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high culture Nurturing core safety values venting fuel 777 maintenance error premium focus Insurers stress risk management CAUSAL FACTORS Recipe for CFIT disaster SUN DANGER CONSIDERING WEATHER FROM SPACE
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n the past few weeks, I have been reminded of The other storm involves air traffic control- just how badly politics mix with safety. There lers’ growing distrust of the Federal Aviation are two separate storms brewing in the United Administration (FAA). In a recent survey of States that could undermine the key ingredient controllers, less than 10 percent said that they Iof our safety programs — trust. trust FAA management. That is pretty serious if The first storm is the user fee debate, which we think about the challenges that the FAA faces. has been building for years. Airlines and business First, it has to deal with ever-increasing demand aviation are battling over the question of who pays on a system that is being pressed to its limits. for how much of the air traffic control system. I Second, it must start dealing with a large turnover worry that this debate could impact our future as controllers hired after the 1981 PATCO strike safety efforts. start to retire. Finally, the organization is going to One of the core functions of Flight Safety have to create and then transition to a Next Gen- Foundation has been to spread safety innovations eration Air Transportation System, which must be from one segment of the industry to another. revolutionary to be successful. But the debate is so intense and the feelings are The only way to deal with challenges like these so bitter that now I am not sure I can get safety is to lean heavily on tools such as safety manage- people from the airlines and business aviation in ment, threat and error management, normal the same room. operation safety studies and so on. These tools We can get a sense of what is at risk by looking rely on open and honest reporting and exchange at some of the safety programs these communi- of safety information. In other words, all of these ties have shared in the past. Our Approach and tools rely on trust. Landing Accident Reduction (ALAR) program I don’t deny anybody the right to lobby for has always reached out to airline and business their interests or fight for a fair deal. But I know aviation audiences. Our Ground Accident Pre- that we cannot let the festering aviation issues vention (GAP) program has been driven by the breed the crippling mistrust that could stop safety airlines, but some of the first products you will improvements in their tracks. At the end of the find on our Web site address business operations. day, regardless of who wins or loses, thousands of The Foundation’s work in the area of fatigue is people are going to have to reach down deep and supporting long-range operations in Boeing 777s find a way to trust again. There is no choice. We as well as Gulfstream 550s. live in a system that is built on trust. While there have always been competing interests, we have been able to put them aside. I hope that the trust and sense of mission that have held us together through the aftermath of the 9/11 attacks and spiraling fuel prices are not lost in this debate. Who knows what the next challenges will be — carbon-emission limits, avian flu, person- William R. Voss nel shortages? One thing is certain: We are always President and CEO going to need each other. Flight Safety Foundation www.flightsafety.org | AeroSafetyWorld | June 2007 | AeroSafetyWorld
12contents June2007 Vol 2 Issue 6 features
12 SafetyCulture | Creating a Safety Culture
22 CoverStory | Space Weather Training
28 CausalFactors | CFIT in Queensland
35 HelicopterSafety | Loss of Control
37 StrategicIssues | Insurers and Risk
42 MaintenanceMatters | Faulty Procedures 22 departments 1 President’sMessage | Trust
5 EditorialPage | Attitude
6 SafetyCalendar | Industry Events
8 InBrief | Safety News
49 FoundationFocus | Membership Update 28
| flight safety foundation | AeroSafetyWorld | June 2007 35 42 contents 37 AeroSafetyWORLD telephone: +1 703.739.6700 50 DataLink | Unsafe Acts William R. Voss, publisher, FSF president and CEO [email protected], ext. 108 53 InfoScan | Aeromedical Primer J.A. Donoghue, editor-in-chief, FSF director of publications 57 OnRecord | Miscalculation [email protected], ext. 116 Mark Lacagnina, senior editor [email protected], ext. 114 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, production designer [email protected], ext. 120
About the Cover Susan D. Reed, production specialist Safety threats from the sun prompt [email protected], ext. 123 greater interdependence of aviation professionals and solar scientists. Patricia Setze, librarian © Fotoeye75/Dreamstime.com [email protected], ext. 103
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| SINCE 1947 flight safety foundation | AeroSafetyWorld | June 2007 Editorialpage Attitude
he aviation safety community is Courts have shown an inclination to might be turned against them in later justifiably proud of what it has protect the investigation process, ruling legal proceedings? accomplished in the past decade against those seeking NTSB-developed But, so far, it remains part of the U.S. or so. Swimming uphill against a information, widening the prohibition culture that accident survivors and par- Tthought stream that held few changes against the introduction of NTSB analy- ticipants are not charged with a crime. were needed since flying was already sis to cover the release of other types of Exactly the opposite is true in safe, safety specialists established a com- information. many countries, where the require- pletely new threat-targeting paradigm, Jim Hall was NTSB chairman in 2000 ment to prosecute is part of the culture, using data from accidents, incidents and when, in a speech, he described one such written into laws and even national events to predict where efforts should ruling: “During oral arguments, the chief constitutions. be focused. judge indicated that it was the court’s de- This is why the battle against the This evolved the idea of “just cul- sire to allow the board to do its job and criminalization of aircraft accidents ture” in an organization, holding that to keep it out of litigation. Using a few is going to be so much more difficult encouraging the flow of information is choice words, he said that ‘we are trying than other recent challenges, such as the more important than punishing those very hard to keep lawyers from screwing effort to reduce controlled-flight-into- who make mistakes. Two authors in this that up with this agency.’ Unfortunately, terrain (CFIT) accidents. The fight issue of AeroSafety World describe very given the litigious nature of our society, against CFIT is a logical effort of hard- clearly the benefits that flow from such such challenges to our procedures and ware and procedures that does not con- an approach in a safety culture. authority may continue.” front issues of tradition, culture and But governments have struggled with It is no more than a matter of U.S. emotion. Those of us who see the clear the conflicting imperatives of the acci- Department of Justice (DOJ) policy that benefit of prosecutorial restraint need dent investigation process and the crimi- individuals are not prosecuted after an to temper our attitude with an apprecia- nal justice system. In the United States, accident; criminal charges generally are tion for the gravity of the changes we are policy and practice — more than rules reserved for investigations that turn up advocating. — protect the process. While analyses evidence of aggravated corporate mis- and accident reports produced by the behavior. This policy keeps information National Transportation Safety Board flowing in U.S. investigations. by law cannot be used in criminal or But that is just a policy, and poli- civil courts, the factual information gath- cies change. Should that happen — and ered by investigators is fair game for the we’ve lately seen previously unimaginable J.A. Donoghue courts, and investigators can be called to things coming out of DOJ — who in their Editor-in-Chief participate in criminal cases. right mind would reveal information that AeroSafety World www.flightsafety.org | AeroSafetyWorld | June 2007 | ➤ safetycalendar
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www.flightsafety.org | AeroSafetyWorld | June 2007 | inBrief Safety News NTSB Recommends TCAS Enhancements
ircraft that are equipped with a In issuing the recommendations, the resolution advisories in the event of a traffic-alert and collision avoidance NTSB cited the September 2006 accident collision risk. Asystem (TCAS) also should have in which a Gol Airlines Boeing 737-800 In a third recommendation, the NTSB an enhanced aural and visual warning in and an Embraer Legacy 600 business said that the FAA should inform pilots the event that the system stops function- jet collided over the Amazon. The 737 who use transponders or TCAS units ing, the U.S. National Transportation was destroyed and all 154 occupants about “the circumstances of this accident Safety Board (NTSB) says. were killed. The Legacy sustained minor and the lack of a conspicuous warning to The NTSB has recommended damage, and its flight crew conducted an indicate the loss of collision protection re- that the U.S. Federal Aviation Ad- emergency landing; the five people in the sulting from a compromise in functionality ministration (FAA) also require the airplane were not injured. of either the transponder or TCAS unit enhanced warnings for existing and The NTSB said that preliminary and ask all pilots who use transponders future system designs. Accompanying findings from the accident investiga- or transponder/TCAS units to become recommendations called on the FAA tion reveal “no indication of any TCAS familiar with the annunciations currently to evaluate the feasibility of including alert on board either airplane.” Both used to indicate failure or lack of active aural and visual warnings in future airplanes had Mode S transponders functionality of these components.” systems designed for ground collision and were equipped with TCAS II, The accident remains under investi- avoidance. which provides traffic advisories and gation by Brazilian authorities.
© Honeywell International Simulated Approaches
esearchers at the U.S. National cockpit displays provided the simulator Aeronautics and Space Adminis- pilots who were “flying” the following Rtration (NASA) have completed airplane with the position and airspeed a study of approaches to very closely of the lead airplane. Pilots flew ap- spaced runways that found that pilots proaches to the runways under eight had no preference for landing on the scenarios, involving different wind left or the right runway. and visibility conditions, and different The study, conducted at the spacing between the two airplanes. NASA Ames Simulation Laborato- The pilots preferred the procedures ries, involved scenarios in which a with clear visibility and greater spacing computer-generated lead Boeing 757 between the two aircraft — 10 seconds and a following 757 represented by rather than five seconds, according to a the advanced cockpit flight simulator preliminary report on the study. were flown to parallel runways that Another report will be issued after were 750 ft (229 m) apart. Enhanced additional data analysis is completed. U.S. National Aeronautics and Space Administration
| flight safety foundation | AeroSafetyWorld | June 2007 inBrief
Campaign Against Fatigue
he U.S. Federal Aviation Admin- of an Aug. 27, 2006, istration (FAA) and the union accident in which Trepresenting air traffic controllers in a Comair CRJ-100 the United States should work together crashed during take- to reduce the potential for fatigue among off from Blue Grass air traffic controllers, the U.S. National Airport in Lexing- Transportation Safety Board (NTSB) ton, Kentucky, U.S. said. The airplane was de- In recommendations to the FAA and stroyed, and all but the National Air Traffic Controllers As- one of the 50 people sociation, the NTSB called for coopera- in the airplane were tive efforts to “reduce the potential for killed. The NTSB’s controller fatigue by revising controller preliminary inves- work-scheduling policies and practices tigation found that, U.S. Federal Aviation Administration to provide rest periods that are long after receiving a enough for controllers to obtain sufficient takeoff clearance for Runway accident at 0607 the next morning,” the restorative sleep, and by modifying shift 22, the crew had mistakenly conducted NTSB said. “The controller stated that rotations to minimize disrupted sleep the takeoff on Runway 26, which — at his only sleep in the 24 hours before patterns, accumulation of sleep debt and 3,500 ft (1,068 m) — is about half the the accident was a two-hour nap the decreased cognitive performance.” length of Runway 22. previous afternoon between these two The NTSB also recommended that The preliminary investigation shifts.” the FAA develop a fatigue awareness found that the air traffic controller A related recommendation called and countermeasures training program who cleared the accident airplane “had on the FAA to require controllers to for controllers and those who develop worked a shift from 0630 to 1430 the complete training in resource man- controller work schedules. day before the accident, then returned agement skills designed to improve The recommendations were nine hours later to work the accident their judgment, vigilance and safety prompted by the ongoing investigation shift from 2330 until the time of the awareness.
Battery Warning End-Around Taxiway Opens
he Civil Aviation Safety Authority presented by lithium batteries being hat is believed to be the second of Australia (CASA) has reiter- transported as freight or in baggage. “end-around” taxiway in the Tated a warning about the risks CASA cited earlier advice from Wworld has opened at Harts- the U.S. Department of Transportation field-Jackson Atlanta (Georgia, U.S.) (DOT), which said that spare lithium International Airport. End-around batteries should be transported in taxiways eliminate the need for aircraft carry-on baggage rather than checked, to be taxied across active runways to spares should be kept in their original reach their arrival gates, instead allow- packaging, and loose batteries should ing crews to taxi to the end of a runway be covered in insulating tape or car- and then turn onto a taxiway that ried in a plastic case to prevent contact travels directly to the gate area. with metal. The new US$42.5 million taxiway, The DOT warning followed which is expected to accommodate two fires this year on commercial the 700 aircraft that are landed daily airplanes that were attributed to loose on Hartsfield-Jackson’s northernmost lithium batteries; in each instance, runway, is part of a $6 billion airport the fire was extinguished by crew- development project. The world’s first members and the airplanes were end-around taxiway was opened in landed safely. Germany at Frankfurt Airport.
© Christine Balderas/iStockphoto
www.flightsafety.org | AeroSafetyWorld | June 2007 | inBrief
Crackdown on Icing
he U.S. Federal Aviation Adminis- accumulating — of determining whether of visual cues for recognition of the tration (FAA) is proposing to amend there is enough ice to activate an ice pro- first sign of ice accretion on a specified Tairworthiness standards for trans- tection system and said that flight crews surface, combined with an advisory port category airplanes certificated for “must be provided with a clear means to ice-detection system that alerts the flight flight in icing conditions to require the know when to activate” an airframe IPS. crew to activate the airframe IPS; or aircraft to be equipped with a method The NPRM said that one of three identification of conditions conducive to of ensuring the timely activation of an alternatives would be acceptable: “a pri- airframe icing as defined by an appropri- airframe ice-protection system (IPS). mary ice-detection system that automati- ate static or total air temperature and The FAA notice of proposed rule cally activates or alerts the flight crew to visible moisture for use by the flight crew making (NPRM) was published April 26 activate the airframe IPS; or a definition to activate the airframe IPS.” in the Federal Register. Public comments © Tomasz Szymanski/iStockphoto on the proposal will be accepted through July 25, and a final rule may be issued after a review of the comments. The FAA said that the proposed amendment followed a review of icing accidents and incidents that identified a number of events in which a flight crew was “either completely unaware of ice accretion on the airframe, or was aware of ice accretion but judged that it was not significant enough to warrant operation of the airframe ice-protection system.” The NPRM acknowledged the diffi- culty — especially at night, during times of heavy workload or when clear ice is
Praise for the SMS In Other News …
anadian aviation officials and After a meeting in Ottawa, the he government of Nigeria has industry leaders are crediting Canadian Aviation Executives Safety withdrawn the operating licenses Cthe 2005 introduction of safety Network issued a statement that cred- Tof seven airlines that failed to meet management system (SMS) regulations ited SMS with providing an additional an April 30 deadline for their recapital- in Canada with a subsequent decrease layer of safety oversight within the ization. … The U.S. Federal Aviation in the aviation accident rate. aviation system. Administration (FAA), which evaluates “The safety management system civil aviation authorities to determine is an international initiative rec- whether they comply with International ognized as the most significant Civil Aviation Organization safety stan- advancement in aviation safety in dards, has said that Indonesia is not in recent years,” said Michael DiLollo, compliance. ... Authorities at many in- senior vice president of Air Transat. ternational airports outside the United “I believe that the development, States do not expect introduction of the implementation and maintenance of Airbus A380 to cause delays at their SMS in all areas of aviation activity is facilities, the U.S. Government Ac- key to improving the safety and well- countability Office says in an analysis of being of the aviation industry.” potential safety and capacity issues.
© Wayne Stadler/iStockphoto
Compiled and edited by Linda Werfelman.
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Priority Code: PM07XP18 12 | SAFETY Culture
by george H. Snyder Jr. points indetermining overall the operational consideredbe as one of many significant data pabilities and performance. This process should captures only asnapshot of an organization’s ca prehensive, well-executed process inspection similar process. inspection Even most the com with flaws NASIP the tal process or any other pears to have been a failure of corporate culture. NASIP were not enough to overcome what ap commented that even a fatal accident and an FAA wing panel and not replaced. The NTSB later appeared that bolts had been removed from a it was discovered that something was wrong. It incident; one of its aircraft had to turn back when eral months later, the same airline had a similar the airline on its internal evaluation systems. Sev ciencies, and the FAA ultimately complimented evaluation. The inspection found very few defi Aviation Safety Inspection Program (NASIP) Federal Aviation Administration (FAA) National airline’s maintenance program underwent a U.S. craft crashed on its of second flight day. the aircraft was returned to The revenue air service. night before had not replaced before been the horizontal stabilizer during maintenance the fasteners removed from leading the edge of the (NTSB)Board investigation that revealed O tributory or causative to airline accidents long procedures.” approved maintenance and quality assurance encouragedwhich and enforced adherence to management to establish acorporate culture have included “the failure of airline’s] [the probablethe cause of accident the should also NTSB member John Lauber, suggested who that safety culture by Meshkati point inassessing importance the of an airline safety of health an airline. There is nothing to indicate any fundamen Immediately following the accident, the The U.S. National Transportation Safety InIssues involving corporate culture were con AirlineThe 1991accident as aturning was seen Aviation killing all 14 people aboard the aircraft. structural failure occurred during descent, ing between cities in Texas crashed after a n Sept. 11, 1991, a commuter flight operat 4
(1997) 3 and by then- 1 - - - - 2 - - - - - High Culture ior most contributed to concept. this understood by line the employees behav whose of words these followed, probably none readily aged, discouraged or tolerated.” Many versions culture involved behaviors that were “encour mid-1980s, we were told that an organization’s Ingies. early versions of training courses inthe crew resource management (CRM)methodolo evidentbecame during development the of The challenge of airline defining safety culture Culture Defining Safety in aspirit of partnership and collaboration. stakeholdersindustry continue to work together safety is by no means inevitable airline ifglobal ever, continuation of negative this influenceon before 1991,and, most likely, afterward. How and Mitchell, in a paper titled ers Zhang, Wiegmann, von Thaden, Sharma on this thought, University of Illinois research tainly can recognize it when you see it. Following may not be able to define something, you cer tance of an organizational safety culture. werestaff not able to quickly grasp impor the It is no wonder that airline line managers and particular, intheoretical terms.” underspecified have “unsystematic, been fragmented and, in existing empirical efforts to study safety culture by Pidgeon’s (1998)informal that observation sibly extending to present, the explained is best There is a common notion that while you collectiveconfusionOur at that time, pos flight safety foundation foundation safety flight |
AeroS Safety Culture: A Continued on page 14. a fety World World | | June 2007 June ------5
© Christian Lagereek/iStockphoto SAFETYCulture In Corporate Aviation viation safety is not a goal unto itself; it counterparts in corporate aviation have is the most critical part of the journey. no need to know the business and opera- The accident rates of major commercial tional issues of the aviation function. airlines and corporate aviation are statis- • Their operational standards are different. Atically equivalent. A more universally effective The governing rules of commercial avia- safety culture could allow corporate aviation to tion, Federal Aviation Regulations (FARs) become the least hazardous mode of air travel. A Parts 121, 135 and their international brash claim? Maybe not. counterparts, are rigorous to protect the A review of accidents involving profession- traveling public. Corporate aviation is held ally flown aircraft shows that four out of five to the much lower standard of FARs Part events included procedural intentional and/or 91 and international counterparts. procedural unintentional noncompliance (PINC, PUNC) by pilots. PINCs and PUNCs are The challenge is to create and maintain an ef- reduced dramatically when an effective safety fective safety culture within a corporate aviation culture exists. operation where there is an apparent potential Building a safety culture in a corporate for less focus and discipline. An effective corpo- aviation operation is very different from rate safety culture starts at the top, in the offices
The art of creating and sustaining a beneficial safety culture in different settings.
building one in the commercial aviation of the executive officers, and permeates the arena, because: entire organization all the way out to the airport. • The safety culture comes in three parts: vision,
The core businesses are different. An Jr. Agur v. Peter by airline’s core business is aviation, while co-reponsibility and performance. corporate aviation is routinely a support- High CultureThe Vision ing service of an enterprise whose core business is not aviation. An effective corporate aviation safety culture starts with a vision for safety. That vision comes • The goals of the businesses are different. in two modes — the grand vision of a powerful Commercial aircraft are operated solely top executive and the focused vision of the avia- for the purpose of revenue and profit. tion services unit leader. Corporate aviation is a service center in It is imperative that the top corporate execu- support of the core business. tives describe a vision of safety. Ideally, the chief • The aviation knowledge of top executives is safety officer (CSO) is also the company chairper- different. The leaders and senior manag- son or the chief executive officer (CEO). If not, ers engaged in commercial aviation are usually aviation professionals. Their Continued on page 19.
www.flightsafety.org | AeroSafetyWorld | June 2007 | 13 SAFETYCulture
the extent to which individuals and vidualism-collectivism, power distance, groups will commit to personal re- uncertainty avoidance and rules and or- sponsibility for safety; act to preserve, der —with certain geopolitical regions.9 If enhance, and communicate safety allowed to progress, this thought process concerns; strive to actively learn, leads to the conclusion that the presence adapt and modify [both individual or absence of these group characteristics and organizational] behavior based is incompatible with acceptable levels of on lessons learned from mistakes; operational safety. and be rewarded in a manner consis- However, through my experiences, tent with these values.7 I conclude that these generalizations This definition brought together the are simplistic and counterproductive. need for personal commitment to Rather than indicating predetermined safety, communication, learning, adapt- performance, they merely indicate ing, modifications and reward. These that a variety of prescriptive measures, are the attributes that airline safety respectful of culture and tradition, may directors have been focusing on for be required in order for assorted groups years, recently finding their way into to achieve optimal safety performance. the precepts of modern safety manage- Organizational culture distinctions
© Kate Tero/iStockphoto © Kate ment system (SMS) programs. can either mimic the national culture within which they exist or, alternatively, Concept in Chaos, cite some common Categories exist essentially unaltered across a wide elements of an airline safety culture: Any discussion of airline safety cultures expanse of geopolitical boundaries.10 • Shared values at a group level; must include the elements of national, or- This latter characteristic describes a ganizational and professional differences.8 global airline’s multiple international • Close relationship to manage- Everything that occurs within an airline airport station network. While the ment and supervisory systems; — from employee hiring, establishment geopolitical location of an outstation • Emphasis on the contributions of of standard operating procedures (SOPs), may support individualistic cultural everyone; employee training, performance evalua- attributes, a strong spirit of collectivism • Impact on the behavior of all tions, managerial oversight, and ultimate often is found among the airline’s home employees in the workplace; levels of compliance and conformance office and regional employees at that — is driven in various ways by these location that optimizes their collective • Relationship between reward and important cultural components. safety performance. performance; I have found no national, organiza- Lastly, unique attributes exist within • A corporate willingness to learn tional or professional subculture that different professions that may be lever- from errors, incidents and ac- contains characteristics incompatible aged or compensated for to ensure the cidents; and, with the establishment of an effective presence of an optimal safety culture. • Stability.6 airline safety culture. Clearly, every While experienced airline employees category brings differences to the table take great pride in their professional- The University of Illinois team devel- — both positive and less positive. But, ism, they may at times overrate their oped the following definition of safety at the end of the day, people are people, abilities to counter the effects of stress culture, which I find to be pragmatic, no matter where they live, what they and fatigue. This personal concept of understandable and useful to front-line do or whom they do it for. This is the invulnerability may actually impede, airline employees: single most important concept for a rather than optimize, their safety The enduring value and priority global airline safety manager to keep performance.11 placed on worker and public safety and use. Modern airline organizations no by everyone in every group at every There is a tendency to equate national longer exist in isolation but operate level of an organization. It refers to culture distinctions — specifically indi- instead as a “system of systems, a culture
14 | flight safety foundation | AeroSafetyWorld | June 2007 SAFETYCulture
of cultures.” To establish and maintain a as a core value, presents the company’s night and in bad weather, demonstrating positive safety culture, airline manage- safety expectations, reinforces the com- that SOPs are not merely daylight, clear- ment must take these complementary mitment to provide employees with weather commodities, can exemplify and conflicting dimensions into account the necessary training and resources, the presence of an effective airline safety in their selection of staff and creation and identifies the reporting of human culture. Alternatively, an equally power- of SOPs, training programs, evaluation errors as a corporate learning experi- ful indicator might be a maintenance processes and supervisory practices. ence not subject to disciplinary action foreman painstakingly troubleshooting a or retaliation, while stating that willful discrepancy in the rain and at night with Culture Elements and deliberate noncompliance with an airplane full of passengers already an The University of Illinois researchers laws, civil aviation regulations and hour behind schedule. described five general areas that com- company policies and procedures will Employees must view themselves as pose the foundation of an organization’s not be tolerated. active participants in the airline safety safety culture. Airline management cannot ef- culture rather than as disenfranchised The airline’s commitment is most fectively promote a safety culture from observers. They must see, and manage- clearly evidenced by the presence or ab- behind closed doors. Safety bulletins and ment must support, a direct correla- sence of a prominently displayed safety circulars are not credible to employees tion between the quality of their work policy signed by the president and chief who observe their supervisors circum- performance and the overarching safety executive officer, frequently updated venting government regulations and performance of the airline as a whole. or revalidated. This forms the basis company policies in favor of commercial What they do or, more importantly, of an explicit safety contract between advantages or, possibly worse, never see what they do not do, must be seen to management, employees and custom- their supervisors at all. A chief pilot fly- make a critical difference. Rather than ers. The policy clearly establishes safety ing an unpopular trip on a weekend, at pass over an opportunity to perform an
© Chris Sorensen Photography
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additional inspection, ask questions or destination of his choice. The impact of “person,” the logical course of action for seek clarification, the employee should these types of corporate gestures cannot the airline to pursue is clear. feel empowered by his supervisors to be understated when it comes to creat- A final necessary element in an take these actions without fear of nega- ing and maintaining a safety culture. airline safety culture is an effective tive consequences. On the other hand, there are times safety hazard reporting system. While When cabin attendants immediately when an employee deliberately dis- word of mouth and informal reporting/ before takeoff passed to the cockpit regards laws, regulations, policies or advisory channels may appear to work a passenger’s observations that the procedures and puts the airline, fellow well in smaller organizations, a formal- aircraft’s ground spoilers were fully employees and passengers at risk. Prior ized reporting process is invaluable. extended, that event became one of the to making any type of final determina- Today’s airline safety culture requires most poignant indicators of a strong tion, the safety culture concept requires an overarching company policy that corporate safety culture that I have ever a comprehensive, objective investiga- provides indemnity for employees re- validated. In this case, there had been tion to determine if the act involved a porting safety hazards and inadvertent an unprecedented cable connection willful disregard for safety. unsafe acts, identification of manda- failure between the actuator handle in There are several possible outcomes tory reporting events, reporting forms the cockpit and the spoiler panels, fail- of such an investigation: It may be customized for each employee group, ing in a way that bypassed the takeoff found that the employee is not fully an effective investigation and analy- configuration warning system. There is suited to his or her job responsibilities, sis process, assignment of corrective every indication that, absent that warn- or that the airline’s SOPs are not clearly action to the appropriate department ing, the crew would have attempted stated or realistic, or that the training in or agency, follow-up to assure that cor- a takeoff with potentially disastrous support of these standards is not com- rective measures are delivering desired results. Repeating an earlier point, prehensive, or that management and results, and, finally, a feedback loop to everyone must be an active participant oversight of the employee’s upholding the reporting employee advising him in the safety culture concept. of these standards is deficient. that his concerns have been addressed While an airline safety culture must My experience as head of safety and resolved. Information and commu- empower employees with the ability to for two major airlines showed me that nication are the lifeblood of an airline’s take strong measures to ensure opera- a brutally honest review usually finds safety culture. tional safety, it must also hold them the organization, not the individual, in accountable for their actions. Safety need of remedial action. In the unlikely Investigation and Analysis performance bonus programs are an event that such is not the case, the It is difficult to question the safety integral part of an effective SMS. airline must move quickly and deci- benefits of a technically sound, open, In one memorable example, a sively to remove this behavior from the honest and comprehensive accident contract ramp worker went above and workplace. investigation process. There are many beyond the scope of his responsibilities Please note that I intentionally stated areas of the world where independent when he questioned a person running that the “behavior” must be removed investigation agencies provide com- across the ramp to board a shuttle bus from the workplace, not necessarily the prehensive fact-finding, exhaustive en route to the remote aircraft parking “person.” If management counseling, root cause analysis and valuable safety location. While it turned out that the additional training and evaluation bring recommendations. Likewise, some person was an airport employee who an employee’s performance to required airline organizations have the techni- had inappropriately used his airport ID standards, the safety culture will have cal expertise and corporate initiative to to bypass normal check-in and security scored a decisive and overwhelming perform similar high-quality internal processes, the person’s intent could win. The rehabilitated employee most investigations of safety events below the have been far more sinister. The ramp likely will become an extremely effective threshold of state involvement; others worker’s actions were formally recog- ambassador of the safety culture to the should strive to achieve this capability. nized when the airline’s head of safety remainder of the work force. Unfortu- Further, other parties should be invited and security rewarded him with two nately, in cases where the “behavior” into the investigation, including appro- round-trip business-class tickets to a cannot be successfully isolated from the priate labor organizations.
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In a dysfunctional safety culture, for- the act would be culpable regardless of not tolerate a perception that an airline mal and informal investigations are not whether it is an error or a violation.”12 or specific region of the world is unsafe. undertaken in a spirit of openness and An effective airline safety depart- Aviation industry participants who candor; rather, deception, secrecy and de- ment, and by default, its leader, is viewed feel that minimizing their safety invest- flection of accountability are key precepts. as the creator and staunch defender of ments improves their long-term commer- In these cases, there are two separate the corporate safety culture. The safety cial interests are sadly mistaken. Analysis tragedies — the first being the event itself department must initiate investigations of an airline’s market capitalization levels where innocent people may have been in an unbiased, open and responsive during a period of incidents or accidents injured or lost their lives, and the second, manner, providing those involved in the clearly shows a downturn when other even greater tragedy, an opportunity is incident a good reason to feel comfort- factors are held constant. When such lost to identify root causes and develop able in providing pertinent details. This safety perceptions improve, the airline’s lifesaving safety recommendations and comfort is further strengthened when financial picture gradually improves. future accident prevention strategies. safety department personnel are recog- Drilling down a bit further, the argu- Internal safety investigations that are nized as having high levels of technical ment of production versus protection, never completed, analysis that is either expertise. While there is a general reluc- money versus safety13 becomes a little nonexistent or fundamentally flawed, and tance among technically oriented airline clearer in this story: Moments before the assignment of accountability that results professionals to receive correction, such pushback of an international widebody in blame and punishment as a terminat- reluctance is minimized if those they flight, a late transfer bag appeared. With ing action should be challenged rather respect deliver it. mistaken good intentions, a baggage than accepted. Whether the investigation With few exceptions, the concept handler jumped into his tug and drove is being conducted at either a govern- of blame and punishment within an as fast as he could across the ramp to mental or organizational level, the truth airline safety culture is simplistic and the aircraft. In violation of established is the truth, and the quest must not end counterproductive. The assignment ramp procedures, he drove full-speed until that truth is fully revealed. of blame artificially and prematurely directly toward the aircraft’s bulk cargo restricts the investigation process, and door. It was raining, the ramp was wet, Blame and Punishment the resultant pronouncement of pun- and he was unable to bring the tug to a A June 2006 Australian Transport ishment largely simulates a terminating stop. The collision rendered the aircraft Safety Bureau (ATSB) report titled action. When the specter of blame, dis- Assessing Institutional Resilience: A cipline and retribution is removed from Useful Guide for Airline Safety Manag- the investigation process, information ers includes the thoughts of Professor and communication exchanges abound. James Reason on the concept of blame: “Disciplinary policies are based on an Commercial Interests agreed (i.e., negotiated) distinction be- Risk management and a strong safety tween acceptable and unacceptable be- culture are in harmony with an airline’s havior. It is recognized by all staff that commercial interests. Passengers a small proportion of unsafe acts are have been increasingly subjected to indeed reckless and warrant sanctions, crowded terminals, invasive security but that the large majority of such acts procedures, reduced in-flight amenities should not attract punishment. The key and periodic delays and cancellations. determinant of blameworthiness is not Surprisingly, these factors alone have so much the act itself — error or viola- not resulted in any appreciable declines tion — as the nature of the behavior in in overall demand levels. However, which it was embedded. Did this be- demand levels for carriers or countries havior involve deliberate unwarranted where questions of operational safety risk-taking, or a course of action likely are raised are quite different. Passengers to produce avoidable errors? If so, then will tolerate many things, but they will www.flightsafety.org | AeroSafetyWorld | June 2007 | 17 SAFETYCulture
unserviceable for four days. The driver chairman’s vision into a functional reality. London. Snyder’s career in aviation has spanned recovered from his injuries and returned The elements of a strong safety culture more than 35 years. He has held line and manage- to work. may resound with universal appeal in ment positions in flight training, flight operations, High costs can accompany an the corporate offices, but when placed up flight safety, ground safety, quality assurance, ac- event below the level of an accident or against longstanding company practices cident investigations, regulatory compliance, and incident. For example, the absence of and short-term commercial interests, it security for regional and international passenger an effective cockpit window inspec- is the head of safety working together and cargo airlines. tion program allowed electrical arcing with the operating department heads that Notes from heater filaments to shatter the ultimately must make it work. window. The flight was canceled, the Leadership within an airline safety 1. U.S. National Transportation Safety aircraft was de-fueled, the passengers culture does not have to be accompa- Board (NTSB). Accident report no. DCA91MA052. Sept. 11, 1991. were re-accommodated, the catering nied with a title or office. Each em- supplies were unloaded and discarded, ployee group normally has an informal 2. Wikipedia. Continental Express Flight crewmembers were rescheduleded, and designee to whom everyone looks for 2574.
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| Culture SAFETY - - - - In- Corporate Aviation When there is no CSO, the role of chief safety safety chief of role the CSO, no is there When for co-responsibility be effective, most To safety for co-responsibility of power The Unlike Esrey, some CEOs mistakenly believe believe mistakenly CEOs some Esrey, Unlike the good ideas. The collective eyes, ears and the good and collective eyes, ears ideas. The dard for teamwork among aviation professionals. aviation among teamwork for dard Performance the of all members involves safety said, I have As professionals aviation However, organization. performance, safe for responsible primarily are leadership. starts with performance safe and situation. That is why the CSO must be directly directly be must CSO the why is That situation. safety. for co-responsible manager. aviation corporate the to falls champion have must manager aviation an effective, be To as vision, safety strong and clear own her or his it champion to character of strength the as well CSO. a by endowed authority of lack the despite aviation the entire of value be a core must safety or egotistical hugely is It services organization. safety leader or department aviation an for naive safety manage can she or he officer assume to manager No the operation. all of phases into becan everywhere ev sure all make the time to has manager one No properly. eryone performs all powerful more far are team the entire of wisdom outcomes. safe in assuring crew of foundation the is It fundamental. is stan defining the (CRM), management resource the cultural importance of safety. The enthusiasm enthusiasm The safety. of importance cultural the at to users aircraft appointed newly by shown the how of evidence strong was course the tend informal an assuming were graduates previous program. the promote to responsibility solely rests safety aviation for responsibility the pilots’ their in trust their take They airport. the at pas executive worst The far. too instincts survival they behaviors the that assume mistakenly sengers business core their within success achieve to use and people their of more and more demanding — at work also — answer an for “no” take to refusing 18-plus for push hard-chargers These airport. the air challenging into go to demand days, duty hour that else anything and conditions risk high in ports pressure The lives. busy their accommodate will no-win a is It subtle. rarely is crews on put they - - - - June 2007 | World fety a AeroS
| .flightsafety.org One CEO added the statement, “Any passen “Any CEO addedOne the statement, It is essential that a CEO/CSO be the source source the be CEO/CSO a that essential is It Not every CEO understands the need for every the need for CEO understands Not About 15 years ago, John Luke, Sr., then the the then Sr., Luke, John ago, years 15 About www passengers to attend a half day of cabin safety safety cabin of day half a attend to passengers manda was program the though Even training. with infected quickly were participants the tory, the corporate organization, but it starts at the top. top. the at starts it but organization, corporate the a endorsed Sprint, at chairman former Esrey, Bill aircraft corporate frequent all required that policy Co-Responsibility throughout shared is safety for responsibility The that the responsibility for safety spanned from from spanned safety for the responsibility that cabin. and office the cockpit the to corner a crew during a trip will a trip corpo her lose during or a crew his declaration His privileges.” travel aircraft rate organization perfectly the entire to it made clear vision and a clear statement of crew authority. authority. crew of statement clear a and vision of the safety-based decisions who challenges ger Business Aviation Association recommend that that recommend Association Aviation Business from letter a contain manuals operations flight safety aviation corporate the declaring CEO the tication of authority from the corner office. That That office. corner the from authority of tication National the and Foundation Safety Flight why is and lead champion for the aviation safety vision. vision. safety aviation the for champion lead and authen powerful the vision safety the gives This in professionally flown aircraft continues to be to continues flown aircraft in professionally other (CFIT). In terrain flight into controlled been misplaced. have trust his may words, are suicidal. They sit in the seats with the best with in the seats They suicidal. sit are was optimism His see coming.” They can it view. fatalities of source the greatest but admirable, their pilots will protect them. One executive was was executive them. One will protect their pilots think pilots our don’t “I say, to enough candid such a clear corporate aviation safety vision. vision. safety aviation corporate a clear such and the regulations that granted for takeSome it aboard the company aircraft, every day and every every and day every aircraft, company the aboard of standard the expected he that said also He leg. everyone. for same the be to care company, told me he expected a standard of care care of standard a expected he me told company, anyone allow would that services aviation his from children her or his placing ease at perfectly feel to CEO of what is now MeadWestvaco, a Fortune 500 500 Fortune a MeadWestvaco, now is what of CEO then the CSO must be someone who can look that that look can who someone be must CSO the then eye the in directly CEO, the high, the of highest modifier. career a being it without “no,” say and SAFETYCulture
A great leader sets people up to suc- Safe trips start with having the right airlines are constrained by efforts to ceed. For someone to be successful the tools for the job — appropriate resourc- maintain fleet commonality as well as goals must be clear and measurable, the es. When working on fleet plans, I ask contain costs. Many corporations have resources must be appropriate and the executives, “Do you want to be limited a policy of aggressive investment in processes must be effective. by aircraft capacity or staff capacity?” aviation safety; if it enhances safety, it In aviation, the goals are a clear In other words, does the corporation will be fit into the budget. That is why and unchangeable hierarchy of per- want to be able to fly anytime the aircraft new technologies often find their way formance: safety (including security), is available (i.e., not flying and not in into corporate aircraft well in advance service and efficiency. maintenance), or is it OK for an aircraft of commercial aircraft. Fully integrated Occasionally, the priority of those to be mechanically ready to go but not digital avionics suites are becoming goals gets confused. A few years ago, be flown because the pilots are out of the norm for new business aircraft. In I had a conversation with a billionaire time? addition, much of the legacy corporate who admitted he demanded that his The most frequent response is they fleet is being retrofitted with digital helicopter crew launch into known want enough pilots to perform the vast displays or augmented with supplemen- icing conditions. His reasoning: “Why majority of trip requests. This is logical. tal screens for weather uplink, terrain should I have aircraft if I cannot go The value delivered by flight crews is too awareness, airport surface moving where I want when I want?” He had not great for most corporations to skimp on maps, and a host of other technolo- accepted the primacy of safety as the staff. But it is up to the aviation leader to gies that improve the crew’s situational ultimate and limiting performance goal. clearly define the staff requirements and awareness, which is a very safe thing. How do you tell a 500-pound gorilla their limitations. Otherwise, the service The processes used to orchestrate what to do? You let an 800-pound go- delivery team will stretch themselves in these resources into action are where rilla deliver the message. To the relief of an effort to do too much with too few safe performance is truly achieved. his flight crews, the billionaire’s board people, raising risks. The standard of performance usually of directors helped him understand The technical resources of corporate expected by corporate executives is “best that they wanted him around for longer aviation can create a safety advantage practices or better.” Executives often do than the next trip. over its commercial colleagues. The not know exactly what that means, nor
© Chris Sorensen Photography
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do most aviation professionals because, the captain how they could do that. the aircraft’s return home, the trip is not until recently, there was no practical The ensuing conversation became the complete until the same team debriefs the definition of “best practices.” Standard foundation for a new practice. When entire trip, every leg. TI has developed an practices are established by government there is to be a judgment call, the most effective and proactive management of regulations and manufacturers’ opera- conservative perspective will prevail and the trip process that works well for them. tional guidelines and limitations. These it will be applied across the board until It keeps the goals of safety, service and standards essentially prevent failure. conditions change. In other words, on efficiency in appropriate order and focus. They are a litany of “Thou Shalls” and that particular day, nobody would fly It identifies potential risks and variances, “Thou Shalt Nots” designed to avoid between Birmingham and Atlanta until and then allows the power of team prob- bent metal and harmed bodies. Taking the weather improved enough to satisfy lem-solving to produce the most effective performance standards to the next level, the young captain, and nobody could guidelines and solutions. to best practices, calls for the proactive pressure him to change his mind. TI has the full complement of tools: achievement of intended outcomes, The opposite of this safe and effec- • A clear executive and organi- including the assurance of safety. tive leadership behavior is a declaration zational vision with a strong From a practitioner’s point of view, by the director of aviation or mainte- emphasis on safety; best practices call for the clear defini- nance that policies and standards may tion of intended outcomes and the ideal be amended with his or her approval. • Culturally driven co-responsi- processes for creating them. The next In other words, this is a declaration that bility permitted by a pervasive step is to monitor the processes in ac- the department’s policies and standards authority to perform; and, tion and proactively manage variances are variable. This approach may appear • Universally understood standards to assure that performance is main- to be high service — standards can be of performance couched in a well- tained within the expected parameters. adjusted to make it easier to complete documented operations manual, A practical example of this oc- the mission — but it has two major implemented effectively through curred when Mike May was director flaws: it can place service above safety a set of practices and processes of aviation for Southern Company. His in the hierarchy of performance, and it structured around an SMS. operation included three U.S. bases; At- clearly undermines the authority of the lanta, Georgia; Birmingham, Alabama; safety delivery team — the crew. But TI is the exception. The vast and Pensacola, Florida. During one Crews are a critical element of one majority of corporate aviation is being particularly thunderstormy day, Mike of the most effective best practices that conducted with less than the complete overheard a conversation between a is gaining wide acceptance: the safety set of tools. Even so, corporate avia- relatively new captain from Birming- management system (SMS). The core tion’s safety rate is equal to that of the ham and one of his Atlanta-based of SMS’s success is the rigorous applica- major commercial airlines. How low senior captains. The youngster was tion of risk assessment and mitigation will our accident rate be when the TI describing how bad the weather was encompassing all facets of a trip. Texas In- standard becomes the norm? Let’s find over the Atlanta-Birmingham route and struments (TI) uses an extremely effective out together. Let’s build a widespread that he planned to delay his return trip multi-functional approach. Prior to each corporate aviation safety culture. It until things quieted down. The senior trip, the scheduler, lead aircraft technician starts with your corporation and your captain from Atlanta was boasting that and the crew, including the cabin safety aviation department. ● he had flown hundreds of flights in attendant, meet to discuss the trip and all Peter v. Agur, Jr. is managing director and identical conditions and he was sure he its parameters and variables — aircraft, founder of The VanAllen Group, a management could leave soon, as scheduled. equipment, maintenance status, passen- consulting firm to business aviation with ex- Mike asked the senior captain to gers, cargo and baggage, times, catering, pertise in safety and security. A member of the join him in his office. In private, Mike weather, airports, runways, fixed-base Flight Safety Foundation Corporate Advisory Committee and the National Business Aviation explained to the senior captain that he operators, ground transportation, etc. Association (NBAA) Corporate Aviation needed his help in urging young pilots The goal of the meeting is at the heart of Management Committee, he has an airline not to exceed their capabilities, putting the SMS, to assure a safe and effective trip transport pilot certificate and an MBA. He is an aircraft and people at risk. He then asked that is punctuated by no surprises. Upon NBAA Certified Aviation Manager. www.flightsafety.org | AeroSafetyWorld | June 2007 | 21 FlightOPS
viation concern for space weather is National Space Weather Program — cites the not new. Dispatchers and flight crews following internationally accepted definition of at airlines carrying the growing volume space weather by the U.S. Office of the Federal of passenger and cargo traffic on four Coordinator for Meteorological Services and Anorth transpolar routes between North America Supporting Research: “Space weather refers to and Asia routinely conduct comprehensive the conditions on the sun and in the solar wind,1 checks on solar activity. But some specialists now magnetosphere, ionosphere and thermosphere recommend that a far wider range of aviation that can influence the performance and reliabil- professionals receive training on space weather ity of space-borne and ground-based techno- regardless of where on Earth they work. Their logical systems and can endanger human life or specific proposal says, “The U.S. Federal Aviation health.” The report summarizes interviews with Administration (FAA) should define a minimum 50 subject specialists and products of a two-day set of requirements for incorporating space workshop in November 2006, involving 60 space weather into operational training for aircrew weather, government/military and civil aviation (pilots and cabin crew), dispatchers, air traffic specialists.2 controllers, meteorologists and engineers.” According to a June 2006 assessment of the The report advocating this training — is- National Space Weather Program, “When the sued in March 2007 by the American Meteo- [program] began in 1995, space weather needs rological Society (AMS) Policy Program and of civil aviation were rarely noted, although such SolarMetrics, a U.K. consultancy, with funding needs were widely recognized for U.S. Depart- from the National Science Foundation and U.S. ment of Defense missions, especially high-altitude
Forecasting a STAR By Wayne Rosenkrans Scientists urge aviation professionals to obtain space weather training before intense solar radiation and geomagnetic storms expected around 2012. © Geopappas/Dreamstime
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After some explosions called solar flares that emit extreme ultraviolet light, X-rays and solar radio bursts, an Earth-directed coronal mass ejection sends out a plasma cloud and solar wind that includes protons and electrons, which initially are deflected by Earth’s magnetosphere but then are accelerated back along Earth’s magnetic field lines until they strike the atmosphere.
reconnaissance missions or those in polar regions.” navigation system errors, and radiation hazards to By Wayne Rosenkrans One finding by participants in the workshop humans and avionics,” the AMS report said. “These was, “Neither the aviation industry nor the space concerns … become even more important at all weather community has a clear understand- latitudes when considered within the framework ing of the aviation industry’s requirements for for the Next Generation Air Transportation System space weather information (e.g., content, tim- (NextGen) … an interagency initiative to trans- ing, interpretation, level of risk).” The report also form the U.S. air transportation system by 2025.” said, “The challenge for the scientific community is that in order to increase investment in space Pro-Training Rationale weather research, the aviation community needs Several events have demonstrated the relevance to demonstrate a need, which requires further risk of space weather to aviation. In April 2007, for assessment of the impacts. However, the aviation example, the U.S. National Aeronautics and community is still trying to understand why they Space Administration (NASA) said that re- should care about space weather.” searchers at Cornell University had confirmed Until this decade, airlines mainly have been that “a solar flare created an intense solar radio concerned about space weather–related risks burst causing large numbers of receivers to stop during high-latitude operations (above 50 de- tracking the global positioning system (GPS) grees north) and polar operations (above 78 signal[s].” The researchers who studied effects degrees north). “Effects include disruption in of two solar flares on Dec. 5–6, 2006, found that high-frequency (HF) communications, satellite although these effects occurred during a period
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of minimum sunspot activity — called corrected geomagnetic latitudes above the largest sunspot clusters in more solar minimum — the burst produced 35 degrees north, or south. Avoiding than 10 years. … Airlines and air traf- 10 times more radio-frequency noise excessive radiation exposure during fic controllers experienced problems on Earth than they had ever recorded. pregnancy is particularly important. almost daily, including severe degrada- “The burst produced 20,000 times Reducing flight altitude may signifi- tion of high-latitude communications.”5 more radio emission than the entire cantly reduce flight doses. Available The FAA’s wide area augmenta- rest of the sun,” said Dale Gary, Ph.D., data indicate that lowering flight alti- tion system (WAAS) for GPS also was a physicist at the New Jersey Institute tude from 40,000 ft to 36,000 ft should affected by the fall 2003 space weather of Technology. “This was enough to result in about a 30 percent reduction storms. “For a 15-hour period on Oct. swamp GPS receivers over the entire in dose rate. A lowering of latitude may 29 and an 11-hour interval on Oct. 30, sunlit side of the Earth.” also reduce flight doses, but the degree the ionosphere was so disturbed that Also in April 2007, the 12 voting is uncertain. Any changes in flight plan the vertical error limit, as defined by members of the international Solar Cy- cle 24 Panel issued a consensus predic- Four transpolar tion that solar cycle 24 — the 24th cycle routes between Asia of quiet to stormy to quiet status since and North America astronomers recorded the 1755–1766 enable fuel-efficient, cycle — would begin in March 2008, time-saving flights, plus or minus six months. Opinion was but space weather– divided as to the characteristics of the related time penalties solar maximum in the new cycle: some can be 80 minutes predicted that the sunspot number for rerouting or 210 would peak at 140, plus or minus 20, in minutes if an en route October 2011; others predicted that the stop is required. sunspot number would peak at 90, plus or minus 10, in August 2012.3 In March 2006, scientists at the U.S. Center for Atmospheric Research — using computer simulations and satellite-based observations of the sun’s interior — predicted “an increase in solar activity in late 2007 or early 2008, and there will be 30 to 50 percent more sunspots, [solar] flares and coronal mass ejections in [solar] cycle 24.” Based on their relatively new methods should be preceded by appropriate [air the FAA’s lateral navigation–vertical of helioseismology,4 which trace acous- traffic control (ATC)] clearance.” navigation (LNAV/VNAV) specifica- tic waves reverberating inside the sun, On several days in October and No- tion to be no more than 50 meters [164 this solar cycle will begin about one vember 2003, flights from the United ft], was exceeded,” NOAA said. year later than had been predicted us- States to Europe were conducted at Teleconferences of dispatchers and ing older methods, according to NASA. lower-than-normal altitudes. Accord- space weather forecasters, sometimes On Oct. 28, 2003, the FAA issued its ing to the U.S. National Oceanic and held daily as requested by airlines, also first solar radiation alert, advising air- Atmospheric Administration (NOAA), have enabled airlines to conduct flights lines, “Satellite measurements indicate “Airlines took unprecedented actions in on transpolar routes when data from the high levels of ionizing radiation coming their high-latitude routes to avoid the sun seemed to preclude the flights. “Per- from the sun. This may lead to exces- high radiation levels and communica- haps the best example of the value of [a sive radiation doses to air travelers at tion blackout areas caused by three of space weather storm] intensity predic-
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tion was on Nov. 3, 2003, when [a solar] information and regulations; education managers responsible for these flights, flare erupted,” NOAA said. “Airline and training; and cost benefit and risk best practices for operating them have companies immediately assumed [that] analyses. To improve current practices, been refined by experience. By apply- a flare this large would surely produce they proposed that the Cross Polar ing company policies for comparing a significant radiation storm. NOAA Trans-East Air Traffic Management data on the NOAA SEC Web page to Space Environment Center (SEC) fore- Providers’ Working Group — augment- predetermined ranges of values, and casters told these dispatchers that be- ed by representatives of NOAA SEC speaking with NOAA space weather cause of the source location [of the flare] and International Space Environment duty forecasters to resolve any uncer- on the sun, an S3 storm [the ‘strong’ Services — help aviation stakeholders tainty, dispatchers know when they level on the NOAA Space Weather define future requirements; Interna- must consider rerouting flights to avoid Scales that airlines have established as tional Space Environment Services specific transpolar routes. “Dispatchers their ‘go/no go’ threshold for transpolar standardize the information formats; receive space weather information from in-house meteorologists, private-sector companies and NOAA SEC alerts and forecasts, or go directly to the NOAA SEC Web site,” the report said. “Typi- Monitoring the cally, dispatchers … review [this Web power flux carried site] and will modify polar flight plans by solar protons and if there is a threat of HF communica- electrons just above tion loss. … Some polar route opera- Earth’s atmosphere tors will use [HF data link and] more at the North Pole, a expensive satellite communications as U.S. polar-orbiting a backup communications medium; satellite’s instruments however, only the Iridium/Intelsat transmit data to systems are available above 82 degrees generate color-coded north [latitude] and their installation statistical maps of [on] commercial aircraft is not wide- the aurora that help spread due to the costs.” airline dispatchers visualize areas where Guidance Versus Regulation these high-speed Workshop participants favored ad- particles produce the ditional official guidance for airlines aurora as they collide to prepare them for the effects of space with the atmosphere. Susan Reed weather storms, and they said that regulators should respect the competi- flights] was not likely. No route altera- and the National Space Weather Pro- tive requirement of a level playing field tions were made, and the prediction gram interact more frequently with and not impose unwarranted costs. materialized when a moderate-size S2 the aviation community to ensure that A related recommendation called for radiation storm unfolded.” future requirements factor into space the FAA to mandate the use of space weather research plans. Similarly, Next- weather information by operators. Priority Policy Issues Gen should be coordinated with NOAA Workshop participants suggested The workshop participants agreed SEC and relevant global initiatives on that the FAA lead the aviation industry that priority space weather–aviation space weather, the report said. in collecting data about airline deci- policy issues are communication that Aircraft on the transpolar routes sions, results and costs from using space enables observations and forecasts to typically are equipped with GPS weather forecasts; conduct related be integrated effectively into global receivers and inertial reference units. risk-benefit analysis and coordinate flight operations; standardization of For dispatchers and flight operations research studies. “Very little information
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is available on how much space weather is however, the GPS receivers alert the flight crew if responsible for delays or reroutes on polar routes signals are unusable so that alternate navigation [and related delays and costs],” the report said. means can be used to complete the flight. “Dur- “The International Civil Aviation Organization ing a geomagnetic storm, the altitude of the lower (ICAO), World Meteorological Organization, boundary of the ionosphere changes rapidly and International Organization for Standardization can introduce [GPS] horizontal and vertical errors and International Space Environment Services of several tens of meters,” the report said. “Dual- should harmonize their separate standards for frequency satellite receivers actually measure [and aviation space weather information, products and correct for] the effect of the ionosphere on the services based upon a set of requirements [and] satellite signals and can better adjust to, but not the FAA should provide [aircraft operators] with eradicate, these difficult circumstances.” a minimum set of requirements for making deci- sions based on space weather information.” Radiation Dose Issues Even people who never fly are exposed to a nor- Beyond Transpolar Flights mal background level of ionizing radiation from Predeparture route changes and en route diver- the particle shower produced by galactic cosmic sions caused by space weather storms and the rays. During high-altitude flight, the dose rates resulting HF communication degradation or are greater compared with the dose rates on the blackouts can affect flight operations in many ground, however, and international authorities world regions other than the polar regions. provide analytical tools and guidance to estimate “[Flight crews operating in] the North Atlantic the level of health risk. “The ‘particle shower’ and Pacific Ocean [flight information] regions and corresponding level of radiation dose reach use HF for aircraft position reporting to maintain a maximum intensity at around 66,000 ft … and separation while outside of ATC radar cover- then slowly decrease with decreasing altitude age,” the report said. “Even relatively minor space down to sea level,” the report said. “The dose weather disturbances can seriously disrupt the rates also increase with increasing latitude until HF signal, causing significant impact on these reaching about 50 degrees, whereupon they oceanic region procedures. While the newest air- become almost constant. … The solar cycle can craft can make use of the latest automated satellite give plus or minus 20 percent variations in dose reporting system, reducing their reliance upon from solar minimum to [solar] maximum.” HF in such regions, ATC can only communicate The reason for the FAA’s October 2003 solar with older aircraft via HF. … Over vast areas radiation alert was that energetic particles — high- of the South American and African continents, ly accelerated protons and electrons — from solar and the Indian Ocean, HF is the only means of flares increase dose rates at typical cruise altitudes communication. Furthermore, in some parts of all over the Earth. The critical issue for occupants central Africa, HF is the only way of communica- of aircraft operating in polar and high-latitude tion between neighboring ATC units.” regions is that the dose rate also increases more Very high frequency (VHF) radio com- rapidly because of geomagnetic storms than munication also can be susceptible to effects of because of increasing altitude and/or latitude. space weather storms. “Although less prone to “Most solar flares emit protons with energies … interference, VHF signals can be lost in the noise [that] can produce [ionizing radiation] increases produced by solar flares, a point not generally at aircraft altitudes and, on average, there have considered when investigating temporary losses been approximately three events per solar cycle of communication between aircraft and ATC,” the with sufficient intensity and energies to produce report said. significant radiation in the atmosphere,” the report GPS also is susceptible to space weather storm said. The Earth’s magnetic poles are especially effects, according to the report. When they occur, vulnerable because of the shape and properties of
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the planet’s magnetic field; geomagnetic few currently apply to space weather times on his sunspot drawings and the storms weaken everywhere on Earth reports and forecasts. “Annex 15, strange phenomena observed in Earth the protection provided by the magnetic Aeronautical Information Services, does skies — helped to launch the quest for the field. “The Earth’s magnetic field does allow for issuance of a notice to airmen knowledge on which current transpolar offer some protection, but [ionizing for solar radiation, but provides very flights now depend.8 ● radiation] particles can spiral down the little guidance for message content,” the For an enhanced version of this article and links [magnetic] field lines, entering the upper report said. “The ICAO International to space weather information, go to
Metro pilots lost the big picture during a difficult approach.
BY MARK LACAGNINA
CFIT in Queensland (NOAA) National Oceanic & Atmospheric Administration U.S. 28 | flight safety foundation | AeroSafetyWorld | June 2007 causalfactors
n experienced pilot with a history of Accident Flight Route noncompliance with standard operating procedures (SOPs), an inexperienced and nonassertive copilot, excessive airspeeds Bamaga Cape York Aand descent rates during a nonprecision approach Ť in bad weather, and the operator’s disregard of its own rules and training standards were found to have played roles in the May 7, 2005, crash of a Fairchild Metro 23 in Queensland, Australia. In its final report, the Australian Transport Wenlock River Safety Bureau (ATSB) said, “The accident was almost certainly the result of controlled flight into terrain [CFIT] — that is, an airworthy Lockhart River aircraft under the control of the flight crew was flown unintentionally into terrain, prob- ably with no prior awareness by the crew of the CAPE YORK PENINSULA aircraft’s proximity to terrain.” Both pilots and all 13 passengers were killed in the accident, Princess which occurred near Lockhart River. Charlotte Bay The Metro 23 and eight other aircraft were op-
erated by Transair from its main base in Brisbane Normandy River and ancillary bases in Cairns, Grafton and Inver- ell.1 The company employed 21 full-time pilots. The morning of the accident, the flight crew had flown the Metro from Cairns to Lockhart QUEENSLAND River and Bamaga. The accident occurred M itch ell R on the return trip to Cairns, on the leg from iver Bamaga to Lockhart River (Figure 1). Staaten River Exceeding the Limits Cairns Gilbert River The pilot-in-command (PIC), 40, held an airline transport pilot license and had 6,072 flight hours, including 3,249 flight hours in Metros. He was
employed by Transair as a line pilot in March Source: Australian Transport Safety Bureau 2001, promoted to supervisory pilot in September 2002 and to Cairns base manager in August 2003. Figure 1 The report said that there were no records indicating that the PIC had received training on conducted by the PIC. Several Transair copilots crew resource management (CRM), as required had expressed concern to a supervisory pilot that by the Transair Operations Manual. the PIC did not follow company procedures, in- The PIC had a history of noncompliance with cluding airspeed limits. One copilot said that the SOPs. A previous employer had placed him on PIC would slow down only if asked to do so by probation for not following company procedures. a copilot he respected. Another copilot said that Flight data recorder (FDR) data from the accident he had to be assertive to prevent the PIC from aircraft indicated that descent rates and airspeeds descending below the minimum sector altitude. had exceeded those specified by Transair’s SOPs “The chief pilot [of Transair] reported that CFIT in Queensland during two previous instrument approaches he could not recall ever receiving any specific www.flightsafety.org | AeroSafetyWorld | June 2007 | 29 causalfactors
indicated that he had passed aircraft ground Fairchild SA-227DC Metro 23 training despite earning a score of 77 percent on a test of aircraft systems and operating limita- tions; the company operations manual required a minimum score of 80 percent. The copilot also was not checked by a check pilot, as required by the manual, before he began line operations. “Pilots who flew with the copilot reported that he was keen to learn,” the report said. “The copilot’s flying ability and systems knowledge were generally reported as being consistent with his fly- ing experience.” The copilot also was described by colleagues as quiet, shy and nonassertive. The PIC and copilot previously had flown together on 10 days, completing 27 flight sec-
@ Craig Murray/Airliners.net tors. The copilot had told other Transair pilots that the PIC was difficult and authoritarian, and esigner Edward J. Swearingen’s Merlin corporate/business aircraft that he did not provide effective instruction and first flew in 1965 with Pratt & Whitney Canada PT6A‑20 engines. did not comply with SOPs. DAll subsequent versions of the Merlin and its longer-fuselage, 19- passenger regional airline derivative, the Metro, have had Garrett, now Bad Weather Honeywell, TPE331 engines. The original SA‑226TC Metro was introduced in 1969 and was Before departing from Bamaga at 1107 lo- replaced in 1974 by the Metro II, which has larger windows and im‑ cal time, the PIC told a ground agent that the proved systems. The SA‑227AC Metro III, introduced in 1981, has lon‑ weather was bad at Lockhart River and that they ger wings, a higher useful load and more powerful engines. Maximum might not be able to land there. takeoff weight was increased from 14,500 lb (6,577 kg) to 16,500 lb The forecast winds were from 130 degrees (7,484 kg) with the introduction of the more powerful SA-227DC Metro at 15 kt, gusting to 25 kt. The crew elected to 23 in 1990. The Merlin/Metro series was produced by Swearingen Aircraft Co., conduct the area navigation/global naviga- Fairchild Aircraft Corp. and Fairchild Dornier. Production was termi‑ tion satellite system (RNAV/GNSS) approach nated in 1999. to Runway 12, which had a minimum descent
Source: Jane’s All the World’s Aircraft altitude (MDA) of 1,040 ft — or 120 ft lower than the MDAs for the RNAV/GNSS approach to Runway 30 and the nondirectional beacon (NDB) complaints about the operational performance approach. of the PIC,” the report said. The chief pilot was The airport did not have a control tower. the managing director of Transair and also The automatic weather station at the airport served as training director and as one of the recorded only wind direction and velocity, tem- company’s two check pilots. perature and rainfall data. A meteorological ob- The copilot, 21, held a commercial pilot server performed observations three times a day license and had 655 flight hours, including 150 but did not have the capability to communicate flight hours in Metros. He had no experience in directly with pilots. The observation performed turbine aircraft or multi-pilot operations before at 1200 the day of the accident did not include being employed by Transair in March 2005. “A information on visibility or cloud bases. family member reported that the copilot was The report said that Australian Bureau of Me- given a training manual to study and was not pro- teorology estimates indicated that “the cloud base vided with any formal classroom training during was probably between 500 ft and 1,000 ft above his ground school,” the report said. His records mean sea level, and the terrain to the west of the
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aerodrome, beneath the Runway 12 RNAV/GNSS Unstabilized Approach approach, was probably obscured by cloud.” FDR data indicated that the aircraft accurately The PIC likely was the pilot flying because tracked the final approach course. However, recorded radio transmissions were made by the airspeeds and descent rates exceeded those copilot. There was no record of communication specified in the Transair Operations Manual and between the pilots because the cockpit voice those appropriate for a stabilized approach, the recorder (CVR) had malfunctioned and provided report said. The company operations manual no usable data for the last 30 minutes of the flight. did not provide specific guidance for conducting The copilot had an endorsement on his a stabilized approach. instrument rating to conduct NDB approaches, The report cited the elements of a stabi- but he was not endorsed for RNAV/GNSS lized approach recommended by Flight Safety approaches. There was no record that he had Foundation that include a maximum speed of received company-required training on the use VREF, landing reference speed, plus 20 kt and a of global positioning system (GPS) equipment maximum descent rate of 1,000 fpm.2 as the sole source of navigation information. An appropriate approach airspeed for the “The crew commenced the … RNAV/GNSS Metro under the existing conditions would approach, even though they were aware that the have been about 130 kt. FDR data indicated copilot did not have the appropriate endorse- that airspeed was about 226 kt when the aircraft ment and had limited experience to conduct this crossed the initial approach fix and about 176 kt type of instrument approach,” the report said. as it crossed the intermediate fix. The aircraft then descended from 3,500 ft to Complex Procedure 3,000 ft and remained at that altitude momen- The approach procedure was relatively complex, tarily (Figure 3, p. 32). “During this level flight, and the crew’s workload during the approach likely was very high (ASW, 2/07, p. 46). The Approach Track aircraft was not equipped with an autopilot. “There was a significant potential for [CRM] problems within the crew in high-workload LHRWG situations, given that there was a steep trans- 1139:56 cockpit authority gradient and neither pilot had 1086 LHRWE previously demonstrated a high level of CRM 124° 1140:28 5NM skills,” the report said. “A steep gradient between 5NM 1140:33 1509 6° E a dominant PIC and a submissive copilot may LHRWI 1625 result in the PIC not listening to the concerns of 124° 5NM the copilot and/or the copilot being less willing to 5NM 1142:19 1047 communicate important information to the PIC.” 1142:51 LHRWD LHRWF The report also said that the copilot’s lack of 5NM
340° training and experience in conducting RNAV/ 3.6NM GNSS approaches might have made it difficult for 124° NOT FOR NAVIGATION1787 7NM him to detect deviations during the approach. 1463 At 1139, the copilot announced on the LHRWM 3NM airport’s common traffic advisory frequency 538
(CTAF) that the Metro was over “Whiskey Golf” 0 5NM LHRWH — the LHRWG waypoint, an initial approach fix — and was inbound to “Whiskey India” Source: Australian Transport Safety Bureau — LHRWI, the intermediate fix, which was 12.5 nm from the runway threshold (Figure 2). Figure 2 www.flightsafety.org | AeroSafetyWorld | June 2007 | 31 causalfactors
the aircraft’s speed reduced to the maxi- The report said, however, that there was respond to the GPWS alert and warn- mum half-flap extension speed (180 no indication that the aircraft encoun- ings that were probably annunciated kt) and the flaps were extended [to half tered wind shear. during the final five seconds prior to of their travel],” the report said. “The impact,” the report said. aircraft did not descend below the seg- Two GPWS Alerts The accident likely would not ment minimum safe altitude (2,200 ft) The crew likely received two ground- have occurred if the aircraft had been during this initial descent and leveling.” proximity warning system (GPWS) equipped with a terrain awareness and Soon after the landing gear was “TERRAIN, TERRAIN” alerts. Postac- warning system (TAWS), which pro- extended, about 1.4 nm from the final cident simulations of the aircraft’s flight vides predictive terrain-hazard warn- approach fix, the aircraft began to path indicated that the first alert would ings, the report said. descend at 1,000 fpm. Airspeed was have occurred about 25 seconds before At 1143, the aircraft struck trees at about 177 kt when the aircraft crossed impact. The second alert would have 1,210 ft — about 90 ft below the crest the final approach fix. Power then was been followed by continuous “PULL of the northwest slope of South Pap, a reduced, and the descent rate increased. UP” warnings for the final five seconds heavily timbered ridge in the Iron Range Airspeed remained about 175 kt and of the flight. FDR data indicate that the National Park — about 11 km (6 nm) the average descent rate was 1,700 fpm crew did not respond to either alert. northwest of the airport. This high ter- during the last 48 seconds of the flight. However, the simulations also rain was not depicted on the approach The aircraft descended below 2,060 ft, indicated that a GPWS “TERRAIN, chart (see sidebar, p. 33). Initial impact the published minimum altitude for the TERRAIN” alert could result during occurred 850 ft below the published approach segment, soon after crossing a normal descent on final approach minimum altitude for the approach seg- the final approach fix. in aircraft with flaps in the approach ment. “The aircraft was destroyed by the “The higher-than-specified speeds configuration, even if the aircraft was impact forces and an intense, fuel-fed, and rates of descent reduced the amount established on the constant descent post-impact fire,” the report said. of time available to the crew to configure angle and/or above the segment mini- Investigators found no indication in the aircraft for the approach, accomplish mum safety altitude. The report said that the FDR data that a flight control or pow- the approach procedures and maintain GPWS alerts that occur during normal er plant problem occurred before impact. their awareness of their position on the operations increase the chances that pi- “There were no radio transmissions made approach,” the report said. lots will ignore them in other situations. by the crew on the air traffic services Turbulence was encountered during The second GPWS alert came too frequencies or the Lockhart River CTAF the last 25 seconds of the flight, which late. “There would have been insuf- indicating that there was a problem with further increased the crew’s workload. ficient time for the crew to effectively the aircraft or crew,” the report said.
Approach Profile
IF FAF MAP IAF LHRWI LHRWF LHRWM 3.49° 3500 124° 340° LHRWD 2860 Forecast LHRWE 124° cloud top LHRWG 2500 2115 2200 2060 1600 1600 MDA MAP Forecast cloud base THR 12 ELEV 46 NM FM 17 12 7 5 3.6 0 3 MAP 0.45
ELEV = elevation FAF = final approach fix FM = from IAF = initial approach fix IF = intermediate fix MAP = missed approach point MDA = minimum descent altitude NM = nautical miles THR = runway threshold
Source: Australian Transport Safety Bureau
Figure 3
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Chart Safety Factors
afety factors” related to the and approved by the Australian Civil aligned vertically with LHRWF in the design and charting of area Aviation Safety Authority (CASA) based profile view. The report said that this “Snavigation/global navigation on ICAO criteria. can cause a pilot to become confused satellite system (RNAV/GNSS) ap‑ The five-letter waypoints for these when scanning the chart. proach procedures were identified by procedures are shown on charts in up‑ Another factor specific to the the Australian Transport Safety Bureau percase. The first three letters identify Jeppesen chart is the use of the same (ATSB) in its final report on the Transair the airport, the fourth indicates the typeface and type size for waypoints Metro 23 accident.1 The report cited general direction from which the air‑ and the stepdown fixes — 5.0 NM and the importance of communicating craft travels on final approach, and the 3.6 NM — on the final approach seg‑ these factors, even though they were fifth is a standard letter that identifies ment. The report said that this results in not found to have contributed to the the purpose of the fix — for example, similar appearance of the letter “M” in accident. “I” for intermediate fix, “F” for final ap‑ the stepdown fixes and in LHRWM, and Among the cited safety factors was proach fix and “M” for missed approach could lead to misidentification of the the unique method used by Airservices point (ASW, 2/07, p. 47). Thus, the only MAP in high-workload situations. Australia to name waypoints. The variation in the waypoint names for a In addition, the stepdown fixes on report said that the similar, unpro‑ specific approach is the last letter. the Jeppesen chart are the only specific nounceable five-letter names cause “Research has (IAF) chart clutter and make it difficult for pi‑ shown that people LHRWG lots to distinguish waypoints shown on can automatically 3500 charts or displayed by on-board global (that is, instantly) (IAF) LHRWE 3500 positioning system (GPS) equipment. identify a number 1 “There was also no regulatory among letters, but (IF) LHRWI requirement for instrument ap‑ when identifying a 124° proach charts … to include colored letter among other (IAF) contours to depict terrain, as re‑ letters, identification LHRWD LHRWF 3500 5.0 NM quired by International Civil Aviation is slower,” the report to LHRWM 3.6 NM Organization (ICAO) Annex 4, to which said. “Research also 2 to LHRWM Australia had not notified a difference,” has shown that when NOT FOR NAVIGATION the report said. searching for a letter LHRWM The Transair flight crew likely in three-letter or five- used Jeppesen charts, rather than letter sequences, the Airservices Australia charts, during the time taken to detect accident flight. The report said that the the letter increases LHRWI Jeppesen chart for the RNAV/GNSS ap‑ the further its posi‑ 1.7 NM to LHRWF LHRWF 3 5.0 NM proach to Runway 12 at Lockhart River tion is moved from 3500' 124° 2860' to LHRWM [3.49°] 3.6 NM had several design aspects that “could the first letter.” 2115' to LHRWM LHRWM 2200' 1600' lead to pilot confusion or a reduction The information 2060' 1600' M in situational awareness.” Examples in‑ alignment factor MDA 4 5.0 2.0 1.4 3.6 cluded limited information on distance on the Jeppesen 12.5 7.5 0.5 0 to the missed approach point (MAP), chart resulted from 1. Similarity of waypoint names may make them more difficult to nonalignment of information on the the absence in the differentiate. plan view and profile view, the typog‑ profile view of the 2. The vertical alignment of two different waypoints may cause confusion. raphy used for waypoint names and initial approach fixes 3. Labels end with the same letter and use the same typeface and minimum segment altitudes, and the — LHRWD, LHRWE size for different information. absence of information on the offset, and LHRWG. The first 4. The lower set of numbers shows the distances to the runway, in degrees, between the final approach waypoint in the pro‑ but not to the missed approach point. The upper set of course and the runway centerline. file view is the inter‑ numbers shows the distance for each segment to the missed approach point, but not the distances from a waypoint to the As of 2005, more than 350 RNAV/ mediate fix, LHRWI. missed approach point. GNSS approach procedures had been This caused LHRWI in Source: Australian Transport Safety Bureau designed by Airservices Australia the plan view to be
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indications of distance to the MAP. The than the optimal 5 nm. The stepdown designing and approving RNAV/GNSS scale at the bottom of the profile view fixes for the final approach also re‑ approaches. “There are limited options shows distances to the runway thresh‑ sulted from terrain considerations. The available to overcome these design old. The scale below the profile view on report said that these factors add to pi‑ problems,” the report said. “However, the Airservices Australia chart, on the lot workload and increase the chances the overall influence that these varia‑ other hand, shows distances to the MAP. for position confusion. tions can have needs to be considered Because of terrain northwest of Neither the Airservices Australia by CASA when evaluating and deciding the airport, the approach procedure chart nor the Jeppesen chart depicts whether to accept the approach.” is relatively complex. The final ap‑ terrain with color contours, as required — ML proach course is offset five degrees by ICAO under specific conditions, such Note from the runway centerline because of as when the final approach gradient is 1. The Australian Transport Safety a mountain northwest of the airport steeper than 3 degrees. The report said Bureau defines safety factor as “an — the 1,787-ft obstacle spot elevation that the charts provide no indication of event or condition that increases depicted on the plan view (Figure 2, the existence of high terrain under the safety risk” and one that, if repeated, p. 31). The constant descent angle is approach path, such as the ridge struck “would increase the likelihood of an 3.49 degrees, rather than the optimal by the Metro. occurrence [accident or incident] and/or the severity of the adverse 3 degrees. The distance from the final ATSB recommended that these consequences associated with an approach fix to the MAP is 7 nm, rather safety factors be considered when occurrence.”
Deficiencies Uncovered certificate and ceased operations in is inadequate” and recommended “fur- The report said that factors contribut- December 2006. ther work to address this safety issue.” ing to the accident included limitations ATSB did, however, recommend The report noted that CASA was in Transair’s safety policies and proce- improvements to government surveil- taking action to address other recom- dures, and deficiencies in regulatory lance of regular public transport opera- mendations, including the implementa- oversight of the company. tors. The report said that the Australian tion of regulations requiring regular “In particular, [Transair’s] flight Civil Aviation Safety Authority (CASA) public transport operators to provide crew training program had signifi- “did not provide sufficient guidance CRM training and to have a safety cant limitations, such as superficial or to its inspectors to enable them to effec- management system. ●
incomplete ground-based instruction tively and consistently evaluate several This article is based on Australian Transport during endorsement training, no formal key aspects of [Transair’s] management Safety Bureau Transport Safety Investigation training for new pilots in the operation- systems. These aspects included evalu- Report 200501977, “Collision With Terrain, 11 al use of [GPS] equipment, no struc- ating organizational structure and staff km NW Lockhart River Aerodrome, 7 May 2005, tured training on minimizing the risk resources, evaluating the suitability of VH‑TFU, SA227-DC (Metro 23).” The 532-page report contains illustrations and appendixes. of CFIT and no structured training in key personnel, evaluating organization- CRM (or human factors management) al change and evaluating risk manage- Notes and operating effectively in a multi- ment processes.” crew environment,” the report said. In November 2006, CASA told ATSB 1. “Transair” was the trading name for The company’s SOPs lacked clear that it was recruiting personnel with Lessbrook Proprietary Limited, which operated the accident aircraft under its air guidance on approach speeds, aircraft management and safety management operator certificate. configuration, elements of a stabilized expertise to improve its surveillance of approach and standard phraseology operators. In March 2007, CASA said 2. Flight Safety Foundation (FSF). “Killers for challenging another crewmember’s that it “has [provided] and continues in Aviation: FSF Task Force Presents Facts About Approach-and-Landing and decisions and actions. to provide substantial guidance mate- Controlled-Flight-Into-Terrain Accidents.” ATSB made no recommenda- rial in all aspects of surveillance.” ATSB Flight Safety Digest Volume 17 (November– tions regarding Transair, because the responded that it still believed that the December 1998) and Volume 18 (January– company surrendered its air operator guidance provided to inspectors “was and February 1999).
34 | flight safety foundation | AeroSafetyWorld | June 2007 HELICOPTERSAFETY
During final approach, the AS 350B3 pilot could not move the cyclic.
BY MARK LACAGNINA EMS Control Loss
nvestigators were unable to deter- 2,631 flight hours as a Robinson R22 was wearing a non-noise-canceling head- mine why a loss of control occurred flight instructor. set, remembered seeing the hydraulic during an emergency medical ser- The pilot conducted preflight checks system warning light illuminate but did vices (EMS) flight the night of Dec. of the helicopter and had the engine not hear the aural warning. I14, 2004, in Apache Junction, Arizona, running when two medical crewmem- The pilot saw shopping-mall build- U.S. The final report by the U.S. National bers arrived for the flight. The helicopter ings nearby and applied full-left cyclic Transportation Safety Board (NTSB), departed from the airport at 2229. control to avoid colliding with them. issued in late April 2007, discussed four “She then grabbed the cyclic with both previous control system discrepancies Parking Lot Approach hands and pulled back and right, but encountered by pilots of the Eurocopter Police and firefighters secured a landing it did not move,” the report said. “The AS 350B3 and a phenomenon called area in a mall parking lot. Fire trucks anti-torque pedals appeared to work and “hydraulic servo transparency.”1 How- were positioned at all four edges of the stopped the spin.” Two witnesses said ever, the report contained no analysis of designated landing area. The pilot cir- that they heard a hissing sound, similar the findings of the investigation. cled the area several times and discussed to the bleeding of airbrake pressure in a The helicopter was operated by obstructions, including tall light poles large truck, as the helicopter descended. Petroleum Helicopters Inc. (PHI). The and power lines, with ground personnel. The helicopter struck the landing pilot was on duty at the company’s Visual meteorological conditions area in a steep nose-down and left-side- EMS crew facility at Williams Gateway prevailed, and a local weather-observing down attitude at 2237. The left side of Airport in Phoenix at 2200 local time station was reporting variable winds. the nose section was crushed, the left when she was assigned to pick up an However, the pilot said that the winds landing skid failed, the main rotor blades accident victim at a shopping mall were calm at the landing site. She ma- fragmented, and the tail boom was about 9 nm (17 km) away, and to trans- neuvered the helicopter to conduct an broken at the attachment point with the port the patient to a hospital. approach from the northeast. fuselage. One medical crewmember was The pilot held a commercial ro- After clearing power lines on final killed; the other medical crewmember torcraft pilot certificate and had 4,604 approach, the helicopter was about 100 ft and the pilot received serious injuries. flight hours in helicopters. After being above ground level and had been slowed A substantial amount of fuel was hired by PHI in October 2001, she to 20 to 25 kt when the nose gently rose spilled onto the parking lot, but there was accumulated 80 flight hours as pilot- and moved right. The pilot said that no fire. “The engine continued to run in-command (PIC) of AS 350B3s, 300 when she used cyclic control to correct after the ground impact, and [the surviv- flight hours as PIC of Messerschmitt- the movement, the helicopter rolled left ing medical crewmember] and multiple Bolkow-Blohm BO-105s and 300 flight “significantly and violently” and began to rescue personnel moved numerous hours as PIC of Bell 206Ls. She also had spin. The report said that the pilot, who switches in the cockpit in an attempt to www.flightsafety.org | AerosafetyWorld | June 2007 | 35 HELICOPTERSAFETY
shut down the engine, hence all postim- Eurocopter AS 350B3 pact switch positions were unreliable [for investigation purposes],” the report said. Firefighters stopped the engine by spray- ing fire-suppressant foam into the intake.
Control Discrepancies The accident helicopter was manufac-
tured in 1999 and had accumulated 2,496 © Sun Valley Aviation/Jetphotos.net hours of service. The report said that during the three months preceding the accident, four flight control discrepan- G‑loading for the phenomenon onset, system test — “HYD TEST” — switch, cies had been reported. The reports cited the hydraulic system does not have which is located next to the landing light stiffness of the flight controls, excessive enough pressure available to move the switch. “Depressing the switch shuts off control inputs required for normal flight main left lateral, right lateral and fore/ the hydraulic pump for preflight system and unwarranted activations of the hy- aft servos against the dynamic forces checks, in part to ensure that the pressure draulic system warning light and horn. being fed back from the rotor system accumulators for the servo channels are “The most recent write-up was one into the controls,” the report said. “At pressurized and working,” the report said. month prior to the accident,” the report the onset of servo transparency, the The “HYD TEST” switch in the said. “The company maintenance de- flight controls essentially go from accident helicopter was found in the partment’s corrective actions included boosted to manual reversion, where “OFF” position, which is the correct cleaning the control system bearings, they remain until the G-loads decrease position for normal flight. replacing the hydraulic system actua- below the onset threshold values.” Postaccident test flights were con- tors and repairing damaged electrical Eurocopter’s chief test pilot for the AS ducted to determine the time intervals wiring and cannon plugs.” 350 program told the NTSB that when between selection of the “HYD TEST” Postaccident inspections and func- the phenomenon begins, the pilot typi- switch to the “ON” position and loss tional testing of the helicopter’s hydraulic cally feels the collective control moving of lateral hydraulic servo accumulator system components found no indication down and the cyclic control moving right. assistance to flight control inputs. The of preimpact failure or malfunction. “Eurocopter personnel stated that times varied from 45 seconds during a “The hydraulic system accumulators the transparency phenomenon is straight-in approach at 80 kt using ex- were found to still have an unquantified nonviolent and transitory, lasting only cessive control inputs, to 3 minutes 30 amount of pressure,” the report said. 2 to 3 seconds, at most, due to the ‘self- seconds during a straight-in approach correcting actions of the pilots’ to reduce at 80 kt with minimal control inputs. Servo Transparency the G loads and/or the natural static The report noted that after the ac- The report said that NTSB investigators and dynamic stability response of the cident, PHI designed, fabricated and discussed the hydraulic servo transpar- helicopter,” the report said. “They also installed guards over the “HYD TEST” ency phenomenon with Eurocopter stated that the controls are fully oper- switches in its fleet of Eurocopters. In engineers and flight test pilots. The able throughout the entire transparency November 2005, Eurocopter issued phenomenon, also called “control re- event; however, the force required to Service Bulletin 67.00.32, which presents versability,” can occur during maneu- effect movement of the flight controls procedures for installing a protection flap vers that result in increased loading against the rotor system dynamic feed- over the pedestal switches, and in Janu- on the helicopter and rotor system. back loads would increase significantly.” ary 2006 began incorporating the protec- The load thresholds vary according to tion flap in production helicopters. ● helicopter speed and gross weight, and Test Switch Guarded atmospheric density altitude. The AS 350 has 36 backlighted, push-on/ Note “As explained by Eurocopter, when pull-off switches on its systems control 1. U.S. National Transportation Safety Board the helicopter reaches a threshold pedestal. Among them is the hydraulic accident report LAX05FA053.
36 | flight safety foundation | AerosafetyWorld | June 2007 Strategicissues he Underwriter’s Perspective © Carlos Santa Maria/Fotolia
viation insurers perceive the airline in- More than ever, insurers are attuned to Aviation insurers dustry as one of the world’s most highly collective efforts by the airline industry that focus on airline safety regulated and safest, yet they still focus demonstrate safety awareness and the capabil- practices that surpass on each airline’s risk-management orien- ity to continue reducing the risk of accidents. Atation and its maturity within an industry sector In mid-2007, the International Air Transport baseline expectations. and region, sometimes called its geosocial area, Association (IATA) Operational Safety Audit says Steve Doyle, global practice manager for (IOSA) program is a common interest. By Wayne Rosenkrans Aon Aviation. Insurance brokers and underwrit- “There is a baseline for the airline industry ers also expect risk management by each airline in IOSA, so it is only a question of ‘How much to be the proactive side of the safety equation better than the baseline are you?’” Doyle said, and aviation insurance to be the reactive side; citing similarities between the interests of IOSA so, when an airline handles risk management auditors and insurance underwriters. “The well, it is likely to elicit a favorable response challenge is any airline’s differentiation over and from underwriters, Doyle said. above that baseline — and over and above peers “From an aviation insurer’s perspective, in terms of the adoption of technology, etc. If pricing — that is, catastrophe coverage limits for everybody or nearly everybody passes IOSA, it fairly low levels of premium — is reflective of is a question of whether those not on the IOSA the risk profile of a very safe industry,” he said. registry would be ‘punished’ by higher insurance “So, insurers today are reacting to the claims ex- premiums rather than whether those with IOSA perience of the industry (Figure 1, p. 38) while, would be credited. IOSA already is reflected on the proactive side, the airlines are managing much more in risk pricing than perhaps it was their risks to reduce the overall level of claims.” previously.”
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A Very Cyclic Aviation Insurance Market Premium Versus Losses, 1992–2006
5,000 Gross premium 4,500 Insured losses 4,000 3,500 3,000 2,500 2,000 1,500 1,000 Amount (millions of U.S. dollars) (millions of U.S. Amount 500 0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Year
Note: The expected worldwide gross premium for aviation insurance is $1.5 billion for 2007, including an average $1.5 million per airline.
Source: Göran Forsberg
Figure 1
Spotlighting IOSA taking into account IOSA participation and Some observers consider the recognition of implementation of a safety management system airlines’ collective safety efforts by insurers to be (SMS) as they examine each airline’s risk profile mutually beneficial. “Clearly, the mandating of and determine the premium to be charged. “Insur- IOSA as a prerequisite for IATA membership is ers have been actively involved in maintaining … a force for good,” said David Gasson, secretary aviation liability insurance, which is key to airlines’ general of the International Union of Aviation ability to operate,” Gates said. “Insurers and bro- Insurers (IUAI). “It is also clear that passing kers work together to provide risk-management an IOSA audit will carry some weight with an assistance to their clients — particularly if there are insurer. That said, insurers still require indepen- areas of concern or special issues to be addressed, dent risk surveys of airlines when they believe such as a recent fatal accident.” circumstances merit it. In addition, the weight IATA also has been promoting more effective given to IOSA audits in risk evaluation will vary interaction within airlines between operations from underwriter to underwriter.” risk managers and the corporate financial risk Giovanni Bisignani, director general and CEO managers, who interact most frequently with the of IATA, said in an April 2007 speech that the as- aviation insurance broker and the lead insurance sociation recently has applied the IOSA concept, underwriter. “The purpose of our Integrated designed for airlines, to airport ground handling Airline Management System guide is exactly that: through a new program called the IATA Safety Au- to engage risk managers and operations person- dit for Ground Operations (ISAGO). “Standard[s] nel in the overall assessment and control of risk,” development is under way, and the first audits will Gates said. “This was our objective in combining take place in 2008,” Bisignani said. Notably, the the two audiences in Montreal at our April 2007 IUAI is providing advice on risk management and conference, which was attended by over 600.” insurance while participating in the IATA steering When an airline proposes safety improve- group that is introducing ISAGO, Gasson said. ments during insurance negotiations, some Carole Gates, IATA’s director of risk manage- insurers offer incentives or participate finan- ment and insurance, also has seen aviation insurers cially. “Aviation insurers make investments in
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airlines that wish them to do so, and generally safety in aviation and when necessary should make available funds built into placement slips establish their own safety standards.” — an amount of money set aside in the insur- After six more years, Barbara Woodward in ance purchase contract that can be used by the a paper presented to the CAS meeting said, “For airline for risk-management activity — and that these reasons [that is, a wide range of airplane activity subsequently will be reflected in the risk values and uses, and rapid changes in design and pricing,” Doyle said. Examples of safety im- operating conditions], it can be seen that the provements financed this way include compre- time for placing aircraft insurance on an actu- hensive risk-management programs, consulting arial basis has not yet arrived. … A fundamental work by third-party specialists, programs for proposition for arriving at a proper rate is, how- closer monitoring of daily operations, upgrading ever, followed by [two U.S. aviation insurance] high-visibility clothing and procedures for plac- groups in making rate quotations; namely, that ing safety cones around parked aircraft. the hazard in connection with any aviation risk is directly related to the amount of flying which Similar Issues Long Ago is done.” Commenting in 1939 on Woodward’s Observing the competition among several U.S. paper, John A. Mills said, “The insurance insurance groups to provide coverage to airlines companies are contributing their share towards in the late 1920s, Stephen Sweeney, an assis- promoting greater safety in flying through safety tant professor of insurance at the University of engineering. … Although statistics so far devel- “When the Boeing Pennsylvania, told the 1928 meeting of the U.S. oped have been limited, they have nevertheless 747 was introduced in Casualty Actuarial Society (CAS) that although served a useful purpose in arriving at a base rate the early 1970s [after “the average operator does not know much about and also in judging the approximate proportion its rollout ceremony insurance,” several developments were important. of the losses attributable to each of the major below in September “Rates were materially reduced,” Sweeney said. hazards connected with flying. Questions asked 1968], airlines paid so “Practically all aviation rates are the results of a prospective [airline] by aviation underwriters much more than they pure judgment. … As actuaries, you will probably are designed to provide the underwriter with all pay today to insure be dissatisfied for some time to come with the data having an important bearing on the causes a 747,” said Göran aviation data available for rate-making purposes. and circumstances surrounding airplane acci- Forsberg, an aviation … I think we might list [general considerations dents. The underwriter knows the approximate insurance manager for coverage] as the pilot, the plane itself, the part of the pure premium attributable to each based in Sweden. engine and the territory of operations. There have of the factors on which information is required, been attempts made to analyze these to deter- mine their relative importance. Probably it is the consensus that the pilot is the most important element from the standpoint of the underwriter. … [An airline’s] poor housekeeping, incomplete inspection routine, unsound financing, superfi- cial experience in the case of those in charge of operations, undue pressure on pilots to take great chances — these are some of the things that must be watched for and guarded against most zeal- ously by the underwriter who would survive.”1 Five years later, W.P. Comstock noted in a paper presented to the CAS, “Pilots are being educated to recognize that safety is as much dependent upon careful flying as upon structural design.
… Casualty companies should point the way to Airplanes Boeing Commercial www.flightsafety.org | AeroSafetyWorld | June 2007 | 39 Strategicissues
and the final rate quoted recognizes within prac- infrastructure in the airline’s areas of operation tical limits the extent to which the individual with standards of the International Civil Aviation risk can be expected to vary from the average.” Organization, and the degree of political stabil- ity, Doyle said. Professionals in both domains, Where Credit Is Due however, pay attention to potential risks linked to In 2007, insurers’ perspectives of airline safety tend the growth of airlines and air traffic. to differ from those within an airline primarily in “Insurers take the view that because the air- terms of scale, according to Doyle. “Global avia- lines are growing, their exposure is growing, and tion insurers write insurance coverage and accept that is very true,” he said. “As brokers, we empha- financial risk from the global airline industry as size the strengths in the overall risk profile of an a whole,” he said. “The fundamental principle is airline and we take the view that increased expo- that the losses of the few are paid for by the many sure is not necessarily translating into increased “As brokers … we (Table 1), so although your airline is part of the claims — that claims levels today are no higher many and has had no losses, if the industry as a in actual dollar terms than they were in excess of take the view that whole has had losses, then your part of the global 15 years ago, and are less than they were pre-9/11 premium ‘pie’ is going to increase. If your geo- [Sept. 11, 2001, when four U.S. commercial jets increased exposure graphic region has had an experience of losses were destroyed in a terrorist attack]. So, while the is not necessarily and your industry sector has had an experience airline industry has demonstrated massively in- of losses, then you are in a different position than creased exposures, the level of losses — one of the translating into airlines outside that region or outside that sector.” key factors that drives the market and insurance One complication for operations risk manag- pricing — has not increased, but the potential has increased claims.” ers who welcome insurers’ influence (ASW, 3/07, increased as award levels have increased.” p. 22) is that some factors still do not translate between the two domains. Insurers focus more Limiting Common Practices on the claims levels, the average cost of awards Airlines logically may be expected to have different by courts for passenger liability, the global loss explanations for specific safety improvements. experience by aircraft type, the compliance of “This is especially true as no airline wants to be named in connection Top 10 Aviation Disasters by Cost of Insured Loss to Aviation Insurers with an accident due Losses incurred1 as of Feb. 22, 2007 to the reputational loss that may follow,” Gas- Airline Date Location Fatalities Loss (U.S. Dollars) son said. “Risk surveys, American Airlines Sept. 11, 2001 New York, New York, U.S. 2,911 1,500–1,900 million inspections, meetings, United Airlines Sept. 11, 2001 New York, New York, U.S. 65 1,650–1,800 million discussions and confer- American Airlines Nov. 12, 2001 Queens, New York, U.S. 265 ~ 700 million ences of airlines and Alaska Airlines Jan. 31, 2000 Pacific Ocean, U.S. 88 ~ 400 million underwriters are com- SriLankan Airlines July 24, 2001 Sri Lanka 0 ~ 400 million mon in today’s aviation Singapore Airlines Oct. 31, 2000 Taipei, Taiwan, China 83 ~ 380 million market,” he said. “Good EgyptAir Oct. 31, 1999 International waters 217 ~ 340 million examples are alli- American Airlines Sept. 11, 2001 Arlington, Virginia, U.S. 188 ~ 270 million ances and code-share American Airlines June 1, 1999 Little Rock, Arkansas, U.S. 10 ~ 230 million agreements, where all SAS Scandinavian Airlines Oct. 8, 2001 Milan, Italy 118 ~ 200 million involved airlines want ~ = approximately to benefit and therefore Note: 1. Aircraft hull, passenger liability and third-party liability. put a further positive emphasis on safety.” Source: Göran Forsberg From the insur- Table 1 ers’ perspective, the
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absence of conformity in many of these practices An Actuarial Perspective of Accidents by Geosocial Area is by design. “Every underwriter needs to analyze Worldwide Large Operators, 1982–2005 and interpret the information available and decide if she/he wants to insure the risk and the premium to be charged,” Gasson said. “There cannot be and 1.5% must not be a common approach, bearing in mind 1 antitrust rules and regulations. This is where the 1.0% independent risk assessment may provide the final evidence to influence the underwriting decision. It 0.5% must never be forgotten that the aviation insurance rate Accident market is fiercely competitive. Loss frequency is ( ve-year moving average) ( ve-year moving 0.0% decreasing while loss severity is increasing, and 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 this makes the pricing process even more difficult.” 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 Year One actuarially oriented method used by underwriters is to assign airlines to geosocial Note: areas (Figure 2) by accident rates, age of aircraft 1. Large commercial jet total loss accidents as a percentage of the total fleet of these aircraft in each color-coded geosocial area. and onboard technology, regulatory oversight, Source: Göran Forsberg infrastructure and various other factors, said Göran Forsberg, general manager, International Figure 2 Insurance Co. of Hannover Ltd. England Filial, and a member of the Flight Safety Foundation some developed countries. “The costs of indem- (FSF) European Advisory Committee. This nification in these areas probably would be on practice also enables airlines to distinguish the higher end of the scale,” Forsberg said. themselves from peers within a geosocial area, The lead insurer selected by the broker has Forsberg said. Significant safety improvements the best opportunity to assess and influence can be easier to achieve, technically speaking, an airline’s risk-management efforts. “We are a for airlines in the most challenging geosocial lead insurer in the Nordic area so when we have environments, he emphasized. a Nordic airline, we ask the questions from a “From the passengers’ point of view, the checklist, discuss their attitudes toward audits and perception of the global airline industry would SMS, rate the particular exposures and set terms be affected very positively if operators in these and conditions of the policy,” he said. “We have geosocial areas improved their safety,” he said. our own actuarial approach to risk assessment, “To do that, they need a combination of modern including a proprietary information technology– technology of fourth-generation aircraft, an SMS, based rating tool.” Aircraft generation, size of intense utilization of the FSF Approach and Land- airline and geosocial area are three of the factors ing Accident Reduction Tool Kit, etc. Not the least considered by the rating tool, he said. ● is auditing under IOSA, so the question we often Notes ask airlines is ‘Have you done the IOSA audit?’” In contrast, one of the most difficult chal- 1. In proceedings of the annual meetings of the U.S. lenges is further safety improvement among Casualty Actuarial Society: Sweeney, Stephen B. “Aircraft Insurance.” 1928. Comstock, W.P. “Aviation airlines in geosocial areas that already have Casualty Insurance.” 1933. Woodward, Barbara H. adopted best practices and achieved the world’s “Aviation Insurance.” 1938. Mills, John A. 1939. lowest accident rates. In these areas, the costs 2. Forsberg, Göran. “Aviation Insurance: The Way It of any accident to insurers are vastly higher Works.” In proceedings of the Flight Safety Foundation because of the level of liability based on passen- European Aviation Safety Seminar, Amsterdam, March ger demographics, jurisdiction and the typical 13, 2007, and interview by Wayne Rosenkrans, April 4, awards/settlements for fatalities and injuries in 2007. www.flightsafety.org | AeroSafetyWorld | June 2007 | 41 MaintenancematterS
Faulty procedures were partly to blame for the failure to reinstall the center wing fuel tank purge door in a Boeing 777 after maintenance, the U.K. AAIB says.
© Ian Kirby/Airliners.net
he failure by maintenance told that a crew waiting at the runway When a maintenance technician personnel to reattach a fuel tank holding point had seen a trail of smoke inspected the airplane after its arrival purge door inside the left main coming from their airplane, the flight at the gate, he “noticed a few drips of landing gear bay of a British crew of the Zimbabwe-bound 777 de- fuel on the left main landing gear but TAirways Boeing 777-200 was a causal clared an emergency, determined that none on the ground,” the report said. factor in an incident in which a vapor the “smoke” actually was leaking fuel, “After opening the left inboard main trail of fuel streamed from the center jettisoned enough fuel to reduce the gear door, he detected a distinct smell wing tank after takeoff, the U.K. Air airplane to maximum landing weight of fuel. An inspection inside the gear Accidents Investigation Branch (AAIB) and returned to Heathrow for a normal bay revealed that the center fuel tank said. landing. Although the report noted purge door was not in place [Figure 1, In its final report on the June 10, that the leak created “potential for a page 44]. The purge door was hanging 2004, incident, which occurred on wheel-well fire,” the airplane was not on a lanyard inside the fuel tank, and departure from London Heathrow damaged and none of its 166 occupants a plastic bag was attached to the purge Airport, the AAIB said that, after being was injured. door opening. The bag contained fuel
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and the screws that would normally hold the that the purge door should be opened by attaching purge door in place.” a lanyard to the door; unfastening the bolts, wash- The report said that the plastic bag was the ers and clamp ring that hold the door in place; and same type that was used at the British Airways using the lanyard to lower the door into the tank. maintenance facility at Heathrow and at British Later, after a maintenance technician enters the Airways Maintenance Cardiff (BAMC), the fuel tank, he or she should remove the purge door operator’s subcontracted maintenance organiza- from the airplane, the entry said. tion in Wales, where the airplane had undergone The maintenance organization used job maintenance between May 2 and May 10, 2004. cards — also called certification cards — that The maintenance was a 2C check — con- contained instructions on how to complete ducted on British Airways 777s every 1,500 days specific maintenance procedures, such as or 8,000 cycles or 24,000 flight hours, whichever draining the center wing tank. Each job card occurs first — that included two tasks requiring listed the tasks involved in the procedure; for access to the center wing fuel tank: an internal each task listed, one box was stamped when inspection of the rear spar and a check of the the task was completed and a second box was bonding of the tank’s float switches (Figure 2, stamped to certify that it had been completed page 45). Safe entry into a center wing fuel tank correctly. The stamps were numbers that were requires that all fuel first be removed and fuel assigned to each member of the maintenance vapors be purged. staff to identify which one had performed a The maintenance organization used a purging particular task. If any nonroutine action was procedure discussed in the aircraft maintenance taken — such as removal of the purge door as manual (AMM) that required removal of seven part of the job of purging fuel vapors from the fuel tank access doors — but not the purge door. center wing fuel tank — a licensed aircraft en- A separate AMM entry — not cross-referenced gineer (LAE) was required to produce relevant in the discussion of the purging procedure — said “defect cards” — such as one card for removal
OpenBY LINDA WERFELMAN Door
Leaking fuel trails the British Airways Boeing 777 after takeoff from London Heathrow Airport. © Steve Flint/Airliners.net © Steve
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Boeing 777 Purge Door Installation
Lanyard attachment Center keel beam
Bolt washer (6 locations)
Clamp ring
O-ring
Center purge door
FORWARD
Source: U.K. Air Accidents Investigation Branch
Figure 1
of the purge door and a second card for its door-removal procedures allowed for the purge reinstallation. door to remain hanging on a lanyard inside the In this instance, removal of the purge door tank and to be reinstalled by using the lanyard was not recorded on a defect card, and there was to pull it back into position. His team of two no card for the door’s reinstallation. technicians and one mechanic also worked primarily on 747s. Unaware of the Purge Door A review of maintenance records revealed During the investigation, interviews with 10 a previous instance in which a purge door was maintenance personnel who had been working removed from the center wing tank of a 777 near the center wing tank revealed no one who without an accompanying defect job card. In remembered having removed the purge door or that instance, in February 2004, an experienced who was aware that anyone else had removed TTL observed the open purge door while he was it. Seven of the 10 were even unaware that 777s conducting the rear spar inspection and ordered have a purge door. a defect card for its reinstallation. The technical team leader (TTL) who certified the completion of the draining and ‘Confusing Diagram’ purging of the center wing tank had been pro- He also wrote a “query for engineering advice moted to TTL one month before the work was note” (QEAN), in which he questioned the rear performed on the incident airplane. He had spar inspection procedure outlined in the AMM undergone training for the 777 technical type and requested “clarification as to whether it rating about 18 months before the incident but was the front spar or the rear spar that needed worked primarily on 747s, in which purge- inspecting,” the report said.
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A technical services engineer responded problems with the rear spar inspection diagram; the next day, saying that the rear spar required Boeing’s first response, sent March 23, was inspection and that he would contact Boeing lost and was sent again April 15, after a second to question a diagram on the Boeing task card, query from the maintenance organization. The which “incorrectly showed the front spar … as response confirmed that the rear spar was the the area to be inspected,” the report said. area to be inspected and said that a corrected “No action was taken to withdraw the con- diagram would be issued. The correction was fusing diagram or to highlight its errors to other included in the May 5 revision of the AMM and maintenance staff,” the report said. “Also, no action the Boeing task cards, which were received by was taken to determine if rear spar inspections on the operator on June 8 — one month after main- previous aircraft had been carried out correctly.” tenance was performed on the incident airplane. The technical services engineer sent a fax to The maintenance technician who conducted the manufacturer on March 16, 2004, outlining the inspection on the incident airplane had
Boeing 777 Center Wing Fuel Tank Configuration
FORWARD
Access door Front spar 139 AZ
Center wing tank
Access doors Access doors 531 AB 631 AB 531 BB 631 BB 531 CB 631 CB
W ing leading edge
ing leading edge W
“No action
was taken to
withdraw the Spanwise beams Rear spar confusing diagram Purge door Openings or to highlight its (closed with ba e doors on ER model) errors to other
Source: U.K. Air Accidents Investigation Branch maintenance staff.” Figure 2 www.flightsafety.org | AeroSafetyWorld | June 2007 | 45 MaintenancematterS
never conducted a similar inspection and had and we unfortunately cannot pressurize Boeing never been inside a 777 center wing fuel tank. to speed up.” He complied with the incorrect illustration on This response was incorrect, the report said. the job card, and, as a result, he did not enter the Boeing had closed the issue after responding to the rear section of the center wing tank where the question the previous year, and the maintenance purge door was located or remove three baffle organization had never resubmitted its question. doors, which were designed to limit rapid fuel Although the maintenance organization had movement within sections of the center wing been aware of the missing baffle-door reference, fuel tank as a result of changes in the airplane’s routine job cards had never been created for attitude and which should have been removed to removal and reinstallation of the baffle doors, perform the inspection. the report said. “A potential opportunity to detect the open As a result, defect cards were required each purge door was lost when the rear spar inspec- time baffle doors were removed. On several oc- tion was carried out in the wrong location be- casions, however, they were removed but there cause of an error in a diagram in the … AMM,” were no corresponding defect cards; the report the report said. “The maintenance organization characterized this as “an unacceptable practice was aware of the error in the AMM diagram that may have contributed to the unrecorded and had notified the aircraft manufacturer, but removal of the purge door.” no action was taken to communicate this fact to After the center wing fuel tank was closed, production staff.” leak checks were conducted. The TTL who In his query to Boeing, the technical services conducted the checks could not remember the engineer also noted that the rear spar inspection specific amount of fuel used for the check, but procedure did not mention the need to remove the report said that it probably was the 40,000 kg the baffle doors, but he did not specifically ask for (88,184 lb) “catch-all” amount that maintenance advice on what to do with them; the reply from personnel typically used to ensure that all access Boeing did not mention the baffle door issue. doors were secure. The AMM said that 30,900 kg (68,122 lb) of Recurring Question fuel was sufficient for a leak check of all center The issue had been raised at the maintenance wing fuel tank access doors, but the “Fuel Leak organization before — about two years be- Detection” procedure did not discuss the purge fore the incident, when a production engineer door. The separate purge door-removal pro- “Several routine requested that routine job cards be produced for cedure said that refueling the center wing fuel the removal and reinstallation of center wing tank with at least 32,000 kg (70,547 lb) of fuel procedures should tank baffle doors. A planning engineer prepared was required for a leak check of the purge door. a QEAN about the absence of any reference to However, after the incident, it was determined have revealed the the baffle doors in the AMM; the response from that 32,000 kg was not sufficient to reach the open purge door, but Boeing indicated that the question had been base of the purge door opening. The AMM misunderstood, but “technical services [at the subsequently was revised to include the correct they all failed.” maintenance organization] appeared to over- figure — 52,163 kg (114,999 lb). look this discrepancy and no further action was The report said, “Several routine proce- taken,” the report said. dures should have revealed the open purge In June 2003, the planning engineer wrote door, but they all failed. Firstly, the paperwork another QEAN, restating his question. The failed because no defect card was raised indi- report said that a technical services engineer cating that the purge door had been opened. responded that the question had been raised Secondly, tank inspection before its closure with the manufacturer and that “these changes failed because the rear spar inspection was will come, but at this present time, they are slow carried out in the wrong location and because
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the engineers closing the tank did not know There was no record of any maintenance the purge door existed. Thirdly, the ‘safety net’ that would have required opening the left main leak checks failed because the job cards and the inboard gear door after the 2C check and before AMM [center wing tank] leak check procedure the incident flight. Without such maintenance, did not refer to the purge door. Moreover, the there was no opportunity to observe the missing purge door leak check fuel quantity was incor- purge door; the area where the door was located rect, and the engineer carrying out the leak could not be seen from the ground when the left checks did not know about the purge door.” inboard main landing gear door was closed, the After the maintenance check, the airplane was report said. flown 53 sectors before the incident flight. Dur- The maintenance organization had a system ing that time, the highest recorded fuel load was for the reporting of maintenance errors, but 26,800 kg (59,083 lb) — about half the amount that such errors were not routinely reported, the re- would have been necessary for fuel to leak because port said (see “Defining the Blame Boundary”). of the missing purge door, the report said.1 Since the incident, analysis of maintenance
Defining the Blame Boundary
six-month review of British Airways would be taken to prevent a recurrence,” the Maintenance Cardiff (BAMC) quality report said. A discrepancy reports (QDRs) — which The maintenance organization had a dis- concerned items “of an airworthiness nature ciplinary policy designed to deal with cases of relating to aircraft maintenance operations/ “misconduct” and “gross misconduct,” but the procedures” — revealed no reports of internal policy did not discuss what types of mainte- maintenance errors, the U.K. Air Accidents nance errors would fall into each category, Investigation Branch (AAIB) said. or what types of disciplinary action might be “However, it is known that maintenance taken in case of a self-reported maintenance errors were occurring because they were being error, the report said. In addition, for some reported by the operator once aircraft had employees, it was unclear where the “blame returned to service,” the AAIB said in its report boundary” lay. on the incident involving the Boeing 777-200 “The company’s disciplinary policy did not fuel leak. set clear boundaries, and it did not encourage “The extent of the lack of internal main- uninhibited reporting,” the report said. “The tenance error reporting could not be deter- company did not have investigators who had mined, but it was discovered that on at least been pre-identified … and the investigators, one previous occasion [in February 2004], the including the investigator of [this incident], purge door had been removed but not record- did not receive any formal maintenance error ed as removed. This event was not reported at investigation training. There was no formal the time but was revealed during the investi- feedback process following an incident inves- gation. Had it been reported and thoroughly tigation, and in cases where disciplinary action investigated, the lessons learned could have was taken, very limited information was made prevented [this subsequent] incident.” available.” The report cited several possible reasons — LW that maintenance errors were not being re- ported under the QDR system, which required Further Reading From FSF Publications reporters to identify themselves. These reasons McKenna, James T. “Maintenance Resource included the would-be reporter’s fear of be- Management Programs Provide Tools for Reducing ing blamed or fear that a colleague would be Human Error.” Flight Safety Digest Volume 21 (October blamed, or a belief that “no effective action 2002).
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error data has begun in an effort to identify and system complies with elements recommended prevent future errors. by the CAA and to ensure that its TTLs ad- equately disseminate information from TTL Causal Factors meetings to personnel on their teams. Another The investigation identified four causal factors: recommendation said that British Airways should conduct a safety audit of BAMC after • “The center wing tank was closed without the maintenance organization had addressed ensuring that the purge door was in other safety recommendations. place; After the incident, both BAMC and Boeing took “significant safety action” to address the • “When the purge door was removed, de- issues identified during the investigation, the fect job cards should have been raised for AAIB said. BAMC, after an internal investiga- removal and refitting of the door, but no tion, delivered presentations to employees on such cards were raised; the risks of unrecorded work, developed new procedures for the identification and storage • “The center wing tank leak check did of temporarily removed parts, revised the job not reveal the open purge door because cards used for work involving center wing tanks the purge door was not mentioned and upgraded the QEAN system to ensure that within the AMM procedures for purging issues would not be closed or forgotten before and leak-checking the center wing fuel they were addressed. tank; with no record of the purge door Boeing published several documents dis- removal, the visual inspection for leaks cussing the purge door, including an all-opera- did not include the purge door; [and] tor message, and revised several sections of the fuel quantity required to leak check the AMM — including discussions of purge the purge door was incorrectly stated in door removal and reinstallation, and rear spar the AMM; [and,] inspection — and related task cards. • “Awareness of the existence of a purge In addition, British Airways took several door on the Boeing 777 was low among related actions, including an audit of BAMC the production staff working on [the job cards. Of 2,200 cards for a maintenance D incident airplane,] due in part to an check, 61 were identified with “highest-risk” absence of cross references within the deficiencies and about 500 with lower deficien- AMM.” cies; all were addressed by BAMC, the report said. ●
As a result of the investigation, the AAIB This article is based on AAIB accident report no. 2/2007, issued safety recommendations calling on “Report on the Serious Incident to Boeing 777-236, G- BAMC to — among other things — “actively YMME, on Departure From London Heathrow Airport on encourage” personnel to inform managers of June 10, 2004.” problems with procedures discussed in job Note cards and AMMs and promptly remedy the problems, and to “identify and publish clear 1. Fuel records showed that the last time before the in- cident that the center wing fuel tank contained more disciplinary policies and boundaries relating than 52,163 kg (114,999 lb) was on Feb. 10, 2003 to maintenance errors to encourage uninhib- — an indication that the purge door was in place on ited internal reporting of maintenance errors.” that date. Maintenance records showed no mainte- Other recommendations called for BAMC to nance between Feb. 10, 2003, and the 2C check in ensure that its maintenance error management May 2004.
48 | flight safety foundation | AEroSafetyWorld | June 2007 FoundationFocus
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Heating Up in Tucson AeroSafety World — harnessing the power of this in- ast month’s 52nd annual Cor- All published issues of AeroSafety dustry-leading search technology to porate Aviation Safety Seminar World and its predecessor Aviation return highly accurate results from L(CASS) was a very hot ticket and Safety World are available in Adobe users’ queries. the most successful CASS ever, with portable document format (PDF) for more than 443 registrants from 10 download at no charge. Issues can be Ground Accident Prevention (GAP) countries participating in the three downloaded in their entirety or by In 2003, the Foundation launched days of events and presentations. Also individual articles. The seven publica- the Ground Accident Prevention setting new high water marks were the tions superseded by AeroSafety World (GAP) program to develop information 35 exhibiting companies and the 19 in July 2006 will remain available for and products (GAP e-tools) to reduce sponsors. download in PDF format. the risk of accidents and incidents Next year, the CASS will be at the that occur on airport ramps and adja- Innisbrook Resort and Golf Club in E-mail Subscription Service cent taxiways, and that directly affect Palm Harbor, Florida, April 29–May 1. Sign up on the Web site home page airport operations and/or result in to receive free e-mail notification of personnel injuries or damage to ser- On the FSF Web Site Flight Safety Foundation publications, viceable aircraft, facilities or Established in November 1995, including AeroSafety World, plus news ground-support equipment. the FSF Web site has been a store- releases, seminars and other special Current GAP e-tools are: “Best house of valuable aviation safety events. Provide your contact informa- Practices for Safely Towing Aircraft,” information. Supported by our tion and select your areas of interest. Part One; “Best Practices for Safely 1,080 individual members and organi- You will receive a direct link via e-mail Towing Aircraft,” Part Two; GAP Cost zations in 142 countries, the Web each time an item in one of the selected Model; and GAP Leadership Tip site continues to expand its content interest areas is posted to our Web site. Sheets. ● and services. Some of the current con- tent improvements and service Site Search — Ann Hill, director, enhancements are highlighted The FSF Web site is now using membership and development, here: Google’s Custom Search Engine Flight Safety Foundation www.flightsafety.org | AeroSafetyWorld | June 2007 | 49 DataLink
Unsafe Acts A study finds more similarities than differences in error patterns among crewmembers on accident aircraft in Australia and the United States.
BY LINDA WERFELMAN
study of errors by flight crewmembers study by the Australian Transport Safety Bureau involved in aviation accidents in Aus- (ATSB). “If this is the case, it may be reasonable tralia and the United States found that to assume that solutions to common problems the patterns of errors were “remarkably developed in one country will be transferable to Asimilar” and that skill-based errors — such as the other.” omitting a checklist item or fixating on a task The study used the human factors analysis — were the most common.1 and classification system (HFACS) to examine “The rationale behind comparing Australian and classify data from aircraft accidents that and U.S. data is to discover whether there are occurred during the 10-year period beginning in similar trends in involvement of human fac- 1993. During that period, 69 percent of accidents tors in aviation accidents,” said a report on the in Australia and 72 percent of accidents in the United States involved at least one unsafe act by flight crewmembers, the report said (Figure 1). Percentage of Accidents Associated With Each Unsafe Act The report said that “unsafe acts” include 84% errors in doing, thinking and perceiving 90 (1,180) 77.3% Australia (sample size: 1,404) 80 (10,589) — known, respectively, as skill-based errors, U.S. (sample size: 13,700) 70 decision errors and perceptual errors. Unsafe 60 acts also include two types of violation, defined 50 in the report as “a deliberate breach of the rules 40 33% (464) 29.2% by an operator who knows they are breaking (3,996) 30 air law” — routine, small-scale violations and 20 12.9% 7.7% (1,767) Percentage of accidents 6.1% 6.6% “exceptional” violations that deviate significantly (108) 10 (85) (899) from the rules. 0 Skill-based error Decision error Perceptual error Violation For example, the report said skill-based er- Unsafe acts rors recorded in Australian accidents included “landing errors, including problems with flare, Source: Australian Transport Safety Bureau alignment, touchdown point, descent rate and Figure 1 distance/altitude and speed; not maintaining
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physical clearance or visual lookout; losing Australian on-demand/commuter operations,” directional control on the ground; and not the report said (Table 1). On-demand/commuter maintaining airspeed.” operations accounted for 26.9 percent of all vio- Decision errors included “selecting unsuit- lations in Australian accidents, 21.2 percent of able terrain for landing/takeoff/taxiing, improp- perceptual errors, 20.4 percent of decision errors er preflight planning; poor in-flight planning or and 11.8 percent of skill-based errors. decision, and performing a low-altitude flight By comparison, in the United States, on- maneuver,” the report said. demand/commuter operators accounted for The report cited perceptual errors such as between 3.5 percent and 8.7 percent of viola- “misjudging physical clearance, losing aircraft tions and errors (Table 2). control, problems with visual/aural perception, In both countries, general aviation ac- and misjudging altitude/distance/speed.” counted for the vast majority of errors and The report also identified several violations: violations. “not following procedures or directives (stan- The study found that, of accidents in- dard operating procedures), visual flight rules volving at least one unsafe act, 11 percent of into instrument mete- orological conditions, operating an aircraft Unsafe Acts Grouped by Type of Flight Operation, Australian Accidents without proper en- Flying Operation (Regulation Part) Skill-based Error Decision Error Perceptual Error Violation dorsement or certifi- General aviation (Part 91) 861 (73%) 298 (64.2%) 51 (60%) 73 (67.6%) cation [or] … outside Air carrier (Part 121) 2 (0.2%) 1 (0.2%) 1 (1.2%) 1 (0.9%) its weight and balance Large civil aircraft (Part 125) 0 (0%) 0 (0%) 0 (0%) 0 (0%) limits, and perform- Rotorcraft with external load (Part 133) 2 (0.2%) 3 (0.6%) 0 (0%) 2 (1.9%) ing low-altitude flight On-demand and commuter (Part 135) 139 (11.8%) 95 (20.4%) 18 (21.2%) 29 (26.9%) maneuvers.” Agricultural (Part 137) 162 (13.7%) 58 (12.5%) 13 (15.3%) 2 (1.9%) A higher propor- Public use 14 (1.2%) 9 (1.9%) 2 (2.4%) 1 (0.9%) tion of Australian accidents were associ- Total 1,180 464 85 108 ated with skill-based Source: Australian Transport Safety Bureau errors. A greater Table 1 proportion of U.S. ac- cidents involved viola- tions. There were no Unsafe Acts Grouped by Type of Flight Operation, U.S. Accidents significant differences Flying Operation (Regulation Part) Skill-based Error Decision Error Perceptual Error Violation between the propor- tions of Australian General aviation (Part 91) 9,485 (89.6%) 3,542 (88.6%) 815 (90.7%) 1,530 (86.6%) and U.S. accidents as- Air carrier (Part 121) 63 (0.6%) 52 (1.3%) 6 (0.7%) 19 (1.1%) sociated with decision Large civil aircraft (Part 125) 1 (0%) 0 (0%) 1 (0.1%) 0 (0%) errors or perceptual Rotorcraft with external load (Part 133) 32 (0.3%) 18 (0.5%) 1 (0.1%) 8 (0.5%) errors. The examination On-demand and commuter (Part 135) 369 (3.5%) 224 (5.6%) 38 (4.2%) 153 (8.7%) of the distribution Agricultural (Part 137) 593 (5.6%) 143 (3.6%) 34 (3.8%) 50 (2.8%) of errors by flight Public use 46 (0.4%) 17 (0.4%) 4 (0.4%) 7 (0.4%) crewmembers found Total 10,589 3,996 899 1,767 “an unexpectedly Source: Australian Transport Safety Bureau large number of er- rors and violations in Table 2 www.flightsafety.org | AeroSafetyWorld | June 2007 | 51 DataLink
Comparison of Australian and U.S. Fatal Accidents by Unsafe Act
Lower 99% Upper 99% Percent Confidence Confidence Unsafe Act Australia U.S. Difference Interval Interval Skill–based error 120 (76.9) 2,201 (75.6) 1 –8 10 Decision error 67 (42.9) 850 (29.3) 14 3 24* Perceptual error 21 (13.5) 249 (8.6) 5 –2 12 Violation 50 (32.1) 826 (28.4) 4 –6 14 Total 156 2,912
*Denotes a statistically significant difference
Source: Australian Transport Safety Bureau
Table 3
Comparison of Australian and U.S. Non-Fatal Accidents by Unsafe Act
Lower 99% Upper 99% Percentage Confidence Confidence Unsafe Act Australia U.S. Difference Interval Interval Skill-based error 1060 (84.9) 8388 (77.8) 7 4 10 Decision error 397 (31.8) 3146 (29.2) 3 –1 6 Perceptual error 64 (5.1) 650 (6.0) –1 –3 1 Violation 58 (4.6) 941 (8.7) –4 –6 –2* Total 1,248 10,788
*Denotes a statistically significant difference
Source: Australian Transport Safety Bureau
Table 4
Australian accidents and 21 percent of U.S. Comparison Of Australian and U.S. Fatal and Non-Fatal Accidents accidents resulted in a fatality. Table 3 shows that the only statistically significant difference 90 Australian fatal Australian non-fatal between fatal accidents in the two countries 80 U.S. fatal was that a greater percentage of Australian 70 U.S. non-fatal fatal accidents were associated with decision 60 errors. 50 Table 4 and Figure 2 show that a higher per- 40 centage of nonfatal accidents in Australia were 30 associated with skill-based errors, when com-
Percentage of accidents 20 pared with nonfatal U.S. accidents, and fewer 10 nonfatal accidents in Australia were associated ● 0 with violations. Skill-based Decision Perceptual Violation error error error Note Unsafe act 1. Australian Transport Safety Bureau (ATSB). Human Source: Australian Transport Safety Bureau Factors Analysis of Australian Aviation Accidents and Comparison With the United States, Report no. Figure 2 2004/0321. 2007.
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Critical Care A primer for aeromedical crewmembers.
BOOKS Noting that the first edition has become the text for several aeromedical courses, the author Aeromedical Transportation: A Clinical Guide said that the second edition has “more meat to Martin, T. Aldershot, England, and Burlington, Vermont, U.S.: each chapter,” as well as two new chapters — one Ashgate, 2006. Second edition. 312 pp. Figures, tables, glossary, devoted to organizational and clinical issues in references, index. the transfer of intensive care patients between he preface to the first edition, published hospitals, the other addressing in-flight nurs- in 1996, dispelled the popular notion of ing of patients “within the harsh environment Taeromedical transportation as “the world of an aircraft cabin.” The author said, “One of of airborne cavalry coming to the rescue … my profoundest discoveries in the last decade of to snatch life from the jaws of death.” On the teaching was that flight physicians often escort contrary, it said, “aeromedical practice usu- patients alone and yet have little concept of ally comprises hours of tedium waiting for an nursing care.” assignment, interspersed with periods of sheer The book is organized in five parts. The first exhilaration and, just occasionally, moments of provides a history and an overview of aeromed- absolute terror.” ical transportation. The second discusses flight Although on-demand pilots can relate to physics and physiology. The third addresses that definition, the intended readership is not operational considerations, including equip- pilots, but “medical, paramedical and nursing ment and crew composition. The fourth covers personnel, and those working in organizations clinical considerations, such as the transport of whose duties include the transportation of the patients with spinal injuries or burns. The fifth sick and injured by air,” the publisher said. part discusses organizational and administrative In his preface to the second edition, the au- aspects of aeromedical transportation. thor says that much has changed in the decade The author said that the book “is intended since the first edition was published: “I could as a basic primer for those who seek to work in not have predicted the acceleration in interest transfer and retrieval medicine.” He foresees the and enthusiasm that was to take place. These next decade as an “exciting time for the academ- years saw continued growth in aeromedical ac- ic development of the subject” — one that will tivities and an upsurge in publications which are see “postgraduates with masters and doctorates starting to bring our specialty in from the cold.” in patient transportation.” www.flightsafety.org | AEROSafetyWorld | June 2007 | 53 InfoScan
REPORTS “To limit the occurrence of communication problems and misunderstandings, controllers The Outcome of ATC Message Complexity should be encouraged to transmit shorter and on Pilot Readback Performance less complex messages,” the report said. “With Prinzo, O. Veronika; Hendrix, Alfred M.; Hendrix, Ruby. U.S. Federal increases in international travel, areas of con- Aviation Administration (FAA) Office of Aerospace Medicine. DOT/FAA/AM‑06/25. Final report. November 2006. 36 pp. Figures, cern related to English language proficiency and tables, references, appendixes. Available via the Internet at
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• Online computerized databases contain- is memory items; the publication advises users ing bibliographic information in aerospace to place no more than six memory items at the medicine and related disciplines. beginning of the checklist, clearly distinguished from other action items. “We believe this guide will be useful as a pri- The publication also contains information mary source of consultation for bibliographic on human performance issues associated with information, especially to those colleagues who detecting and resolving problems, errors typi- are in their formative years and to those who do cally made when using checklists, processes for not have easy access to computer-aided litera- reviewing and revising checklists, and methods ture search systems,” the FAA said. of training pilots in their use. Separate chapters provide guidance for REGULATORY MATERIALS manufacturers, operators, pilots and instructors, as well as recommended checklist design at- Guidance on the Design, Presentation and Use of tributes, including physical characteristics, con- Emergency and Abnormal Checklists tent, layout and format. A list of recommended U.K. Civil Aviation Authority (CAA) Safety Regulation Group. Civil checklist contents is provided in an appendix. Aviation Publication (CAP) 676. Issue 3. Aug. 30, 2006. 76 pp. Other appendixes provide examples of incidents Figures, tables, glossary, references, appendixes. Available via the involving deficiencies in the design or use of Internet at
The Web site contents are almost exclusively Recognizing that the site is designed for in French, the exceptions being reports of cabin investigators, there is information for safety pro- safety and human factors studies in English. fessionals and others with an interest in safety Documents are full-text and can be read, and investigation. Among the resources are: printed and downloaded at no charge. • A collection of accident and incident Airport Fire — ARFF — Around the World, investigation manuals (e.g., International
56 | flight safety foundation | AEROSafetyWorld | June 2007 OnRecord
Load Miscalculation Aft CG causes pitch and steering problems.
BY MARK LACAGNINA
The following information provides an aware- “The crew suspected a wrong CG location and ness of problems in the hope that they can be contacted the company office through SAT- avoided in the future. The information is based COM [satellite communication].” The company on final reports on aircraft accidents and inci- advised the crew that the CG had been miscal- dents by official investigative authorities. culated and would be 10.7 percent MAC aft of the aft limit on landing in Seoul. “This could at JETS best have caused a loss of control or a tail strike during landing,” the report said. Commander Did Not Notice Error The crew relocated some cargo pallets to Boeing 747-400F. No damage. No injuries. shift weight forward; the CG was 7.2 percent he center of gravity (CG) was 4.8 percent MAC aft of the aft limit as the aircraft neared mean aerodynamic cord (MAC) behind the Seoul. “During the approach briefing, the land- Taft limit when the aircraft took off Sept. 21, ing configuration and performance parameters 2004, from Oslo Airport in Gardermoen, Nor- were discussed to reduce the possibility of a tail way, with three crewmembers aboard for a cargo strike during touchdown and landing rollout,” flight to Incheon International Airport in Seoul, the report said. “Emergency equipment was South Korea. As a result of the imbalance, the requested to stand by.” aircraft began an uncommanded “autorotation” The report said that the approach and land- at a calibrated airspeed of 120 kt — 34 kt below ing went as planned. However, during the land- the target rotation speed, said the report by the ing roll, the aircraft pitched nose-up at 60 kt; the Accident Investigation Board of Norway. nose landing gear strut extended, which caused The aircraft was relatively light and was ac- the nosewheel-steering system to disengage. celerating rapidly. It became airborne at 165 kt, “The commander stopped the aircraft on the and pitch attitude increased from 11.5 degrees runway and shut down all engines,” the report nose-up to 19.5 degrees. The commander used said. “The aircraft was subsequently towed to stabilizer trim to control the pitch attitude. the parking stand.” Airspeed during initial climb was 158 kt — 18 kt The report said that the load master had below the target safety speed. made a mistake in calculations during load plan- “[During cruise flight,] the commander ning, and the loading resulted in a CG at 37.8 realized that the aircraft balance was wrong due percent MAC; the aft CG limit is 33.0 percent to the far forward trim setting,” the report said. MAC. The load manifest, however, indicated that www.flightsafety.org | AEROSafetyWorld | June 2007 | 57 OnRecord
the CG was at 27.0 percent MAC. The command- The aircraft continued to descend, and the er did not notice the mistake in the load master’s controller told the crew, “Yes, if you could climb calculations before he signed the load manifest. back up to two thousand five hundred, please, The report said, however, that the pilot operating and turn right now onto one two zero degrees.” manual did not contain aircraft-specific data that After a brief pause, the copilot acknowledged would have enabled the commander to check the the instructions, but the aircraft continued to load manifest. “In reality, the commander was descend. The controller said, “You are still de- merely checking that the [weight] and CG values scending. Climb two thousand five hundred feet. were within limits for takeoff and landing,” the Acknowledge.” The copilot acknowledged the report said. instructions; the aircraft continued to descend. The aircraft was equipped with an on-board The controller then told the crew that there weight and balance system that automatically was a 1,358-ft television mast 4 nm (7 km) computes and displays gross weight and CG. “At ahead of the aircraft and to climb immediately. the time of the incident, the operating proce- Suspecting that the crew had misset their altim- dures of the aircraft’s weight and balance system eters, the controller added, “QNH nine eight were not provided to the crew, and the crew was two. Confirm you are indicating one thousand not trained for their use,” the report said. five hundred feet.” “At this point, the crew realized that the Misset Altimeter Results in Altitude Bust altimeters were still set to the standard pressure Airbus A310. No damage. No injuries. setting of 1013 hPa and not the Birmingham he aircraft was en route with 84 passengers QNH of 982 hPa,” the report said. The com- from Tehran, Iran, to Birmingham (Eng- mander initiated a climb, and both pilots set Tland) Airport the night of Nov. 24, 2006. their altimeters to 982 hPa. The copilot told the Reported weather conditions at Birmingham controller, “Just got it now and climbing, reading included surface winds from 160 degrees at 10 two thousand feet.” The controller cleared the kt, visibility greater than 10 km (6 mi) in light crew to maintain 2,000 ft until intercepting the rain, few clouds at 1,600 ft and scattered clouds localizer and advised that the aircraft was clear at 2,200 ft. QNH, the altimeter setting that re- of the television mast. The crew conducted the sults in a display of height above mean sea level, approach and landed without further incident. was 982 hPa. “The crew could not recall any distractions “The operating The U.K. Air Accidents Investigation Branch or unusual flight deck activity at the point at procedures of the (AAIB) report said that the copilot, the pilot which they would normally have adjusted the monitoring, advised the approach controller on altimeter sub-scales,” the report said. With the aircraft’s weight and initial radio contact that they had received the altimeters set at 1013 hPa, the indicated altitudes automatic terminal information system (ATIS) during approach were 930 ft higher than the balance system were information; he read back the reported altimeter aircraft’s actual altitudes. not provided to setting of 982 hPa. However, the flight crew had not reset their altimeters from the cruise setting, Elevator Trim Controls Rigged Incorrectly the crew.” 1013 hPa. Hawker 800 XP. No damage. No injuries. While providing radar vectors for the instru- fter being repainted, the aircraft was ment landing system (ILS) approach to Runway departing from Peterborough, Ontario, 15, the controller cleared the crew to descend ACanada, for a positioning flight to Buffalo, to 2,500 ft. The controller later observed on his New York, U.S., on June 2, 2005. As indicated radar display that the aircraft was descending airspeed neared 190 kt during initial climb, the through 2,500 ft and told the flight crew that they pitch-trim system reached its nose-down limit, had been cleared to 2,500 ft. The copilot replied, the Transportation Safety Board of Canada “Two five hundred, two thousand five hundred.” report said.
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The flight crew maintained airspeed below received clearance from air traffic control (ATC) 190 kt and diverted to Lester B. Pearson Interna- to return to Zurich. The commander trans- tional Airport in Toronto. “During the approach ferred control to the copilot and conducted the to Toronto, the rudder began to vibrate and emergency checklist, which included deactiva- seize, and the flight crew declared an emer- tion of the air-conditioning packs. “During the The tractor operator gency,” the report said. “The aircraft landed … approach, the smoke dissipated in the cockpit without further incident. An inspection revealed and cabin,” the report said. “For safety reasons, forgot that he had a that the elevator trim controls were incorrectly the crew kept their oxygen masks on.” baggage cart in tow rigged.” The commander told investigators that he The landing gear doors and flight control was unable to stop the continuous flow of oxy- when he drove under surfaces had been removed from the aircraft in gen in his mask, which made communication preparation for repainting. “When the elevators with the copilot and ATC difficult. “As a result, the airplane. were removed, the elevator trim control rods during the approach, he also handed over to the — two on each of the left and right horizontal copilot communication with ATC in addition stabilizers — were also removed,” the report to controlling the aircraft,” the report said. After said. A maintenance engineer had marked the an otherwise uneventful approach and landing, number of turns required to remove each rod the aircraft was taxied to the stand, where the 63 on tags and attached the tags to the rods. After occupants deplaned normally. repainting, the rods were reinstalled using the Investigators found a defective oil seal in same number of turns marked on the tags. the no. 2 engine. “It is highly probable that this The rigging of the elevators was not checked, caused oil residues to evaporate, smoke to be as required by the aircraft maintenance manual. generated and this smoke to enter the cockpit “The rationale for this was that there were no re- and cabin air-conditioning circuit,” the report ported flight control problems when the aircraft said. arrived, the aircraft was reassembled back to the way it was received, and the rigging should not Neglect of SOPs Leads to Ramp Damage have changed,” the report said, noting that the Boeing 767-300. Substantial damage. No injuries. company that performed the work did not have he airplane was at the gate, ready to be the equipment required to perform a rigging pushed back for departure from Washing- check. Tton Dulles International Airport on June Investigators found that the rigging of the 17, 2006. “A ramp employee, operating a tractor elevator controls was such that “with full nose- with a baggage cart in tow, was on the left side of down trim selected, the aircraft was rigged in a the airplane when a pushback guideman on the nose-up condition,” the report said. right side of the airplane signaled that he needed hand wands for the pushback,” said the U.S. Smoke Prompts Emergency Landing National Transportation Safety Board (NTSB) Avro 146-RJ100. No damage. No injuries. report. oon after departing from Zurich–Kloten The tractor operator told company officials (Switzerland) Airport for a scheduled flight that he forgot that he had a baggage cart in tow Sto Brussels, Belgium, the morning of Dec. and did not follow standard operating proce- 5, 2005, the flight crew saw smoke emerge from dures (SOPs) when he drove under the airplane the left console. The senior flight attendant to reach the guideman. “In the process, the bag- advised the flight crew that smoke also was gage cart impacted the underside of the fuselage visible in the cabin, the Swiss Aircraft Accident about 25 ft [8 m] aft of the nose and 17 ft [5 m] Investigation Bureau report said. in front of the wings,” the report said. The flight crew donned their oxygen masks, NTSB said that the tractor operator’s failure declared an emergency and requested and to follow SOPs was the probable cause of the www.flightsafety.org | AEROSafetyWorld | June 2007 | 59 OnRecord
accident and that a factor was his “diverted at- the techniques for recovering from bounced tention to an on-time departure.” landings.”
TURBOPROPS Pilot Expedited Landing, With Gear Up Piper Cheyenne. Substantial damage. No injuries. Lack of Training Cited in Tail Strike he pilot was conducting a post-maintenance ATR 72-200. Minor damage. No injuries. test flight in Fairbanks, Alaska, U.S., on July he copilot was the pilot flying during the T8, 2006. The maintenance was not related to scheduled flight with 40 passengers from the landing gear, the NTSB report said. While TLondon Gatwick Airport to Guernsey, returning to the airport, the pilot was asked by Channel Islands, the morning of May 23, 2006. ATC to expedite his landing because of traffic. The copilot conducted a visual approach using The pilot told investigators that he extended the correct approach speed and the runway’s the landing gear and that it collapsed on land- precision approach path indicator (PAPI) lights ing. The investigation determined, however, that for glide path guidance, said the AAIB report. the landing gear was retracted when the airplane The aircraft bounced after touching down on touched down on the runway. the runway. The company that employed the pilot rec- The commander said that the copilot had ommended to NTSB that “the gear-unsafe horn conducted a good approach and that the bounce should be wired through the audio panel, so as was caused by “insufficient flare being applied to be more easily heard by pilots wearing noise- before touchdown.” Neither pilot believed that attenuating headsets,” the report said. the bounce was sufficiently severe to warrant a go-around. Distraction Blamed for Runway Incursion “In an attempt to cushion the second touch- de Havilland Twin Otter. No damage. No injuries. down, the copilot … over-pitched the aircraft, isual meteorological conditions (VMC) resulting in the tail bumper making contact with prevailed when the aircraft, with 16 pas- the runway surface,” the report said. The com- Vsengers aboard, was landed on Runway 27 mander took control after the second bounce at Glasgow (Scotland) Airport the morning of and landed the aircraft. The only repair required Aug. 29, 2006. The airport tower controller told was repainting the steel skid-shoe at the base of the crew to back-taxi on Runway 27, hold at the the tail bumper. intersection of Runway 23 and cross Runway 23 “The copilot was relatively inexperienced, after an Embraer 145 passed by after landing on this being his first airline aircraft type, and Runway 23. he could not recall ever having received While holding at the intersection, the com- formal instruction in recovery techniques mander, who also was a training captain, began for bounced landings,” the report said. “The debriefing the copilot on topics that were not company operating manuals contained no specified in the AAIB report. During the de- information on bounced landings. … There is briefing, the commander sketched illustrations no formal requirement in the United King- on a piece of paper. “By being ‘head down’ on dom for pilots to receive training in bounced the flight deck, he became distracted and lost his landing recovery techniques at any stage in sense of time and situational awareness regard- their training.” ing the landing Embraer 145,” the report said. Based on the findings of the incident in- After completing the debriefing, the com- vestigation, the AAIB recommended that the mander perceived that the Twin Otter had been U.K. Civil Aviation Authority “require aircraft stationary for some time and, not having the manufacturers, operators and training provid- 145 in sight, believed that it already had passed ers to issue appropriate guidance to pilots in by. He began to slowly taxi the Twin Otter onto
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Runway 23 but then saw the 145 about to touch Inspection of the left engine revealed that down and used reverse thrust to back off the the starter adapter shaft gear had failed. The runway. report said that visual inspections of the starter The airport’s runway incursion monitoring adapter had not been performed in compli- and conflict alert system (RIMCAS) did not pro- ance with a service bulletin issued by the engine vide a warning because, after the Twin Otter was manufacturer. “The service bulletin contained a landed on Runway 27 to expedite its arrival, the warning that stated, ‘Compliance with this bul- system was set to the “VISUAL” mode, which letin is required to prevent possible failure of the caused it to monitor only the surface area of starter adapter shaft gear and/or crankshaft gear Runway 05/23. At the time, Runway 23 was the which can result in metal contamination and/or active runway. The report said that the system engine failure,’” the report said. Three months would have provided a warning if the “CROSS after the accident, the U.S. Federal Aviation Ad- RUNWAY” mode had been selected to monitor ministration issued an airworthiness directive the holding-point areas on Runway 09/27 as well requiring compliance with the service bulletin. as the surface area of Runway 05/23. Long Touchdown on a Short, Wet Runway PISTON AIRCRAFT Beech 58 Baron. Substantial damage. No injuries. line of thunderstorms was approaching the Stall During Single-Engine Go-Around airport from the northeast as the aircraft Cessna 421C. Destroyed. Two minor injuries. A neared Denham Aerodrome in Uxbridge, he left engine failed when the pilot reduced Middlesex, England, on Aug. 13, 2006. The pilot power about 600 ft above ground level believed that his first approach to Runway 06, Twhile departing in VMC from Runway 06 which had an available landing distance of 706 at Palwaukee Municipal Airport near Chicago, m (2,316 ft), was too fast, and he conducted a Illinois, U.S., on Aug. 5, 2005. The pilot said go-around, said the AAIB report. that he confirmed that the landing gear and As the pilot maneuvered the Baron for flaps were retracted, and then declared an another approach to Runway 06, rain began to emergency and told the airport tower control- fall heavily on the airport, and witnesses saw ler that he was returning to land. The control- standing water on the runway. Several witnesses ler cleared the pilot to land on Runway 34, the said that the second approach appeared to be NTSB report said. faster than normal and that the aircraft touched The pilot said that although the operating down with about 470 m (1,542 ft) of runway engine was at idle power, the landing gear was remaining. extended and the flaps were extended to 45 The pilot told investigators that he conduct- degrees, he was unable to slow the airplane on ed a normal approach, but the aircraft floated short-final approach to the 5,000-ft (1,524-m) as it crossed the runway threshold. “As the runway. “I crossed the fence at 118 kt,” he said. [pilot] applied the brakes, the aircraft began to “Because of the excessive airspeed, I overshot slide, departing the left side of the runway and the runway.” skidding with its right wing foremost through The airplane was about halfway down the a hedge at the aerodrome boundary,” the report runway when the pilot attempted to go around. said. “It came to rest on a public road just He brought the operating engine to full power beyond this hedge. There was no fire.” The six and retracted the flaps to 15 degrees, but did not occupants deplaned without injury. retract the landing gear. The airplane stalled, “Standing water can cause an aircraft to struck the roof of a building and then struck an aquaplane or lose directional control, which embankment and trees about 0.5 nm (0.9 km) may account for the aircraft sliding off the side from the airport. of the runway,” the report said. www.flightsafety.org | AEROSafetyWorld | June 2007 | 61 OnRecord
Control Lost During Missed Approach continuous descent. Witnesses saw the Seneca Piper Seneca III. Destroyed. Two fatalities. emerge from the clouds at a high rate of descent uring his preflight weather briefing the and in a nose-low and a nearly vertical left- morning of Nov. 6, 2005, the pilot was wing-low attitude. The airplane struck the roof Dtold that overcast ceilings from 100 ft to of a truck parked near the airport boundary, 700 ft had been reported along the entire route a power line pole, a berm adjacent to a public from Fredericksburg, Texas, U.S., to Tomball, road and a vehicle on the road, and came to rest Texas. However, the destination airport, David in dense vegetation off the side of the road. The Wayne Hooks Memorial Airport, reported a vehicle driver received minor injuries. clear sky below 12,000 ft and 7 mi (11 km) “A weather observation taken approxi- visibility. mately two minutes after the accident included The NTSB report said that the pilot ques- a visibility of 1 3/4 statute miles [2,800 m] with tioned the briefer about the reported ceiling at mist and an overcast ceiling of 300 feet,” the the destination airport. The briefer said, “That’s report said. what they are saying, but I kind of find it hard to believe that everyone around them is [reporting] HELICOPTERS one to three hundred overcast and they’re clear below twelve thousand.” Loose Fuel Line Fitting Causes Power Loss As the Seneca neared the destination, the pi- Bell 206L-1 LongRanger. Destroyed. Two fatalities, two minor injuries. lot was cleared by ATC to conduct the localizer he helicopter lost power about five minutes approach to Runway 17R. Reported weather after departing from an airport near Pat- conditions at the airport now included a 300-ft Tterson, Louisiana, U.S., for a charter flight overcast and 3 mi (4,800 m) visibility with fog. to an offshore platform in the Gulf of Mexico The published minimum descent altitude for the the morning of March 14, 2006. “The commer- localizer approach was 620 ft — 468 ft above the cial helicopter pilot subsequently made a hard runway touchdown zone elevation — and the forced landing at an off-airport site comprised minimum visibility was 1 mi (1,600 m). of tall vegetation and soft terrain,” the NTSB Recorded ATC radar data indicated that report said. the airplane remained right of the inbound The helicopter came to rest upright, and the approach course and descended to about 300 two rear-seat passengers exited before it was ft above ground level (AGL). As the airplane engulfed in flames. The pilot and front-seat pas- descended, the airport tower controller issued a senger were killed. low-altitude alert and told the pilot to check his Examination of the engine revealed that the altitude. The pilot replied, “We’re going to climb nut connecting the fuel line to the fuel nozzle back up and go missed approach.” The airplane was loose and had not been secured with a began a right turn but remained at about 300 ft lock wire. A fuel-nozzle inspection, which was AGL. The published missed approach procedure required every 50 hours, had been performed calls for a climb to 1,000 ft and a climbing right the evening before the accident occurred. “This turn to 1,800 ft. inspection required the removal, disassembly, About 40 seconds after reporting the missed cleaning, inspection, reassembly and reinstal- approach, the pilot said, “I got the tower. Can lation of the fuel nozzle,” the report said. “An I go ahead and land?” About this time, the interview with maintenance personnel revealed airplane began a left turn. The controller cleared that fuel nozzle installation procedures found in the pilot to land but received no response. the engine manufacturer’s maintenance manual The airplane’s height above the ground had not been followed.” varied between 300 ft and 800 ft as the left turn Postaccident tests indicated that a loose fuel was continued. The airplane then entered a nozzle can cause a substantial loss of power and
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a flameout. “Testing further revealed that condi- to reach his destination — Las Vegas, Nevada tions would have been conducive for an in-flight — by 1600. Estimated flight time was between fire,” the report said. “Investigators could not 2.6 and 3.0 hours. He departed from Torrance determine if the fire originated in flight or dur- at 1425, flying the last helicopter in a group of ing the ground impact.” four helicopters bound for Las Vegas and spaced about 15 minutes apart. Wind Shear Blamed for Hard Landing “While en route, other pilots in the group Bolkow 105DB. Substantial damage. No injuries. observed rain and lightning to the northeast of he helicopter was engaged in a public trans- their track once they were east of the mountain port flight to resupply and maintain several pass and elected to [continue eastbound to] Tlighthouses in Ireland on Dec. 13, 2006. remain clear of the observed weather,” the report Wind velocities in the area were 60 to 65 kt at said. After crossing the mountain pass, the ac- 2,000 ft and 25 to 30 kt with gusts to 45 kt on the cident pilot radioed another pilot that he was surface, said the Irish Air Accident Investigation heading northeast. Unit report. “The helicopter was equipped with a GPS The pilot expected to encounter turbulence [global positioning system] navigation system, on approach to the helipad at a lighthouse in which had the capability to guide the pilot on Howth. He described the initial approach as a straight-line course to his destination, which relatively smooth. About 15 ft above the helipad, could save about 17 minutes of flying time,” however, the helicopter began to descend rap- the report said. “The pilot [likely] followed the idly, and application of power had no effect on GPS direct course and encountered restricted reducing the rate of descent. visibility, rain and moderate turbulence. He The helicopter landed hard and remained unintentionally flew into a box canyon and upright. The pilot shut down the engine, and he collided with rising terrain while attempting to and his passenger exited the helicopter. Exami- reverse course out of the canyon.” The accident nation of the helicopter revealed substantial occurred about 1600. The pilot had not filed a damage to the landing gear cross-tubes. flight plan; the U.S. Civil Air Patrol located the “Because of the strength of the gradient wreckage at 3,370 ft on a 3,900-ft slope at 1100 wind, there was certainly potential for local- the next day. ized significant wind shear and severe low-level mechanical turbulence,” the report said. “These Engine Failure Traced to Fuel Control Unit effects could have been exacerbated by moun- Eurocopter France EC120B. Destroyed. Two fatalities, one serious injury. tain wave activity.” n overspeed and catastrophic failure of Adverse Weather Encountered in Box Canyon the engine occurred during a law en- Robinson R22 Beta. Destroyed. One fatality. Aforcement patrol flight near Fair Oaks, he pilot was among several pilots who were California, U.S., on July 13, 2005. The pilot delivering helicopters from Torrance, Cali- and front-seat observer were killed, and the Tfornia, U.S., to various locations on Sept. 20, observer-trainee was seriously injured when 2005. The NTSB report said that all the flights the helicopter struck terrain near the bottom of “required a departure along the same easterly a steep hill. route, through a mountain pass and then over NTSB said that the probable cause of the high desert terrain that included another line of accident was the failure of a diaphragm in the mountains.” engine fuel control unit that caused increased While waiting for weather conditions to fuel flow. “The diaphragm’s failure was the result improve sufficiently for departure, the pilot of improper installation by the engine manufac- appeared to be anxious, and he said that he had turer,” the report said. ● www.flightsafety.org | AEROSafetyWorld | June 2007 | 63 OnRecord
Preliminary Reports
Date Location Aircraft Type Aircraft Damage Injuries
April 1, 2007 Klagenfurt, Austria Piper Seneca destroyed 2 fatal
The aircraft reportedly broke up while cruising in visual meteorological conditions.
April 1, 2007 Lake Germain, Quebec, Canada Piper Chieftain destroyed 1 fatal
The aircraft was en route from Sept-Îles, Quebec, to Wabush, Newfoundland, when it crashed on the frozen lake.
April 1, 2007 Milwaukee, Wisconsin, U.S. Bombardier CRJ none 43 none
A horizontal stabilizer nose-down trim runaway occurred soon after departure. The flight crew declared an emergency and returned for a landing in Milwaukee. The preliminary report said that the aircraft was returned to service after the trim switches were lubricated and the horizontal stabilizer electronic control unit was replaced.
April 2, 2007 Darwin, Northern Territory, Australia IAI Westwind none NA none
The aircraft was climbing through Flight Level (FL) 340, en route to Alice Springs, when loud bangs were heard and cabin pressure was lost. The crew donned oxygen masks, descended to 10,000 ft and returned to Darwin.
April 11, 2007 Wagga Wagga, New South Wales, Australia de Havilland Canada Dash 8 none NA none
Soon after departing from Wagga Wagga for a flight to Sydney, the left engine failed. The crew returned and landed the aircraft without further incident.
April 11, 2007 Wheeling, Illinois, U.S. Swearingen Merlin III substantial 5 none
The aircraft had accelerated to about 75 kt on the takeoff roll when the left engine began to surge. The pilot could not maintain directional control and rejected the takeoff. The aircraft departed the left side of the 5,000-ft (1,524-m) runway.
April 12, 2007 Traverse City, Michigan, U.S. Bombardier CRJ200 substantial 52 none
Visibility was 1/2 mi (800 m) with snow when the aircraft overran the 6,501-ft (1,982-m) runway while landing at Cherry Capital Airport. The nose gear separated, and the aircraft came to a stop about 100 ft (30 m) beyond the runway.
April 18, 2007 Abu Dhabi, United Arab Emirates Airbus A300 destroyed none
The aircraft was destroyed by a fire that erupted during maintenance.
April 19, 2007 Kahuku, Hawaii, U.S. Hughes 500 substantial 4 none
The pilot conducted a forced landing at Turtle Bay Resort after the engine failed.
April 19, 2007 Chicago, Illinois, U.S. McDonnell Douglas DC-9-30 minor NA none
The roof of the tug struck the aircraft’s radome during pushback from the gate.
April 20, 2007 Jackson Bay, British Colombia, Canada Beech D18S destroyed 1 minor, 5 NA
The left engine lost power immediately after liftoff. The aircraft yawed left, and the floats separated on contact with the water. All six occupants exited with life vests before the aircraft sank; they were rescued about a half hour later.
April 21, 2007 Changuinola, Panama Bell 206 destroyed 2 fatal, 2 serious
The pilot reportedly lost control while landing the helicopter in a confined jungle clearing on the side of a mountain.
April 23, 2007 Revelstoke, British Colombia, Canada Piper Navajo destroyed 2 NA
Returning from an aerial-photography flight, the pilot noticed an unsafe gear indication after turning final. He attempted to conduct a go- around, but the engines did not respond. The aircraft was landed gear-up beyond the end of the runway. Both occupants exited before the aircraft was consumed by fire.
April 25, 2007 Kopinang, Guyana Pilatus Britten-Norman Islander destroyed 3 fatal, 2 NA
The aircraft was on a scheduled flight from Kato to Kopinang when it struck trees and crashed.
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 | June 2007 Now you have the safety tools to make a difference.
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Order the FSF Member price: US$40 Recommended System Requirements Nonmember price: $160 Windows® Mac® OS Quantity discounts available! • A Pentium®-based PC or compatible computer • A 400 MHz PowerPC G3 or faster Macintosh computer • At least 128MB of RAM • At least 128MB of RAM Contact: Namratha Apparao, • Windows 95/98/NT/ME/2000/XP system software • Mac OS 8.6/9, Mac OS X v10.2.6 or later Mac OS and Macintosh are trademarks of Apple Computer Inc. registered in the United States and other countries. Microsoft, Windows and are either registered trademarks or membership services coordinator trademarks of Microsoft Corp. in the United States and/or other countries. +1 703.739.6700, ext. 101. The FSF ALAR Tool Kit is not endorsed or sponsored by Apple Computer Inc. or Microsoft Corp. International Federation International Air Transport of Airworthiness Association Joint meeting of the FSF 60th annual International Air Safety Seminar IASS, IFA 37th International Conference, and IATA
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