the lack of qualified personnel is a ma- transport business, and at what skill level, now jor challenge to that growth. International falls on the shoulders of overburdened chief Air Transport Association estimates that pilots and training managers at hundreds of itsG member airlines will need 17,000 new pilots a regional airlines and developing low-cost carri- year over the next 20 years. Boeing estimates look ers. They typically have few resources and must for 360,000 new pilots over the same time period, cope with massive turnover rates as their pilots and that doesn’t include business aviation, the very get hired away by the pilot-needy legacy carriers. light jet market and so on. But somehow they have to deal with a succession That’s a lot of pilots. So, how do we decide of new pilots, some with minimum qualifications, when new pilots are ready to go on the line fly- and teach them to fly transport category jet aircraft ing jets? Current international regulations are while maintaining a perfect level of safety. Some not much help. The minimum legal requirement have to cope with trainees that may speak different is an instrument rating and a commercial pilot languages, come from incompatible cultures and license; a commercial pilot license earned on small hold certificates of questionable origin. When you piston-engine airplanes may have made sense 60 step back and look at this, it doesn’t make much years ago, but it doesn’t do much to prepare a first sense: Some of the most constrained people in officer for an RJ or an Airbus A320. our business are being asked to do something In the past, this hasn’t mattered; the military, that is nearly impossible yet at the same time is the marketplace and the legacy airlines set stan- absolutely essential. dards far above the legal requirements. During What can we do? First, we had better lend the ’70s and ’80s, big militaries with high turnover these people a hand. They need the best practical supplied lots of pilots to the civil aviation market. tools and advice, and when they say the system is Places like North America and Australia could being pushed too far, we need to listen. Second, count on the rich reservoir of their large gen- this industry should take another look at how eral aviation segments for experienced personnel, we want to set competency and qualification while legacy airlines in Europe and Asia invested requirements and put in place a sensible system heavily in ab initio training programs to produce of regulation that matches the demands of this pilots at a controllable rate. century. More could be done, but that would be Things have changed. The flow of military a good start. pilots has slowed. The industry is only a few years into this new expansion, and the pool of highly qualified general aviation pilots is largely gone. The world that was dominated by legacy carriers is increasingly influenced by start-up airlines whose expansion plans do not allow for William R. Voss the time or overhead costs associated with ab President and CEO initio programs. Flight Safety Foundation www.flightsafety.org | AeroSafetyWorld | February 2008 | 1 AeroSafetyWorld
contents February2008 Vol 3 Issue 2 features
12 2007Review | LOC Up 12 18 CoverStory | Culture Counts 24 AviationMedicine | Antidepressants in Aviation
28 CausalFactors | Overrun at Midway
34 CabinSafety | Speaking Up
40 CausalFactors | Blindsided
46 FlightTech | Lighting Strikes 18 departments
1 President’sMessage | Achilles’ Heel
5 EditorialPage | Management Risk
6 AirMail | Letters From Our Readers
8 InBrief | Safety News 24
2 | flight safety foundation | AeroSafetyWorld | February 2008 28 34 40
AeroSafetyWORLD telephone: +1 703.739.6700 11 SafetyCalendar | Industry Events William R. Voss, publisher, FSF president and CEO [email protected], ext. 108 49 | Making Headway on the Runway DataLink J.A. Donoghue, editor-in-chief, FSF director of publications 53 InfoScan | At Your Surface [email protected], ext. 116 Mark Lacagnina, senior editor [email protected], ext. 114 57 OnRecord | Throttle Trouble Wayne Rosenkrans, senior editor [email protected], ext. 115 Linda Werfelman, senior editor [email protected], ext. 122 Rick Darby, associate editor [email protected], ext. 113 Karen K. Ehrlich, web and print production coordinator [email protected], ext. 117 Ann L. Mullikin, art director and designer [email protected], ext. 120 Susan D. Reed, production specialist [email protected], ext. 123 About the Cover Measuring a safety culture enables management. Patricia Setze, librarian Photo: © Brett Charleton/iStockphoto [email protected], ext. 103
Editorial Advisory Board We Encourage Reprints (For permissions, go to
www.flightsafety.org | AeroSafetyWorld | February 2008 | 3 22-24 April 2008 Rosen Shingle Creek Resort Orlando, Florida EARLY BIRD DISCOUNTS AVAILABLE
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hange happens, as they say, and departments, suppliers and maintenance A written safety policy statement success largely is a measure of operations, but this drift has occurred at from the CEO also provides protection how change is anticipated and major airlines with sterling technical rep- from tampering from lower levels and ultimately handled. utations; no organization is immune. can serve as a legacy document to in- CWhen it comes to safety culture, The defense of safety programs is fluence future CEOs, impressing upon whether change is good or bad depends made difficult by the fact that when they them the importance of maintaining the on the starting point. Naturally, we ap- are performing well, there is an absence effort. It strikes me that getting some plaud changes for the better. However, I of accidents and incidents. A new leader buy-in from the chairman of the board cringe at the harmful change that could may come to the conclusion that since and several board members also would be inflicted by management hotshots there is no safety problem, safety is not be beneficial in deeply embedding the arriving in their new executive positions a problem. And while a safety manage- safety focus into the corporate DNA of not simply full of ideas, but with firmly ment system (SMS) or a flight operational any organization. held beliefs that they know all they need quality assurance program is not costly The last line of defense against po- to know. When they encounter issues in the big scheme of things, it is difficult tentially risky corporate trimming is the beyond their experience, some tend to from a traditional beancounter point of operational people, those with the deep discount the importance of what is not view to clearly identify a program’s cost- knowledge of aviation and its lurking already in their operating plan. benefit justification for a newcomer who threats, those with a vested interest in The company does not have to be in lacks an appreciation of the real risks that maintaining the culture. The fight for trouble for a new manager to have this aviation presents. Difficult, that is, until aviation safety generally is in ascension, mindset; the very fact that the new man- something regrettable happens, the kind but episodic retreats must be anticipated ager has not been in charge is sufficient of proof we are working to avoid. and battled. evidence for some to believe that major A safe operation is the product of changes are essential. dedicated, relentless efforts. Guarding While I am concerned mostly about against a reduction of those efforts is conscious management actions, harm one of the reasons that SMS involves the also may be done without a conscious firm’s CEO (ASW, 1/08, p. 18). The CEO’s decision — to slight this safety program direct involvement, along with endow- J.A. Donoghue or that aspect of the safety culture — by ing the SMS with the blessing of the top Editor-in-Chief allowing a small wedge of neglect to corporate officer, helps to eliminate the AeroSafety World begin a drift away from best practices possibility that a lower-level manager and proven procedures. This discussion will make unilateral decisions that might applies mostly to corporate aviation degrade an effective safety culture. www.flightsafety.org | AeroSafetyWorld | February 2008 | 5 AirMail
ALAR Tools ‘On the Shelf’? Tool Kit and the continuing he recent report (see p. 40) con- efforts of the ALAR team cerning the A340 overrun accident and their worldwide work- Tat Toronto Pearson Airport recom- shops, particularly so as the accident mends more training “to better enable report referenced the ALAR Tool Kit in pilots to make landing decisions in the analysis. deteriorating weather.” This view might identify a problem The thorough and well-balanced re- with the use of the tool kit, where its port also observes that if the trend in the full potential has yet to be achieved in number of recent overrun accidents with daily operations. The industry cannot AeroSafety World encourages similar factors involved continues, then afford to have such a good safety tool comments from readers, and will “the resultant risk of loss of life and dam- “sitting on the shelf” as occurred with assume that letters and e-mails age to property and the environment will some previous initiatives. Thus, in this are meant for publication unless increase considerably. This is worrisome respect I hope that the Foundation can otherwise stated. Correspondence because it is a clear indication that, in restate the need for all national authori- is subject to editing for length spite of the efforts of all concerned, and ties to reference the ALAR Tool Kit in and clarity. although we are learning from these ac- their training programs and, together Write to J.A. Donoghue, director cidents or the experiences of others, we with operators, ensure that the ALAR of publications, Flight Safety seem unable to develop adequate tools materials are both made available to ev- Foundation, 601 Madison St., to mitigate this specific risk.” ery pilot and used in daily operations. Suite 300, Alexandria, VA The comment above appears to 22314-1756 USA, or e-mail belittle the value of the FSF Approach- Dan Gurney
FSFSeminars Exhibit and Sponsorship Opportunities Available EASS March 10–12, 2008 Flight Safety Foundation and European Regions Airline Association 20th annual European Aviation Safety Seminar JW Marriott Bucharest Grand Hotel, Bucharest, Romania CASS April 29–May 1, 2008 Flight Safety Foundation and National Business Aviation Association 53rd annual Corporate Aviation Safety Seminar
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6 | flight safety foundation | AerosafetyWorld | February 2008 Serving Aviation Safety Interests for More Than 60 Years
light Safety Foundation is an international membership organization dedicated to Officers and Staff Chairman, the continuous improvement of aviation safety. Nonprofit and independent, the Board of Governors Amb. Edward W. Foundation was launched officially in 1947 in response to the aviation industry’s need Stimpson F President and CEO William R. Voss for a neutral clearinghouse to disseminate objective safety information, and for a credible Executive Vice President Robert H. Vandel and knowledgeable body that would identify threats to safety, analyze the problems and General Counsel recommend practical solutions to them. Since its beginning, the Foundation has acted in the and Secretary Kenneth P. Quinn, Esq. public interest to produce positive influence on aviation safety. Today, the Foundation provides Treasurer David J. Barger leadership to more than 1,170 individuals and member organizations in 142 countries. Administrative Manager, Support Services Linda Crowley Horger MemberGuide Financial Flight Safety Foundation 601 Madison Street, Suite 300, Alexandria, VA, 22314-1756 USA Chief Financial Officer Penny Young tel: +1 703.739.6700 fax: +1 703.739.6708 Staff Accountant Maya Barbee www.flightsafety.org Membership Director, Membership and Development Ann Hill Membership Services Coordinator Namratha Apparao Membership Services Coordinator Ahlam Wahdan
Communications Director of Communications Emily McGee
Technical Director of Technical Programs James M. Burin Member enrollment ext. 105 Technical Specialist/ Ann Hill, director, membership and development [email protected] Safety Auditor Robert Feeler Seminar registration ext. 101 Manager of Namratha Apparao, membership services coordinator [email protected] Aviation Safety Audits Darol V. Holsman Seminar/AeroSafety World sponsorships ext. 105 Ann Hill, director, membership and development [email protected] Past President Stuart Matthews Founder Jerome Lederer Exhibitor opportunities ext. 105 1902–2004 Ann Hill, director, membership and development [email protected] AeroSafety World orders ext. 101 Membership Department [email protected] Technical product orders ext. 111 Maya Barbee, staff accountant [email protected] Library services/seminar proceedings ext. 103 Patricia Setze, librarian [email protected] Web Site ext. 117 Karen Ehrlich, web and print production coordinator [email protected]
www.flightsafety.org | AeroSafetyWorld | February 2008 SINCE 1947 | 7 inBrief Safety News Runway Distance Markers
he U.K. Air Accidents Investigation the accident said that the Branch (AAIB) has recommended airplane, registered in Jordan Ta reassessment of runway distance and being operated for a markers for runways with “a profile that Spanish charter airline, had prevents the end of the paved surface touched down just beyond from being in view continuously from the marked touchdown zone, the flight deck.” with low autobrake selected. The AAIB said that the International The pilots began manual Civil Aviation Organization (ICAO) wheel braking soon after the should conduct a reassessment of the main wheels touched down, © Lowell Sannes/iStockphoto.com advantages and disadvantages that the but the brakes stopped oper- distance markers present for runway ating for about 17 seconds. the cause of the brake failure was “consis- situational awareness. If the reassessment “A pronounced dip in the runway tent with the effects of excessive noise in indicates that advantages would outweigh surface initially prevented the pilots from the electrical signals from the main wheel disadvantages, ICAO should encourage seeing the runway end,” the report said. tachometers used to sense groundspeed.” installation of the distance markers at The pilots used nosewheel steering to turn Other AAIB recommendations called for “relevant civil airports,” the AAIB said. the airplane to the right, and it skidded to the European Aviation Safety Agency to re- The recommendation was one of a stop with the nosewheels off the runway quire replacement of the tachometer drive seven that resulted from the AAIB in- “shortly before the end of the paved surface shafts and to require Airbus to “take mea- vestigation of a runway overrun that fol- and the start of a steep downslope,” the sures aimed at ensuring that anomalies in lowed a brake failure on an Airbus A320 report said. A318/319/320/321 aircraft braking systems at Leeds Bradford International Airport The 178 people in the airplane were that may lead to loss of normal braking are in England. The AAIB final report on not seriously injured. The AAIB said that clearly indicated to the flight crew.”
Radar Altimeter Requirement
ll emergency medical ser- radar altimeter provides a pilot with con- vices (EMS) helicopters used in stant information about the helicopter’s Anighttime operations should be height above ground level and has an equipped with functioning radar altim- alerter function that can visually and/or eters, the U.S. National Transportation aurally alert a pilot when the helicopter Safety Board (NTSB) says. approaches and then descends below a The NTSB cited two recent nighttime pre-selected altitude.” accidents involving EMS helicopters, noting The two accidents cited were: Air Force U.S. that both aircraft had “inoperative or errati- • The Jan. 10, 2005, controlled • The April 20, 2004, CFIT crash of a cally operative” radar altimeters. As a result flight into terrain (CFIT) crash of Bell 206L-1 in Boonville, Indiana, of its investigations of those accidents, the a Eurocopter EC 135P2 into the during a patient transport flight in NTSB issued two safety recommenda- Potomac River near Oxon Hill, nighttime VMC. The patient was tions to the U.S. Federal Aviation Admin- Maryland, in nighttime visual killed, and the pilot, paramedic istration (FAA) to require operators to meteorological conditions (VMC). and flight nurse received serious install radar altimeters and to ensure that The pilot and flight paramedic injuries. The NTSB said that the minimum equipment lists for helicopters were killed, and the flight nurse probable cause was “the pilot’s in- used in EMS specify that radar altimeters received serious injuries. The adequate planning/decision, which be operable during nighttime flights. NTSB said that the probable cause resulted in his failure to maintain “Radar altimeters are needed to was the “pilot’s failure to identify terrain clearance.” The NTSB said maintain ground clearance when visual and arrest the helicopter’s descent, that the pilot who had flown the references to terrain are limited during which resulted in CFIT.” One of helicopter before the accident flight night conditions,” the NTSB said. “Dur- the contributing factors was the reported that the radar altimeter ing low-altitude flight, a functioning lack of an operable radar altimeter. was “operating erratically.”
8 | flight safety foundation | AeroSafetyWorld | February 2008 inBrief
Inspections Recommended
perators of Boeing 777s should The operator’s subsequent inspec- external power receptacles to “eliminate be required to conduct regular tion found indications of overheating the possibility of debris entering the Oinspections of external power on contact pins in 55 percent of the 43 receptacles and causing electrical short- receptacles and their protective cover 777s in its fleet. Twelve percent of the ing and arcing between the receptacle guards to detect and repair worn or receptacles contained loose contact studs.” overheated pins and thermal damage, pins that displayed indications of the U.S. National Transportation Safety melting. Board (NTSB) says. The NTSB said that it was concerned The safety recommendation, as well that “the proximity of the NLG hydraulic as several accompanying recommenda- line to the primary and secondary power tions, follow the investigation of a Nov. receptacles makes it susceptible to dam- 15, 2004, fire in the electrical/electronic age resulting from uncontained electrical equipment center compartment of a arcing that may occur.” British Airways 777-200ER after the In August 2007, Boeing issued airplane arrived at Boston Logan Inter- Service Bulletin 777-29-0032, which national Airport. No one was injured in recommended installing fire-resistant the incident, which the NTSB said was tape around the hydraulic line in the area caused by “a combination of electrical next to the receptacles. The NTSB said arcing between the lower terminal studs that the U. S. Federal Aviation Admin- at the primary power receptacle and istration should issue an airworthiness misting hydraulic fluid from a ruptured directive to require operators to comply nose landing gear (NLG) hydraulic with the service bulletin. line.” There was extensive thermal The NTSB also called on the FAA damage to the power receptacle, its to require Boeing to modify — and air protective cover guard, wiring and the carriers to install — protective cover hydraulic line. guards for 777 primary and secondary © Bart Claeys/iStockphoto.com
Analyzing Pilot Error
ilot error has declined as a cause of airline accidents, the overall rate of airline mishaps remained stable during the according to public health researchers who analyzed data period studied, the proportion involving pilot error decreased Pfrom 558 airline mishaps that occurred in the United by 40 percent and the rate of mishaps involving poor decision States between 1983 and 2002. making by pilots decreased 71 percent. The report by researchers at the Johns Hopkins The report, published in the January issue of Aviation, Bloomberg School of Public Health in Baltimore said that Space, and Environmental Medicine, said that the reduction in pilot error resulted from improved training and technology that aided pilot decision making. The decrease in mishaps resulting from pilot error was offset by increases in mishaps involving other causes, includ- ing errors by air traffic controllers or ground personnel, the report said. Researchers found an increase — from a rate of 2.5 to 6.0 per 10 million flights — in mishaps that occurred while aircraft were motionless on the ground or during pushback. They also found decreases of about 70 percent each in mishaps related to weather, mishaps that involved “mishandling wind or runway conditions” and mishaps related to poor crew interaction. © Dragan Trifunovic/iStockphoto.com
www.flightsafety.org | AeroSafetyWorld | February 2008 | 9 inBrief
CFIT in Australia
ontrolled flight into terrain (CFIT) accounted for four, the report occurs rarely in Australia, but of 25 said. CCFIT accidents between 1996 and “In line with international 2005, 60 percent were fatal, the Australian experience, nearly two-thirds of Transport Safety Bureau (ATSB) says. CFIT accidents and incidents The ATSB report said that only one of in Australia occurred in the ap- the 25 CFIT accidents and two CFIT in- proach phase of flight, of which cidents involved regular public transport half … were during an instru- operations — the May 7, 2005, crash of a ment approach,” the report said. © Jean-Marie Maillet/Fotolia.com Transair Fairchild Metro 23 near Lockhart “Approach phase CFIT oc- six occurrences]. Of these, four occur- River in Queensland (ASW, 6/07, p. 28). currences were further analyzed on the rences involved an area navigation global Both pilots and all 13 passengers were basis of whether the accident or incident navigation satellite system approach, killed in the crash; that number accounts occurred during a visual or instrument which only came into service in Australia for nearly one-third of all CFIT fatalities approach. Of the 17 CFIT occurrences in in the late 1990s, part way through the in Australia during the 10-year period. the approach phase, 53 percent were con- [period that was studied]. The imple- Private/business flights accounted ducting an instrument approach. … The mentation of approaches with vertical for 14 CFIT occurrences, charter opera- highest number of instrument approach guidance would aid CFIT prevention on tions accounted for eight, and “other CFIT occurrences involved satellite-based approaches previously only capable of aerial work general aviation” operations instrument approaches [67 percent, or providing lateral guidance.”
Online Bird Strikes In Other News …
ircraft operators and airport Yearwood of the CAA Aerodrome ir China Chairman Li Jiaxi- employees in the United Standards Department. “We believe ang has been named to replace AKingdom now can file reports that this automated procedure will AYang Yuanyuan as minister of of bird strikes online. The U.K. Civil make it quicker and easier for pilots the General Administration of Civil Aviation Authority (CAA) introduced and aerodrome officials to file bird Aviation of China, published reports its new online reporting system on strike reports. This will ensure that say. … The U.S. National Trans- Jan. 1, with a reporting form on the we have a more accurate record of portation Safety Board has called CAA Web site. bird strike events that we can share on manufacturers of lithium batteries The CAA said that online report- with the industry in order to improve and electronic devices to work with ing — now the preferred method of bird control procedures.” air carriers and other organizations to reporting a bird disseminate guidance to flight crews strike — will be a and aircraft passengers about the safe more efficient way carriage of secondary (rechargeable) of managing bird lithium batteries (ASW, 1/08, p. 9). … strike data. Report- Regulatory changes in Canada will ing of bird strikes require implementation of safety man- became mandatory agement systems for airports and air in 2004. traffic services (ASW, 1/08, p. 14). … “Prior to bird The Civil Aviation Safety Author- strike reporting ity of Australia (CASA) has warned becoming maintenance personnel to check fuel mandatory, there filters in piston-engine aircraft for was a large degree silicone grease contamination. CASA of under-report- says the grease may lead to a rough- ing,” said Nick running engine. © Eremin Sergey/Dreamstime.com
Compiled and edited by Linda Werfelman.
10 | flight safety foundation | AeroSafetyWorld | February 2008 safetycalendar
FEB. 5–7 ➤ 16th Annual Safety-critical Systems MARCH 13–15 ➤ ARSA 2008 Annual Repair APRIL 29–MAY 1 ➤ 53rd annual Corporate Symposium. Centre for Software Reliability. Bristol, Symposium. Aeronautical Repair Station Aviation Safety Seminar (CASS). Flight Safety England. Joan Atkinson,
FEB. 18 ➤ Air Transport World 34th Annual MARCH 18–20 ➤ Search and Rescue 2008 MAY 11–15 79th ➤ Annual Scientific Award Ceremony. Air Transport World. Singapore. Conference and Exhibition. The Shephard Group. Meeting. Aerospace Medical Association. Boston. Barbara Rose,
www.flightsafety.org | AeroSafetyWorld | February 2008 | 11 2007review LOC UpBY JAMES M. BURIN
Loss of control accidents replaced CFIT as the leading cause of commercial aviation fatalities in 2007.
he overall safety of commercial there were more fatalities in turboprop 7 percent of the commercial turbojet jet operations worldwide re- accidents, rising from 139 in 2006 to 159 fleet and 13 percent of the commercial mained excellent in 2007, but last year. Business jets last year had 12 turboprop fleet are inactive. loss of control (LOC) accidents accidents that killed 21 people, com- Of the 15 major accidents involving Tovertook controlled flight into terrain pared with 10 accidents in 2006 and 19 commercial jets in 2007 in all sched- (CFIT) as the leading cause of fatali- deaths (Table 3, p. 14). uled and unscheduled passenger and ties. However, fatalities in accidents The encouraging safety picture cargo operations, 11 were approach and involving commercial jets, commercial came with a larger fleet in 2007. The landing accidents. There were two CFIT turboprops and business aviation jets total fleet of large jet transports rose accidents and four LOC accidents. dropped to 763 from 903 in 2006. 3.7 percent to 20,262, with 8 percent of Last year started out with only six While major commercial jet crashes that number Eastern-built. The fleet of major turboprop accidents by July. Nor- increased from 11 in 2006 to 15 last year, commercial turboprops seating more mally, commercial turboprops average eight accidents involved fatalities, com- than 14 passengers, 25 percent of which two to three times the number of com- pared with nine in 2006 (Table 1); deaths are Eastern-built, declined 2.1 percent mercial jet major accidents. The acci- in commercial jet accidents dropped to 6,350 airplanes. The number of busi- dent rate for the second half of the year from 745 to 583. The 24 crashes of ness jets jumped 8.9 percent to 13,853. was more typical for the turboprops. commercial turboprop aircraft in 2007 Fleets in regular commercial service While the major accident rate equaled the 2006 experience (Table 2); are somewhat smaller; approximately in accidents per million departures
12 | flight safety foundation | AeroSafetyWorld | February 2008 2007review
Major Accidents, Worldwide Commercial Jets January 1, 2007–December 31, 2007
Date Operator Aircraft Location Phase Fatal Jan. 1, 2007 Adam Air 737 Sulawesi, Indonesia Enroute 102 Jan. 13, 2007 RPX Airlines 737 Kuching, Malaysia Landing 0 Feb. 13, 2007 Fort Aero CRJ-100 Vnukovo, Russia Takeoff 0 Feb. 21, 2007 Adam Air 737 Surabaya, Indonesia Landing 0 March 7, 2007 Garuda Indonesia 737 Yogyakarta, Indonesia Landing 22 March 17, 2007 UT Air Tu-134 Samara, Russia Landing 6 May 5, 2007 Kenya Airways 737 Douala, Cameroon Takeoff 114 LOC Up May 20, 2007 Air Canada Jazz CRJ-100 Toronto, Canada Landing 0 June 28, 2007 TAAG Angola 737 M’banza Congo, Angola Landing 5 July 17, 2007 TAM A320 São Paulo, Brazil Landing 187 July 17, 2007 Aero República EMB-190 Santa Marta, Colombia Landing 0 Aug. 20, 2007 China Airlines 737 Naha, Okinawa, Japan Post-Taxi 0 Sept. 16, 2007 One-Two-Go Airline MD-82 Phuket, Thailand Landing 90 Oct. 26, 2007 Philippine Airlines A320 Butuan, Philippines Landing 0 Nov. 30, 2007 Atlasjet Airlines MD-83 Ispara, Turkey Approach 57
Loss-of-control accident CFIT accident
Source: Ascend and Aviation Safety Network
Table 1
Major Accidents, Worldwide Commercial/Corporate Jets January 1, 2007–December 31, 2007 © Chris Photography Sorensen
Date Operator Aircraft Location Phase Fatal Jan. 7, 2007 Ahrenkiel Consulting Premier 1A St. Tropez, France Landing 0 Jan. 9, 2007 Ameristar Jet Charter Lear 24 Guadalajara, Mexico Approach 2
Jan. 12, 2007 SunQuest Air Charter Citation I Van Nuys, CA, USA Takeoff 2 Jan. 24, 2007 Air Trek Air Ambulance Citation II Butler, PA, USA Landing 0 May 3, 2007 Hamilton Ranches Citation II Dillon, MT, USA Approach 2
June 4, 2007 Toy Air Citation II Milwaukee, WI, USA Climb 6 June 30, 2007 IHR Admin Services Citation I Conway Field, AK, USA Landing 1 July 5, 2007 Jett Paquetería Sabreliner Culiacán, Mexico Takeoff 3 Oct. 7, 2007 Private Gulfstream II Santo Domingo, Landing 2 Venezuela Nov. 4, 2007 Reali Táxi Aéreo Lear 35 São Paulo, Brazil Takeoff 2 Nov. 11, 2007 Jetport Inc. Global 5000 Fox Harbor, Canada Landing 0 Dec. 26, 2007 Jet Connection CL-604 Almaty, Kazakhstan Takeoff 1 Business
Loss-of-control accident CFIT accident
Source: Ascend and Aviation Safety Network
Table 2
www.flightsafety.org | AeroSafetyWorld | February 2008 | 13 2007review
CFIT, LOC and Major Accidents, Worldwide Commercial Turboprops (> 14 Seats) approach and landing January 1, 2007–December 31, 2007 accidents continue to Date Operator Aircraft Location Phase Fatal claim the majority of Jan 9, 2007 Aeriantur-M Airlines AN-26 Adana, Turkey Approach 32 the aircraft and account March 30, 2007 Airlink EMB-110 New Britain, PNG Descent 2 for the majority of the May 17, 2007 Safe Air Company LET-410 Walikale, DRC Climb 3 commercial aircraft June 21, 2007 Karibu Airways LET-410 Kamina, DRC Climb 10 fatalities, with only two June 25, 2007 PMT Air AN-24 Sihanoukville, Cambodia Approach 22 commercial jet CFIT accidents in 2007. The June 26, 2007 Business Aviation LET-410 Brazzaville, Congo Enroute 0 chart highlights how July 1, 2007 Jet Airways ATR-72 Indore, India Landing 0 difficult it is to elimi- July 8, 2007 Laird Air DHC-6 Muncho Lake, Canada Climb 1 nate CFIT accidents, July 23, 2007 Djibouti Airways AN-26 Dire Dawa, Ethiopia Takeoff 1 except for one fact: No July 29, 2007 ATRAN Cargo Airlines AN-12 Moscow, Russia Climb 7 aircraft equipped with Aug. 9, 2007 Air Moorea DHC-6 Moorea-Temae, Polynesia Climb 20 a functioning terrain Aug. 12, 2007 Jeju Air DHC-8 Busan, Korea Landing 0 awareness and warning Aug. 21, 2007 SELVA Colombia AN-26 Pasto, Colombia Landing 0 system (TAWS) has Aug. 22, 2007 Two Táxi Aéreo EMB-110 Curitiba, Brazil Enroute 2 ever had a CFIT acci- Aug. 26, 2007 Great Lake Business AN-32 Kogolo, DRC Approach 10 dent. Only 5 percent of Aug. 27, 2007 SELVA Colombia AN-32 Mitu, Colombia Ground 0 the commercial jets in Aug. 31, 2007 Solenta Aviation DHC-6 Punia, DRC Enroute 0 the world do not have Sept. 7, 2007 Transavia Service AN-12 Goma, DRC Landing 8 TAWS, yet all of the Sept. 20, 207 Arctic Circle Air Svc Skyvan Mystic Lake, Alaska, USA Climb 1 eight CFIT accidents Sept. 24, 2007 Free Airlines LET-410 Malemba Nkulu, DRC Landing 1 over the last three years Oct. 4, 2007 Africa One AN -26 Kinshasa, DRC Climb 21 came from that small Oct. 8, 2007 Nacional de Aviación LET-410 Cubarral, Colombia Enroute 18 fraction of the fleet. Oct. 17, 2007 Imtrec Aviation AN-12 Phnom Penh, Cambodia Landing 0 In addition to Nov. 8, 2007 Juba Air Cargo AN-12 Khartoum, Sudan Landing 0 the commercial jet
Loss-of-control accident CFIT accident approach and landing accident record, busi- Source: Ascend ness jets were involved Table 3 in seven approach and landing accidents increased for the year, the five-year rolling aver- among the year’s 12 accidents, and 50 percent of age rate continues to show an encouraging slow the turboprop major accidents occurred during decline (Figure 1). The major accident numbers approach and landing. are for both Western- and Eastern-built com- Clearly, the industry must continue to focus mercial jets, but the rate is for Western-built on this critical phase of flight (Figure 2, p. 16). aircraft only because there are no reliable world- Most, if not all, of the causes of these accidents wide exposure data on Eastern-built aircraft are well documented; interventions that would with which to calculate rates. have prevented them are addressed in the Flight The accident rate data highlight the con- Safety Foundation ALAR Tool Kit. siderable improvement made in aviation safety. LOC accidents have taken over from CFIT If 2007 had the same rate as 1996, there would as the leading killer in commercial jet opera- have been more than double the number of ac- tions. The term “loss of control” is somewhat cidents during the year. misleading, since the flight crew often has total
14 | flight safety foundation | AeroSafetyWorld | February 2008 2007review
control of the aircraft in this type of accident. Islands. The worst run- The Foundation’s definition of an LOC accident way incursion accident Accident Classification is: “an accident in which an aircraft is put into in the U.S. was at Los an unrecoverable position due to aircrew, air- Angeles International ast year, Flight Safety Foundation craft or environmental factors, or a combination Airport in 1991, re- changed from using “hull loss” as the of these.” Thus, the American Airlines Airbus sulting in 34 fatalities. Lprimary accident criterion to a new A300 accident in 2001 was an LOC accident, the The worst runway standard, “major accident.” A major ac- crew having no control after the loss of the verti- incursion accident in cident is defined as an accident in which cal tail after takeoff from New York. Likewise, Europe occurred in any of three conditions is met. The first condition is that the aircraft is destroyed the 2004 Flash Airlines Boeing 737 accident in 2001 at Linate airport, or sustains major damage. Major damage Egypt was an LOC accident, even though the Milan, Italy, and re- is defined by the Ascend Damage Index crew had full control of the aircraft. sulted in 118 fatalities. (ADI), a measure developed by Paul Hayes Runway incur- of Ascend. The ADI is the ratio of the cost Runway Safety Initiative sions are part of a of repairs to the projected value of the air- The aviation industry today faces a major chal- new breed of safety craft had it been brand new at the time of the accident. If the ADI is over 50 percent, lenge in improving runway safety. Accidents challenges in which the damage is considered major. The sec- on or near runways normally are high-visibility there are not a lot of ond condition defining of a major accident accidents since they happen at an airport, where accidents — 10 in is that there are multiple fatalities. The there are a lot of people. As the numbers of oth- the last 14 years — third condition is that there is one fatality er types of accidents decline, the relative impor- but there are many and the aircraft is substantially damaged. tance of runway accidents has increased. When incidents. Since basic The major accident classification criteria ensure that an accident is not determined several international aviation organizations early risk management says by an aircraft’s age or by its insurance last year asked the Foundation to coordinate a risk equals probability coverage, and it gives a more accurate joint international effort to understand and ad- times severity — and reflection of the high-risk areas that need dress this challenge, the Runway Safety Initiative the severity potential to be addressed. (RSI) was launched. of a runway incursion — JB The RSI is using this definition of a runway is high — the risk is safety issue: “Any safety issue that deals with the runway environment, or any surface being utilized as a runway, and the areas immediately adjacent to Western-Built Commercial Jet Major-Accident Rates, 1993–2007 it, such as overruns or high-speed taxiways.” 1.6 Runway safety issues fall into three broad Major-accident rate Five-year moving average categories: runway incursions (RI), runway excur- 1.4 sions (RE) and the inappropriate use of runways 1.2 — runway confusion (RC). International Civil 1.0 Aviation Organization has published the following 0.8 definition of a runway incursion: “Any occurrence 0.6 at an aerodrome involving the incorrect presence 0.4 of an aircraft, vehicle or person on the protected 0.2 area of a surface designated for the landing and
Accident rate per million depatrtures rate Accident 0.0 takeoff of aircraft.” This new definition, recently 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 adopted by the U.S. Federal Aviation Administra- Year tion, brings most runway confusion incidents into Note: Worldwide departures are estimated through Dec. 31, 2007. Total departure data are the runway incursion category. not available for Eastern-built aircraft.
A runway incursion was the cause of the Source: Ascend largest single aviation disaster ever, the 1977 collision of two Boeing 747s at Tenerife, Canary Figure 1 www.flightsafety.org | AeroSafetyWorld | February 2008 | 15 2007review
Operators must use available manufacturer Approach-and-Landing Major Accidents, Commercial Jets, information and provide crews with good stan- 1995–2006 dard operating procedures, to include stabilized approach criteria and a true “no fault” go-around 13 13 policy. They must also provide crews with the 11 training that will enable them to address runway 10 10 safety challenges during line operations. The 9 9 crews must practice good decision making, and 7 7 they must have the information available to make 6 5 5 good decisions. Although the flight crew may be the final link in the chain of runway safety, Number of Accidents finding that the crew made an error should be the beginning of an investigation, not the end. The investigation needs to determine what role 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Year the airport, ATC, the regulator and even manage- ment played in the accident or incident. Source: Boeing, Ascend Airports have a vital role in runway safety. Figure 2 Issues like airport design, lighting, approach aids, runway design, runway markings and high. Thus, runway incursions get a lot of atten- signage, runway cleaning and clearing, runway tion despite the low number of accidents. condition measurement, and runway end safety However, runway excursions, including areas are only part of a long list of items that overruns — going off the end of a runway — and an airport controls that can reduce the risk of a veer-offs — going off the side of the runway — runway safety event. must not be overlooked. Many runway excursions ATC also plays a big role. As any pilot incur minimal damage and do not cause deaths knows, ATC can destabilize any approach. Late or injuries, yet in most years there are more fatali- runway changes and “slam dunk” approaches are ties associated with excursions than incursions. just two examples of how ATC can destabilize A runway excursion accident is unlike a CFIT an approach, and a stabilized approach is critical accident, which, by definition, is “without prior in reducing the risk of runway excursions. knowledge of the crew.” A runway excursion is Finally, the regulator plays a vital role in run- normally not a total surprise to the crew. way safety. It oversees all the stakeholders. It can Runway safety is influenced by many avia- also provide approaches with vertical guidance, tion industry elements. The stakeholders in critical to a stabilized approach. this issue include almost everyone involved in The first product of the RSI is a Runway Safe- aviation — manufacturers, aircraft operators, ty Products Catalog (Table 4). This lists the mate- airports, air traffic control (ATC) and regulators. rial available to address certain aspects of runway Manufacturers do a great job of providing the safety. The RSI team has also provided data on operators with safe, reliable aircraft. They also runway safety issues. In compiling runway safety provide operators with the data and procedures data (Table 5), runway excursions predominate in that crews need for normal and many non-nor- the number of both accidents and fatalities. mal operations. They currently are not required The RSI team has concluded that as an to provide data and procedures easily used by pi- industry we are being effective in preventing lots for landing in all runway conditions. Without runway incursion accidents, but the number of good data on how the aircraft will perform under incidents and potential severity still present a certain runway conditions, landings become a very high risk. Runway excursions are the most series of physics experiments. common type of runway accident, and the most
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Runway Safety Products Catalog
Product Title Originator Type Product Target Audience Runway incursion 1. ICAO Runway Safety Toolkit ICAO CD and web Aircrew, airports, ATM, management 2. Runway and Surface Safety FAA CD and web Flight instructors, pilot examiners 3. Taxi 101 FAA CD and web Maintenance personnel 4. Runway Incursion Prevention FAA, ACI, IATA, PAAST CD and web Aircrew, airports, ATM program 5. European Action Plan for the Prevention of Eurocontrol et al CD and web Aircrews, airports, ATM vehicle drivers Runway Incursions 6. Runway Incursion Joint Safety Analysis and FAA (CAST) CD Aircrews, airports, ATM Implementation Team Reports 7. FAA Runway Safety Website FAA Web site Aircrews, ATM, vehicle drivers 8. Enhanced Taxiway Centerline FAA CD and web Aircrews, ATM, airports 9. AOPA Runway Safety Course FAA, AOPA Web site General aviation pilots 10. ALPA Runway Safety Course FAA, ALPA Web site Aircrews 11. ACI Airside Safety Handbook ACI Handbook Airports 12. Sporty’s Pilot Guide to Runway Safety Sporty’s CD General aviation pilots Runway excursion 1. ALAR Tool Kit Flight Safety CD Aircrews, ATM, airports Foundation 2. Managing Threats and Errors During Approach Flight Safety Web Aircrews and Landing: How to Avoid a Runway Overrun Foundation 3. Takeoff Safety Training Aid FAA CD and web Aircrews Runway confusion Many runway incursion products may be applicable here.
Note: These groups are participating in the RSI: European Aviation Safety Agency, Civil Air Navigation Services Organisation, International Federation of Air Line Pilots Associations, U.S. Federal Aviation Administration, Air Traffic Control The Netherlands (LVNL), Boeing, Airbus, Embraer, Direction Générale de l’Aviation Civile - France, International Federation of Air Traffic Controllers’ Associations, National Aerospace Laboratory (NLR) - Netherlands, Airports Council International, International Air Transport Association, European Regions Airline Association, Eurocontrol, Association of Asia Pacific Airlines, U.S. National Transportation Safety Board, and Association of European Airlines.
Source: FSF Runway Safety Initiative
Table 4 common type of fatal runway safety for runway incursions, such as moving Runway Safety Fatality Data, accident. The severity of a runway maps, signage, etc., will be beneficial. 1995–2007 excursion depends on the energy of The Foundation continues to strive to the aircraft when departing the runway make aviation safer by reducing the risk Number of Fatal Onboard environment and on the airport layout. of an accident. We have had great success Accidents Fatalities A major risk reduction factor is flying a advancing toward that goal, but chal- Incursions 5 129 stabilized approach and landing in the lenges remain. In an industry where the Excursions 31 680 touchdown zone. Not every unstabi- risk will never be zero, we face a constant Confusion 2 132 lized approach ends up as an excursion challenge in meeting the public’s expec- Total 464 941 — but almost every excursion starts tation of perfection as the minimum Note: The total number of accidents was 1,332. with an unstable approach. acceptable standard. ● Source: FSF Runway Safety Initiative In preventing runway confusion, James M. Burin is FSF director of technical many of the interventions developed programs. Table 5 www.flightsafety.org | AeroSafetyWorld | February 2008 | 17 Coverstory
he importance of establishing and (NTSB) found. This training gap led to pilot maintaining a positive safety culture and judgment error, inappropriate procedures and a climate in any aviation organization is breakdown in flight crew communication. This now beyond debate. But little attention has accident was among several that led airlines to Tbeen paid to measuring an organization’s safety develop crew resource management training. environment, an omission that is important Similarly, the chain of errors that led to the because, as business schools preach, you can’t May 1996 ValuJet Airlines McDonnell Doug- manage what you can’t measure. las MD-80 crash in Florida is one of several However, an assessment tool developed examples of an “organizational accident,” an originally for U.S. Navy aviation units now can accident deeply rooted in a company’s lack of provide the foundation for a process of measur- leader commitment and support for safety. ing and tracking an organization’s safety culture. The term “safety culture” first appeared in Awareness of the existence of safety culture the accident investigation report published by in aviation, and its importance, evolved over re- the International Atomic Energy Agency’s (AEA) cent years through the examination of high-pro- Nuclear Advisory Group following the April 1986 file catastrophes. The first major airline accident meltdown and steam explosion of the nuclear attributed in part to organizational factors was power plant near Chernobyl, Ukraine. The AEA the January 1982 Air Florida Boeing 737 crash concluded that the nuclear reactor was poorly in Washington. designed and the people operating the plant were The flawed decision chain that led to the not properly trained or supervised. The acci- accident was a consequence of the company’s dent, said the World Nuclear Association, was a failure to give the flight crew adequate training, direct consequence of Cold War isolation and the the U.S. National Transportation Safety Board resulting lack of a safety culture.
By Anthony Ciavarelli
Measuring an organization’s safety culture provides an understanding of its strengths and weaknesses. Culture Counts Culture © iStockphoto
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Among the first to bring the term scrutiny by the U.S. Federal Aviation Following the F-14 accident, I served “culture” to the aviation community Administration. And the Columbia ac- as a member of a blue-ribbon panel was John Lauber when he was an NTSB cident was believed to have involved a formed to study the underlying causes member. Recognizing the influence of continuation of the poor safety culture of naval aviation aircraft accidents. The organizational factors as the root cause that had been revealed after the 1986 panel recognized that, in the Tennessee of some aviation accidents, he said of the Challenger accident. In both cases, accident and others like it, investigation September 1991 Britt Airways Brasilia NASA employees in the working ranks boards would find known circumstances accident in Texas, “a probable cause … had warned their supervisors about the that produce risks that were not appro- was the failure of this airline’s senior risk of losing a shuttle crew because of priately managed by the commanders. management to establish a corporate known system design flaws. The panel’s review concluded that culture that encouraged and enforced accidents of this type are very similar to adherence to approved maintenance and Safety Culture and Aviation civilian accidents like ValuJet, Cher- quality assurance procedures.” In spite of the professional’s use of the nobyl, Challenger and Columbia. This More recently, the Columbia space term and many popular notions about finding led to the development of the shuttle accident investigation linked it, there is no widely accepted defini- initial survey instrument designed to safety culture with the closely related tion of “safety culture.” Because there is assess safety climate, safety culture and concept of the “high-reliability organiza- no common metric for measuring the related organizational factors. tion” (HRO). The Columbia Accident strength of a particular safety culture, I also was part of a group from the Investigation Board (CAIB) concluded there is no clear method by which an U.S. Naval Postgraduate School that ex- that the shuttle’s breakup upon re-entry organization can assess its safety culture plored innovative methods for assessing in February 2003 had as much to do with or diagnose its particular strengths organizational factors, including safety the organizational culture and structure and weaknesses. This results in some climate and safety culture. We worked of the U.S. National Aeronautics and frustration on the part of the execu- with Professor Karlene Roberts of the Space Administration (NASA) as it did tives who must manage organizations University of California at Berkeley to with the foam chunks that detached from that necessarily operate in hazardous construct an employee survey based on the fuel tank and damaged the shuttle’s environments. her theory of an HRO. heat shield during the launch. The Navy responded to the chal- Roberts and her colleagues believe The CAIB determined that lenge of measuring and managing that some organizations operate more HRO concepts safety culture in 1996, when its avia- reliably than others because they place would be ex- tion squadrons experienced a rash of a higher value on safety and a greater tremely useful accidents attributed to human factors. focus on avoiding failure. Roberts in describing the One accident, in particular, captured conducted field studies on Navy aircraft culture that should the Navy’s attention. An F-14 crashed carriers, at air traffic control facilities exist at NASA. The on takeoff from an airport in Tennessee, and at nuclear power plants, organiza- CAIB discussed killing both crewmembers and several tions that have learned from experi- differences between the Navy and civilians on the ground. Investigators ence how to manage their risks. Some NASA in terms of safety culture and pointed to the failure of commanders characteristics that typify HROs are: operation as an HRO, and concluded to manage the pilot, who was known to • Accurate perception of hazards that NASA could substantially benefit take unnecessary risks. and operational risks; Measuring an organization’s safety culture by following the Navy’s example of best The accident occurred during a provides an understanding of its strengths and weaknesses. practices. cross-country flight, which included a • Commitment and involvement of The most egregious aspect of the visit to the pilot’s home town. With his all management levels in safety; organizational accident probably is the relatives watching, the pilot attempted • Open reporting of unsafe condi- failure of management to recognize a dangerously high-angle takeoff, flew tions or risk situations; the signs of an impending disaster. For into low clouds, became spatially dis- example, ValuJet’s maintenance even oriented and crashed into a residential • Good communication up and before the Florida accident was under complex. down the command chain;
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• Continuous training, with high safety principles and ensure adherence given by senior commissioned officers performance standards; and, to safety standards and procedures. (lieutenant commanders, commanders The CSA and MCAS surveys, and and captains) compared with lower- • A culture of trust between work- later applications in civilian aviation, ranking officers (ensigns, lieutenants ers and their supervisors. aerospace and health care, are designed junior grade and lieutenants). This The safety climate survey developed on to address key aspects of safety cli- relationship also holds for the noncom- principles of HRO theory is called the mate. Results from the surveys some- missioned officers (NCOs) — higher Command Safety Assessment Survey times can be used in the estimation of ranking NCOs (petty officers) gave (CSA). A Web-based version of the CSA accident risk based on the extent to higher ratings than the lower ranks. is in regular use by all U.S. Navy and which the organization exhibits HRO Ratings by an organization’s senior Marine Corps aviation units. Respon- attributes of leadership commitment to management also have been consistent- dents voluntarily and anonymously pro- safety, adequacy of policies, adherence ly higher in the civilian aviation, aero- vide opinions about their organization’s to standards and other factors. space and health care industries. This safety climate. The similar Maintenance The safety climate surveys have been suggests that supervisors might not be Climate Assessment Survey (MCAS) well received in naval aviation and serve fully aware of the thoughts and feelings was developed later for aircraft mainte- as an important source of performance of their subordinates when it comes to nance personnel. To see an example of feedback that commanders use to im- the organization’s safety climate and the the CSA, go to
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Differences in Average Ratings Across Military Ranks for Survey Items 1-61
5
4.5
4
3.5
3 Average CSA score Average Short resources Military rank Over-committed O4 - O6 2.5 O1 - O3 E6 - E9 E1 - E5 2 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 Survey items
CSA = command safety assessment
Source: Anthony Ciavarelli
Figure 1 survey items that reflect some of the underlying Five categories, representing different key com- Supervisors might organizational dimensions like climate, culture ponents of an HRO, are: not be fully aware or HRO attributes. • Safety process auditing — a system of The following are examples of survey state- checks and reviews to monitor and im- of the thoughts ments, selected for adherence to content validity: prove processes; and feelings of • My organization has a realistic view of our • Safety culture and reward system — social operational risks. recognition that reinforces desired behav- their subordinates • The leadership in this organization is very ior or corrects undesired behavior; when it comes to committed to safe operations. • Quality assurance (QA) — policies and • All levels of management are actively procedures that promote high-quality the organization’s involved in keeping us safe. performance and work performance safety climate … • I am not reluctant to report an unsafe • Risk management (RSK MNGT) — whether condition or a high-risk incident. or not the leaders correctly perceive opera- • Deliberate violations of rules or standards tional risks and take corrective action; and, are very rare in my organization. • Leadership and supervision (LDSHP) — • Sometimes the goal of diagnostic analysis policies, procedures and communication is achieved by organizing survey items processes used to improve people’s skills into specific measurement areas that and to proactively manage work activities reflect different components of climate, and operational risk. culture or HRO attributes. For the CSA, Using Survey Data the categories were adapted from studies by UC Berkeley researchers Roberts and When completed, a survey’s results can be Carolyn Libuser. reviewed as an overall outcome, with an average www.flightsafety.org | AeroSafetyWorld | February 2008 | 21 Coverstory
Normative information can be presented on a Supervisor’s Display Showing Survey Item Results supervisor’s display (Figure 2). The survey feed- back display shows a typical bar chart with agree- ment percentages along a five-point Likert scale.1 This display also shows a bell curve indicating the placement of a specific organization’s average rating on the bell curve. This placement allows a particular organization — a single department within a company — to compare its average to an overall company average or norm.
Validation Process Once a reasonable sample of survey data is obtained, another aspect of statistical goodness — predictive validity — can be addressed. We would expect organizations with a good safety climate and strong safety culture to have a better safety record than those organizations that do not — and this is exactly what we have found in examining the safety climate ratings from surveys taken over the past few years in naval aviation. Looking at the relationship between safety climate ratings and safety performance defined in terms of accident frequency we found a much Source: Anthony Ciavarelli higher number of accidents for low safety cli- Figure 2 mate ratings (Figure 3).
Navy Squadrons’ Flight Mishaps by Risk Management Score rating across all survey items, or the results can be broken down and compared for each indi- 10 Operational squadrons vidual HRO component. 9 All squadrons The normal distribution curve, or “bell 8 curve” can compare survey results to a specific 7 average or central value in the normal distribu- 6 tion. Using this device, and some statistical com- putation, an organization can compare its results 5 to an overall average or norm. The norm can be 4 based on a particular company’s average rating 3 or on the average for a particular industry. 2
With this “normative” approach, it would mishaps within one year A ight Class 1 be possible to establish norms for the entire 0 airline industry or another sector of the avia- Bottom Mid-low Mid-high Top tion industry — for example, air traffic control Quartiles based on risk management average
— or beyond aviation to include industry sec- Source: Anthony Ciavarelli tors such as aerospace, health care and oil and gas extraction. Figure 3
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the number of accidents (94 versus 49) in the Mishap Severity by Risk Management Score 24-month time frame. In another application of HRO-based safety climate measurement, we compared ratings ob- Class C tained from the Navy’s CSA to ratings obtained Class B from similar surveys of hospital personnel. Class A 72 Figure 5 shows an example of the results obtained when 23 common Likert scale survey 51 items used in Navy and hospital studies were
Mishaps 40 compared in terms of the number of “problem- atic responses,” that is, responses that should 14 have been favorable but were not, indicating a 13 14 fair-to-poor safety climate. The overall problem- 27 7 atic response rate was about 6 percent for naval 20 16 aviation versus 18 percent for hospitals. Lowest Mid-low Mid-high Highest A conclusion from the comparison of the Quartiles based on risk management average Navy and hospital survey responses was that the perception of naval personnel was far more Note: A, B and C are levels of accident severity, “A” being the most severe. positive because the Navy has had a longer his- Source: Anthony Ciavarelli tory of focusing on potential failures and has Figure 4 formulated specific processes over the past 60 years or so to ensure that its leadership is active in preventing accidents. Safety Climate Survey Comparison Industries such as aviation, aerospace and health care, as well as the Navy, now recognize 30 Navy the influence of such organizational factors 25 Hospitals as safety climate and culture on their safety
20 performance. Measuring the state of safety climate and culture, as perceived by employees 15 closest to the daily routines and risk issues, is
10 important to allow managers to keep abreast of hazards and risks inherent in their organiza- 5 tion. Survey results provide an organization
Problematic response rate (percent) 0 with the opportunity to identify otherwise Climate Communication Management Safety issues exibility unknown risks and to intervene in time to ● Safety climate survey concepts prevent accidents.
Notes: Anthony Ciavarelli, Ed.D., is a professor at the U.S. Naval
Source: Anthony Ciavarelli Postgraduate School, where he teaches and conducts research in human factors. Ciavarelli founded Human Figure 5 Factors Associates to expand his work to the civilian sector.
Accident frequency compared to the CSA Note risk management subscale also shows a clear 1. The Likert scale, developed by psychologist and social relationship between safety climate and safety, scientist Rensis Likert, often is used in surveys. With with fewer accidents for units scoring higher on a five-point scale, respondents are asked whether they safety climate ratings (Figure 4). The units in the strongly disagree, disagree, neither agree nor disagree, lowest quartile of the MCAS had nearly twice agree or strongly agree with survey statements. www.flightsafety.org | AeroSafetyWorld | February 2008 | 23 aviationmedicine
Antidepressants in Aviation
Australian researchers found that pilots who took prescribed antidepressants were no more likely than others to be involved in accidents and incidents.
BY LINDA WERFELMAN
© Christine Balderas/iStockphoto.com
se of antidepressant medications by crew or air traffic controllers while using antide- pilots and air traffic controllers does not pressants, provided specific criteria are met and increase the risk of aviation accidents maintained,” the report on the study said. or incidents, according to a study of The criteria include having the pilot or 10U years of aviation safety data from Australia, controller interrupt flight or control duties while where aeromedical authorities have allowed the being introduced to the antidepressant medica- supervised use of antidepressants since 1987. tion and ensuring that the pilot or controller The study, published in Aviation, Space, experiences only minimal side effects that do and Environmental Medicine, the journal of not interfere with flight or control duties, the the Aerospace Medical Association (AsMA), report said. reviewed the cases of 962 pilots and controllers, The Civil Aviation Safety Authority of Aus- half of whom were treated with prescribed an- tralia (CASA) includes these criteria in assessing tidepressants and half of whom were not. There pilots and controllers — including those who was no statistical difference between the number participated in the study — along with other of accidents and incidents involving members of criteria requiring them to be under the care of the two groups.1 a medical practitioner with experience treat- “This study found no evidence of adverse ing depression; to be “stable on an established safety outcomes arising from permitting indi- and appropriate dose of medication for at least viduals to operate as commercial or private air four weeks” before resuming flight or control
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duties; and to have minimal side effects, no drug The Australian study included pilots and interactions and no allergies to the antidepres- controllers taking all types of antidepressants sant medication. and found no difference in accident or incident Other CASA requirements call for those history based on the type of antidepressant.
© Regina Catharina Fernandi Paassen/iStockphoto.com Catharina © Regina Fernandi taking antidepressants to undergo a clinical Data indicated that a slightly higher num- review at least once a month and to submit a ber of accidents and incidents occurred among progress report to CASA every six months for pilots and controllers immediately before the at least the first year of treatment. In addition, start of antidepressant medication. Although CASA requires an absence of other significant the increase was considered statistically insig- psychiatric problems and no use of other psy- nificant, the report said that “the data raise the choactive medications, along with control of all possibility that the earlier use of antidepressants symptoms of depression; an absence of suicidal might actually improve safety in a group who Antidepressants in Aviation thoughts and “features of arousal,” such as ir- subsequently go on to use them. If so, early ritability or rage; and the presence of a normal identification and treatment of this group may sleep pattern. improve aviation safety while allowing contin- CASA’s decision to allow pilots and control- ued flying or controlling duties.” lers taking antidepressants to participate in The report added, “If there is an excess of aviation operations came soon after the intro- accidents in aircrew who would benefit from duction of a class of antidepressants called selec- antidepressants but were not [using] them at tive serotonin reuptake inhibitors (SSRIs), which the time of the accident, this might provide an had fewer and milder side effects than older argument for wider use of antidepressants than antidepressant medications such as monoamine is currently the case in Australia, and has pro- oxidase inhibitors (MAOIs) and tricyclics.2 found implications in those jurisdictions where The side effects associated with SSRIs and antidepressant use is prohibited [by] certificate a related class of antidepressants known as holders.” serotonin-norepinephrine reuptake inhibitors (SNRIs) — most common during the first days Common Condition or weeks of use — are individualized, but they Depression within the general population is include decreased appetite, nausea, diarrhea, relatively common. The United Nations World nervousness, insomnia, headache and sexual Health Organization (WHO) estimates that dysfunction. Tricyclics may have side effects it affects 121 million people worldwide; other that include sedation, decreased blood pres- estimates have been considerably higher.5 Symp- sure, increased heart rate, dry mouth, blurred toms include a depressed mood, loss of interest vision, constipation, difficulty urinating or pleasure, feelings of guilt or low self-worth, and confusion. MAOIs — which usually are disturbed sleep, poor appetite, lack of energy prescribed in cases in which other classes of and poor concentration — problems that WHO antidepressants have not helped — can cause says can lead to “substantial impairments in a dramatic increase in blood pressure if they an individual’s ability to take care of his or her are taken in combination with cold and cough everyday responsibilities.” Depression also can remedies that contain phenylpropanolamine lead to suicide, which claims about 850,000 lives and dextromethorphan.3 worldwide every year, WHO said. CASA guidelines today specify that the au- WHO data show that 60 to 80 percent of thority may “on a case-by-case basis” certificate people with depression can be effectively treated applicants who are prescribed (and are taking) with antidepressant medications and “brief, SSRIs sertraline (brand name Zoloft) and cit- structured forms of psychotherapy.” alopram (brand name Celexa), and venlafaxine The Australian study estimated that about (brand name Effexor) — a type of SNRI.4 4.5 percent of the adult population uses
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antidepressant medications, but only about 1 medication has been “well established and the percent of “aviation certificate holders” could depression has been fully treated,” Evans said. be identified as having taken antidepressants If the proposal is adopted, considerable time while certificated. The study said that the lower may be required to establish procedures for “There is a groundswell rate among pilots and air traffic controllers monitoring the pilots, she said. “may reflect under-reporting of antidepressant “It is considered that it is safer to know that use rather than different levels of medication pilots are being treated for depression and being of opinion that supports among pilots and air traffic controllers.” monitored rather than have pilots fly whilst de- CASA’s requirements differ from those of pressed (not on medication) or fly whilst taking the carefully controlled most other civil aviation authorities, including undisclosed treatment,” Evans said. those in the United States and Europe, which do use of antidepressants.” not currently allow aeromedical certification of Canadian Study pilots taking antidepressants. Civil aviation authorities in a few countries In the United States, the Federal Aviation in addition to Australia already have taken Administration (FAA) policy is that “the medi- steps to allow some pilots to fly while taking cal condition of depression is disqualifying, as antidepressants. well as every medication that is used for the In Canada, for example, a long-term study condition,” Dr. Warren S. Silberman, manager is being conducted involving several pilots tak- of the FAA Civil Aerospace Medical Institute ing specific types of antidepressants to evaluate Aerospace Medical Certification Division, wrote their performance while using the medications, in a 2005 Federal Air Surgeon’s Medical Bulletin.6 and authorities are continuing to review related He added, however, that an FAA panel has been medical literature, a Transport Canada (TC) studying “the feasibility of granting medical cer- spokeswoman said. Each of the pilots is permit- tification to individuals that have been stable on ted to fly only as part of a two-member crew. SSRIs for the treatment of depression,” provided The study began in the mid-1990s, and in the depression has not been accompanied by 2001, Dr. Hugh O’Neill, then the TC director of suicidal thoughts. civil aviation medicine, said that TC was “pro- The FAA allows pilots who have been treated ceeding very, very cautiously” with the study with antidepressants to receive medical certifi- while “looking for some consensus of opinion cation if they have had no significant symptoms throughout the world.”7
© Infocus/iDreamstime.com of depression for at least 90 days after stopping TC’s Handbook for Civil Aviation Medical the medication. They also must be evaluated by Examiners describes requirements similar to a psychiatrist and a psychologist before issuance those outlined by CASA: Applicants for aero- of a medical certificate, and reports must be medical certification “who have been treated forwarded periodically to the FAA. for a depressive illness and who are on main- In Europe, the Joint Aviation Authorities tenance or prophylactic therapy with … SSRIs medical committee has agreed to a proposal may be considered for medical certification on that — if it receives final approval — eventu- an individual basis after review by the CAM [the ally would allow commercial pilots taking “a TC Civil Aviation Medicine Division] Aviation few specific antidepressants” to continue flying, Medicine Review Board.”8 said Dr. Sally Evans, chief medical officer of the U.K. Civil Aviation Authority and head of the Changing Opinions European Aviation Safety Agency Flight Crew Worldwide, the opinions of some aeromedical Licensing Medical Core Group. The proposal specialists are changing. would limit acceptable medications to a few “There is a groundswell of opinion that sup- SSRIs, require close monitoring of the pilots ports the carefully controlled use of antidepres- and allow medical certification only after the sants, this being better than having a policy that
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grounds pilots when they take any antidepres- groups to manage depressed aviators who require sant medication,” said Dr. Anthony Evans, chief SSRI antidepressants. Protocols designed to ag- of the Aviation Medicine Section at the Interna- gressively manage the full spectrum of adverse tional Civil Aviation Organization (ICAO) and possibilities related to SSRI use may enable the no relation to the U.K. CAA’s Dr. Sally Evans. safe use of SSRIs in formerly depressed aviators “The latter policy results in pilots flying when who suffer no aeromedically significant side ef- depressed and untreated, or failing to declare fects. In these closely managed cases of depressive their depression/treatment to an AME [aviation disorders, special issuances or waivers for SSRI medical examiner] and potentially taking anti- use are justified.” ● depressants that have unacceptable side effects from the flying viewpoint.” Notes Despite the increasing tendency of special- 1. Ross, James; Griffiths, Kathleen; Dear, Keith; ists to believe that some use of antidepressant Emonson, David; Lambeth, Len. “Antidepressant Use medications by pilots would be acceptable, and Safety in Civil Aviation: A Case-Control Study debate continues about precisely what medica- of 10 Years of Australian Data.” Aviation, Space, and tions are acceptable and what problems should Environmental Medicine Volume 78 (August 2007): 749–755. be treated by these medications, which some- times are administered for conditions other 2. MAOIs include phenelzine (brand name Nardil) than depression; how long pilots might be and tranylcypromine (brand name Parnate). Tricyclics include amitriptyline (brand name required to stop flying before and after they be- Elavil), desipramine (brand name Norpramin), gin using the medications; and how these cases imipramine (brand name Tofranil) and nortrip- should be monitored. “In other words,” Evans tyline (brand name Pamelor). said, “the logistics of introducing such medica- 3. FSF Editorial Staff. “Regulations Allow Pilots With tion into the aviation system without compro- Depression to Fly After Successful Treatment.” mising safety is not yet fully harmonized.” Human Factors & Aviation Medicine Volume 48 ICAO has begun changing its standards and (January–February 2001). recommended practices to enable the use of an- 4. Ross et al. ICAO has begun changing tidepressants by pilots and air traffic controllers if the national licensing authority determines 5. United Nations World Health Organization. that the medications present no significant risk Depression.
Overrun The crew applied reverse thrust too late.
BY MARK LACAGNINA at Midway
he Southwest Airlines captain said that the regarding company policies and procedures weather on the night of Dec. 8, 2005, was the related to arrival landing-distance calcula- worst he had experienced. Visibility was near tions; programming and design of its on-board the minimum required for the approach, and performance computer, which did not present brakingT action was being reported as both fair and inherent assumptions in the program critical poor on the runway at Chicago Midway Interna- to pilot decision making; plan to implement tional Airport. However, calculations derived from new autobrake procedures without a familiar- the on-board performance computer indicated ization period; and failure to include a margin that the Boeing 737‑700 could be brought to a stop of safety in the arrival assessment to account on the slippery runway. for operational uncertainties,” the report said. The landing-distance calculations were “Also contributing to the accident was the pilots’ based on crucial assumptions, including prompt failure to divert to another airport given reports application of reverse thrust after touchdown — that included poor braking action and a tailwind which the flight crew did not know and failed to component greater than 5 knots.” do, said the U.S. National Transportation Safety The report also said that the absence of an Board (NTSB). engineered materials arresting system (EMAS) Reverse thrust was applied late during the in the nonstandard runway safety area (RSA) landing roll, and the 737 overran the runway, beyond the end of the runway contributed to the rolled through a blast fence and an airport pe- severity of the accident. rimeter fence, and struck an automobile before coming to a stop on a road. One automobile Delayed Departure occupant was killed, one was seriously injured, The 737, being operated as Flight 1248, departed and three received minor injuries. Of the 103 from Baltimore two hours late because of a airplane occupants, 18 received minor injuries; snowstorm in the Chicago area. It was the first the pilots, two of the three cabin crewmembers flight of the first day of a scheduled three-day and 81 passengers were not injured. The 737 was trip for the crew. substantially damaged. The captain, 59, was a U.S. Air Force pilot for In its final report on the accident, NTSB 26 years before being hired as a first officer by said that the flight crew failed to promptly apply Southwest in August 1995. He upgraded to captain reverse thrust because they were distracted by in July 2000. He had about 15,000 flight hours, the autobrake system, which they were using for including 4,500 flight hours as a 737 captain. the first time. The first officer, 34, was a Saab 340 pilot “Contributing to the accident were South- for Mesaba Airlines for six years before being west Airlines’ failure to provide its pilots with hired by Southwest in February 2003. He had clear and consistent guidance and training a 737 type rating and about 8,500 flight hours,
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including 2,000 flight hours as a 737 changed implementation date while during the flight to Chicago, the captain first officer. reviewing the bulletin and believed that expressed concern. “I don’t know if I’m The pilots had completed a self- the autobrake system policy and proce- comfortable using the autobrakes in study training module distributed by dures already had been implemented. this situation,” he said. Later, during the The crew applied reverse thrust too late. the airline to familiarize crews with its “A previous autobrake-related read- approach briefing, he said, “As far as the forthcoming policy and procedures for before-flight letter indicated that the autobrakes go, I think I will use manual the use of autobrakes. However, the autobrake policy would be in effect as braking.” The captain suggested that implementation date had been changed soon as materials were available in the they postpone using the autobrakes for several times, pending completion of cockpit,” the report said. “On the day of the first time until the next leg of the autobrake system installation in all 441 the accident, ‘flow’ cards and checklists flight but then asked the first officer, of the 737s in the Southwest fleet. On with information regarding autobrake “You want to try them into Midway?” the day of the accident, the airline is- procedures had been placed in SWA The first officer said that a friend sued a bulletin that delayed implemen- [Southwest Airlines] airplanes.” who was experienced in the use of auto tation until Dec. 12, 2005. Neither pilot had used autobrakes brakes had told him that the system is The crew of Flight 1248 told inves- in an airplane or in a flight simula- very effective. “I know they work better
© Gabriel Widyna/Airliners.net © Gabriel tigators that they had not noticed the tor. While discussing the procedures than we do [with manual braking],” the
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first officer told the captain. “At least that’s what The airplane was nearing Midway at 1833 my buddy told me. … It is going to get maxi- local time when air traffic control (ATC) issued mum braking out of the aircraft.” holding instructions because the landing run- “Well, keep talking,” the captain said. “I way was being cleared of snow and treated with guess we could do it. Let’s see what the condi- deicing fluid. The crew had used the on-board tions are up there. We’ll do it.” performance computer several times during the flight. While holding at 10,000 ft, the first officer Mixed Reports again entered updated weather and runway A winter weather advisory with a heavy snow conditions in the computer. warning had been issued for the Chicago area. “The first officer entered multiple scenarios Snow began falling early in the afternoon and into the [computer], entering fair and poor pilot accumulated to 10 in (25 cm) before stopping braking action reports separately because the late at night. [computer program] was not designed to accept Visibility at Midway was 1/2 mi (800 m) in mixed braking action report inputs,” the report moderate snow and freezing fog. Runway visual said. “Based on the first officer’s inputs, the © Chris Bungo/Airliners.net [computer] estimated that the airplane would stop about 560 feet [171 m] before the departure end of the runway with fair braking action and about 40 feet [12 m] before the departure end of the runway with poor braking action.” Although the computer calcula- tions showed that the crew would be landing with an 8-kt tailwind component, the landing-distance An engineered range (RVR) for the landing runway, 31C, was calculations for poor braking action assumed materials arresting reported as 4,500 to 5,000 ft (1,400 to 1,500 m). a tailwind component of only 5 kt, because system was Minimum RVR required for the instrument this was the limit established by Southwest. installed at the end landing system (ILS) approach to Runway 31C “SWA policies and flight operations manuals of Runway 31C was 3,000 ft (1,000 m). Ceilings were broken indicate that the company does not authorize after the accident 400 ft above ground level (AGL) and over- landings on runways with more than a 5-knot (see photo, p. 32). cast at 1,400 ft AGL. Surface winds were from tailwind component with poor braking ac- 090 degrees at 11 kt, and braking action was tion,” the report said. If the landing-distance reported as “fair” on the first half of the runway calculations for poor braking action had and “poor” on the second half. Runway 31C is been based on the actual 8-kt tailwind, they 6,522 ft (1,988 m) long, but, due to a displaced would have shown that the airplane would threshold, available landing distance is 5,826 ft stop about 260 ft (79 m) beyond the end of the (1,776 m); the runway is 150 ft (46 m) wide. runway.
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Unknown Assumptions The report noted that on-board performance Boeing 737-400 computers and other types of electronic computing devices reduce pilot workload but, unlike tabular performance charts, do not show the assumptions on which the calculations are based and, thus, can foster decision-making errors. In addition to the 5-kt tailwind component as- sumed for a landing with poor braking conditions, the crew did not know that the landing-distance calculations for the 737‑700 assumed use of reverse thrust. The on-board performance computers for the airline’s 737‑300s and ‑500s did not assume use of reverse thrust. “Because of this, the accident pilots believed that their intended use of reverse thrust during the landing roll would provide them © Matt Coleman/Airliners.net with several hundred feet more stopping margin than the [computer] estimated,” the report said. roduced from 1988 to 2000, the 737-400 is 10 ft (3 m) longer than The crew discussed the landing-distance the 737-300, has strengthened landing gear and can accommo- calculations for Midway and the more-favorable Pdate 146 to 168 passengers. Powered by CFM56‑3B2 or -3C turbo- fan engines, maximum operating speed is 0.82 Mach, and maximum weather conditions at their alternate airports — range is 2,808 nm (5,200 km). Maximum standard weights are 138,500 Kansas City and St. Louis, Missouri. “Although lb (62,824 kg) for takeoff and 121,000 lb (54,886 kg) for landing. the pilots’ calculations resulted in positive The accident airplane, after repairs, is shown in the photo above. stopping margins for both fair and poor brak- Source: Jane’s All the World’s Aircraft ing conditions and company policy indicated that landing was authorized with any positive stopping margin, the crew was concerned about controller said, “Braking action reported fair the small positive stopping margin with poor except at the end, it’s poor.” braking action,” the report said. They decided The crew said that the airplane was clear of to divert the flight to an alternate if the tailwind clouds after descending through 1,400 ft and component increased above 10 kt or if braking that RVR was about 5,000 ft. The 737 touched action was reported as poor for the full length of down about 1,250 ft (381 m) beyond the runway Midway’s Runway 31C. threshold. “Flight data recorder (FDR) data The crew did not follow a company proce- indicated that the airplane was aligned on the dure that required pilots to use the “most critical runway centerline as it touched down at an term” provided in a mixed braking action report. airspeed of about 124 knots [and a groundspeed “Because ‘poor’ braking conditions were reported of about 131 kt],” the report said. “The speed for a portion of the runway and SWA guidance brakes deployed and brake pressure increased indicates a maximum 5-knot tailwind to land if within about 1 second. Both pilots described the such conditions are reported, the pilots should touchdown as ‘firm.’ not have landed at Midway,” the report said. “The captain stated that he tried to deploy the thrust reversers immediately after touch- Fifteen Seconds Late down but had difficulty moving the thrust The crew was cleared by ATC to leave the hold- reverser levers to the reverse thrust position. He ing pattern at 1854 and followed radar vectors further stated that he felt the antiskid system to the ILS final approach course. After clearing cycle after the airplane touched down but the crew to conduct the approach at 1904, the then felt it stop cycling and that the airplane www.flightsafety.org | AeroSafetyWorld | February 2008 | 31 causalfactors
seemed to accelerate. He said that he “Damage to the airplane was largely Interviews of other Southwest pilots subsequently applied the wheel brakes limited to the forward lower fuselage, revealed that several had “difficulties manually but made no further effort to engine cowlings and components, deploying the thrust reversers when they activate the thrust reversers. He told in- forward portions of the wings and tried to move the reverse thrust levers vestigators that he believed that the use other wing components, with limited past the interlock position too rapidly,” of the autobrake system distracted his damage farther aft,” the report said. the report said. “Those pilots reported attention from the thrust reversers after Examination of the airplane disclosed that the levers moved readily when they his initial attempt to deploy them.” no preimpact anomalies. tried to deploy the thrust reversers again The first officer also sensed a decrease after the interlocks released.” in deceleration and manually applied Simulation Results Guidance on the use of reverse the wheel brakes. “He stated that he then Four Southwest 737s and a United Air- thrust differed. Although Southwest looked at the throttle console and saw lines Airbus A320 had been landed with- and Boeing both recommended that that the thrust reverser levers were still in out incident on Runway 31C during the reverse thrust be applied as soon as the stowed position,” the report said. “The 25 minutes preceding the accident. The possible after touchdown, the airline first officer moved the captain’s hand 737 landings were conducted without said that pilots should begin reducing away from the thrust reverser levers and, autobrakes but with application of reverse reverse thrust after decelerating to 80 about 15 seconds after touchdown, initi- thrust early in the landing roll. “Three kt, while Boeing said the reduction ated deployment of the thrust reversers to out of the four flight crews commanded should begin at 60 kt. After the acci- the maximum reverse setting.” maximum reverse thrust,” the report said. dent, Southwest revised its procedure to Groundspeed was 53 kt when the Simulations conducted during the be consistent with Boeing’s guidance. 737 overran the runway at 1914. The investigation indicated that if the crew of Investigators found that while nosegear collapsed, and the airplane Flight 1248 had promptly applied maxi- participating in the development of came to a stop about 500 ft (152 m) mum reverse thrust and maintained the airline’s autobrake program, check beyond the end of the runway. Aircraft it until stopping, the airplane could airmen and their first officers also had rescue and fire fighting personnel ar- have been stopped with 271 ft (83 m) become distracted and delayed applica- rived two minutes later and assisted of runway remaining. Interviews of the tion of reverse thrust during their first in the evacuation of the passengers 10 previous flight crews who operated few landings. After the accident, South- through the left forward cabin door and the accident airplane revealed no dif- west revised its training procedures to
through the right rear cabin door. ficulty in deploying the thrust reversers. require that “pilots complete at least Corp. Systems Arresting Engineered
EMAS installation at Midway.
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four familiarization landings — two as airplane operators develop procedures departed airport property,” the report the flying pilot and two as the monitor- for arrival calculations. The alert further said. “After the accident, the FAA ap- ing pilot — on dry runways with ample recommended that “once the actual land- proved the installation of nonstandard stopping margins before using the ing distance is determined, an additional EMAS beds at [Midway].” autobrake system on a routine basis,” safety margin of at least 15 percent should the report said. be added to that distance.” Better Data Needed The SAFO noted, however, that ar- The report said that the accident Padding the Margin rival calculations are not recommended showed the need for an “airplane- Landing performance calculations for before every landing. “In many cases, the based” method of quantifying runway U.S. air carrier operations typically are before-takeoff criteria, with their large surface condition and transmitting the conducted before flight by dispatchers safety margins, will be adequate to ensure information for use by pilots of other and before arrival by the pilots. The that there is sufficient landing distance airplanes in landing performance calcu- preflight calculations are based, in part, with at least a 15 percent safety margin at lations. As a result, NTSB called on the on landing performance demonstrated the time of arrival,” it said. “Only when FAA to explore the feasibility of “outfit- by the airplane manufacturer during the conditions at the destination airport ting transport category airplanes with certification flight tests. deteriorate when en route [would an ar- equipment and procedures required to “Dispatch landing distance cal- rival calculation] normally be needed.” routinely calculate, record and convey culations are intended to ensure that the airplane braking ability required dispatched airplanes will be able to Hemmed In and/or available to slow or stop an land safely at the intended destination The RSA beyond the end of Runway airplane during the landing roll.” airport or a planned alternate and are 31C — and several other RSAs at Among other recommendations based on estimated landing weights and Midway — do not meet FAA standards. based on the accident investigation forecast conditions,” the report said. The Runway 31C RSA extends 82 ft (25 were that the FAA should require “According to [U.S. Federal Aviation m) beyond the runway end; the FAA operators of commercial and fractional Regulations], the dry and wet/slippery standard is 1,000 ft (305 m). ownership aircraft to conduct arrival landing performance data used for The airport operator, the Chicago landing performance calculations in- dispatch calculations are obtained by Department of Aviation (DOA), told corporating a 15 percent safety margin multiplying the numbers demonstrated the FAA in 2004 that no practical before every landing and ensure that during certification landings on a level, alternatives existed for extending the on-board electronic computing devices smooth, dry, hard-surfaced runway by Runway 31C RSA to meet the standard. clearly display the critical assumptions factors of 1.67 and 1.92, respectively.” It said that shortening the runway to on which calculations are based. ●
Arrival calculations are based on extend the RSA would reduce the oper- This article is based on NTSB Accident Report updated information on airplane land- ational capacity of the airport and that NTSB/AAR‑07/06: “Runway Overrun and ing weight, weather, runway conditions acquiring land beyond the existing RSA Collision; Southwest Airlines Flight 1248; and other factors. “Airplane landing would have a major impact on public Boeing 737‑7H4, N471WN; Chicago Midway performance data for conditions other roadways, businesses and residences. International Airport; Chicago, Illinois; December 8, 2005.” than bare and dry are typically calcu- The Chicago DOA also said that an lated rather than demonstrated via a alternative to enhance the RSA, installa- Further Reading From FSF Publications flight test,” the report said, noting that tion of a standard 600-ft (183-m) EMAS no “safety margin” typically is added to arrestor bed, also would require shorten- Johnsen, Oddvard. “Improving Braking Action arrival landing-distance calculations. ing the runway. The FAA did not ask the Reports.” ASW, 8/07, p. 36. There are no regulatory require- airport operator to consider installation Rosenkrans, Wayne. “Knowing the Distance.” ments or standards for arrival calcula- of a shorter, nonstandard EMAS bed. ASW, 2/07, p. 22. tions. In August 2006, the U.S. Federal Simulations conducted by an EMAS Rosenker, Mark V. “Margins of Safety.” ASW, Aviation Administration (FAA) issued a manufacturer “indicated that a non- 12/06, p. 11. safety alert for operators, SAFO 06012, standard EMAS installation would have Rosenkrans, Wayne. “Rethinking Overrun “urgently recommending” that all jet stopped the accident airplane before it Protection.” ASW, 8/06, p. 13. www.flightsafety.org | AeroSafetyWorld | February 2008 | 33 CABINSafety
Voluntary safety reports by flight attendants prove to be more valuable than expected.
SpeakingBy Wayne Rosenkrans Up
ith computer networks (Figure 1).1 The challenge slowing may prevent accidents. The mission ready to pull together expansion is persuading people to step is to identify and address safety issues diverse safety information, beyond outmoded safety programs that wherever evidence leads, regardless of the U.S. Federal Aviation discipline employees for inadvertent violations of federal regulations by the AdministrationW (FAA) during 2008 will errors. employee or the company. keep promoting aviation safety action In a typical ASAP, the air carrier en- “Under an ASAP, safety issues are programs (ASAPs) — including ASAPs ters a formal partnership with specially resolved through corrective action for flight attendants — at air carriers trained FAA aviation safety inspectors rather than through punishment or and major domestic repair stations. Al- and the labor organization of a specific discipline,” says FAA Advisory Cir- though introduction of flight attendant employee group. The partners create cular 120-66B, Aviation Safety Action versions of this voluntary program is an event review committee, a non- Program (ASAP). “The ASAP provides relatively new, benefits from a handful threatening environment that invites for the collection, analysis and reten- of these ASAPs so far appear to be sur- the certificate holder’s employees to tion of the safety data that is obtained. passing the expectations of participants voluntarily submit written reports that ASAP safety data, much of which
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would otherwise be unobtainable, is used to Employee Groups in U.S. Aviation develop corrective actions for identified safety Safety Action Programs (ASAPs) concerns, and to educate the appropriate par- ties to prevent a reoccurrence of the same type 60 of safety event.” FAA Order 8900.1, Flight Standards Infor- 41 mation Management System, reminds aviation 39 safety inspectors that ASAPs enable employees to tell what happened “without fear that the FAA will use reports accepted under the program Number of ASAPs to take legal enforcement action against them, 10 or that companies will use such information to take disciplinary action.” Historically, the former primarily has been a concern of airline pilots Dispatchers Flight Pilots Maintenance Attendants Technicians and the latter primarily has been a concern of Employee Group flight attendants. To make good on these promises and main- Note: These data from December 2007 reflect the 150 ASAPs at 68 U.S. airlines for which the U.S. Federal tain trust, nearly all details of setting up and Aviation Administration has accepted a memorandum conducting an ASAP have been prescribed in of understanding that authorizes an ASAP for a specific employee group. FAA guidance documents, although participants Source: U.S. Federal Aviation Administration can diverge from the template in preparing the required memorandum of understanding. Event Figure 1 review committees must determine by “unani- mous consensus” (Figure 2, p. 36)2 either that a covered by the program’s protections; otherwise
© Michele Lugaresi/iStockphoto report is acceptable or it falls under exclusion- he or she can face a reopening of the case and ary exceptions, and learn methods of reviewing referral for an FAA investigation. ASAP reports and reaching decisions, formu- FAA basically expects ASAP reports involv- late corrective action and verify its successful ing a possible regulatory violation to be accepted completion, and know how the FAA handles if the flight attendant acted as an employee exceptional situations such as when the ASAP of the air carrier; the report is submitted in a Speaking Up report is not the sole source of evidence of a timely manner, such as within 24 hours after regulatory violation. the end of a duty day; the alleged regulatory Committees know when and how to use violation is inadvertent and does not appear to FAA’s enforcement decision tool and how FAA involve an intentional disregard for safety; and A may conduct an independent investigation the event does not appear to involve FAA’s “big A L V I R A of an event disclosed in an ASAP report. five” exceptions — criminal activity, substance E T I D O They also learn to interpret employee abuse, controlled substances, alcohol or inten- E conduct that raises a question of air- tional falsification. N
F man competence or qualification,
medical certification or other employ- Conditional Union Support A ee competence/qualification issues. Candace Kolander, coordinator, air safety, D N The safety risks/threats identified in health and security, Association of Flight At- M O I sole-source reports must be addressed tendants–Communications Workers of Amer- I N T I S T R A by the committee (see “ASAP Report ica (AFA), said that the union supports ASAPs Insights,” p. 37). A key to the arrangement for flight attendants, but on the condition that is that the flight attendant must successfully reports be sent within 10 days to the U.S. Na- complete recommended corrective action to be tional Aeronautics and Space Administration
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concerns that they have not necessarily been Event Review Committee Dynamics able to solve at the air carrier level.”
Law and Airline Experiences regulations Susan Reed Valerie Walker and Jack O’Brien, representatives of the United Airlines Onboard Service Safety Agency Passenger Action Program implemented in March 2005, culture interests said that ASAP for flight attendants enables air- FAA representative lines “to gain objective feedback relating to the effectiveness of training, policies and processes.” Zone of They said that they found that a critical element ‘unanimous of success is for the senior leader of the division consensus’ to “stand up before his/her leadership team and deliver a message supporting the program.”3 Through the ASAP event review com- mittee, the United Airlines Safety Division receives reports from flight attendants, investigates them, provides a weekly update on reports to review, maintains a log of action items, closes out ASAP reports, manages the safety database and interfaces with managers of ASAPs for pilots, dispatchers and mainte- Airline Flight attendants representative representative nance technicians. At Alaska Airlines, the FAA’s template was Corporate Industry Professional Work force followed “fairly closely” before the memoran- culture culture culture culture dum of understanding was accepted by the FAA in September 2006. Minor changes are
Source: Sandia National Laboratories expected as this ASAP evolves from a dem- onstration program to a continuing program Figure 2 in 2008, said Cassandra Bennett-Chaffee, (NASA) Aviation Safety Reporting System manager, in-flight policy, safety and regulatory (ASRS). This practice typically protects sub- compliance.4 mitters, if an ASAP report proves unacceptable, Reviewing 200 reports from some of the and reports become beneficial industrywide. company’s 2,700 flight attendants the first year Historically, the apparently slight risk of FAA was not difficult, she said, contrary to her ex- enforcement action against flight attendants pectation. “Right off in the first month, we had may explain the reluctance of some to submit four potential violations of the Federal Aviation voluntary safety reports. Unlike pilots’ risk of Regulations [FARs], and I worried that I would airman certificate revocation or suspension, spend all my waking hours on this program,” for example, “flight attendants don’t have that Bennett-Chaffee said. “It has become far more big question of a violation hanging over their manageable because of established patterns. We heads all the time,” she said. are looking for trends, we would like to validate Flight attendants’ feedback to AFA about whether corrective actions are indeed working.” current ASAPs has been positive. “One of the ASAP protections for submitters encourage things they are most excited about is addressing event review committee members to be proac- concerns in the cabin,” Kolander said. “They tive. “To find out about safety-related events, want FAA to be given a little ‘heads up’ about including those that may have required an
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ASAP Report Insights
viation safety action programs (ASAPs) for flight at- quick taxi so flight attendants can take precautions, tendants identified the following issues in 2005–2007. such as taking a seat and strapping in!”4 AThe excerpts from flight attendant reports, selected • The cabin crew violated the minimum crew require- from the Aviation Safety Reporting System (ASRS) Online ments during boarding and deplaning. One report Database, reflect a few of these issues but may or may not said, “We were three flight attendants and two pilots. have originated as ASAP reports: … I immediately mentioned to another flight atten- • Inadequate procedures, or non-adherence to dant that I thought we were supposed to have four procedures, were noted when gate agents closed flight attendants now that we were on Aircraft Y. She aircraft boarding doors. One report said, “Once the kind of shrugged it off. So I went to the purser and [Boeing 737-300 overhead] bins filled up, I called to let asked her. Her explanation was that because we still the [gate] agent know the bins were full. … When the only had 113 passengers on board there was no prob- agent approached the door to the aircraft, I told her lem. … I got out my flight attendant manual and saw not to close the door as we had bags to check. Her re- that minimum crew on Aircraft Y was four.”5 sponse to me was, ‘I don’t want to open the [checked- • The cabin crew did not follow approved procedures baggage compartment] at this point; find some space for stowage of in-flight trash. One report said, “On the in the middle seats where there is no one sitting.’ … front of the [main waste receptacle] door, it states that I again told her not to close the door; she chose to ‘waste container must be installed.’ … At 10 minutes ignore my request and closed the door and pulled the prior to departure … nothing had arrived. I spoke with Jetway. We had no choice but to violate U.S. Federal [the on-board service supervisor] again, who told me Aviation Regulations, and overload the closet on our to ‘stack things on the floor, and before landing, put 1 aircraft as they were not bringing the Jetway back.” the garbage in the bathroom.’ … I was told that there is • Doors were left armed and inadvertent slide deploy- nothing else to do.”6 ments occurred or were narrowly averted. One report • Galley security — checking/using restraint devices said, “When I went to disarm door 2L on this flight, I for inserts and carts — required emphasis in train- stood up, faced the door, and instead of immediately ing scenarios. One report said, “[The seat belt sign was disarming, I bent down to check for airstairs being on at the time for turbulence and] I had just walked to brought up to the door. … In making my visual sweep monitor at the 2R door. … Very suddenly, the [Boeing of the outside, I stood up and grabbed the wrong 777-300] started to shake violently. … I saw and heard 2 handle.” glass breaking and flying out of the business class galley • Improper passenger selection or noncompliance into the area I was in. Inserts, carts, food, everything that with passenger briefings affected exit row seating. was in the galley was thrown all over the floor and aisle. One report said, “On this [Airbus A320] flight, I was Shards of broken glass were everywhere. … The first flight attendant no. 2 and my responsibility was to class galley had broken glass, food, carts, everything in brief the [passengers in] exit rows. Out of my 12 pas- it was on the floor and broken. The passenger in 3D got sengers in my exit row there was one gentleman that up to look. He said, ‘This looks like something out of a I was not able to communicate with at all. … [A cabin movie.’ … No passengers were hurt that I observed.”7 supervisor] said that they don’t have to speak English. I — WR told him that I knew that, but I picked up a safety card Notes and showed him where it states that ‘they must be able 1. NASA ASRS report no. 697849. March 2006. to understand crewmembers’ verbal instructions.’ ”3 2. NASA ASRS report no. 987886. April 2006. • Flight attendants failed to remain at the duty station and fasten their safety belt and shoulder harness 3. NASA ASRS report no. 683532. November 2005. during taxi. One report said, “While [the Boeing 4. NASA ASRS report no. 700747. June 2006. 737-800] taxied to the runway, I was literally thrown, 5. NASA ASRS report no. 714723. August 2006. right arm first, into the base of the no. 2 jump seat. … We were taxiing fast and making quick turns as we 6. NASA ASRS report no. 683549. November 2005. headed to the runway. … We should be warned of a 7. NASA ASRS report no. 705022. July 2006.
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employee disciplinary measure in the past, we of the safety concern. No names are divulged. contact individual flight attendants and encour- The committee produces ASAP Circulars that age them to report,” she said. are issued to each flight attendant through a The ASAP supplements mandatory cabin bimonthly newsletter as well as posted on a safety reports, which flight attendants cannot company intranet giving details of the event monitor. In comparison, products of com- and the committee’s conclusion and recom- mittee meetings twice a month include the mended preventive measures.” quarterly ASAP report to FAA and a monthly American Airlines representatives Shannon ASAP bulletin securely distributed on line to Stewart and Penney Pollard told cabin safety all flight attendants at the airline. “Verbatim professionals that “earning and keeping trust deidentified ASAP reports in the monthly should be a primary goal of the [ASAP] pro- bulletin are high value … the lessons learned gram.” Numerous safety reports generated by have been amazing,” Bennett-Chaffee said. an ASAP for flight attendants help validate that “Some flight attendants say that a policy or “employees trust the process,” they said.5 procedure was not clear to them until they read somebody else’s report and then they say, ASRS Magnifies Impact ‘I realized why I need to follow the procedure In 2007, reports received from 68 ASAPs at 32 in the manual.’” U.S. airlines surpassed the total ASRS reports Beyond words, ASAP-related actions by received directly from air traffic controllers, the airline have high visibility. “We see flight dispatchers, flight attendants, maintenance attendant manual changes and sometimes technicians and pilots, said Linda Connell, daily changes in procedures,” she said. Since program director of ASRS at the NASA Ames the ASAP was established, the company’s cabin Research Center (Figure 3). “We are the largest supervisors also have been reporting improved repository of ASAP information,” Connell said. adherence to written procedures. As of December 2007, three airlines with six Latricia Foulger, di- ASAPs for flight attendants were submitting Voluntary Safety Reports in 2007 rector, InFlight, SkyWest their reports to ASRS. Data for total intake Airlines, said that under of reports “absolutely show increasing inter- Maintenance an FAA-funded collab- est” from flight attendants in voluntary safety Technicians Other 1,146 174 orative project between reporting (Figure 4), she said. the airline and the Connell considers ASRS and ASAPs as Universal Technical Re- complementary, neither a sufficient replace- source Services Aviation ment for the other. A past disadvantage of General Consulting Group, flight ASAPs was separation of programs by em- Aviation Pilots Flight 10,529 attendants explain the ployee group so that events and concerns Attendants 1,035 cause and outcome of became “stove-piped” (segregated) within and Air Carrier Pilots the event in their ASAP among airlines instead of being aggregated, 31,261 Air Tra c report. “Sometimes, con- she said. FAA and NASA are addressing this, Controllers 1,458 tact by our event review realizing that some aviation safety special- committee will be for the ists prefer ASAP reports because they involve sole purpose of counsel- internal investigations, corrective actions and Note: The U.S. National Aeronautics and Space ing the flight attendant permanent access to a record, protected from Administration Aviation Safety Reporting System received 55 percent of 45,603 safety reports from aviation safety in proper procedures,” public disclosure by federal law, with only the action programs at 32 U.S. airlines and 45 percent directly from these aviation professionals. Foulger said. “ASAP submitter’s name deleted. Underscoring this reports are selected for point, the FAA said, “The value of ASAP for Source: NASA ASRS publication based on the safety enhancement lies in its capacity to retain Figure 3 severity or frequency specific information on individual events,
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including, for example, specific information on Flight Attendant Voluntary Safety Reports Increase aircraft make, model and series.”6
1,200 SMS-Ready Under the FAA’s Voluntary Aviation Safety 1,000 Information-Sharing Process, work has been 800 under way since 2004 to develop a “technical process to extract deidentified data from any 600 participating airline flight operations qual- ity assurance [program] or [ASAP], aggregate 400 it through a distributed database and make it 200 accessible to appropriate industry stakeholders Number of NASA ASRS reports for analysis.”7 FAA therefore encourages ASAPs 0 2001 2002 2003 2004 2005 2006 2007 to develop data acquisition, event categoriza- Year tion and risk analysis methods that gradually will enable voluntary national sharing of ASAP NASA = U.S. National Aeronautics and Space Administration; ASRS = Aviation Safety Reporting System information from multiple programs, a common Note: Since 2002, NASA ASRS has received reports from aviation safety action programs taxonomy (classification scheme) tailored to the (ASAPs) for airline pilots, dispatchers and maintenance technicians in addition to the ASRS reports submitted directly by these employee groups and by air traffic controllers, types of events, and classification of corrective general aviation pilots and other sources. New ASAPs for flight attendants at 10 airlines, actions for flight attendants and other specific including three that began sending reports to ASRS in 2006-2007, will help the industry and government to monitor cabin safety issues. employee groups. In May 2008, the Voluntary Aviation Safety Programs Conference in San Source: NASA ASRS Diego will include presentations on how ASAP, Figure 4 ASRS and related programs can be integrated into an airline’s safety management system 3. Walker, Valerie; O’Brien, Jack. “Safety Action (SMS) and how voluntary safety information Program in a Flight Attendant Environment.” can be shared by airlines and the FAA. ● In proceedings of the 23rd annual International Aircraft Cabin Safety Symposium. Oklahoma City, For an enhanced version of this story, go to
Notes 4. Bennett-Chaffee, Cassandra. “Value of the Cabin Crew Aviation Safety Action Program (ASAP) at 1. As of December 2007, the FAA had accepted 10 Alaska Airlines.” Paper and presentation to the Air memorandums of understanding authorizing ASAPs Transport Association of America. October 2007. for flight attendants at Alaska Airlines, Eos Airlines, 5. Stewart, Shannon; Pollard, Penney. “Cabin ASAP: Horizon Air, PACE Airlines, Pinnacle Airlines, The International and Non-Labor Perspective.” In Skyway Airlines, SkyWest Airlines, Swift Air Group, proceedings of the 23rd annual International Aircraft United Airlines and USA3000 Airlines. Cabin Safety Symposium. 2. Ganter, John H.; Dean, Craig D.; Cloer, Bryon K. 6. FAA. Order 8000.82, Designation of Aviation Safety Fast Pragmatic Safety Decisions: Analysis of an Action Program (ASAP) Information As Protected Event Review Team of the Aviation Safety Action From Public Disclosure Under 14 CFR Part 193. Partnership. Sandia National Laboratories. Report Sept. 3, 2003. no. SAND2000-1134. May 2000. Researchers said, “Potential corrective action can be visualized as a 7. Chidester, Thomas R. Voluntary Aviation Safety steel ball on [a tilt table]. In order for this poten- Information-Sharing Process: Preliminary Audit tial action to be implemented, the ball must pass of Distributed FOQA and ASAP Archives Against through a hole at the center: the zone of unanimous Industry Statement of Requirements. FAA Office of consensus. The representatives must cooperate in Aerospace Medicine. Report DOT/FAA/AM-07/7. achieving a reasonably balanced table.” April 2007. www.flightsafety.org | AeroSafetyWorld | February 2008 | 39 causalfactors
he Air France Airbus A340-300 was high The Transportation Safety Board of Canada and fast when it crossed the threshold of (TSB) said in its final report on the accident that, Runway 24L at Toronto/Lester B. Pearson “in hindsight, the risk presented by the rapidly International Airport during a thunder- deteriorating weather conditions was greater than Tstorm, with heavy rain and lightning strikes most pilots would deem acceptable. However, that significantly reduced visibility before the when the [pilots] assessed the available weather touchdown 3,800 ft (1,159 m) down the 9,000-ft information and the traffic flow into the airport, (2,745-m) runway. The crew selected reverse they did not expect that such a severe deteriora- thrust 12.8 seconds after touchdown and full tion in the weather was imminent.” reverse 16.4 seconds after touchdown but was Among the causes of the accident and the unable to stop the airplane before it departed contributing factors, the TSB cited the approach the far end of the runway at 80 kt, crossed two and landing during the thunderstorm, with great- roads, plowed into a ravine and burned. ly reduced visibility, lightning strikes and shifting The airplane was destroyed in the crash at winds — including a 10-kt tailwind component 1602 local time Aug. 2, 2005, and 12 of the 309 for part of final approach and a crosswind that, occupants received serious injuries during the because the runway was contaminated by water, crash and subsequent evacuation. exceeded the airplane’s landing limits. BY LINDA WERFELMAN blindsided
The pilots of an Airbus A340 did not anticipate the ‘severe deterioration’ of weather as they approached the runway threshold at Toronto.
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Other factors in- Runway 24L Safety Areas, Actual and Recommended cluded the absence of Air France procedures D C Accident for distance required site from thunderstorms A during approach and landing; the crew’s B belief, as the airplane neared the runway threshold, that a go-around was no longer an option; and the crew’s delays in selecting the thrust reversers and applying full reverse thrust. The crew did not calculate the landing FAA = U.S. Federal Aviation Administration; ICAO = International Civil Aviation Organization; Transportation Safety Board of Canada RESA = runway end safety area; RSA = runway safety area distance required and Notes: “consequently, they A. Runway strip: Area extending 200 ft/60 m from end of runway, 500 ft/150 m from either were not aware of side of centerline. Transport Canada standard, in place at Runway 24L. B. RESA: Area extending 300 ft/90 m from end of runway, twice runway width. ICAO standard, the margin of error TC recommendation, not in place at Runway 24L. available … [or] that C. RESA: Area extending 1,000 ft /300 m from end of runway, twice runway width. ICAO it was eliminated recommendation, not in place at Runway 24L. D: RSA: Area extending 1,000 ft/300 m from end of runway, 250 ft/75 m either side of center once the tailwind line. FAA standard, not in place at Runway 24L, not applicable outside U.S.
was experienced,” the Source: Transportation Safety Board of Canada Transportation Safety Board of Canada Board Safety Transportation TSB said. In addi- tion, “there were no Figure 1 landing distances indicated on the op- for an extra 23 minutes of holding time in erational flight plan for a contaminated runway Toronto. condition” at the airport, and although the About seven hours into the flight, the pilots first 500 ft/150 m beyond the departure end of made their initial contact with the Toronto Area the runway complied with Transport Canada Control Centre (ACC), asked about the weather, (TC) standards, “the topography of the terrain and told Air France operations personnel in To- beyond this point, along the extended runway ronto that, because of thunderstorms near their centerline, contributed to aircraft damage and alternate airport — Niagara Falls (New York, to the injuries to crew and passengers,” the TSB U.S.) International — they were designating Ot- said (Figure 1). tawa Macdonald-Cartier International Airport as their new alternate. Eight-Hour Flight Soon afterward, the crew discussed the The crash occurred after an eight-hour flight weather with air traffic control (ATC). The crew from Charles de Gaulle International Airport subsequently was told to reduce speed because in Paris. Before leaving Paris, the flight crew of landing delays at Toronto. They requested and obtained a weather forecast for Toronto that received vectors to avoid weather and also re- included possible thunderstorms; as a result, ceived an aviation routine weather report, which additional fuel was added to the tanks to allow included information about thunderstorms and
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They conducted a briefing for the instru- Airbus A340 ment landing system (ILS) approach to Runway 24L but did not discuss runway length, missed approach procedure or landing distance calcula- tions for a wet or contaminated runway, the report said. Around 1540, some pilots on the same radio frequency told ATC that they were proceeding to alternate airports, but by 1549, when the ac- cident crew requested and received a deviation because of weather on the approach, airplanes were landing.
© Frank Robitaille/Airliners.net ‘Pretty Bad’ Weather At 1553, “the number one aircraft on approach he Airbus A340, first flown in 1991, is a large-capacity, widebody, medium/ultra long-range airliner. It is closely related to the A330. [the accident airplane was number three] was TThe A340-300 began service in 1993. asked by ATC about their likelihood of being The A340-300 can seat as many as 440 passengers; the accident able to land,” the report said. “The reply was that airplane was configured to seat 291 passengers. It has four CFM the weather was to the north and looking pretty 56-5C2 turbofan engines and a maximum operating speed of 0.86 bad.” Mach. Typical standard range with fuel reserves is 12,223 km (6,600 The two airplanes ahead of the accident nm). Maximum standard weights are 257,000 kg (566,582 lb) for take- off and 186,000 kg (410,056 lb) for landing. airplane were landed without incident. At 1558, the report said, the accident Source: Jane’s All the World’s Aircraft airplane was “at the approach speed on final approach. The previous aircraft had reported that braking action was poor, the tower wind heavy rain. They briefed the wind shear ap- instruments were not functioning because they proach, planning to conduct a missed approach were knocked off line during thunderstorm if they encountered wind shear. activity, the last wind available in the tower was At 1528, they were cleared for the Simcoe 230 degrees at 7 kt, and there was lightning all 2 arrival to Toronto; at the time, they had 9.3 around the airport.” metric tons (10.3 short tons) of fuel remaining, The crew of a regional jet landing ahead and the airplane was 137 nm (254 km) from of the accident airplane reported winds from Toronto. Having determined earlier that, with 290 degrees at 15 to 20 kt and said that braking Ottawa as their alternate, a diversion would action was poor until the airspeed decreased to require 7.3 metric tons (8.0 short tons), with 14 less than 60 kt. minutes of fuel for holding at Toronto, they re- The crew of the accident airplane delayed viewed company procedures on when to declare the pre-landing checklist because the land- minimum fuel. ing memo had not yet been displayed on the At 1533, automatic terminal information electronic centralized aircraft monitor (ECAM), service (ATIS) information indicated that and although they had acted on all items on the Toronto had reduced visibility in thunderstorms challenge-and-response checklist, the checklist and heavy rain, and rapidly changing weather itself was not completed before landing. conditions. After reviewing weather reports For the remainder of the approach, weather from possible alternate airports, they selected conditions fluctuated, but portions of the ap- Ottawa — a decision that meant they would proach were conducted in “very dark clouds, have fuel for six minutes of holding in Toronto. turbulence and heavy rain,” the report said.
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“The runway was covered with wa- “The aircraft then began to deviate inputs in roll on the PF side stick. ter, producing a shiny, glasslike surface,” above the glideslope, [and] the wind Combined, these inputs would indicate the report added. “There was lightning direction shifted, changing from a that significant workload and attention on both sides and at the far end of the 90-degree crosswind component to an were required on the part of the PF to runway.” increasing tailwind component of up to control the aircraft.” The airplane’s navigation display 10 kt.” Throttle levers were moved to the indicated a right crosswind of 70 to 90 The airplane was 40 ft above the idle position when the airplane was 20 degrees at 15 to 20 kt. Autopilot and glideslope when it crossed the runway ft above the runway. autothrust were engaged during the ap- threshold and entered an area of heavy After touchdown, the captain did proach, and the airplane was stabilized rain and lightning strikes; visual con- not make the standard callouts for on the localizer and glideslope at the tar- tact with the runway environment was deployment of spoilers and reversers. geted airspeed of 140 kt. At 1601, as the “severely reduced,” the report said. The The airplane was traveling at a ground- airplane descended through 323 ft above PF began the flare when the airplane speed of 80 kt when it departed the end ground level (AGL), the first officer — was 40 ft above the runway (Figure 2). of the runway. Within seconds after the pilot flying (PF) — disengaged the “From this point to touchdown, the airplane stopped in the ravine, the autopilot and autothrust and increased there were numerous and sometimes cabin crew saw flames and ordered an engine thrust from about 42 percent of significant pitch inputs made on the PF evacuation. N1 (engine compressor speed) to 82 per- side stick, and the aircraft leveled off Both flight crewmembers had cent of N1 “because he sensed that the at approximately 25 ft for a period of airline transport licenses and Class 1 airspeed was decreasing and the aircraft 2 ½ seconds,” the report said. “There medical certificates. The captain had was sinking,” the report said. were also regular and sometimes large 15,411 flight hours, including 1,788 on
Key Events in Landing Sequence
1601:56 1602:06 1601:39 local time 1601:48 Ground spoilers extend, Reverse thrust selected, 1602:18 Over threshold 24L, Engines at idle thrust, brakes applied, 118 KIAS, 238° Aircraft departs runway, 147 KIAS, 243°, 146 KIAS, 241°, 138 KIAS, 246°, 2,200 ft 86 kt corrected 70–80 ft AGL 19 AGL 4,600 ft runway remaining runway remaining ground speed, 238°
1601:41 1601:53 1602:23 Thrust levers retarded, Touchdown, DFDR and CVR 150 KIAS, 243°, 143 KIAS, 243°, stop recording, 53 ft AGL 3,700–3,800 ft 66 kt corrected past threshold ground speed, 235°
AGL = above ground level; CVR = cockpit voice recorder; DFDR = digital flight data recorder; KIAS = knots indicated airspeed
Source: Transportation Safety Board of Canada
Figure 2 www.flightsafety.org | AeroSafetyWorld | February 2008 | 43 causalfactors
[aircraft flight manual] and the aircraft touch- ing down at the recommended speed, the aircraft would have used 5,574 ft (1,699 m) of runway.” From the point that the acci- dent airplane touched down, however, only 5,200 ft (1,586 m) of runway stopping distance remained. Analysis of weather radar data found that, although there had been a downburst about eight km (five mi) northeast of Run- way 24L at the time of the accident, wind conditions at the time © Ernie Horvath/Airliners.net were not those typi- cally associated with type, and had been employed since 1997 by Air microburst. Conditions precluded any significant France, where he had a “good reputation for be- upward wind component at the runway, the report ing easy to fly with,” the report said. said. Numerous lightning strikes occurred just be- Departures had The first officer had 4,834 flight hours, fore touchdown, including nine cloud-to-ground including 2,502 on type. He was hired by Air strikes at the end of the runway that were recorded been halted by a France as a cabin crewmember in 1985; he in just one second.
“red alert” — a became a pilot for the company in 1997 and was considered “solid and competent,” the report said. ‘Red Alert’ warning of numerous The accident airplane was built in 1999. Total At the time of the accident, Runway 24L was in airframe time was 28,426 hours. The investiga- use because other flight crews had refused to op- lightning strikes at tion found that all aircraft systems were working erate on Runway 23 — at the far end of the air- as intended and that weight and balance at the port terminals, more than 3,500 ft (1,068 m) to or near the airport … time of the accident were within normal limits. the northwest — citing storms on the approach. Investigators calculated required stopping dis- Lightning strikes had rendered the ILS for tances for Runway 24L using the environmental Runway 24R and other runways unserviceable at conditions present at the time of the landing and various times in the hours before the accident. determined that, “for the actual touchdown speed Departures had been halted by a “red alert” — a of 143 KIAS [knots indicated airspeed], with warning of numerous lightning strikes at or near a 10-kt tailwind and the actual deployment of the airport typically accompanied by operators’ thrust reverser time of 16.4 seconds, the aircraft discontinuation of ground activities to protect would have stopped in 6,674 ft (2,034 m) after ground personnel from lightning. touchdown. … With full reverse thrust selected “During the course of the investigation, it after touchdown in accordance with the AFM was determined that a perception existed among
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both the occurrence pilots and other procedures were changed to allow approach. They must be ready to conduct pilots that airports could be closed if either pilot to make the call. a missed approach at any time one of weather conditions were too severe Although Air France had guidelines these conditions escapes their control or to allow approaches and landings to about the distance required from convec- understanding. They must not get them- be conducted safely,” the report said. tive activity during cruise flight, the air- selves into a situation where the missed “ATC may restrict the flow of aircraft line — like many others — had no such approach option is no longer available.” into a particular airport due to weather guidelines for approach and landing, the The asphalt blast pad and grassy area conditions, but the ultimate decision to report said. Air France had considered beyond the departure end of Runway conduct an approach or landing rests such guidelines after an earlier accident 24L extend for 200 ft/60 m, the mini- with the pilot.” but concluded that their adoption would mum length required by TC but shorter The report said that, although there be “contrary to the goal of enabling crews than the 1,000-ft/300-m runway end have been numerous reports and stud- to make decisions based upon each spe- safety area (RESA) recommended by the ies on runway overrun accidents and cific situation,” the report said. International Civil Aviation Organiza- many recommendations on how best “However, some companies do pro- tion (ICAO), the report said. If the Run- to avoid them — including the Flight vide such guidelines and, in some cases, way 24L RESA had been constructed Safety Foundation Approach and Land- directives related to approaches around in accordance with the ICAO recom- ing Accident Reduction (ALAR) Tool Kit thunderstorms. Previous accident in- mendation, “an obstacle-free overrun — and although Air France recognized vestigations have recognized their value area, free of hazardous ruts, depressions the potential for overrun accidents and to assist crews in making decisions in and other surface variations, would took steps to prevent them, this ac- situations where the choices before have extended to … approximately 75 cident “essentially fits the pattern of the them are less than obvious.” m [246 ft] beyond Convair Drive [about accident these programs and training After the accident, Air France re- the point where the accident airplane procedures were aimed at preventing.” vised sections of its operations manual stopped]. Similarly, if the requirement The report said that only after the that discussed thunderstorms. The had been the same as those established airplane was on very short final — TSB recommended that TC estab- by the U.S. Federal Aviation Admin- when the airplane encountered intense lish standards to restrict approaches istration (FAA) — calling for either a precipitation and reduced visibility and and landings during thunderstorms 1,000-ft /300-m RESA or a 600-ft/200-m departed from the glideslope — were and that TC and other civil aviation engineered materials arresting system there clear indications to the crew that authorities require flight crews to (EMAS) — “the damage to aircraft and a landing was unadvisable. “establish the margin of error between injuries to the passengers may have been “The crew had two courses of landing distance available and landing reduced,” the report said. action with potentially undesirable distance required before conducting an After the accident, TC said that, af- outcomes: proceed with an approach approach into deteriorating weather.” ter a review of RESA specifications and that was becoming increasingly difficult related information, it would require or conduct a missed approach into More Training all airports to construct RESAs. The potentially dangerous conditions,” the Another recommendation called for TC TSB issued a safety recommendation report said. “At that moment, although and other civil aviation authorities to calling on TC to require construction Air France procedures called for a go- require air transport pilots to undergo of a 1,000-ft/300-m RESA at the end of around any time the ideal trajectory is training “to better enable them to make all runways longer than 2,400 m (7,874 not maintained up to thrust reverser landing decisions in deteriorating ft), or an alternative means of “stopping deployment, the captain, doubting weather.” aircraft that provides an equivalent level that a go-around could be conducted The report added, “Crews need to of safety.” ● safely, committed to continue with the be more acutely aware that an approach This article is based on TSB Aviation landing.” near convective weather is a hazardous Investigation Report A05H0002, “Runway At the time, Air France procedures situation. … They must acquire a better Overrun and Fire, Air France, Airbus A340-313 said that only the captain could call for understanding of all the conditions that F-GLZQ, Toronto/Lester B. Pearson International a missed approach; after the accident, they may expect to be faced with on final Airport, Ontario, 02 August 2005.” www.flightsafety.org | AeroSafetyWorld | February 2008 | 45 FlightTEch © Alenia Aeronautica
Lighting Realistic lighting conditions are crucial to tests of the readability of flight deck displays. BY CLARENCE E. RASH Strikes hen pilots are taxiing their • Outside ambient lighting, which Whatever the lighting environment, aircraft to a runway for can be both natural and artificial, pilots must be able to access instrument takeoff, little if any thought is dominant. Natural contributors data whenever it is needed. During the is given to the effort that has are the sun, the moon and stars. day, there must be sufficient illumination Wgone into ensuring that the instruments Outside artificial light sources without glare, adequate contrast between are readable — that is, until they aren’t. include runway lights, surround- the displayed information and the back- One of the most challenging display ing operational lighting and city/ ground, and acceptable color rendition.1 lighting situations occurs during the industrial background lights; At night, flight deck lighting must day, with full sunlight reflecting off the provide uniform illumination through- • Interior compartment lighting, displays. Another occurs at night, for he- out the crew station and a minimal which may include instrument- licopter pilots using night vision goggles level of illumination to allow pilots to panel lights and overhead lights; (NVGs). Inadequate instrument lighting acquire information, to activate switch- and, design can make reading the displays es and controls, to consult navigational impossible in either situation. • Supplemental utility lighting, charts and yet not degrade the ability to Flight decks are affected by a range which pilots may introduce in perform additional visual tasks outside of lighting conditions, often during a the form of flashlights, chemical the flight deck, such as detecting and single flight. The lighting environment light sticks and other auxiliary identifying obstacles, locating land- is derived from three sources: lighting. marks and scanning for other aircraft.
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Instrument lighting must not interfere are straightforward. Lighting measure- luminance pattern. Lamp performance with the operation of NVGs. ments of any kind often are considered is stabilized and prolonged by a cooling half science and half art, and the skills re- system that recirculates the ambient air Evaluation Challenge quired to conduct the measurements are 60 times per second while maintaining The many types of display technologies, obtained more through experience than the dome environment at 50 percent lighting conditions and visual tasks in through training. But even the best test humidity and from 59 degrees F to 77 today’s aircraft place great demands on and measurement approach in artificial degrees F (15 degrees C to 25 degrees C). the lighting designer. Designs are driven environments is an approximation of the The sun simulator uses a 12-kW and complicated by the limited space of actual performance that will be achieved lamp to illuminate the dome center. The the modern crew station, the differing in the real-world environment. This is simulator can be operated in two modes, operating principles of various display especially true in aviation lighting. either to reproduce the effect of direct technologies and the wide range of am- The real challenge in validating sunlight into the cockpit or to reproduce bient lighting conditions under which the true performance of instrument a solar disk of the correct apparent size. displays are used. Nevertheless, the displays lies in reproducing realistic An approximately 29-ft (9-m), two-axis, actual lighting values achieved on the lighting conditions that represent the moveable mechanical arm allows the flight deck are most important. Test and lighting environments of full sunlight, lamp of the sun simulator to be posi- evaluation engineers validate whether dawn/dusk, moonlight and starlight. tioned at any location around the aircraft. the displays provide the required lumi- The effects of clouds are simulated nance (brightness), contrast, color and Simulating the Sun by two lamp projectors used in conjunc- other visual display characteristics that To provide realistic lighting conditions in tion with the light panels. This is most define acceptable readability. a testing facility and to minimize the costs useful in evaluating a pilot’s ability to The necessary validation must be ac- of testing, Alenia Aeronautica designed discern symbology presented on head- complished through a set of assessments and built a sophisticated test and evalua- worn — or helmet-mounted — displays. using quantitative tests and operator tion lighting facility at Turin (Italy) Inter- Dawn and dusk illumination condi- evaluations of readability and legibility national Airport. The facility provides a tions are achieved by using another in an authentic set-up of all flight deck cost-effective methodology for evaluating light projector. displays, instruments and control panels actual, full-scale, state-of-the-art aircraft By combining the various lighting under a comprehensive complement of displays under virtually the full range of simulations, many “worst case” lighting Strikes 2 3 realistic ambient lighting conditions. ambient lighting conditions. scenarios such as these can be created These quantitative assessments The Alenia Aeronautica facility Sky and tested:4 require instruments to measure visible Light Simulator light, color and specific forms of light (SLS) consists of energy. The first analysis of display per- 79 lighting panels formance involves basic measurement and 112 reflective of the aircraft instruments themselves, panels, a sun simu- conducted in darkened laboratories. lator and a cooling These results are compared with speci- system. The lighting fications and assigned a pass/fail rating. panels each contain If the instrument display passes the a variable number qualification tests, it next may undergo of fluorescent tubes limited user acceptance tests in flight to reproduce the deck mock-ups. Well-designed human appropriate lighting factors studies and surveys are used to condition. All pan- evaluate user performance in these con- els are controlled trolled but not very realistic settings. by computer and Although the tests can be arduous can be configured and require meticulous effort, they also for a specific sky © Alenia Aeronautica
www.flightsafety.org | AeroSafetyWorld | February 2008 | 47 FlightTEch
• A daytime combination of direct makes evaluation essential when NVGs computer-controllable illumination sunlight, sky diffuse light and are the primary source of visual flight levels.7 cloud-diffused light; information. This simulation and testing In addition to supporting lighting • A nighttime combination of under nighttime lighting conditions is tests and evaluations for the aircraft in- moonlight and starlight; one of the most difficult procedures. dustry, the SLS is a laboratory for other To provide the unique lighting lighting testing activities, including • High ambient lighting, rear sun requirements needed for testing pilot architectural assessments, vision and position; performance with NVGs, the night psychophysical research, aeromedical • High ambient lighting, front sun system used by Alenia Aeronautica research, and human factors and ambi- position; employs a dedicated specialized light ent lighting interactions. • Dawn/dusk, front sun position; source to simulate the nighttime moon To ensure safety during testing and and, and star conditions. evaluation activities, a number of sen- • Low ambient lighting, with or The nighttime projector consists of sors are deployed. Included are fuel va- without NVGs. dual sets of halogen lamps and illumi- por detectors and fire detectors located nates the flight deck indirectly. Black in the dome region and smoke and fuel Moon and Stars curtains reduce stray light — an essen- detectors in the air-cooling system. A With the emergence of NVGs in the tial quality for NVG evaluations — by fire-suppression system incorporates civilian cockpit, lighting and its effects blocking external light and absorbing foam dispensers and water sprinklers. ●
on pilot performance take on a new em- internal reflections. Clarence E. Rash is a research physicist at the phasis. Because modern NVGs amplify U.S. Army Aeromedical Research Laboratory the intensity of light approximately 2,000 Aircraft, Trains and Automobiles at Fort Rucker, Alabama, U.S. He has three times, even small levels of light that can- The SLS also tests actual, full-size decades of experience in aviation safety, opera- not be detected by the human eye can aircraft over the simulator’s full range of tional performance and human factors issues. greatly affect NVG performance — and, lighting conditions. Anna Russo, aero- Notes as a result, pilot performance. space engineer with Alenia Aeronautica, NVGs are designed to allow pilots said that the facility “can host a multi- 1. Godfrey, G.W. Principles of Display to view outside scenes under lighting tude of aircraft, both fixed- and rotary- Illumination Technologies for Aerospace conditions that extend down to the wing, as well as automobiles and train Crew Stations. Tampa, Florida, U.S.: Aerospace Lighting Institute, 1991. overcast starlight range. NVGs have locomotives.” The facility is built on a automatic circuitry that increases or 30-ton (27-metric ton) steel frame sup- 2. Russo, A.; Fabbri, M. “Ambient Lighting decreases their light amplification, or porting a 12-m (39-ft) diameter spheri- Simulation for Human-Vehicle Integration Purposes: The Alenia Aeronautica Sky gain, in response to the level of outside cal dome above a cylindrical drum.6 Light Simulator.” Presented at North ambient light. Unfortunately, NVGs are The structure has a specialized Atlantic Treaty Organization Human unable to differentiate between light opening — about 10 m by 6 m (33 ft by Factors and Medical Conference originating outside the aircraft and 20 ft) — that accommodates the front (HFM-141), Crete, Greece, 2007. inside. As a consequence, inadequate fuselage of an aircraft. A customized 3. Alenia Aeronautica. Sky Light Simulator. interior lighting design can negatively system of doors and curtains completes 2006. affect NVG performance by uninten- the light-tight sealing needed for the 4. Ibid. tionally reducing the amplification of lighting tests. exterior light as the NVGs respond to By reproducing an array of fully 5. Rash, C.E.; Verona, R.L. Cockpit Lighting the specific cockpit instrument lighting. controllable lighting environments and Compatibility with Image Intensification The possible outcome is that pilots have presenting these conditions directly Night Imaging Systems: Issues and Answers. Fort Rucker, Alabama, U.S.: U.S. Army a reduced capability to view critical onto actual aircraft, the SLS has several Aeromedical Research Laboratory. outside scenes, an outcome that may go advantages, including its availability USAARL Report No. 89-6, 1989. unnoticed by the pilots.5 regardless of outside weather condi- This unobserved effect of flight deck tions, its objectivity and repeatability 6. Alenia Aeronautica. lighting on NVG/pilot performance in measurements and a full range of 7. Ibid.
48 | flight safety foundation | AEroSafetyWorld | February 2008 DataLink
Making Headway on the Runway The FAA is meeting its performance targets for limiting runway incursions.
BY RICK DARBY
or each of the FYs [fiscal years] 2003 The FAA performance target is to limit through 2006, the FAA met its perfor- category A and B incursions to a rate of no more mance targets to reduce the most severe than 0.45 per million operations by 2010 and (category A and B) runway incursions,” maintain or improve that rate through 2011.3 “theF U.S. Federal Aviation Administration (FAA) says in its latest report.1,2 “The category A and B FAA Severity Categories of Runway Incursion incursion rate for FY 2006 was 0.51 incursions Increasing Severity per million operations, which is 7 percent less Category D Category C Category B Category A than the FY 2006 performance target of 0.55 incursions per million operations.” Little or no Separation Separation Separation chance of collision decreases but decreases decreases and The FAA analyzes incursions according to but meets the there is ample and there is participants take safety metrics that include frequency, severity definition of a time and distance a significant extreme action runway incursion to avoid a collision potential for to narrowly avoid and type. Frequency is expressed both as num- collision a collision, or the bers and rates. Severity considers factors such as event results in a the speed and performance characteristics of the collision aircraft involved, the proximity of the aircraft to FAA = U.S. Federal Aviation Administration another aircraft, vehicle, person or object, and Source: U.S. Federal Aviation Administration the evasive action taken (Figure 1). Figure 1
Runway Incursion Severity Distribution, U.S. Towered Airports, 2003–2006
FY 2003 FY 2004 FY 2005 FY 2006 Total Rate per Rate per Rate per Rate per Rate per Million Million Million Million Million Number Operations Number Operations Number Operations Number Operations Number Operations Category D 181 2.88 178 2.82 203 3.22 224 3.65 786 3.14 Category C 110 1.75 120 1.90 95 1.51 75 1.22 400 1.60 Category B 22 0.35 16 0.25 15 0.24 7 0.11 60 0.24 Category A 10 0.16 12 0.19 14 0.22 24 0.39 60 0.24 Total 323 5.10 326 5.20 327 5.20 330 5.40 1,306 5.20 FY = FAA fiscal year, Oct. 1 through Sept. 30.
Source: U.S. Federal Aviation Administration Table 1
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Of the more than 500 U.S. towered airports, Severity of Commercial Aviation Runway Incursions, 215 (43 percent) had no runway incursions, 215 U.S. Towered Airports, 2003–2006 had one to five incursions and 47 airports (9 FY 2003 FY 2004 FY 2005 FY 2006 Total percent) had six to 10 incursions from 2003 Category D 80 79 100 106 365 through 2006. Twenty-seven airports (5 percent) Category C 50 54 39 37 180 had more than 10 runway incursions, including Category B 6 3 3 2 14 two airports that had more than 30. Category A 3 6 6 8 23 The numbers and rates of incursions were Total 139 142 148 153 582 little changed from 2003 through 2006, with an FY = FAA fiscal year, Oct. 1 through Sept. 30. average of 5.2 incursions per million opera- Note: Incursions involve at least one commercial aviation aircraft. Source: U.S. Federal Aviation Administration tions (Table 1, p. 49). The three more incursions in 2006 compared with 2005 brought the rate Table 2 for that year to 5.4 per million operations, a 4 percent increase. FAA Classification of Runway Incursions Runway Incursion Severity Operational An operational error (OE) is an action of an air traffic controller Errors/ (ATC) that results in: From 2003 through 2006, 120 of the 1,306 Deviations • Less than the required minimum separation between two or runway incursions were category A or B. Four more aircraft, or between an aircraft and obstacles (e.g., vehicles, equipment, personnel on runways). category A runway incursions ended in colli- • An aircraft landing or departing on a runway closed to aircraft. sions during the four-year period — three in An operational deviation (OD) is an occurrence attributable to an element 2003 and one in 2005. One of those collisions of the air traffic system in which applicable separation minima were involved a commercial aircraft, a freighter, and maintained, but an aircraft, vehicle, equipment, or personnel encroached upon a landing area that was delegated to another position of operation no fatalities resulted. without prior coordination and approval. “The composition of runway incursions has Pilot A pilot deviation (PD) is an action of a pilot that violates any Federal changed over the four-year period,” the report Deviations Aviation Regulation. For example, a pilot fails to obey air traffic control instructions to not cross an active runway when following the authorized says. “Category B incursions decreased substan- route to an airport gate. tially from 22 in [2003] to seven in [2006].” Vehicle/ A vehicle or pedestrian deviation (V/PD) includes pedestrians, vehicles, Commercial aviation operations accounted Pedestrian or other objects interfering with aircraft operations by entering or for 582 of the total 1,306 incursions, or 45 per- Deviations moving on the movement area without authorization from air traffic control. Note: This runway incursion type includes mechanics taxiing cent, in the 2003–2006 period.4 aircraft for maintenance or gate re-positioning. At least one commercial aircraft was FAA = U.S. Federal Aviation Administration involved in 23 category A incursions and 14 Source: U.S. Federal Aviation Administration category B incursions during the four-year pe- Table 3 riod (Table 2). The two categories combined
Numbers and Rates for Incursion Types, U.S. Towered Airports, 2003–2006
FY 2003 FY 2004 FY 2005 FY 2006 Total Rate per Rate per Rate per Rate per Rate per Million Million Million Million Million Number Operations Number Operations Number Operations Number Operations Number Operations Pilot Deviations 174 2.8 173 2.7 169 2.7 190 3.1 706 2.8 Operational Errors/Deviations 89 1.4 97 1.5 105 1.7 89 1.5 380 1.5 Vehicle/Pedestrian Deviations 60 1.0 56 0.9 53 0.8 51 0.8 220 0.9 Total 1,306 5.2 FY = FAA fiscal year, Oct. 1 through Sept. 30. Source: U.S. Federal Aviation Administration
Table 4
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represented 6 percent of commercial aircraft Numbers and Types of Runway Incursions, incursions. The annual number of category Commercial Aviation, U.S. Towered Airports, 2003–2006 A incursions involving a commercial aircraft was largest — eight — in 2006. Category B FY 2003 FY 2004 FY 2005 FY 2006 Total incursions declined over the four years and Pilot Deviations 63 67 74 69 273 represented a smaller percentage of the total Operational Errors/Deviations 50 58 54 60 222 for commercial aircraft than those of Cat- Vehicle/Pedestrian Deviations 26 17 20 24 87 egory A. Total 582
Persistent Pilot Deviations FY = FAA fiscal year, Oct. 1 through Sept. 30. Note: Incursions involve at least one commercial aviation aircraft. FAA categories split runway incursions into Source: U.S. Federal Aviation Administration three error types: pilot deviations, operational errors/deviations and vehicle/pedestrian devia- Table 5 tions. The criteria are in Table 3. Pilot deviations were found in 706 of 1,306 Numbers and Severity of Runway Incursions incursions in the four-year period, or 54 at 35 U.S. Airports, 2003–2006 percent (Table 4). “During that time, the FAA Number of Runway Incursions focused efforts on reducing pilot deviations 0 5 10 15 20 25 30 35 through awareness, education, procedures Chicago O’Hare Atlanta and surface technology initiatives,” the report Dallas-Fort Worth says. Los Angeles Las Vegas Nevertheless, the rate was 0.4 per million Phoenix operations higher in 2006 than the period’s low- Denver Houston est rate. The rate of pilot deviations was 2.8 or Minneapolis-St. Paul 2.7 per million from 2003 through 2005, rising Detroit Philadelphia in 2006 to 3.1 per million. During the four-year Charlotte period, 55 of 120, or 46 percent, of incursions in Cincinnati/Northern Kentucky Washington Dulles categories A and B involved pilot deviations, the Newark FAA says. Salt Lake City Boston Limiting the picture to commercial aviation, New York LaGuardia Miami pilot deviations were responsible for 273 incur- Memphis sions, or 47 percent of the total of 582 in all cat- San Francisco New York Kennedy International egories (Table 5). Operational errors/deviations Seattle-Tacoma accounted for 222 incursions, or 38 percent, and Orlando St. Louis 87 incursions, or 15 percent, were ascribed to Honolulu vehicle/pedestrian deviations. Chicago Midway Fort Lauderdale “The total number of combined category A Baltimore/Washington International and category B operational errors/deviations Pittsburgh Reagan Washington National involving a commercial aircraft increased Portland, Oregon Category A Cleveland Category B from [2003] through [2005] and decreased Tampa Category C by one in [2006],” the report says. “Category San Diego Category D A incursions increased during the four-year FY = U.S. Federal Aviation Administration fiscal year, Oct. 1 through Sept. 30. period, with a total of four commercial avia- Notes: The 35 airports are those identified in the FAA Operational Evolution Partnership. tion operational errors/deviations in [2006] Airports arranged in decreasing number of operations (FY 2003 through FY 2006). compared to one in [2003].” No commercial Source: U.S. Federal Aviation Administration operational errors/deviations in category B occurred in 2006. Figure 2 www.flightsafety.org | AeroSafetyWorld | February 2008 | 51 DataLink
Airports identified in the FAA Operational Numbers and Types of Runway Incursions Evolution Partnership (OEP), known as OEP-35 at U.S. Airports, 2003–2006 airports, primarily handle commercial aviation Number of Runway Incursions and have a large traffic volume. Their runway 0 5 10 15 20 25 30 35 incursion records were analyzed for correlations Chicago O’Hare Atlanta between incursions and traffic. Figure 2 (p. 51) Dallas-Fort Worth shows the numbers and severity of incursions at Los Angeles Las Vegas the OEP-35 airports for the 2003–2006 period. Phoenix At these airports, category A and B incursions Denver Houston accounted for 4 percent and 3 percent, respec- Minneapolis-St. Paul Detroit tively, of the total. Philadelphia The numbers and types of incursions at Charlotte Cincinnati/Northern Kentucky the OEP-35 airports are shown in Figure 3. Washington Dulles Operational errors/deviations were the largest Newark Salt Lake City single category, at 42 percent of the total. Pilot Boston deviations, at 40 percent, and vehicle/pedes- New York LaGuardia Miami trian deviations, at 18 percent, were next in the Memphis ranking. ● San Francisco New York Kennedy International Seattle-Tacoma Notes Orlando St. Louis 1. FAA. FAA Runway Safety Report: Runway Incursion Honolulu Chicago Midway Trends and Initiatives at Towered Airports in the Fort Lauderdale United States, FY 2003 through FY 2006. Accessible Baltimore/Washington International via the Internet at
52 | flight safety foundation | AeroSafetyWorld | February 2008 InfoScan At Your Surface The FAA has implemented most of its planned runway and ramp safety improvements, but ASDE-X implementation is lagging.
REPORTS education and training materials to controllers, pilots and other airport users; (2) supporting Aviation Runway and Ramp Safety: and developing new technologies intended Sustained Efforts to Address Leadership, to reduce the potential for runway collisions; Technology, and Other Challenges Needed and (3) assessing and modifying procedures to to Reduce Accidents and Incidents enhance runway safety,” says the report. “The re- U.S. Government Accountability Office (GAO). Report no. GAO-08-29. sults of our survey of experts indicated that the November 2007. Figures, tables, appendixes. Available via the Internet at
“Although it took about four years for addressing air traffic controller overtime and ASDE-X to be commissioned at those 11 fatigue issues that may affect runway safety.” airports, FAA plans to deploy the system at the remaining 24 additional airports in less than Preliminary Results of an Experiment to four years,” the report says. “Furthermore, not Evaluate Transfer of Low-Cost, Simulator- all 11 ASDE-X commissioned airports have key Based Airplane Upset-Recovery Training safety features of the system. For example, as Rogers, Rodney O.; Boquet, Albert; Howell, Cass; DeJohn, Charles. U.S. Federal Aviation Administration (FAA) Office of Aerospace of August 2007, three of the ASDE-X commis- Medicine. DOT/FAA/AM-07/27. Final report. October 2007. 21 pp. sioned airports did not have safety logic, which Figures, tables, references. Available via the Internet at
54 | flight safety foundation | AEROSafetyWorld | February 2008 InfoScan
airspeed, vertical speed, altitude, attitude, g he FAA has adopted the System Airport force, manifold pressure and yoke movement. Efficiency Rate (SAER), a metric of air The FDR added measurements of yoke move- Ttraffic control’s ability to handle arrivals ment and rudder pedal displacement. or departures by adjusting for weather, aver- “During testing, each participant was sub- aged over time. But, the report says, although jected to four randomly ordered upsets,” the the SAER has been widely accepted and used at report says. “For each upset, a participant was U.S. airports, the question remains whether it told to close his or her eyes while the safety pilot is “sensitive enough to evaluate the efficacy of induced the upset. Then — when instructed to interventions aimed at improving performance do so — the now open-eyed participant as- during inclement weather.” sumed control of the airplane and attempted to One such intervention is the Integrated recover it to straight and level flight.” The safety Terminal Weather System (ITWS), a suite of pilot intervened if needed. If a participant pilot weather information products for improving air returned the aircraft to straight and level flight terminal planning, capacity and safety. ITWS with no verbal or physical assistance from the integrates sensors and information systems from safety pilot, the recovery was considered suc- the FAA and National Weather Service into cessful; otherwise, unsuccessful. displays of current and predicted weather condi- The experiment encountered practical tions for controllers and facility managers to use problems, such as recording-equipment failures, in decision making. described in the report. The researchers “failed To assess SAER’s ability to measure the effec- to obtain, or discarded, a significant amount of tiveness of ITWS, researchers used time series data,” says the report. analysis, in which “data are statistically mod- Nevertheless, using what they had, the eled to remove the lingering effects of previous researchers analyzed the data and found statisti- scores, general trends and the lingering effects cally significant differences in some measures of preceding random errors,” the report says. related to the four categories of upset — nose- “Once outside sources of systematic variation high upright, nose-low upright, nose-high have been removed, interventions may be tested inverted and nose-low inverted. to determine whether they have an effect.” “Experimental group performance exceeded Two time series analyses were conducted control group performance 44.4 percent of the for each of 13 major U.S. airports. “Though time,” the report says. “This superiority ap- some statistically significant effects were found peared in all four [categories of] upsets and in (both positive and negative), the patterns of six of the nine dependent measures [such as these effects were not consistent enough to draw average g during pullout]. By contrast, in three any definite conclusions about the efficacy of dependent measures — altitude loss, seconds to the ITWS implementation,” the report says. first roll and rudder input — there was never a “Though the SAER is clearly doing what it was significant difference between experimental and intended to do on a daily basis, it may ‘control control group performance.” out’ the variance needed to detect the conse- quences of interventions.” Time Series Analyses of Integrated Terminal Weather System Effects on WEB SITES System Airport Efficiency Ratings Pfleiderer, Elaine M.; Goldman, Scott M.; Chidester, Thomas. U.S. U.S. Federal Aviation Administration (FAA), Federal Aviation Administration (FAA) Office of Aerospace Medicine.
noise, spatial disorientation, simultaneous offset instrument fatigue, vision and medications. approaches. There is also a ques- Most are five to six pages with tion and answer review for pilots: color illustrations. Instructions
56 | flight safety foundation | AEROSafetyWorld | February 2008 OnRecord Throttle Trouble Inadvertent thrust increase caused a fatal overrun.
BY MARK LACAGNINA
The following information provides an aware- captain nor the copilot had received crew ness of problems in the hope that they can be resource management training on two-pilot avoided in the future. The information is based operations. The pilots had conducted 12 previ- on final reports by official investigative authori- ous A310 flights together. ties on aircraft accidents and incidents. The flight crew that had conducted the previous flight in the accident airplane had JETS reported a malfunction of the thrust reverser on the left engine, and it had been deactivated ‘The Crew Failed to Perceive the Cause’ by maintenance personnel in accordance with Airbus A310. Destroyed. 125 fatalities, 41 serious injuries. the A310’s minimum equipment list before the he A310 overran the runway while land- airplane departed from Moscow. ing at Irkutsk, Russia, the morning of July The flight to Irkutsk was uneventful. The T8, 2006. The airplane struck the reinforced report noted, however, that the copilot used an concrete airport perimeter fence and several incorrect radio frequency to report to air traffic brick garages before stopping, said the report control (ATC) that they were beginning descent. by the Russian Interstate Aviation Committee. After correcting the error, the copilot told the Both pilots, three cabin crewmembers and 120 captain, “I didn’t switch it over. … It’s night, and passengers were killed. Three cabin crewmem- we’re not getting enough sleep.” bers and 38 passengers were seriously injured. The Irkutsk airport was reporting surface Twenty-two passengers sustained minor injuries, winds from 270 degrees at 4 m/second (8 kt), and 15 escaped injury. The A310 was destroyed 3,600 m (2 1/4 mi) visibility with weak rain by the impact and fire. showers and an overcast ceiling at 190 m (623 The airplane was on a scheduled flight from ft). The runway was wet, and braking action was Moscow. The captain, 45, had 10,611 flight reported as good. hours, including 1,056 flight hours in type. He The crew disengaged the autopilot and had flown Antonov An‑24s, Boeing 757s and autothrottles while conducting a nondirec- Tupolev Tu‑154s before transitioning to A310s tional beacon (NDB) approach to Runway 30. in May 2005. The copilot, 48, had 9,771 flight After the airplane touched down in the runway hours, including 158 flight hours in type. He touchdown zone — about 200–300 m (656–984 had flown An‑26s as a captain and Tu‑154s ft) from the threshold, the spoilers deployed and as a copilot before transitioning to A310s two the autobrakes activated in the “LOW” mode. months before the accident. The report noted “The captain moved the right engine (no. 2) that while transitioning from the three-pilot thrust reverser [lever] forward,” the report said. Tu‑154 to the two-pilot A310, neither the “However, simultaneously with the subsequent www.flightsafety.org | AEROSafetyWorld | February 2008 | 57 OnRecord
reduction of the reverse mode of engine no. Maximum wheel braking was applied, but 2, engine no. 1 started to speed up (forward “because of the significant forward thrust of the thrust), which led to an increase in airplane left engine … the braking force came to equal speed and the onset of torque that pulled the the total thrust of the engines, [and] speed airplane to the right. The crew failed to perceive stabilized [at] about 180 km/hour [97 kt],” the the cause of what was happening.” report said. In accordance with the engine manufac- Aircraft rescue and fire fighting (ARFF) ve- turer’s recommendation, the captain had not hicles arrived about one minute after the airplane moved the lever for the deactivated left thrust came to a stop. The report said that 67 occupants reverser. Postaccident experiments indicated were evacuated by flight attendants and 11 were that he might have inadvertently moved the rescued by ARFF and municipal fire and rescue left throttle lever forward with the palm of his personnel before rescue efforts were halted six hand when he used his fingers to move the minutes later because of intense flames inside the right thrust reverser lever aft. The report said cabin. The fire was extinguished about 2.5 hours that shaking and vibration of the airplane from later. Of the 120 fatalities, 119 were caused by contact with the rough runway likely contrib- acute carbon monoxide poisoning, and one was uted to the unintended movement of the left caused by severe trauma and burns. throttle lever, which caused engine power to increase to 60 percent of maximum takeoff Engine Separates During Departure thrust. The airplane’s groundspeed, which had Boeing 747-100. Substantial damage. No injuries. decreased to 165 km/hour (89 kt), began to ighttime visual meteorological condi- increase. The left throttle lever movement also tions (VMC) prevailed when the airplane caused the spoilers to retract and the auto- Ndeparted from Chicago for a cargo flight brakes to disengage. to New York on Oct. 20, 2004. The 747 was The left throttle The pilots received aural and visual warn- climbing through 15,000 ft over Lake Michigan ings that the airplane was not configured prop- when the flight crew heard a loud bang, detected lever movement also erly for takeoff. Because the warnings were not a left yaw and observed indications that the no. related to landing and were not expected by 1 — left outboard — engine had failed, said caused the spoilers the pilots, they might have contributed to their the report by the U.S. National Transportation to retract and the inability to recognize the developing situation. Safety Board (NTSB). “The unusual behavior of the airplane, espe- “A visual inspection by the crew of the no. autobrakes to cially the strong turn to the right, increased 1 engine to check for damage revealed that the mental and physiological load on the pilots the [mounting] pylon was still in place but the disengage. and facilitated the distraction of attention from engine was missing,” the report said. The crew control over the engine rpm and speed,” the diverted to Detroit and landed without further report said. incident. The copilot did not comply with a require- Most of the no. 1 engine was recovered from ment to continuously monitor engine parameters the lake bottom, about 270 ft (82 m) below the and airspeed during the landing. The airplane surface, during the summer of 2005. Examina- was about 850 m (2,789 ft) from the end of the tion of the engine showed that an uncontained 2,425-m (7,956-ft) runway when the captain separation of about half of the second-stage said, “What’s wrong?” The copilot replied, “Speed turbine disk rim had occurred in flight, creat- increasing.” The captain told the copilot, “Reverse ing a severe imbalance that caused the turbine once again.” The copilot moved the right thrust exhaust case to break up and release the engine. reverser lever, but, because of the position of the The report said that an anti-seize compound left throttle lever, the thrust reverser doors on the that is not authorized for use because it causes right engine did not unlock. corrosion had been used on second-stage
58 | flight safety foundation | AEROSafetyWorld | February 2008 OnRecord
turbine bolts during maintenance of the engine blocked by a windshield post. The pilots heard and no preservation procedures had been a “graunching” sound but felt no impact when performed before the engine subsequently was the bottom of the right engine nacelle struck the placed in storage for five years. Only a visual rear of the tractor and pushed it out of the way. inspection of the high-pressure turbine and They observed no abnormal indications but The right engine turbine exhaust case had been performed before decided to have the aircraft inspected after they the components were installed on the no. 1 en- were clear of the narrow portion of the taxiway. nacelle struck the gine of the accident airplane 94 operating hours “Just as the commander was about to transmit a rear of the tractor before the separation occurred. request for ATC to dispatch a vehicle to inspect the aircraft, he heard a transmission [by the and pushed it out ‘All Clear’ Signal Given Prematurely tractor driver] advising ATC to stop an aircraft Airbus A320-200. Substantial damage. No injuries. as it had hit a tractor,” the report said. “Realizing of the way. ight rain was falling, but visibility was good that they were the aircraft involved, the crew when the aircraft was pushed back from its stopped the aircraft and applied the parking Lstand onto a taxiway at London Heathrow brake. At the same time, ATC advised them to Airport the afternoon of June 26, 2006, for a stop the aircraft.” scheduled flight to Munich, Germany. The A320 The right engine was shut down, and ARFF was given a long pushback to a relatively narrow personnel observed substantial damage but no part of the taxiway, to allow another aircraft to be fuel leaks. The pilots then taxied the aircraft on taxied to the stand, said the report by the U.K. Air one engine to a stand, and the 83 passengers Accidents Investigation Branch (AAIB). disembarked. The pushback was conducted by a marshaller and the driver of a towbarless tractor. After the Taxiway Mistaken for Takeoff Runway pushback was completed, the tractor was discon- Cessna Citation CJ1. No damage. No injuries. nected and parked near the A320’s right engine. he pilot had been on duty nearly 13 hours The marshaller did not signal the tractor driver to when he was cleared to take off on Runway reposition the vehicle outside the aircraft move- T36L at Memphis (Tennessee, U.S.) Inter- ment area before disconnecting his headset and national Airport the night of Oct. 11, 2007. He giving the flight crew the “all clear” hand signal. turned onto parallel Taxiway M and began the The marshaller then got into the tractor and takeoff, toward a Bombardier CRJ200 that was was told by the driver that the vehicle could holding at an intersection, facing away from the not be driven forward because a warning light Citation, about 5,320 ft (1,622 m) away. indicated that the nosegear cradle retracting “The tower controller made two transmis- mechanism had malfunctioned, causing the sions to advise that the aircraft was departing on “drive inhibit” system to engage. Neither ground a taxiway,” the NTSB report said. The Citation crewmember used the drive inhibit override pilot did not acknowledge the warnings until the button. “[They] heard the aircraft’s engines start airplane lifted off the taxiway. “He did not real- to increase power and saw the aircraft start to ize the centerline lights were green until he was move,” the report said. “They both got out of near flying speed, so he continued the takeoff the tractor in an attempt to indicate, with hand and offset to the left of the taxiway immediately signals, that they wanted the aircraft to stop. after liftoff,” the report said, noting that runway [When] it became apparent that the flight crew centerline lights are white. The Citation passed were not looking in their direction … they both 400–500 ft (122–152 m) over the regional jet. returned to the tractor to make another attempt “The Memphis air traffic quality assurance to move it and also for their own protection.” manager stated that there had been a number The commander could not see the trac- of previous attempts to commence takeoff from tor, and the copilot’s view of the tractor was the 150-foot [46-m] wide taxiway but that the www.flightsafety.org | AEROSafetyWorld | February 2008 | 59 OnRecord
mistake had always been caught before takeoff,” the tug preferred for regional jet pushbacks but the report said. “was approved, with caution, at stations where a preferred tug was not available,” the NTSB Stomach Bug Incapacitates PIC report said. Boeing 767-300. No damage. No injuries. “As the tug began to move, the landing he 767 was en route from Nagoya, Japan, gear tires skidded against the tarmac, and the to Cairns, Queensland, Australia, with two pushback was aborted,” the report said. “Ap- Tflight crewmembers, seven cabin crew- proximately 14 inches [36 cm] of skid marks members and 162 passengers the night of July 9, were observed near the main landing gear tires. 2007. The aircraft was about 1,390 km (751 nm) The airplane sustained damage to the forward from Cairns when the pilot-in-command (PIC) pressure bulkhead, forward longerons and nose collapsed on the cockpit floor after getting out of landing gear.” his seat to go to the lavatory, said the report by NTSB said that the probable cause of the the Australian Transport Safety Bureau (ATSB). accident was “the captain’s failure to follow “There was no response from the PIC to the company procedures, which resulted in push- copilot’s questioning,” the report said. “The copilot back with the parking brake set.” The report said switched on the cockpit lights and saw that the PIC that the captain and the ramp marshaller had appeared to be staring into space and remained not complied with aircraft operating manual unresponsive.” The copilot summoned the cabin requirements that the marshaller query, and the service manager, who administered oxygen to the captain verbally confirm, that the parking brake PIC and then helped him to the lavatory. Medical is released before pushback is begun. assistance also was provided by MedAire, through a radio link, and by a medical practitioner who was TURBOPROPS a passenger aboard the flight. The aircraft was midway between Guam and Broken Turbine Blade Causes Engine Fire Cairns. The copilot decided to continue the flight Bombardier DHC-8-400. Substantial damage. No injuries. to Cairns because of tropical storms on the route he airplane was climbing through 13,500 to Guam. About 50 minutes after he collapsed, ft, en route from Sandefjord, Norway, to the PIC returned to the cockpit. The copilot TBergen with 27 passengers on May 19, 2004, remained the pilot flying. When the 767 entered when the flight crew heard a bang, felt a jolt and Australian airspace, the PIC transmitted a “PAN” observed indications that the left engine had call and requested that emergency services be on failed. “Shortly later, the fire alarm actuated,” standby for the landing, which subsequently was said the report by the Accident Investigation conducted without further incident. Board of Norway. “The PIC was subsequently examined and The crew conducted the “Engine Failure/ cleared to return to flight duties by a designated Fire/Shutdown” checklist, declared an emer- aviation medical examiner (DAME),” the report gency and turned back to Sandefjord. While said. “The DAME determined that the PIC conducting the checklist, the crew shut down probably had been affected by a gastrointestinal the left engine and discharged a fire extin- illness that had previously been experienced by guisher bottle into it. The fire warning light members of the PIC’s family.” remained illuminated, however, so the crew discharged the second fire extinguisher bottle Parking Brake Set During Pushback into the engine. The warning light stayed on, Embraer 135LR. Substantial damage. No injuries. but the approach and landing were conducted he tug used to push the airplane from the without further incident. The report said that gate at Newark, New Jersey, U.S., on July 24, the engine fire likely was extinguished by the T2006, was larger and more powerful than extinguishing agent from one or both of the
60 | flight safety foundation | AEROSafetyWorld | February 2008 OnRecord
bottles, or went out by itself about seven min- m (112 ft) from the end of the runway. One tire utes before the landing. was damaged, and the brakes on all four main After the Dash 8 came to a stop on the wheels were replaced because of wear and sus- runway, the right engine was shut down and the pected overheating. passengers were evacuated. ARFF personnel “During the investigation, the manufacturer “With a forward CG, sprayed foam into the left engine, which was not and another [Metro] operator were contacted burning but was still very hot. regarding the handling characteristics of the the handling pilot Examination of the Pratt & Whitney Canada aircraft during takeoff,” the report said. “They (PWC) PW150A engine showed that one of the confirmed that, with a forward CG, the han- would be required first-stage low-pressure compressor blades had dling pilot would be required to pull the control to pull the control fractured due to fatigue. The resulting compres- column back a large amount in order to rotate sor imbalance caused major internal damage the aircraft and complete the takeoff.” column back a and an oil leak from a crack in the fuel heater. The pitch trim had been set in the middle “This oil flowed backward and was ignited by of the takeoff range, rather than in the nose-up large amount.” the hot exhaust gases at the rear of the engine,” position recommended for a forward CG. “This the report said. “The fire caused major dam- would have exaggerated the need for a large aft age to the engine and caused the fire alarm to movement of the control column during rota- continue even after the engine had been cooled tion,” the report said. completely.” The crew’s relative inexperience was a fac- After the accident, PWC issued several tor in the incident, the report said. The com- service bulletins, recommending engine inspec- mander had 2,150 flight hours, including 1,915 tions and installation of an improved first-stage flight hours in Metros, of which 250 flight compressor. hours were as commander in type. The copilot had 585 flight hours, including 295 flight hours Inadequate Rotation Leads to Overrun in type. Fairchild Metro III. Minor damage. No injuries. he center of gravity (CG) was at the forward Electrical Discharge Damages Engine limit when the Metro crew began the Cessna 208. Substantial damage. No injuries. Ttakeoff from Lasham Airfield in Hampshire, he float-equipped airplane departed from England, for a cargo flight on Oct. 10, 2006. Strahan, Tasmania, Australia, with 10 pas- The copilot, the pilot flying, said that he pulled Tsengers for a chartered sightseeing flight the control column “a bit” after the commander on Feb. 5, 2006. The Caravan was at 4,500 called “rotate,” but the aircraft did not respond, ft when the pilot observed the chip detector the AAIB report said. warning light, indicating the presence of metal- He pulled the column “a bit more,” but the lic fragments in the engine oil and abnormal aircraft still did not respond. “He reported engine wear. that he then pulled the control column back “The pilot decided to land the plane as soon half to three-quarters of its full travel,” the re- as possible,” the ATSB report said. “During the port said. “The nose of the aircraft pitched up diversion, five minutes after the chip detector a small amount but no further. He advised the light illuminated, a loud noise was heard, and commander of the problem. The commander the engine lost power. The pilot immediately took control and, after trying to rotate the feathered the propeller and carried out a forced aircraft himself without success, he rejected landing on Lake Burbury.” The airplane came the takeoff by applying reverse thrust and to a stop on a mud bank, with its floats clear of maximum braking.” the water. The Metro overran the 1,797-m (5,896-ft) Examination of the engine revealed pre- runway and came to a stop in a grassy area 34 existing thermal damage to the no. 1 main www.flightsafety.org | AEROSafetyWorld | February 2008 | 61 OnRecord
shaft bearing that was consistent with electri- Commander was found in a wooded area about cal discharge, or arcing. “The source of the a mile from the runway. NTSB said that the electrical discharge damage was a starter/ probable cause of the accident was “clearance generator that was replaced due to a malfunc- not maintained with terrain during a nonpre- tion 18.7 hours prior to the engine failing,” cision approach.” the report said. Examination of the failed unit showed that insulation on the armature wind- Crossfeed Misuse Leads to Fuel Starvation ings had been overheated and damaged dur- Cessna T303 Crusader. Destroyed. Six serious injuries. ing one or more engine starts and had created he heaviest passengers and baggage were a short circuit through the starter/generator in the rear of the aircraft, and the CG to the engine. The failed unit had been oper- Twas more than 1.0 in (2.5 cm) aft of the ated 852 hours since its last overhaul and had aft limit throughout the round-trip flight 748 hours remaining before its next scheduled between Denham (England) Airfield and overhaul. Durham Tees Valley Airport near Darlington The report said that PWC records showed on Aug. 5, 2006. The T303 was 156 lb (71 kg) that there were 42 previous PT6A starter/ over its maximum takeoff weight and did not generator electrical discharge incidents have adequate fuel reserves for the round-trip worldwide, most of which led to bearing flight when it departed from Denham, the failures. Among recommendations based on AAIB report said. The airports are about 178 the Lake Burbury accident, ATSB said that nm (330 km) apart. PWC should electrically isolate the starter/ After landing at Durham Tees Valley Air- generators from the no. 1 main shaft bearings port, the pilot checked the fuel gauges, which in PT6A engines. indicated about 60 gal (227 L) remaining, and decided not to have the aircraft refueled PISTON AIRPLANES before the return flight to Denham. “The pilot, who suffered serious head injuries during the Airplane Hits Trees During Night Approach accident, had very poor recollection of some Aero Commander 500B. Destroyed. One fatality. aspects of the flight,” the report said. “He he pilot was conducting a cargo flight from could remember operating the fuel crossfeed Grand Rapids, Michigan, U.S., to Gaylord, and thought he may have retarded one of the TMichigan, the night of Nov. 16, 2005. The throttles to idle in order to conserve fuel.” Gaylord airport had 3/4 mi (1,200 m) visibility This likely occurred during descent, when the in light snow and mist, a broken ceiling at 800 ft, front-seat passenger observed the pilot turning an overcast at 1,200 ft and temperature and dew rotary controls and noticed that one fuel gauge point both at minus 1 degree C (30 degrees F), was “in the red marking” and the other was the NTSB report said. “just above the red marking.” The glideslope for the instrument land- Noting that use of the fuel crossfeed system ing system (ILS) approach to Runway 09 was is prohibited during landing or when less than reported as unmonitored and out of service, so 10 gal (38 L) remain in the selected tank, the the pilot requested and received clearance from report said that the system was being used to ATC to conduct the localizer approach, which deliver fuel from the left tank to both engines has published minimums of 1,700 ft — 381 ft when the pilot turned left onto final approach height above touchdown — and 1/2 mi (800 m) at Denham Airfield. Both engines lost power visibility. due to fuel starvation during the turn, and ATC radio and radar contact were lost after airspeed decreased. The aircraft then stalled the pilot was cleared to change to the airport and descended into a densely wooded area. advisory frequency. The wreckage of the Aero There was no fire. The six occupants were
62 | flight safety foundation | AEROSafetyWorld | February 2008 OnRecord
unable to exit the aircraft; they were treated by HELICOPTERS paramedics and transported by ambulances to Downwash Forces Rotor Into Tail Boom a hospital. Hughes OH-6A. Substantial damage. No injuries. Heart Problem Incapacitates Pilot he OH‑6A, a military version of the Model Piper PA-23-160 Apache. Destroyed. One fatality. 500, had been landed and shut down at ighttime VMC prevailed for the cargo Ta private landing site near Newbridge, flight from Peoria, Illinois, U.S., to Smith- Ireland, on Oct. 13, 2006, a few minutes before Nfield, North Carolina, on Nov. 9, 2005. a Eurocopter EC‑120B passed in close proxim- The door opened on departure, and the pilot ity while being maneuvered to land. Downwash returned to the airport to close it. During the from the Eurocopter’s main rotor caused one second departure, the Apache was about 44 nm of the main rotor blades on the OH‑6A to flap (81 km) from Peoria when the pilot reported down and strike the tail boom, said the report a problem with the right engine and requested by the Irish Air Accident Investigation Unit. clearance to return to the airport, the NTSB “As the main rotor of the Hughes OH‑6A is report said. not equipped with a rotor brake, it is free to ro- The approach controller issued a heading to tate in the effect of downwash,” the report said. Peoria and asked the pilot if he was declaring an “Damaged was caused to the tail boom, a main emergency. The pilot said, “Negative. It’s just … rotor blade and its associated rotor damper.” developing partial power. I’m in good shape.” The controller said that the Bloomington, Il- Wind Gust Causes Control Loss linois, airport was about 7 nm (13 km) from Bell 206B JetRanger. Substantial damage. One minor injury. the airplane’s position, and the pilot requested a local airport was reporting winds at 16 kt, vector to Bloomington. gusting to 27 kt, when the pilot prepared to The pilot established radio communication Adepart from a private landing site in Stock- with the Bloomington airport traffic control port, Cheshire, England, on April 30, 2007. “Hav- tower. After he reported downwind and was ing lifted into the hover, approximately into wind, cleared to land, his transmissions included sev- the pilot turned and hover-taxied the helicopter eral expletives and the sound of heavy breath- downwind in order to give himself the full length ing. The pilot did not respond to transmissions of the field for the takeoff,” the AAIB report said. by the controller. The Apache crashed and The pilot then conducted a spot turn to the burned in a field about 1 nm (2 km) from the right, to position the helicopter into the wind. airport. “Although he would normally have carried out the “The pilot’s autopsy revealed evidence that spot turn to the left, on this occasion, he was keen to a tear in the aorta (aortic dissection) had oc- keep some nearby power cables in sight,” the report curred prior to the accident and resulted in the said. “Carrying out a spot turn to the right involved rapid accumulation of blood around the heart, reducing the thrust produced by the tail rotor.” substantially impairing heart function and lead- A sudden loss of tail rotor effectiveness ing to impairment or incapacitation,” the report occurred when the wind gusted during the said. “This type of tear in the aorta typically spot turn. The JetRanger struck the ground [results in] a sudden onset of severe pain [and] and rolled onto its right side. The pilot was not would most likely have been fatal regardless of injured. The passenger sustained a minor injury. the circumstances under which it occurred.” The “The wind speed at the time of the accident report noted that the pilot had been receiving was probably in excess of the demonstrated treatment for hypertension and diabetes, and maximum sideways and rearwards airspeed [i.e., had obtained a “special issuance” airman medi- 17 kt] to which the helicopter had been [certi- cal certificate. fied],” the report said. ● www.flightsafety.org | AEROSafetyWorld | February 2008 | 63 OnRecord
Preliminary Reports
Date Location Aircraft Type Aircraft Damage Injuries Dec. 2, 2007 Coeur d’Alene, Idaho, U.S. Cessna Citation IISP substantial 8 none The Citation departed the right side of a slush-covered runway while landing with a left crosswind at 19 kt, gusting to 29 kt. Dec. 3, 2007 Whittier, Alaska, U.S. Eurocopter BK 117C-1 destroyed 4 fatal The helicopter is presumed to have crashed in the ocean during an air ambulance flight in instrument meteorological conditions (IMC) from Cordova to Anchorage. Dec. 4, 2007 New Castle, Delaware, U.S. Beech Duke destroyed 1 fatal The Duke was departing in visual meteorological conditions when it entered a steep left turn and descended to the ground. Examination of the wreckage indicated that the right flap was fully extended and the left flap was retracted. Dec. 5, 2007 Columbus, Ohio, U.S. Cessna 208 Caravan destroyed 2 fatal The cargo airplane struck terrain while departing in IMC from Rickenbacker International Airport. Dec. 9, 2007 Kiev, Ukraine Beech C90B King Air substantial 5 fatal The King Air, en route from the Czech Republic, struck terrain on approach to Zhulyany Airport. Dec. 10, 2007 Salmon, Idaho, U.S. Beech 200 Super King Air destroyed 2 fatal, 2 none Visibility was 1 mi (1,600 m) in snow showers when the pilot departed from the uncontrolled airport under visual flight rules, intending to obtain an instrument clearance in flight. He was attempting to return to the airport when the airplane struck a hangar. The pilot and one passenger were killed. Dec. 13, 2007 Curaray-Loreto, Peru Bell 204B destroyed 5 serious The helicopter struck terrain while departing from an oil-exploration site. Dec. 15, 2007 Gulf of Mexico Bell 407 destroyed 2 none The pilot lost tail-rotor control while en route between offshore platforms and ditched the float-equipped helicopter. Both occupants exited into a life raft before the helicopter was overturned by high waves and sank. Dec. 16, 2007 Providence, Rhode Island, U.S. Bombardier CRJ200 substantial 34 none Ceiling was 300 ft and visibility was 1 1/2 mi (2,400 m) in mist when the regional jet landed hard and ran off the left side of the runway. Dec. 17, 2007 Greenville, South Carolina, U.S. Bombardier CRJ200 minor NA none During pushback from the gate, the tow bar broke and the airplane’s nose penetrated the tow vehicle’s windshield. Dec. 17, 2007 Vernal, Utah, U.S. Beech C-99 substantial 1 none Visibility was 4 mi (6 km) in haze when the cargo airplane touched down before reaching the runway. The landing gear collapsed, and the C‑99 came to a rest on the runway. Dec. 20, 2007 Mount Patterson, Antarctica Douglas DC-3T substantial 10 minor The turboprop-converted DC‑3 struck snow drifts while departing from a remote research site. Dec. 20, 2007 Andros Island, Bahamas Cessna 208B Caravan substantial 2 none The airplane was returning to the United States from a missionary flight to the Dominican Republic when the engine lost power. The pilots ditched the Caravan and were rescued by a sailboat before the airplane sank. Dec. 26, 2007 Almaty, Kazakhstan Canadair Challenger 604 destroyed 1 fatal, 3 serious The Challenger made a fuel stop in Almaty during a business flight from Germany to Thailand. On takeoff in nighttime IMC, the airplane veered off the runway, struck a wall and caught fire. Dec. 30, 2007 Sabang, Indonesia GAF Nomad destroyed 5 fatal, 2 NA About 15 minutes after departing for a maritime surveillance flight, the flight crew reported engine problems. While returning to Sabang, the Nomad crashed in adverse weather about 200 m (656 ft) offshore and sank. Two occupants were rescued. Dec. 30, 2007 Bucharest, Romania Boeing 737-300 substantial 123 none The 737 was accelerating through about 90 kt on takeoff when the left engine and main landing gear struck an airport-maintenance vehicle on the runway. The airplane then ran off the left side of the runway. Visibility was 250 m (820 ft) in fog.
NA = not available This information, gathered from various government and media sources, is subject to change as the investigations of the accidents and incidents are completed.
64 | flight safety foundation | AEROSafetyWorld | February 2008 Let us give you the world. AeroSafety W ORLD
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