AeroSafety world
TRAINING FOR DIVERSITY CRM in a multicultural cockpit GEN Y WORKFORCE Young professionals and safety culture NO OFFENSE Avoiding in-cockpit turbulence HELICOPTER TREND Stubborn human error
The Crash of AF447 SUSTAINED STALL
The Journal of Flight Safety Foundation August 2012
EEXECUTIVE’sXECUTIVE’sMessageMessage Seminars and Summits or those of you who have attended any or all Business Aviation Safety Summit. The reason for of our three main seminars, International Air “Summit” instead of “Seminar” is that we are going Safety Seminar (IASS), European Aviation to launch a new set of meetings called Regional Safety Seminar (EASS) and our Corporate Aviation Safety Seminars (RASS). The two large AviationF Safety Seminar — now re-branded as summits will be the showcases for the deep dive into Business Aviation Safety Seminar (BASS) — I want aviation safety in general and in business aviation to thank you! For those who haven’t, I would like safety. The regional aviation seminars will focus on to encourage you to do so. Why, you ask, would I issues that pertain to specific regions of the world, want to attend when my budget is limited and I have with presentations, instruction and vendor breakout other required seminars and summits to attend? presentations. We successfully completed a partner- Well, over the past year-and-a-half, since our ship RASS in Bali, Indonesia, this past May, with the IASS in Milan, Italy, the Foundation staff began International Civil Aviation Organization and with to make some subtle changes to the seminars in the mineral and mining industry participating. It response to your feedback. Some of those changes succeeded largely because it was within a region include better check-in at the Foundation registra- and it had take-away information that could be im- tion desk; the re-introduction of panel presentations; mediately used by the participants. Each RASS will questions, comments and answers at the end of a last for no more than a day-and-a-half, depending speaker’s presentation; and timely keynote speakers on the topics. RASS topics will change, depending on such as Capt. Richard de Crespigny, whose topic was the region and its needs. For 2013, we are planning the Qantas Flight 32 catastrophic engine failure and at least two regional seminars. landing (p. 54). We have also decided to site the semi- You may have noticed that I did not mention nars in cities with greater nonstop flight possibilities the EASS for 2013. Unfortunately, due to the eco- to cut down on the need for connecting flights. nomic conditions in Europe, we are going to put In the future, we want to add more social media the EASS on hold. Once the European economies interaction, speakers who have cutting edge topics grow stronger, we will re-evaluate the need, and not yet considered and possibly a debate. Our format when that happens, a RASS-E (Regional Aviation has always been one of the hallmarks of the Founda- Safety Seminar– Europe) may be scheduled. tion seminars, and we intend to build on that success- We realize that attending a summit or seminar ful reputation. Many of you do not know that we have is a large expense of your time and funds. Our goal specific committees convening for each seminar to is to make the Foundation summits and seminars vet papers submitted for presentation. This ensures well worth that investment in safety knowledge that we have quality topics to present. One way to for your situation! look at a Flight Safety Foundation seminar is that we provide a “deep dive” into safety-related topics. We are not there to sell or promote products. We are there to provide information that you can use, and potentially apply to your situation. All that being said, we are going to shake up our Capt. Kevin L. Hiatt seminars somewhat. First, we will change the names Chief Operating Officer in 2013 to International Aviation Safety Summit and Flight Safety Foundation flightsafety.org | AeroSafetyWorld | August 2012 | 1 AeroSafetyWorld
August 2012 Vol 7 Issue 7
FIR Rochambault FIR AtlanticocontentsTASIL Estimated 02h 20 FIR Atlantico ORARO 02h 04 FIR Amazonica FIR Dakar SALPU 02h 04 FIR Atlantico INTOL 01h 33 features NATAL 00h 54 RADAR covered area Fernando de Noronha 14 CoverStory | Air France Flight 447 Your instructions are not clear.
FIR Recife FIR Brasilia Brazil 19 FlightTraining | Multicultural CRM
FIR Recife FIR Atlantico 14 24 StrategicIssues | Integrating Generation Y
FIR Brasilia 30 FlightDeck | Emotional Loss of Control FIR Curitiba
Route own by AF447 Planned route 35 HelicopterSafety | Persistent Pilot Error FIR Curitiba FIR Atlantico 40 InSight | FAA Voluntary Safety Reports
44 GroundOps | Risk Mitigation Update 24 departments 30 1 Executive’sMessage | Seminars and Summits 5 EditorialPage | Startle Effect
7 AirMail | Letters From Our Readers
8 FoundationFocus | Making Strides in Latin America
10 SafetyCalendar | Industry Events
2 | flight safety foundation | AeroSafetyWorld | August 2012 35 44
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AeroSafetyWORLD telephone: +1 703.739.6700 11 InBrief | Safety News William R. Voss, publisher, FSF president and CEO [email protected] 49 DataLink | Latest Boeing Statistical Summary Frank Jackman, editor-in-chief, FSF director of publications 54 InfoScan | QF32 Captain’s New Book [email protected], ext. 116 Mark Lacagnina, senior editor [email protected], ext. 114 57 OnRecord | Long Float Leads to Overrun 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, webmaster and production coordinator [email protected], ext. 117 Ann L. Mullikin, art director and designer About the Cover [email protected], ext. 120 Debris is recovered following the crash of AF447. Susan D. Reed, production specialist © AP Photo/Brazilian Air Force [email protected], ext. 123
Editorial Advisory Board David North, EAB chairman, consultant We Encourage Reprints (For permissions, go to
flightsafety.org | AeroSafetyWorld | August 2012 | 3
Editorialpage
Startle Effect
eginning on p. 14, Mark Lacagnina high-amplitude roll control inputs,” ac- overspeed warning. “Sometimes this ef- delves into the causes of the crash cording to the English translation of the fect sparks primal instinctive reaction, of Air France Flight 447 (AF447) BEA’s final report on the accident. “He instant and inadequate motor responses,” in June 2009 as laid out by the final also made a nose-up input that increased the report said. “These basic reflexes may Breport of France’s Bureau d’Enquêtes et the aeroplane’s pitch attitude up to 11 prove to be incorrect and difficult to cor- d’Analyses (BEA). Next month, we will degrees in 10 seconds,” the report said. rect under time pressure and may affect take a closer look at some of the BEA’s Investigators surmised that “the ex- the pilot’s decision-making ability.” recommendations. cessive nature of the PF’s inputs can be In recommending that the Euro- To anyone who has followed the in- explained by the startle effect and the pean Aviation Safety Agency review the vestigation and read the interim reports, emotional shock at the autopilot discon- requirements for initial, recurrent and the final report did not contain any real nection.” Of course, the PF’s initial, startled type rating training for pilots “in order surprises, but it did, among other things, reaction was not the sole problem, but it to develop and maintain a capacity to shine a spotlight on training needs, situ- did play a “major role in the destabilization manage crew resources when faced with ational awareness, crew resource man- of the flight path,” the BEA report said. the surprise generated by an unexpected agement and the “startle effect,” which, Two years later, on an A340 flight situation,” the BEA authors of the AF447 coincidentally, appears in two stories in from Caracas to Paris, a strong wind gust final report said: “Initial and recurrent this month’s issue. caused airspeed to increase momentarily training as delivered today do not pro- The first and most significant story to 0.87 Mach (p. 58). The pilots said that mote and test the capacity to react to the involves AF447, the Rio de Janeiro to they were surprised when the master unexpected. Indeed, the exercises are Paris nonstop flight that crashed into the warning light illuminated and the aural repetitive and well known to crews, and Atlantic Ocean, killing all 228 people on overspeed warning sounded. The pilot do not enable skills in resource manage- board. As Mark details in his story on the not flying (PNF) manually disengaged ment to be tested outside of this context.” BEA’s final report, ice crystals blocked the autopilot and “a pitch-up input on Stay tuned for more on the BEA’s the aircraft’s pitot probes, resulting in the PNF’s sidestick going as far as three- recommendations next month. the production of unreliable airspeed quarters to the stop was recorded for six information. The Airbus A330-200’s elec- seconds,” the BEA’s report said. “This in- tronic flight control system, reacting as it put was accompanied by an input to bank was designed to do, rejected the air data, to the right then left. The PNF stated that disengaged the autopilot and autothrottle he did not remember these inputs.” and reverted to a lower control law. The report said that the control inputs Frank Jackman When the autopilot disengaged, likely were reflexive actions that resulted Editor-in-Chief the pilot flying (PF) “made rapid and from the “startle effect” produced by the AeroSafety World flightsafety.org | AeroSafetyWorld | August 2012 | 5 Serving Aviation Safety Interests for More Than 60 Years
Officers and Staff light Safety Foundation is an international membership organization dedicated to Chairman, the continuous improvement of aviation safety. Nonprofit and independent, the Board of Governors Lynn Brubaker Foundation was launched officially in 1947 in response to the aviation industry’s need President and CEO William R. Voss F for a neutral clearinghouse to disseminate objective safety information, and for a credible Chief Operating Officer Capt. Kevin L. Hiatt and knowledgeable body that would identify threats to safety, analyze the problems and General Counsel recommend practical solutions to them. Since its beginning, the Foundation has acted in the and Secretary Kenneth P. Quinn, Esq. public interest to produce positive influence on aviation safety. Today, the Foundation provides Treasurer David J. Barger leadership to more than 1,075 individuals and member organizations in 130 countries. Administrative
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flight safety foundation | AeroSafetyWorld | August 2012 AirMail
Leaving Failure as an Option improve their processes. We also need successes along read with great interest the article an avenue to share both our failures the way, and I discussing SMS by William Voss and our successes with each other. The suspect that ASW and I( ASW, 5/12, p. 1), and the letter by many safety round tables that have gentlemen like Mr. Voss and Mr. Whit- Jeff Whitman (ASW, 6/12, p. 8), and grown up around the country are excel- man who care about business aviation I have to agree with both of them on lent conduits for the exchange of ideas and safety will be there to articulate the their assessments. However, I want to and creative thinking. Last, we should processes and help improve aviation add some thoughts on the role of inno- consider bringing in individuals from safety on a global scale. For the time vation in framing the future of SMS. our companies who have no background being, those of us on the front line of The definition of innovation is “a in aviation, and allow them to serve as business aviation must be willing to new idea, device, or method, or “the act “interpreters” to look at our SMSs. You experiment with our SMSs, and to pass or process of introducing new ideas, might be surprised at the insights that along our results to our colleagues in the devices, or methods.” It has been my they bring to the table. They may view field. When this happens we will see real observation that most innovation does the world from a different paradigm. improvements in SMS. Thank you. not come from government or aca- The French were very close to beat- demia, and, in fact, they often suppress ing the Wright brothers in the develop- Cliff Jenkins creativity. Many of the initiatives passed ment of the first airplane. However, Director of Aviation through academia and the government the paradigm that the Europeans were Milliken & Company are led by individuals who don’t want using was that of a “coach” design to challenge the status quo. Addition- for an aircraft. In other words, they ally, we in the aviation community tend believed that the airplane would fly on to be “rule followers,” which makes us two axes, yaw and pitch. The paradigm encourages mostly compliant. This is a good thing, that the Wright brothers were basing AeroSafety World comments from readers, and will but I’m not sure that it lends itself to in- their design on was that they had been assume that letters and e-mails novation and creative thinking (at least riding and building bicycles most of are meant for publication unless in my case). That said, I believe that their lives, and as such they were very otherwise stated. Correspondence any progress in SMS in the business comfortable with leaning into the turn, is subject to editing for length aviation community will come from i.e., roll. The Wright Flyer was therefore and clarity. the rank-and-file operators such as designed with three axes, yaw, pitch and maintenance technicians, flight atten- roll. The rest is history. Write to Frank Jackman, director dants, pilots and schedulers who have a SMS is already improving safety. of publications, Flight Safety vibrant SMS in place and who see a real It will continue to evolve as innova- Foundation, 801 N. Fairfax St., need for improvement. tive flight departments develop their Suite 400, Alexandria, VA For innovation to occur in SMS, we own creative ways to address SMS and 22314-1774 USA, or e-mail must leave failure as an option. In- challenge the paradigms in place. There
The Foundation membership comprises organizations from around the world — air carriers, business aviation operators, manufacturers, airports, educational institutions, non-profit and government organizations and support service companies. Individual members range from pilots to accident investigators to regulators and beyond. The Foundation achieves its goals by undertaking challenging projects that make aviation safer, thereby benefitting each member. Our work is exemplified in the following areas:
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Making Strides in Latin America
he team at Flight Safety Founda- environmentally friendly air transport factors and other issues for scheduled tion (FSF) is busy gearing up for in the Latin American and Caribbean airlines, manufacturers and equip- our largest event of the year. Now region for the benefit of the associa- ment suppliers, trainers, flight crews, in its 65th year, the International tion’s members, their customers and maintenance personnel and industry TAir Safety Seminar (IASS), will be the industry. executives. Delegates will hear re- held in Santiago, Chile, on Oct. 23–25, Alex de Gunten, executive direc- marks from dignitaries, civil avia- and will be hosted by the Director- tor of ALTA, said, “The ongoing tion authorities and the CEOs of key ate General of Civil Aviation of Chile. partnership between ALTA and FSF airlines in the Latin American and You can find further details and a draft underscores the ultimate goal of Caribbean Region. agenda on our website at
8 | flight safety foundation | AeroSafetyWorld | August 2012 ➤ safetycalendar
SEPT. 10–21 ➤ Aircraft Accident OCT. 2–4 ➤ CAE Flightscape Users OCT. 22–24 ➤ SAFE Annual Symposium. Investigation. U.S. National Transportation Conference. CAE Flightscape. Montreal. SAFE Association. Reno, Nevada, U.S. Jeani Safety Board. Washington. Peter Knudson,
SEPT. 12–14 ➤ Aviation Law Americas. OCT. 8–12 ➤ Aviation English for Pilots and OCT. 23–25 ➤ 65th annual International Latin American and Caribbean Air Transport Air Traffic Controllers. Joint Aviation Authorities Air Safety Seminar. Flight Safety Foundation Association. Miami.
EARN A CERTIFICATION IN AVIATION SAFETY FOR MANAGERS FROM SAINT LOUIS UNIVERSITY AND THE CENTER FOR AVIATION SAFETY RESEARCH. The Center for Aviation Safety Research (CASR) offers Aviation Safety courses designed for orga- nizational leaders. Courses provide managers with valuable insight on how to achieve the highest level CENTER FOR AVIATION of safety within an organization while SAFETY RESEARCH improving operational performance. CALL FOR PAPERS The International Journal of Safety Across High- Consequence Industries contains peer reviewed The Center for Aviation Safety Research (CASR) papers and articles on various aspects of safety as was established at Saint Louis University’s Parks it relates to high consequence industries such as College of Engineering, Aviation and Technology healthcare, construction, aviation and aerospace. by the U.S. Congress to solve crucial aviation safety research questions. CASR serves as a central Authors interested in submitting papers or articles resource for transfer of best practices across to the journal may do so online by registering at: air transportation and other high-consequence http://www.edmgr.com/ijsahi/. The journal is also industries. looking for reviewers. s aint l ouis u niversity PARKS.SLU.EDU/FACULTY-RESEARCH/CASR
10 | flight safety foundation | AeroSafetyWorld | August 2012 inBrief Safety News Proposed Penalty for Boeing
he Boeing Co. faces a proposed One directive, issued in 2008, set a civil penalty of $13.6 million for its Dec. 27, 2010, deadline for Boeing and Talleged failure to meet a govern- Airbus — the companies responsible ment deadline to submit service in- for the affected airplanes — to “develop structions for airlines to install systems design changes and service instructions designed to reduce the risk of fuel tank for installing systems to further reduce explosions. fuel tank flammability” and submit the “Manufacturers must provide the plans for FAA approval, the FAA said.
necessary instructions so the airlines can The agency’s plans called for the instal- © Ramon Berk/Dreamstime.com comply with this important safety regu- lation of systems that would replace the lation,” U.S. Transportation Secretary oxygen-rich air in the fuel tanks with Under the Fuel Tank Flammability Ray LaHood said. nonflammable nitrogen. Rule, airlines are required to retrofit half The U.S. Federal Aviation Admin- “Boeing missed the deadline for sub- of their affected airplanes by 2014 and istration (FAA) says that, since the July mitting service instructions for the 747s the remainder by 2017. The FAA said 1996 crash of a Trans World Airlines by 301 days, delivering them to the FAA that most operators — including those Boeing 747 — which investigators at- on Oct. 24, 2011,” the FAA said. “The that received the late instructions from tributed to an explosion of flammable company was 406 days late in submitting Boeing — will be able to meet those vapors in a fuel tank — it has issued service instructions for the 757s. In total, deadlines. 283 directives aimed at preventing 383 U.S.-registered Boeing aircraft are The manufacturer has 30 days from vapor ignition in and around aircraft affected by these delays.” its receipt of the FAA letter to respond to fuel tanks. Airbus met the 2010 deadline. the allegations.
African Action Plan TAWS Requirement
nternational aviation organizations Association’s (IATA’s) Operational anadian operators of certain are urging African nations to adopt Safety Audit. smaller aircraft have been given Ia plan designed to correct deficien- These key areas were identified Ctwo years to install a terrain cies and strengthen regulatory over- through IATA and International Civil awareness and warning system sight in the region’s aviation system. Aviation Organization (ICAO) analysis (TAWS) in their airplanes. The Africa Strategic Improve- of air transport accidents that occurred Denis Lebel, minister of trans- ment Action Plan calls for estab- in Africa between 2006 and 2010. port, infrastructure and communi- lishing and funding independent “This analysis identified … the ties, said the new requirement will civil aviation authorities in African main contributing factors to accidents “significantly increase safety for nations; implementing “effective and [as] insufficient regulatory oversight small aircraft, which fly into remote transparent safety oversight systems,” and the lack of SMS implementation,” wilderness or mountainous areas accident-prevention measures that ICAO said. “Implementation of tools where the danger of flying into ter- address runway safety and loss of such as FDA could have pinpointed rain is highest.” control, flight data analysis (FDA) precursors to the major accident types, Transport Canada said that the programs and safety management namely runway excursions, controlled requirement will apply to operators systems (SMS); and requiring all flight into terrain and loss of control. of “private turbine-powered and African air carriers to undergo Runway excursions alone accounted for commercial airplanes with at least six the International Air Transport about a quarter of African accidents.” passenger seats.” Lebel said the regulations comply Hansueli Krapf/Wikimedia with International Civil Aviation Organization standards. In the past, the Transportation Safety Board of Canada has recommended wider use of TAWS “to help pilots assess their proximity to terrain.”
flightsafety.org | AeroSafetyWorld | August 2012 | 11 inBrief
Positioning Problem
perators of airplanes with General The NTSB cited a Feb. 8, 2012, en- Electric (GE) CF6-80C2 engines gine fire aboard an American Airlines Oshould be required to take steps to Boeing 767-300ER shortly after takeoff ensure the correct assembly of a spray from John F. Kennedy International shield and support bracket unit that — Airport (JFK) in New York for a flight when incorrectly installed — has been to Haiti. The pilots shut down the associated with engine fires, the U.S. engine, discharged two fire extinguisher National Transportation Safety Board bottles into the engine, declared an (NTSB) says. emergency and returned to JFK. None The NTSB issued a safety recom- of the 213 people in the airplane were Kristoferb/Wikipedia mendation to the U.S. Federal Aviation injured. Administration (FAA), calling on the The investigation is continuing, but flange and the … fuel-oil heat exchanger.” FAA to issue an airworthiness directive the NTSB said that investigators found Part of the seal was missing. to “require the incorporation of [GE] that “numerous wires and cables on the A similar engine fire occurred on a Aircraft Engines Service Bulletin 73- lower half of the engine showed signs of Delta Air Lines 767-300ER on July 12, 0242, ‘Fuel and Control — (73–00–00) insulation that had been burned away or 2006, shortly after takeoff from Rio de Ja- — Spray Shields and Support Bracket partially melted.” They also found that the neiro, Brazil, the NTSB said. The airplane — Improvement’ to prevent fires support bracket and spray shield had been returned to Rio de Janeiro for a landing on CF6-80C2 engines due to mis- assembled incorrectly, with the bracket that resulted in a hot brake warning and assembly of the two-piece support over the spray shield. The incorrect posi- deflation of six main landing gear tires, bracket and spray shield on the front of tioning of the two parts “distorted the fuel the board said. Damage to the engine was the integrated drive generator fuel-oil tube flange, resulting in an inadequate “virtually identical” to the damage found heat exchanger.” clamping of the seal between the fuel tube on the American Airlines 767.
In Memoriam ATC Consolidation
wo key figures in aviation safety Aviation Safety Lifetime Achieve- lans to consolidate a number of relatively — Robert L. Helmreich and ment Award in 2005, two years small air traffic control (ATC) facilities into TBryan Wyness — have died. before he retired from the Uni- Plarge integrated facilities over the next 20 Helmreich, a pioneering versity of Texas and was named a years will depend on the U.S. Federal Avia- developer of crew resource man- professor emeritus. He also was tion Administration’s (FAA’s) ability to meet a agement initiatives and the line a recipient of the American Psy- number of technical and financial challenges, a operational safety audit, died July chological Association’s Franklin report from a government oversight office says. 7. He was 75. Taylor Award and the University The U.S. Department of Transportation’s He was a psychology professor of Texas’ highest honor, the Pro Office of Inspector General (OIG) said that the at the University of Texas at Austin Bene Meritus Award. challenges include successfully aligning ongoing and the principal investigator of Wyness, a commissioner with construction projects; coordinating the projects the University of Texas Human the New Zealand Transport Ac- with the offices of the Next Generation Air Factors Research Project, which cident Investigation Commission Transportation System (NextGen), the elaborate studies individual and team per- (TAIC), died July 20 in a motor- overhaul of air traffic management; and final- formance, human error and the cycle accident. He was 71. izing cost estimates. influence of culture on behavior in He was first appointed to the The FAA already has approved a plan to aviation and medicine. TAIC in 2004, after a long career consolidate 49 ATC facilities into one integrated He served in the U.S. Navy with Air New Zealand, where he facility handling traffic in New York, New Jersey and received bachelor of science, had been vice president for flight and the Philadelphia area. The agency has not master of science and doctoral operations. He also was a former yet determined where to build the $2.3 billion degrees from Yale University. member of the Flight Safety Foun- facility, the report said. He was awarded the Flight dation International Advisory The FAA operates 561 ATC facilities nation- Safety Foundation–Boeing Committee. wide, many of which are outdated, the report said.
12 | flight safety foundation | AeroSafetyWorld | August 2012 inBrief
C100 M62 Y0 K38
In Other News … SAR Upgrade Urged
ew requirements for Australian rench aviation accident investigators are calling pilots to undergo more train- for better coordination of search and rescue Ning and checking exercises in F(SAR) plans in maritime and remote areas. simulators are expected not only to Recommendations accompanying the Bureau improve training but also to reduce d’Enquêtes et d’Analyses (BEA) final report on the aircraft wear and tear and limit the risk June 1, 2009, crash of an Air France Airbus A330, of training accidents, the Australian operating as Flight 447, into the Atlantic Ocean Civil Aviation Safety Authority says. said there was no SAR coordination plan between Pawel Kierzkowski/Wikipedia The requirements take effect in 2013. Brazil and Senegal for the section of the South Atlantic where the airplane struck … The European Parliament’s transport the water. and tourism committee has approved “This lack of a plan caused a considerable delay in the start of SAR operations,” a non-binding resolution urging the report said. All 228 people in the airplane were killed in the crash (p. 14). member states to meet their obligations The BEA recommended that the International Civil Aviation Organization to implement the Single European (ICAO) “ensure the implementation of SAR coordination plans or regional proto- Sky, reasoning cols covering all of the maritime or remote areas for which international coordi- that Europe’s air nation would be required in the application of SAR procedures, including in the traffic control South Atlantic area.” “urgently” needs Related recommendations said that ICAO should “define the framework for modernization to the training of SAR operators” and that French civil aviation authorities should enhance safety. develop a framework for SAR training in France. © Dan Barnes/iStockphoto
Compiled and edited by Linda Werfelman.
flightsafety.org | AeroSafetyWorld | August 2012 | 13 Coverstory
Blocked pitot tubes, excessive control inputs and cockpit confusion doomed Air France 447. Sustained Stall BY MARK LACAGNINA
ithin four and a half minutes in the produce unreliable airspeed information. Reacting early hours of June 1, 2009, an Airbus as designed, the electronic flight control system A330-200 operating as Air France (EFCS) rejected the air data, disengaged the Flight 447 from Rio de Janeiro, Brazil, autopilot and autothrottle, and reverted to a lower Wto Paris, departed from cruise flight at 35,000 ft control law that provides fewer protections against and descended into the Atlantic Ocean, killing all flight-envelope deviations. Startled by the unex- 216 passengers and 12 crewmembers. Glimpses pected and unfamiliar situation, and with turbu- of what might have gone wrong emerged from lence making sidestick control inputs difficult, the several interim reports issued by the French pilot flying (PF) inadvertently commanded a steep Bureau d’Enquêtes et d’Analyses (BEA) during its nose-up pitch change while leveling the airplane’s long investigation of the accident. In July 2012, wings. The flight crew — a copilot and a relief pilot the bureau published a nearly 300-page final filling in for the resting captain — recognized the report providing a full picture of what likely hap- loss of reliable airspeed data but did not conduct pened during those critical moments. the associated checklist procedure. Confusion According to the report, the trouble began reigned on the flight deck, and crew coordination when the A330’s pitot tubes were obstructed by vanished. Without automatic angle-of-attack pro- ice crystals, causing the various air data sources to tection, the airplane entered a stall. The crew either
14 | flight safety foundation | AeroSafetyWorld | August 2012 coverStory
believed that the stall warnings were spurious or 2229 coordinated universal time (1929 local), mistook the airframe buffeting as a sign of an over- the captain was in the left seat and serving as speed. No recovery action was taken, and the A330 pilot not flying (PNF), and one of the copilots © Joseph K. Wagner/Airliners.net © Joseph K. remained in a stall as it descended to the sea. was flying from the right seat. Based on the findings of the investigation, The captain, 58, had 10,988 flight hours, in- the BEA made 41 recommendations to various cluding 1,747 hours as pilot-in-command in type. organizations worldwide on topics including pilot The PF, 32, had 2,936 flight hours, including 807 training, equipment certification, air traffic con- hours in type. The other copilot was 37 and had trol (ATC) and search and rescue (see p. 13).1 6,547 flight hours, with 4,479 hours in type. About two hours after departing from Rio, Augmented Crew the flight crew received information from the Air France 447 had an augmented flight crew airline’s operations center about an area of comprising a captain and two copilots. When convective activity developing along the route the airplane departed from Rio de Janeiro at between the SALPU and TASIL navigation waypoints (Figure 1). Shortly thereafter, the PF remarked that the airplane was “entering the Air France 447 Flight Path cloud layer,” and the light turbulence to which the flight had been exposed increased slightly. The report said that statements captured FIR Rochambault by the cockpit voice recorder indicated that the FIR Atlantico TASIL Estimated 02h 20 PF became preoccupied with the conditions they might encounter as the flight progressed FIR Atlantico ORARO 02h 04 FIR Amazonica FIR Dakar through the intertropical convergence zone SALPU 02h 04 FIR Atlantico Blocked pitot tubes, excessive control inputs (ITCZ). Several times, he expressed concern and cockpit confusion doomed Air France 447. INTOL 01h 33 about the turbulence and the relatively warm outside air that limited the airplane’s perfor- mance and precluded a climb to Flight Level NATAL 00h 54 (FL) 370 (approximately 37,000 ft), to get above RADAR covered area the clouds. He suggested that they request clear- Fernando de Noronha ance from ATC to climb to FL 360, which is not a standard level for their direction of flight.
FIR Recife FIR Brasilia Brazil “Some anxiety was noticeable” in the PF’s statements, the report said. “The captain ap- peared very unresponsive to the concerns FIR Recife expressed by the PF about the ITCZ. He favored FIR Atlantico waiting and responding to any turbulence not- ed.” The report said that the captain had crossed the ITCZ many times and likely considered the
FIR Brasilia present conditions as normal. FIR Curitiba Preparing for a rest break at 0152, the captain woke the other copilot, who was in the Route own by AF447 Planned route crew rest facility, and summoned him to the FIR Curitiba cockpit. The copilot took the left seat vacated by FIR Atlantico FIR = flight information region the captain and was briefed by the PF about the flight conditions. The turbulence had subsided, Source: Bureau d’Enquêtes et d’Analyses but the PF said that they could expect more tur- Figure 1 bulence ahead and that they presently could not
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Exiting the Envelope At 0210:05, the autopilot and autothrottle disengaged, and the PF announced, “I have the controls.” The PNF responded, “All right.” The airplane, which already had been near its performance limits in high-altitude cruise, “exited its flight envelope” within a minute of autopilot disengagement, the report said. “Nei- ther of the two crewmembers had the clarity of thought necessary to take the corrective actions. However, every passing second required a more purposeful corrective piloting input.” The airspeed shown on the left primary flight display (PFD) decreased rapidly from about 275 kt to 60 kt. A few moments later, the airspeeds shown on the integrated standby instrument system and the right PFD also decreased. attempt to climb above the clouds. The PF also The ice crystal icing that had blocked the noted that they had not been able to establish A330’s pitot probes is a phenomenon that is not a position-reporting data link with the Dakar well understood, according to the report. “In the Oceanic flight information region. presence of ice crystals, there is no visible accre- The captain did not contribute any infor- tion of ice or frost on the outside, nor on the nose mation to the briefing before he left the cockpit of the probe, since the crystals bounce off of these All three pitot probes at 0200 and went to the crew rest facility. surfaces. However, the ice crystals can be ingested were blocked by He also did not specifically designate which by the probe air intake. According to the flight ice crystals, and copilot would serve as the “relief pilot” — that conditions (altitude, temperature, Mach), if the airspeed information is, the captain’s replacement — although he concentration of crystals is greater than the capac- became unreliable. implied that the copilot in the right seat (the ity for deicing of the heating element and evacu- PF) would fill that role. The report said that ation by the purge holes, the crystals accumulate the decision was questionable considering the in large numbers in the probe tube.” The resulting significantly higher experience level of the disruption of total pressure measurement produces other copilot. unreliable airspeed information, causing reversion At this point, the A330 was nearing the from normal to alternate flight control law. ORARO waypoint, which is between SALPU The airplane had pitched about 2 degrees and TASIL, and entering the ITCZ. Airspeed nose-down and had begun rolling right when was 0.82 Mach, and the pitch attitude was 2.5 the autopilot disengaged. “The PF made rapid degrees nose-up. The turbulence increased and high-amplitude roll control inputs, more again, and the PF advised the cabin crew that or less from stop to stop,” the report said. “He the turbulence soon would intensify. “You’ll also made a nose-up input that increased the have to watch out there,” he said. “I’ll call you aeroplane’s pitch attitude up to 11 degrees in 10 when we’re out of it.” seconds.” As a result, the airplane began to climb At 0208, the PNF, who was examining the rapidly. The aural and visual stall warnings acti- weather radar display, suggested that they “go vated twice, briefly. to the left a bit.” The selected heading then was “The excessive nature of the PF’s inputs can be adjusted 12 degrees left. In addition, “the crew de- explained by the startle effect and the emotional cided to reduce the speed to about Mach 0.80, and shock at the autopilot disconnection,” the report
engine deicing was turned on,” the report said. said. “Although the PF’s initial excessive nose-up d’Enquêtes et d’Analyses Bureau
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reaction may thus be fairly easily understood, the 50 kt since the autopilot disconnection and the same is not true for the persistence of this input.” beginning of the climb,” the report said. The PNF was not immediately aware of the PF’s control inputs or that, because of the ‘I Don’t Have Control’ unreliable airspeed data, the EFCS control law The PNF was calling the captain to return to the had changed from normal, which would pre- cockpit at 0210:51, when the stall warnings ac- vent the airplane from reaching stall angle-of- tivated again. Pre-stall buffeting began seconds attack, to alternate, which would not prevent a later. “The crew never referred either to the stall stall. He reacted to the stall warnings by saying, warning or the buffet that they had likely felt,” “What was that?” the report said. The PNF then noticed the airspeed anoma- The PF applied takeoff/go-around thrust but lies, as well as the reversion to alternate control continued to apply nose-up control inputs. This law. At 0210:16, he announced, “We’ve lost the is how pilots typically are trained to react to speeds,” and added, “alternate law protections.” stall indications at low altitude, the report said, The PF also noticed the airspeed anomalies. “We noting, however, that “at this point, only descent haven’t got a good display of speed,” he said. However, neither pilot called for the abnormal/emergency checklist that addresses Airbus A330-200 unreliable airspeed indications. Among the checklist actions is disengagement of the flight directors, which can — and did in this case — present erroneous cues in the absence of consistent airspeed information. The report said that the pilots did not focus on the problem involving the abnormal airspeed indications because they might have perceived “a much more complex overall problem than simply the loss of airspeed information.” Several messages appeared on the elec- tronic centralized aircraft monitor (ECAM), and the PNF read them out “in a disorganized manner,” the report said, also noting that none © Garrett Lockhart/Airliners.net of the ECAM messages provided an “explicit indication that could allow a rapid and accurate he widebody twin-engine A330 was developed simultaneously with the four-engine A340, both of which entered service in 1994. diagnosis” of the situation. The A330-200 is the extended-range version, introduced in 1998 At 0210:27, the PNF observed indications T with a shorter fuselage and a higher fuel capacity than the base-model that the airplane was climbing and said, twice, A330-300. Engine options for both models include General Electric “Go back down.” The PF acknowledged and CF6-80, Pratt & Whitney PW4000 and Rolls-Royce Trent 700 series tur- made several nose-down sidestick inputs that bofans, all rated at approximately 70,000-lb (31,752-kg) thrust. reduced the pitch attitude and the vertical speed. The twin-aisle aircraft accommodates up to 293 passengers. Maximum weights are 230,000 kg (507,058 lb) for takeoff and 180,000 However, the report said that, possibly due to kg (396,828 lb) for landing. Typical operating speed is 0.82 Mach. an erroneous flight director prompt to increase Maximum range with reserves is 6,650 nm (12,316 km). the pitch attitude, the PF did not make control In 2012, maximum takeoff weight was increased to 240,000 kg inputs sufficient to halt the climb. (529,104 lb), with extra fuel capacity that boosted range to 7,050 nm At 0210:36, the airspeed information shown (13,057 km). Currently, 464 A330-200s are in operation worldwide. on the left PFD returned to normal; the indica- Sources: Airbus, Jane’s All the World’s Aircraft tion was 223 kt. “The aeroplane had lost about flightsafety.org | AeroSafetyWorld | August 2012 | 17 Coverstory
… through a nose-down input on the sidestick continuous aural master warning and intermit- would have made it possible to bring the aero- tent stall warning, the confusing instrument plane back within the flight envelope.” indications and the stress conveyed by the two The buffeting, aerodynamic noise and copilots when they told him that they had lost misleading flight director indications might control of the airplane likely made it difficult have caused the PF to believe that an overspeed for the captain to grasp the situation, the report situation existed, the report said. He reduced said. “Subsequently, his interventions showed that he had also not identified the stall.” The airplane was descending through 35,000 ft at 10,000 fpm with a 40-degree angle-of-attack and with roll oscillations reaching 40 degrees. “Only an extremely purposeful crew with a good comprehension of the situation could have carried out a maneuver that would have made it possible to perhaps recover control of the aero- plane,” the report said. At 0212:02, the PF said, “I have no more displays,” and the PNF said, “We have no valid indications.” “At that moment, the thrust levers were in the ‘IDLE’ detent and the engines’ N1s [fan speeds]
U.S. National Aeronautics and Space Administration were at 55 percent,” the report said. “Around 15 seconds later, the PF made pitch-down inputs. The upset occurred thrust to idle and attempted to extend the In the following moments, the angle-of-attack soon after the A330 speed brakes. decreased, the speeds became valid again and the entered clouds in The EFCS autotrim system reacted to the PF’s stall warning triggered again.” the intertropical continued back pressure on the sidestick by mov- At 0214:17, the ground-proximity warning convergence zone. ing the horizontal stabilizer to its full airplane- system began to generate “SINK RATE” and nose-up position, where it remained until the end “PULL UP” warnings. of the flight. “The PF continued to make nose-up The flight data recorder ceased to function inputs,” the report said. “The aeroplane’s altitude at 0214:28. “The last recorded values were a reached its maximum of about 38,000 ft; its pitch vertical speed of 10,913 fpm, a groundspeed of attitude and angle-of-attack were 16 degrees.” 107 kt, pitch attitude of 16.2 degrees nose-up, At 0211:38, the PF told the PNF, “I don’t roll angle of 5.3 degrees left, and a magnetic have control of the plane at all.” The PNF re- heading of 270 degrees,” the report said. “No sponded by announcing, “Controls to the left,” emergency message was transmitted by the crew. and pressing the pushbutton on his sidestick The wreckage was found at a depth of 3,900 m to transfer flight control priority from the PF’s [12,796 ft] on 2 April 2011.” sidestick to his sidestick. This article is based on the English translation of the BEA’s “The PF almost immediately took back priority “Final Report on the Accident on 1st June 2009 to the Airbus without any callout and continued piloting,” the re- A330-203, Registered F-CZCP, Operated by Air France, port said. “The priority takeover by the PF could not Flight AF 447, Rio de Janeiro–Paris.” The report is available be explained but bears witness to the de-structuring in English and the original French at
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Your instructions Your instructions are not clear. are not clear. Please Please Please clarify. clarify. clarify. Please clarify.
Please clarify.
Airlines must adopt culture-specific training if they are to capitalize on the strengths of crewmembers of all nationalities.
BY DAVID M. BJELLOS Multicultural CRM
he 2005 crash of a Helios Airways Greece, during what was to have been a German, and the first officer was Cypriot Boeing 737-300 — with its pilots flight from Larnaca, Cyprus, to Prague, — contributed to poor communication incapacitated by hypoxia after Czech Republic, with a stop in Athens. during the confusing, high-stress event. they failed to recognize a cabin In its final report on the accident, Stressors reduce the ability of humans pressurizationT system malfunction — is the Hellenic Air Accident Investigation to exchange information even when they a prime example of what can happen and Aviation Safety Board said the crew are fluent in the same language. The when communication and crew resource had failed to recognize that the cabin added dimension of a dynamic environ- management (CRM) break down in a pressurization mode selector was in the ment and complex set of specialized tasks modern, multicultural cockpit.1 wrong position. in the cockpit adds to the difficult under- All 121 people in the airplane were The Helios crew exhibited poor CRM taking of effective communication. killed when the 737 depressurized and before takeoff and during climb, and In the Helios accident, a blaring ran out of fuel, the engines flamed out the difference in their nationalities and cabin altitude warning horn and the
© Mark Stay/iStockphoto.com and the airplane crashed in Grammatiko, primary languages — the captain was illumination of master caution lights
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(due to lack of equipment-cooling airflow in all levels, with renewed emphasis directly on the aircraft’s unpressurized state) degraded pilot crewmembers. the crew’s cognitive abilities and processes; inter-cockpit communications were reduced, A Different Approach? perhaps in part because English was a second It would be impossible to account for all the (or possibly third) language for the crew. variables that exist among cultural norms and address each individually. Therefore, the CRM New Phenomena model of the future must return to the basic Prior to the 1980s, there were relatively few premises of advocacy, communication and multicultural, multilingual cockpits. As the inquiry. That means that commanders and number increased, many developing countries subordinates will be required to “re-learn” the did not appreciate the value of CRM. The Helios way they communicate during high-workload accident report indicated that CRM training was periods and emergencies. This does not mean Prior to the in place at the airline, but it was perfunctory. that they must learn a new “language”; rather, it Like many early detractors of CRM training, introduces new idiomatic principles. 1980s, there were Helios management may have felt that it was of To understand the new principles, it is vital relatively few little benefit to them due to the (then) lack of to introduce some basic terms from psychology quantitative data on accident reductions directly that help define how groups within a profes- multicultural, attributed to applied CRM principles.2 sion interact culturally: How, then, do we expect new entrants into • Power distance (PD) — One’s perception of multilingual global aviation to implement innovative solu- (and response to) hierarchy, seniority or rank. tions to bridge the gulfs that separate pilots cockpits. in language, professional expectations and • Individualism and collectivism (IND) — cultural interaction in many of today’s cock- A reference to whether a person’s goals are pits so as to maintain an exceptional record self-oriented (individualism) or team- of safety? The answer includes involvement at oriented (collectivism). © Mark Bowden/iStockphoto.com
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• Uncertainty avoidance (UA) — The threat Helmreich, who died in July (see p. 12) — level perceived during high-stress events. which incorporated CRM procedures into the High uncertainty avoidance involves a implementation of the U.S. Federal Aviation preference for standard operating proce- Administration’s advanced qualification pro- dures (SOPs), direct face-to-face commu- grams (AQP). nications and leaving as little as possible As described by Helmreich, “The AQP gave to chance. Low uncertainty avoidance airlines the ability to develop innovative train- involves acceptance of high stress and ing reflecting the needs and cultures of their higher exposure to risk as part of the job, organizations. Two of the requirements of AQP with more tolerance and flexibility.3 have been the integration of CRM into technical Once learned, these three basic premises must be applied at the individual pilot level through a Individualism and Uncertainty Avoidance three-step developmental mode: • Awareness — Be mindful that you cannot 0 Weak uncertainty avoidance EQA PAN GUA Strong VEN COL accurately profile another crewmember 8 Collectivist COS uncertainty INO PAK PER avoidance TAI KOR simply because of assumptions about his 16 SIN WAF SAL Collectivist THA CHL or her national culture or language. HOK EAF 24 MAL POR MEX YUG • Knowledge — Incorporate the skills PHI 32 ARA TUR URU GRE BRA learned from your company’s formal CRM 40 JAM IRA ARG JPN IND courses and recognize key phrases and 48 terms that will better enable communica- SPA 56 ISR tion success and understanding of anoth- AUT 64 FIN SAF GER er’s perceived strengths and weaknesses. SWI 72 SWE NOR FRA IRE • Skill — Apply the lessons learned to your Individualism index DEN ITA BEL 80 NET daily flying activities, and recognize what CAN NZ 88 works (and, more importantly, what does GBR AUL not) with your colleagues.4 96 USA 114 Returning to the basics of early CRM will re- Weak uncertainty avoidance Strong uncertainty avoidance quire trainers to incorporate explicit phrases — Individualist Individualist the new idiom — for crewmembers of different 10 20 30 40 50 60 70 80 90 100 110 primary languages and cultures to employ when Uncertainty avoidance index a message is ambiguous. Relearning is required to ensure proper communication when dealing with people of “Please confirm you would like me to multiple cultures. This figure compares various countries according to their extent of perform the following procedure …” and “Your individualism and uncertainty avoidance, defined on this page and on p. 20. instructions are not clear — please clarify …” Source: David M. Bjellos; Hofstede, Geert. Culture’s Consequences: Company Values, Behaviors, Institutions and Organizations Across Nations, 2nd Edition. Thousand Oaks, California, U.S.: Sage Publications, 2001. are examples of procedural, word-specific SOPs planned for the latest iteration of CRM. Figure 1
Error Management CRM training and the provision of full mission, non- Well into its third decade, CRM has evolved jeopardy simulation (line oriented flight training, through several generations — with advances or LOFT). As part of this integration of CRM in the cockpit, in airspace and, increasingly, in with technical training, some airlines began to many other facets of aviation, such as air traffic ‘proceduralize’ CRM by adding specific behaviors control (ATC), dispatch and maintenance. Of to their checklists and to require formal evalu- significance to aviators was the fourth genera- ation of crews in full mission simulation (line tion — developed by CRM pioneer Robert operational evaluation or LOE).”5 flightsafety.org | AeroSafetyWorld | August 2012 | 21 flighttraining
The true value-added benefit of like fatigue and danger. EM-CRM’s Training the Trainers AQP-type training is the ability of central task is to convince pilots that Early CRM programs exported from trainers to tailor innovative programs error is unavoidable; as pilots capital- the United States were not always well that combine competency (accuracy ize on the strengths of their aviation received in other countries. Having of airmanship skills) with crews using culture, such as pride and motivation junior first officers question the au- scenario-based simulation where the to succeed, they also need to under- thority of senior commanders was met outcome is not certain until completion. stand their weaknesses. Although an with incredulity in high PD cultures.11 Training and checking then become organization’s training procedures Therefore, each airline must tailor the continuous and contiguous, and simula- emphasize error-managing techniques, EM-CRM to meet the specific needs tor instructors are able to evaluate the culture-specific CRM for flight crews of its pilots. Even within regions with decision-making processes (broadly of all languages and cultures most common languages or other character- defined as aeronautical decision making, likely will help crewmembers interact istics — such as some countries of the or ADM) and not just the outcome of a better, personally and professionally, Middle East, Latin America and Asia particular maneuver. Examples of good and their cultural differences will be — EM-CRM is not transferable from scenario-based training profiles might viewed as strengths, not shortcomings, one airline to another.12 include the Nov. 4, 2010, uncontained by top management.9 Trainers should encourage flight engine failure on a Qantas A380 en route Another negative behavioral marker crewmembers to communicate clearly from Singapore to Sydney, New South is a pilot’s prejudicial attitude toward with each other. Just as pilots have no Wales, Australia (p. 54),6 or the June 1, mistakes by fellow aviators. As trainers problem asking ATC to “say again” 2009, loss of control and crash into the and universities expand their non- or “please clarify” instructions, they Atlantic Ocean of an Air France A330 punitive policies on error, they report should be unwilling to accept an in- (p. 14). tremendous resistance from aviators to struction from an aircraft captain or a Accumulated LOFT and LOE data accept other people’s errors, while will- reply from a first officer that is impre- have shown that better ADM is a direct ingly admitting their own. This ironic cise or unclear. result of better CRM. intolerance must be understood and ac- With practice, this becomes a The current model of CRM — the knowledged by all airmen before CRM repeatable and consistent tool for pilots “sixth generation” — added the “er- can be effectively applied in real life. to use to overcome misunderstandings ror management” CRM (EM-CRM) during all flight scenarios, and espe- approach, which was more broadly Establishing Expectations cially during high-stress events. accepted among diverse national The foundational components of effec- cultures than earlier versions. This tive EM-CRM are full and interactive The Cost of Failure model broadens its scope by “trap- briefings and strict adherence to SOPs. Many successful airlines outside the ping” errors before they become Knowing that many flight crews meet Western hemisphere — such as Emir- consequential and by mitigating the for the first time at the pre-flight brief- ates, EVA Air and Singapore Airlines — consequences of errors that have ing, it might appear difficult to quickly operate with robust multicultural CRM/ eluded earlier defenses.7 establish team spirit and encourage open ADM training, and their focus on safety dialogue. The airlines’ training programs has paid significant results. But what of Aviator’s Mindset must encourage trust and reinforce their the emerging-market nations, includ- Certain high-risk/high-stress profes- non-punitive policy on error as part of ing China, India, Indonesia, growing sions such as aviation and medicine that SOP. With organizational emphasis Middle Eastern countries and Vietnam, attract individuals with specific psy- on the commitment to further reduce which are rapidly filling their ranks with chological characteristics, particularly error-inducing conditions, captains can skilled, Western-trained (and, increas- communicative processes. These pro- then more effectively brief all crewmem- ingly, Eastern-trained) expatriate pilots cesses are called behavioral markers.8 bers on expectations and obligations and staff? One of the negative behavioral to diminish hesitation and uncertainty, Many air carriers in these coun- markers of aviation professionals is either of which constitutes a serious tries are purchasing advanced equip- denial of vulnerability to stressors safety threat.10 ment. However, some lack the ab
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initio training and multi-crew pilot licensing Notes that are used by most Western European 1. Hellenic Air Accident Investigation and Aviation carriers with superlative safety records. It Safety Board. Aircraft Accident Report 11/2006, is vitally important that new entrants cre- Helios Airways Flight HCY522, Boeing 737-31S, at ate proactive, sixth-generation CRM-based Grammatiko, Hellas, on 14 August 2005. training, as have their Western counterparts. 2. Helmreich, Robert L.; Merritt, Ashleigh, C. Safety Recurring regional instances of safety lapses and Error Management: The Role of Crew Resource Each airline using advanced equipment suggest that ne- Management. University of Texas Aerospace Crew glecting or overlooking human factors issues Research Project, Department of Psychology, The must tailor the — including effective CRM training — will University of Texas at Austin. 2000. EM-CRM to meet continue to adversely affect commercial avia- 3. Li, C.; Harris, D.; Yu, C. “Routes to Failure: Analysis tion accident rates. of 41 Civil Aviation Accidents From the Republic the specific of China Using the Human Factors Analysis and Conclusions Classification System.” Accident Analysis and needs of Prevention. 2008. Helios Airlines employed 33 percent of its workforce seasonally, in spring and summer 4. Pedersen, Paul. A Handbook for Developing its pilots. only, to move people quickly, and this tran- Multicultural Awareness (2000, 3rd edition). sience of staff contributed to individualism American Counseling Association. over collectivism in the airline’s approach to 5. Helmreich, Robert. “Red Alert.” Flight Safety safety. The first officer had a history of not Australia Volume 10 (September–October 2006). following checklist SOPs, and the captain was
By Wayne Rosenkrans | FROM Orlando Positive Space for Gen Y Engaging young aviation professionals without stereotyping strengthens multi-generational safety culture.
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ascination with generational differences sweeping youth safety movement in American among today’s working aviation profes- history”; confident, with high levels of trust, op- sionals has moved beyond specialists in re- timism and a sense of their generation’s power cruiting and training to others with direct and potential but, individually, relatively fearful responsibilitiesF for operational safety. A recent of failure and prone to pursue “less risky career indicator was the number of presentations and goals”; team-oriented with “strong team instincts Engaging young aviation professionals without stereotyping discussions during the World Aviation Train- and tight peer bonds”; achieving in relation to ing Conference and Tradeshow (WATS 2012) in standardized testing with a “mindset of plan- strengthens multi-generational safety culture. Orlando, Florida, U.S., in April about integrating ning ahead for an orderly future”; pressured in Generation Y (Gen Y) into the industry. Gen Y terms of expectations “to study hard, avoid per- — one of several popular terms, such as millen- sonal risks [and] excel”; and conventional, that nials — refers to people born between 1982 and is “comfortable with their parents’ values” and 2004 by some definitions (Figure 1). supportive of social mores. People who train pilots, maintenance techni- Shelby Beauregard, ambassador for recruit- cians and flight attendants for regional and ment and outreach for the College of Aviation at major airlines raised a few concerns relevant to Western Michigan University (WMU), spoke on safety, but also pointed to advantageous attri- behalf of about 30 WMU students who con- butes based on their experiences with this gen- sider many Gen Y attributes valid, though not eration (see “Cabin Crew Adaptations,” p. 28). necessarily applicable outside the United States Several Gen Y college students acknowledged or to specific individuals. Overall, this group is the concerns and encouraged collaborative concerned that aviation employers will prejudge solutions free of stereotyping. They also shared them as members of Gen Y without knowing their personal ambitions and adaptation to them as individuals, she said. industry safety culture. Maintenance technology “When I [attended] last year, I learned that students said that most Gen Y classmates have some aviation professionals were afraid to retire had lifelong mechanical interests and hands-on because they were afraid of what my genera- experiences, quickly adapt to the most advanced tion was going to do,” Beauregard said. “So instructional/reference technology and now how do we bridge this generation gap we all expect to earn international certifications. feel? … There are many stereotypes that have “As a group, Millennials are unlike any other been placed on Generation Y, and many of these youth generation in living memory,” Neil Howe stereotypes are seen as weaknesses. But I think and William Strauss, specialists in generational issues in the United States, wrote 12 years ago Workforce Generations Today in one of their series of books.1 “They are more numerous, more affluent, better educated and Birth Year Range1 Generation more ethnically diverse. More important, they 1922–1945 Traditionalists are beginning to manifest a wide array of social 1946–1964 Boomers habits … including a new focus on teamwork, 1965–1980 Generation X achievement, modesty and good conduct. Only 1981–2000 Millennials2 a few years from now, this can-do youth revolu- Notes: tion will overwhelm the cynics and pessimists.” 1. Depending on research cited, birth dates for They predicted that Gen Y would be dif- Generation Y typically vary from the early 1980s to ferentiated from older coworkers in the degree the early 2000s. 2. Some demographic specialists prefer this term to which they are special, that is, raised with instead of Generation Y.
the sense that they are collectively “vital to the Source: Sherry Saehlenou, Boeing Commercial Airplanes nation and to their parents’ sense of purpose”;
sheltered, that is, partly “the focus of the most Figure 1 Michigan of Aviation University College Western ©
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that these weaknesses are often misunderstood … I have been taught from a young age that work- and misinterpreted, and that they can actually ing in a group and working as a team is the way become strengths for companies.” to get things done.” The assertion that this generation sees itself At the same time, this generation’s penchant as “entitled” is the most common stereotype for high-stimulation digital environments — she has heard, but she said that “achievement- such as habitually texting, accessing social oriented” is a truer descriptor. However, their networks and listening to music during study, lifestyle aspirations often are seen by older work and leisure activities — and its reputation aviation professionals as out of synch with for leaving employers after one or two years are aviation workplace demands. Citing a few among topics worth cross-generational dialogue tragic, news-making events that have shaped in aviation environments, she suggested. their ideas about spending time with family “We have to remember that we are four gen- since 2001, Beauregard said, “All of the [life] erations working in this industry together, and events that have happened to us constantly re- we all have one dream,” Beauregard said. “[Gen mind us that life is short, so we enjoy flexibility Y] wants to learn from you, so talk with us, not in our schedules … a work[-life] balance. … to us. … We also we need mentorship, [so] con- Generation Y is ambitious; we are not afraid to nect with us … and share your passion.” take on the big tasks. And we appreciate when our creativity and our input are accepted into Gen Y First Officers the workplace.” John Colquitt, describing his preparations before Craig Bentley, a captain and vice president being hired by American Eagle Airlines, re- of operations, Cape Air/Nantucket Airlines, also called that he had spent an unexpectedly long, mentioned these professional/lifestyle aspira- and sometimes discouraging, period as a flight tions. “What has that translated to for those of us instructor. He applied to four air carriers and two in the hiring community at the regional airlines?” cargo operators, and received interview invita- he said. “We see new-hire pilots who request tions from two. Colquitt said that his interview vacation time prior to serving the customary preparation was a team effort by a study group, one year … at the airline, [the point] where most and included Internet-based research on current [airlines] would begin to offer that benefit. We questions that other applicants to airlines had also see numerous requests for time off posted after actual interviews. and restrictions on the Members of the study group role-played to days that they can practice answering expected interview questions, work, which then “took it a step further” by imagining how was unheard- interviewers might ask more probing questions of years ago. and rehearsing how they would buttress answers. But they have They also practiced attitude instrument flying busy social and conducting instrument flight procedures on calendars, their personal computers equipped with Microsoft families are Flight Simulator, a control yoke, rudder pedals important. … and a throttle quadrant, he said. We definitely see that Flight time as a certificated instrument at our airline.” flight instructor and familiarity with analog Some of the Gen Y at- instrumentation proved to be advantages after tributes that ring true to the students being hired in August 2010, recalled Colquitt, also are relevant to aviation safety. who described his training experience on “We like clear instructions,” Beau- two aircraft types. “[If the simulator] instruc-
© Paul Bartlett/iStockphoto© Paul regard said. “We work in groups. tor says, ‘Hey, we are going to shoot NDB
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[nondirectional beacon] approaches’ … [I’m] like ‘OK, I can do this because [I] taught that,’” he said. Sometimes, however, his simula- tor partner would struggle to recall how to conduct that type of approach “because he was raised on GPSs [global positioning system avionics] and GPS approaches,” he said. Colquitt fielded a question about how dis- concerting economic news affects his outlook about his new airline career. “I bring myself to the airline and to the situation [with] the sense that I am not entitled to anything; this is an in- credible opportunity,” he said. “[I think,] ‘You’re going to let me fly this $30 million airplane? Awesome, let’s go — this is fun!’ … That is what drives my positive attitude a lot of the time. … Now, I do see the signs … and I am trying to be smart with my decisions professionally.”
Surprising Failures Areas of failure by Gen Y and other pilot ap- data and say, ‘You need to know the weather.’ So Some leaders of U.S. plicants in regional airlines’ pilot hiring pro- that’s a weakness. regional airlines said cesses also were highlighted. “We have found “We give them [the type of instrument ap- they highly value in our own syllabus that if somebody is not proach chart] that they are used to using and say, pilot applicants who getting through the simulator training program ‘Alright, the glideslope is out of service on this bring advanced … either they can’t keep up with the pace of the runway. What is the missed approach point on jet training, flight program, or they are far behind on instrument a non-precision approach?’ We hear a variety of instructor experience skills and procedures,” said Paul Preidecker, a disappointing answers. … We make an assump- and high academic captain and chief instructor, Air Wisconsin tion that a commercial–instrument-rated pilot performance. Airlines. “I am not talking about [instrument] knows those things. If we discover [such weak- scanning, although that is certainly part of it. I nesses] in an interview, the chance that they will am talking about fundamental knowledge of get hired is not so good.” instrument procedures. This, of course, is a Research by Air Wisconsin into the underly- surprise to us. … Maybe we are taking an ‘old ing causes of such applicant failures suggested that school approach’ and trying to apply it to the some Gen Y pilots may be unfamiliar with piloting ‘new school,’ but I don’t think so.” fundamentals associated with legacy systems During the technical portion of face-to-face because of their sometimes-exclusive experience interviews by the airline, “we put a METAR with advanced avionics and flight systems. [aviation routine weather report] in front of When asked the question about the missed them and just say, ‘Read this to us,’” he said. approach point, one applicant erroneously “said “There are people coming to us who cannot do very confidently, ‘It’s at the end of the runway,’” that. In moments of exasperation, when I say, Preidecker recalled. “We said … ‘Suppose you ‘What’s the problem?’ [their] common comment are in the clouds, and you can’t really see? He is, ‘Well, I don’t get it in raw format. I pull out said, ‘I don’t know, I just look on my [Garmin] my iPhone and read the decoded version.’ [Then G1000.’2 Has there become an over-reliance on I tell them,] ‘That’s great, except we don’t do automation? Perhaps. … A lot of the people we
© Embry-Riddle University Aeronautical that in our airplanes. We hand [flight crews] raw are hiring right now … only know the new way.
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Cabin Crew Adaptations
ntegrating Generation Y (Gen Y/millennial) flight attendants Johan Bostrom, a captain and director, training opera- into the airline industry has required a bit of flexibility in tions, Novair, focused on lessons learned while teaching a Ithe training community, according to several specialists. six-week course in 2011 at the Swedish charter airline. “We “The millennials are coming up with their own experiences, graduated 36 brand-new cabin crew between the ages of 21 their own ways of communication — which we need to learn,” and 45,” he said. “The majority of the students actually were Sherry Saehlenou, cabin safety instructor, Boeing Commercial born in the late 1980s and early 1990s — [Gen Y] people.” Airplanes, told a session of the World Aviation Training Trainers had been “nervous” that their exciting new comput- Conference and Tradeshow 2012. “They want to know what er-based training modules and online testing were not ready is expected from them right from the top, and then [to be in time for this group, he said. shown] the steps leading up to it. … They want their informa- “To our surprise, [Gen Y students] weren’t so eager to go on- tion in chunks, they want it right now. … They want it simple, line for the course-related issues,” said Anna Mellberg Karlsson, and they want you to be honest. So eliminate the unnecessary.” chief cabin safety instructor, Novair. Moreover, in post-training She said that one Gen Y student explained to her, “We get 80 feedback, they rarely mentioned technology and preferred texts in a day. We are so connected. … So you [had] better tell studying a printed manual in the classroom. Gen Y students, me in the first two sentences why I need to read your email. … however, immediately adapted to using a new Internet portal Life is moving so quickly that I don’t have time [otherwise].” outside the classroom to access online manuals and weekly Generational differences can exacerbate interpersonal company bulletins. “[Other flight attendants] from age 37 and communication barriers, a potential safety issue for crewmem- up … didn’t like it at all when we put our manual on our portal bers, said Colette Hilliary, flight/cabin attendant program man- and took their books away, and there is also hard resistance ager, FlightSafety International. “We don’t want to box anyone against Web-based training among them,” Karlsson said. in [with stereotypes], but we do understand that the genera- In the airline’s crew resource management (CRM) course, tions are diverse. … [Gen Y people] are very confident [about] Gen Y pilots and flight attendants “actually are very assertive,” their preferred methods of communication … and sometimes Bostrom said. “Today, we [still] need to train our crew to be are impatient with people like me who haven’t kept up with assertive, but to understand when [to be assertive].” Karlsson the leading edge of technology,” she said. added that among Gen Y CRM students, “The majority are One effect is that a choice of communication method ‘blind’ to hierarchy.” can be emotionally divisive, said Shari Frisinger, president, Ann-Charlott Strandberg, head of training and quality CornerStone Strategies. “I hate when people text me … manager, Cabin Aviation Training, said that about three- especially if [they] are in the next room. My thought is, ‘You’re fourths of the Swedish company’s first 500 students were texting me? I am not worth [the] five steps to come over and born between 1981 and 1990. “We’ve had to change our talk to me?’ So we have to look at this, again, from the other methods of training to suit the students,” she said. This person’s point of view, from the different generations.” involves taking a learning-style inventory and customizing In 2011, Austrian company Flight Attendant Safety lessons accordingly for each category of student. Training trained 2,000 new flight attendants for Lufthansa Instructors encourage appropriate classroom Internet with particular attention to the attributes of Gen Y students, uses, such as Google/YouTube research conducted on said CEO Wolfgang Jabornik. “They are used to doing last- smartphones, but struggle to enforce a “Facebook-free en- minute learning, and they do not read manuals because they vironment in the classroom during classes,” Strandberg said. [prefer to] learn with trial-and-error,” he said. “They also have They ended up creating a Facebook group for students and a shorter attention span than earlier generations, and they instructors to post after-hours questions, answers and com- lose interest very quickly if the learning environment does ments about the course. not facilitate [creativity].” — WR
Somewhere in between [the old way and only academies or flight programs accredited by having automation experience] is probably what the Aviation Accreditation Board International we are looking for.” have experienced a washout rate of less than 5 A counter-impression of recently hired Gen percent in company training. As a result, the Y pilots came from Cape Air’s Bentley. He noted airline’s hiring process for these applicants omits that pilot applicants trained by professional simulator checks and written exams, he said.
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“The most important thing that we look for for some time, although I think that the con- … is a safety mindset,” Bentley said. “Where do solidation that is taking place is probably going they get that? Early in their training, hopefully, to be good for the industry and good for the where they understand what a just culture is employees. … We may end up hiring entry- and the value of open, non-punitive reporting level [airline] pilots for their first airline to programs. … Some of the key things we look for be a major airline, which we have never done are fundamental stick and rudder skills … good before. This would be a major paradigm shift communication skills, leadership qualities, the for us if it happens.” ability to be a lifelong learner [and] to change Gen Y’s professional/lifestyle aspirations to the demands in the industry, whether they have been reiterated in two surveys, includ- be regulatory or economic. … So I would put it ing one with responses from 206 University to … the industry that [given Gen Y technical of North Dakota (UND) aviation students, prowess], we will spend a lot less time training primarily concerning the proposed rulemak- the new aviators on the gadgets that we have ing to implement a 2010 U.S. law mandating in our airplanes, and a lot more time teaching airline transport pilot (ATP) certificates and them the fundamentals of flying an airplane.” 1,500 hours of flight time for airline first officers Chief pilot offices and airline training de- (ASW, 9/10, p. 12), said Kent Lovelace, chair- partments swap anecdotes about Gen Y pilot be- man, UND Department of Aviation. havior that falls outside company expectations, “It goes back to those generational priorities and companies’ corrective responses. “Stories that some of these young people have,” Lovelace ‘We may end up from my colleagues … sort of let me know that said. “Time away from family and friends is a hiring entry-level what I experience at Cape Air and our group big concern, and it is a priority. … We all maybe
is not unique in the industry,” Bentley said. have those feelings.” He suggested industry con- [airline] pilots for “There is the story of a first officer at a [major sideration of explicitly setting up schedules and air] carrier who was skateboarding across the other practices to make aviation careers more their first airline to ramp on his way to preflight his airplane for attractive to Gen Y. the first flight of the day. … There is the story “Another [theme in the UND survey] was the be a major airline, of the [commuter air carrier] captain who was kind of flying they want to do, which is more which we have jumpseating home and thought it would be a hands-on flying as opposed to autopilot-FMS great idea if she used the [skate shoe wheels] in [flight management system], which obviously for never done before.’ her sneakers to get down the jetway to ask for an airline career isn’t necessarily realistic,” he said. [a] ride home. In the past, those indiscretions Other responses reflected firm commit- might have been met with stiff consequences.” ments to stay the course to airline flight decks, He advised mentoring and leadership to “help however. “So, we still have a lot of determined steer [young aviators] in the right direction so young people out there that want this career,” that we have what the public demands.” Lovelace said, quoting a student who wrote, “I’ve had the dream to fly for an airline forever, Contextual Issues since I was three or four years old. I won’t let “Any way you cut it, this is a difficult business … anything stand in my way.” the last 10 years since 9/11 have been extreme- ly difficult,” said Paul Railsback, a captain and Notes director of operations, Airlines for America 1. Howe, Neil; Strauss, William. Millennials Rising: The (formerly the Air Transport Association of Next Great Generation. Cartoons by Matson, R.J. America). “Anybody who comes into this New York: Vintage Books, 2000.
industry needs to realize — and needs to be 2. The Garmin G1000 is an all-glass, integrated avion- emotionally prepared for the fact — that this is ics suite designed for installation by original equip- … probably going to remain a tough business ment manufacturers.
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flightDECK
How to prevent hazardous emotions in the cockpit.
Angry BirdsBY HEATHER BALDWIN
n May 2011, a European regional airline While the situation falls at the extreme of captain, in what he thought was jovial banter, pilot anger and miscommunication, it highlights called his first officer (FO) a derogatory the complexities of cockpit communication. Pi- name during preflight preparations. Later, lots often fly with crewmembers they barely know Ihe ignored the FO’s advice to avoid dark storm — or have never met — and with whom they clouds. The FO, still seething from the preflight may well have innate personality conflicts. If they put-down and now furious about the heavy are former military, they may have firm notions turbulence they were encountering, called the about rank and hierarchy that are not shared by captain a “control freak,” and a heated argument their flying partner. They may be dealing with ensued. They flew the return trip in virtual marital or financial difficulties that make them silence, and both pilots subsequently were fired more irritable than usual. They might have slept for their unprofessional and unsafe conduct. 1 poorly in an unfamiliar hotel in a far-flung time
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flightDDECKECK
zone. Add to all that the high-pressure environ- FOs, he made some changes and his workplace ment of commercial flight — and the inability of relationships improved dramatically. pilots to “step out of the office” and walk off anger — and it’s easy to see how a brusque, unthinking Seek to Understand comment can bruise an ego, fuel a temper and When you first meet the person with whom become the source of a multi-day standoff. you’ll be flying on a trip, be careful not to judge “Negative interactions between cockpit too quickly, advised Michael Crom, executive crewmembers can contribute to an environ- vice president and chief learning officer at Dale Better ment where people feel unsafe or unsure Carnegie & Associates. “Check your assump- understanding about saying what’s on their mind,” said Ron tions; they may not be accurate,” said Crom. Nielsen, a retired US Airways captain, profes- If someone initially comes across as cold, it your flying partner sional counselor and founder of FearlessFlight. may simply mean they are slow to warm up to “I have been in many crew situations where unfamiliar people, not that they are difficult. Or starts with better ‘elephants’ in the cockpit were as much a part if you make a joke and the other pilot doesn’t of the crew as either of the pilots.” Nielsen and react, it doesn’t mean that person is a jerk, Crom understanding other behavioral specialists say that eliminating said. It could mean that he or she has heard the yourself. these elephants and maintaining a congenial, joke 10 times before, or is a serious person, or is professional relationship in the cockpit is a thinking hard about something else and not able matter of learning good relationship-building to process the joke while processing the other and conflict-resolution skills. Here are five information. Be open to other possibilities. Too- steps for becoming better at both: quick judgments lead to misunderstanding and miscommunication. Know Your Style Better understanding your flying partner starts Be Slow to Anger with better understanding yourself, said Nielsen, Pilots can head off personal conflict before it ever who recommends that all pilots take the DISC gets started by making a conscious decision to personality assessment.2 When Nielsen used to keep their anger in check. “The things that start counsel with “difficult” pilots, one of his first arguments seem important in the moment, but moves was to administer a DISC assessment, when you think about it later, you realize they were which helps people better understand their really petty,” said Doug Staneart, chief executive own behavioral style and what other behavioral officer of The Leaders Institute, an organization fo- styles are likely to cause conflict or tension. cused on next-generation leadership development. This knowledge minimizes personality clashes For instance, the captain who called his FO by helping pilots understand the “why” behind a derogatory name was certainly unprofessional, their differences. but had the FO not allowed it to light the flames Nielsen once counseled a captain whose of anger, both pilots might still be employed. “The DISC assessment revealed that he highly valued natural human reaction when we feel insulted or both adherence to standards and not imposing offended is to get angry and respond in kind,” said his will on others. These values would often Staneart. “But generally people aren’t intentionally clash when an FO wasn’t exactly following trying to make the other person mad.” procedures but the captain was reluctant to force “You’ve got to be able to distinguish between the issue. “The captain would just sit there and what was said and your interpretation of what wait,” Nielsen recalled. “It took the FO about was said,” added Larry Barkan, an expert in three seconds to get steamed, and then there conflict resolution and associate of The Pivotal was a war in the cockpit.” Once the captain Factor, a consulting firm. The vast majority of the understood these aspects of his personality and time people are not aware that they have caused
© kickers/iStockphoto.com became conscious of how they were affecting his offense and did not mean to do so. “Hold onto
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your anger until you understand the other per- and even though it [the checklist] was in front of son’s intent,” said Barkan. “Be willing to give up me, he could tell I was doing it from memory,” being right and making the other person wrong.” he said. “He let me get about two-thirds of the way down the list and then he said, ‘Read the Question Mistakes [expletive] checklist!’ I’d been doing this all trip, Occasionally, one pilot needs to point out so obviously his ire had been gradually rising another’s mistake. To bring attention to an error until he finally blew.” without creating hostility, use a question, said Had the captain said, “Hey, Ron, could Staneart. Questions feel less threatening than you reference the checklist more accurately?” direct orders or factual statements, so they are Nielsen said he’d have been happy to comply. more likely to keep the atmosphere congenial. Instead, with just a few heated words, the cap- For instance, if an FO shows no sign of initiat- tain destroyed their working relationship for the ing the descent at the right time, the captain could remainder of the trip. say, “Hey, would you mind beginning the descent To bring attention in the next five to ten miles?” Or if a pilot misses Speak Up an item on a checklist, the other could say, “Could No matter how well someone manages cockpit re- to an error without you double check those last three items?” This ap- lationships, there will be times when a flying part- creating hostility, proach will elicit cooperation and appreciation for ner causes feelings of anger, frustration, offense cool handling of a lapse, whereas an admonition or or other negative emotions. When that happens, use a question. biting remark will create animosity. speak up as soon as it is feasible, because silence Unfortunately, the latter approach is all too gives tacit approval to the action, fosters misunder- common. Nielsen once flew with a captain who standing and is unfair to the offender, who likely painstakingly adhered to standard operating has no idea he or she caused bad feelings. procedures. One day after about three legs, the Start by asking permission. Questions such as captain called for a checklist, and Nielsen started “Can I give you feedback on something?” or “Can calling the items. “I’d done it about 50,000 times I tell you how your last comment landed with me?” are good openers and will prepare the person to receive input. Barkan likens the “per- mission” question to letting someone know you are going to throw a ball. “If I throw you a ball without telling you it’s coming, you might not catch it because you aren’t ready,” said Barkan. “It’s the same thing in resolving conflict.” Next, describe how their words or behavior impacted you and what you’d like the person to do
instead. For example, Woodward/iStockphoto.com © Forest
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“When you swear at me, it feels demean- ‘Innerview’ Conversation Starters ing. When you’d like me to do something ockpit conversations can be tricky. What and appreciate their flying partners and foster differently, my request do you talk about with a person you’ve a positive atmosphere in the cockpit. Here are is that you point out Cnever met and with whom, based on some examples: the problem without initial impressions, it seems you have little in Factual Questions using profanity.” Then common? The age-old advice about avoid- Where did you grow up? leave it there. Many ing conversational minefields such as politics and religion still holds true today, and smart people make the What kind of activities were you involved with pilots will sidestep these topics. So how do as a child? mistake of going on you start a good conversation that builds a What was your first job? to explain themselves, positive relationship? Where did you go to school? but that’s a trap. Ask your flying partner about himself or “Use as few words herself, says Michael Crom, executive vice How long have you worked here? as possible because president and chief learning officer, Dale What is your family situation? Carnegie & Associates. “Most people like to the more you ex- What do you do outside of work? talk about themselves, and if you’re interested plain yourself, the in me, that’s a pretty interesting topic,” said Causative Questions weaker your argu- Crom. Furthermore, by getting co-workers to Why did you pick that particular school? ment becomes,” said open up about their backgrounds, their hob- How did you happen to work for this company? Barkan. “If you get bies, their families and more, you will better How did you get involved with that particular into the reasons you understand them, decreasing the likelihood of conflict. hobby? feel insulted or of- The key to doing this well is to plan ahead. Value-Based Questions fended, you’ll wind Crom and his team arm clients with a list of up in a discussion of “innerview” questions so they are always pre- Tell me about a person who had a major im- whether your reasons pared to build relationships and gain insights pact on your life. are valid.” into others. The questions, he said, should Tell me about a turning point in your life. Last, gain commit- not feel like an interrogation but should be Tell me about a high point in your life. sprinkled naturally into conversations. When ment by asking, “Will What was a particularly low point for you? delivered with an attitude of genuine interest you do that?” Don’t ask What got you through it? and nonjudgment, they help to open the lines — HB “Can you?” or “Could of communication so pilots better understand you?” or ”Will you try?” And make sure your tone of voice is neutral so the other person doesn’t feel threatened cooperative, more enjoyable and ultimately safer or challenged. Most of the time, you’ll get a “yes” working environment. and the conflict will be resolved, paving the way Heather Baldwin is a Phoenix, Arizona–based freelance for a positive working relationship. If you get a writer. A pilot and former U.S. Army officer, she writes “no,” seek to understand the other pilot’s point of regularly about aviation, military issues and topics related view with genuine curiosity, not judgment. to management and workplace performance. In an emergency, safety must take prece- Notes dence over worries about interpersonal relation- 1. Daily Mail Online. April 19, 2012. ships. If the left engine is on fire, the captain shouldn’t be fretting about how to best com- 2. DISC, or DiSC, is a behavioral model developed by William Moulton Marston, a psychologist. As described municate this. But those situations are rare. The in Marston’s 1928 book Emotions of Normal People, rest of the time, it’s worth paying attention to the model comprises four primary behavioral styles: the critical skills of relationship building and dominance, inducement, submission and compliance. conflict resolution in order to create a more DISC self-assessments are available via the Internet. flightsafety.org | AeroSafetyWorld | August 2012 | 33 Let AeroSafety World give you Quality and Quantity
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persistent problem BY CLARENCE E. RASH
• Performing an extra or non-required task; An analysis of lthough annual accident rates for U.S.- U.S. helicopter registered civil helicopters decreased and • Failing to perform a task within the re- leveled off in the past decade (Figure 1, p. accident rates quired time limit; and, 36), the role of human error — primarily • Failing to respond adequately to an emer- shows no pilotA error — persists (ASW, 12/11–1/12, p. 34). gency situation (which abruptly changes decrease in Sixty-nine percent of the 1,653 accidents in not only the goal but also the tasks re- pilot error. the U.S. National Transportation Safety Board quired to achieve the new goal). (NTSB) database involving U.S.-registered civil helicopters from 2001 through 2010 were Humans are a remarkably robust species — cre- attributed to pilot error.1 This implies that ap- ative, flexible and adaptive to our surroundings proximately seven of every 10 accidents were and the constantly changing demands placed on a consequence of human action — or lack of us. Our weaknesses include frequent inability to action — by pilots (Figure 2, p. 36). maintain alertness (attention) and to respond to Exactly what constitutes human error? One a situation with the correct actions.4 formal definition is “an inappropriate action or Realistically, human error may be unavoid- intention to act, given a goal and the context in able. However, it can be reduced significantly which one is trying to reach that goal.”2 through training, mistake-proofing designs and Human error can include any of the developing prevention strategies such as check- following:3 lists. Errors can increase with fatigue, physical and emotional stress, use of alcohol and other • Failing to perform, or omitting, a task; drugs and medications, and a host of other
© Manwoiste/Dreamstime.com • Performing a task incorrectly; environmental and psychosocial factors.5 These
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for a task or are overwhelmed by other events. For Accident Rates Involving U.S.-Registered Helicopters, 1963–2010 example, in the Three Mile Island nuclear power plant accident in Middletown, Pennsylvania, U.S., in 1979, the attention resources of the safety moni- 38.4 toring personnel were overwhelmed by more than 100 simultaneous warning signals. Mistakes are errors that correspond to in- correct intentions or plans. These are errors in
15.9 choosing an objective or specifying a method of achieving it. Mistakes are identified as being rule- 9.6 7.8 8 5.7 based or knowledge-based. Rule-based mistakes are made when the wrong rule is selected for ac- Accidents per 100,000 ight hours** per 100,000 ight Accidents
1963–1970* 1971–1980 1981–1990 1991–2000 2001–2010 tion — that is, actions match intentions but do not Decade achieve their intended outcome due to incorrect application of a rule. An example is the use of the * The first helicopter accidents in the U.S. National Transportation Safety Board database occurred in 1963. wrong type of fuel in an engine. Knowledge-based ** Estimated flight hours mistakes are made when the wrong plan is created
Source: Clarence E. Rash for a particular situation. In this type of mistake, the plan may suffer from a lack of knowledge or Figure 1 understanding of the situation. An example is factors can negatively when a pilot incorrectly diagnoses a problem with Accidents by Causal Factor, 2001–2010 influence the ability a new navigation system without having a full to observe, detect and understanding of how the system works. assess ongoing events. Undetermined This can lead to slow Learning From Mistakes 10.4% Other reaction times and To characterize the types of human error associ- 3.1% Environment poor decision making, ated with individual accidents, it is necessary 1.3% both of which can to apply a formal accident causal factor analysis Manufacturer fault 1.0% Pilot error lead to errors. and classification system to accidents in which Maintenance error 69.0% 3.9% Cognitive science the NTSB identified pilot error as the first event Material failure describes several pri- causal factor. 11.1% mary types of human One system for analyzing human error in errors, each corre- aviation accidents is the Human Factors Analy- sponding to different sis and Classification System (HFACS). HFACS Note: Does not total 100 percent because of rounding. stages in the cognitive was originally developed for the U.S. Navy and Source: Clarence E. Rash or decision-making Marine Corps as an accident investigation and 6 9 Figure 2 process. In one analysis tool. Since its original application, it model, human errors has been used worldwide by both military and are typed as either slips and lapses or mistakes. civilian organizations as a supplement to stan- Slips and lapses correspond to errors in execu- dard accident investigation and analysis meth- tion and/or recall of learned steps of an action ods. HFACS is widely recognized for its ability sequence; for example, a person may intend to to produce comprehensive human error data. perform an action but actually does something else HFACS is a broad human-error approach for instead. Errors of this type also include forgetting investigating and analyzing the human causes of to reposition a switch, or shutting off the wrong aviation accidents. Based upon human perfor- engine during an emergency.7 Slips and lapses usu- mance specialist James Reason’s Swiss cheese ally occur when attention resources are insufficient model of latent and active failures, HFACS
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addresses human error at all levels of from transmission wires while per- but rare departures from mandated the system, including the condition of forming low altitude operations.”12 procedures and are not necessarily in- the aircrew and organizational factors. Examples of decision errors include dicative of an individual’s typical behav- HFACS captures data for four top using the wrong procedure, misdiag- ior or condoned by management.15 levels of human-related failure: nosing an emergency and performing The most common violations an incorrect action. One such accident were improper preflight planning • Unsafe acts; involved a dynamic rollover during and inspections. Inadequate in-flight • Preconditions for unsafe acts; the attempted Oct. 29, 2002, takeoff fuel management also was com- • Unsafe supervision; and, of a Hughes 369D in Kaaawa, Oahu, monly cited in accident investigation Hawaii, U.S., because of what the NTSB reports. In an October 2002 accident • Organizational influences. called “the combined effects of the soft, involving a Bell 47G3B1 helicopter, These four top levels of human-related sloping terrain and the pilot’s failure to a commercial pilot had completed a failure are expanded into 11 causal cat- redistribute the passengers to a more timber spraying operation near High- egories that are further expanded into 10 favorable lateral [center-of-gravity] falls, Georgia, U.S., and felt a surge subcategories, described as follows:10,11 condition.” The pilot and a passenger of engine power, then a power loss. on the on-demand air taxi flight were The helicopter struck trees during the Unsafe Acts seriously injured and the second pas- autorotative landing. The NTSB said The unsafe acts level is divided into two senger received minor injuries in the there was no fuel in the helicopter’s categories: errors and violations. These crash, which destroyed the helicopter.13 fuel tanks and cited as the probable categories differ in “intent.” Perceptual errors are those made cause the pilot’s “inadequate fuel Errors are unintended mistakes because of visual illusions or spatial management and subsequent loss of and are further categorized as skill- disorientation. An accident attributed engine power due to fuel exhaustion, based errors, decision errors and to perceptual error was the Sept. 17, and an in-flight collision with trees.”16 perceptual errors. 2010, crash of a Robinson R44II into a Examples of skill-based errors in- lake near Duluth, Minnesota, U.S. The Preconditions for Unsafe Acts clude inadvertently omitting an item on pilot said that, after taking off around The preconditions for unsafe acts level is a checklist, failing to prioritize actions midnight from a beach at the lake, he divided into two major categories: sub- and omitting a procedural step. had “a sinking feeling in the seat all of a standard conditions of operators and One accident in which a skill-based sudden” and saw that the vertical speed substandard practices of operators. error was cited as the major causal fac- indicator displayed a descent. He could The substandard conditions of op- tor was the Nov. 10, 2002, collision of a not determine the helicopter’s height erators category is divided into three Eurocopter AS 350B with a transmis- above the water because of the dark- subcategories: adverse mental states, sion line in Kingman, Arizona, U.S. ness, and the helicopter hit the water at such as complacency, “get-home-itis” The purpose of the flight was to film a about 60 kt and was destroyed. The pilot and misplaced motivation; adverse traveling motor home for a television received minor injuries. The NTSB said physiological states, such as medi- series. While maneuvering 60 to 75 ft the probable cause was the pilot’s “failure cal illness and physical fatigue; and above ground level to maintain the best to identify and arrest the helicopter’s physical/mental limitations, such as angle for the camera, the pilot saw a descent due to spatial disorientation.”14 inadequate reaction time and incom- cable in the flight path. He initiated a Violations are willful errors. patible intelligence/aptitude. rapid deceleration, but the helicopter Examples include violating training The substandard practices of opera- struck the cable and then the ground. rules, performing overly aggressive tors category has two subcategories: The two passengers received minor maneuvers and intentionally exceeding crew resource management, including injuries and the helicopter was substan- mission constraints. Violations are sub- problems such as failure to use all avail- tially damaged in the crash. The NTSB categorized as routine violations, which able resources and failure to coordinate; report cited as the probable cause the tend to be habitual by nature and often and personal readiness, which includes pilot’s “inadequate visual lookout and tolerated by governing authority, and as problems of self-medication and viola- failure to maintain adequate clearance exceptional violations, which are willful tion of crew rest requirements. flightsafety.org | AeroSafetyWorld | August 2012 | 37 HelicopterSafety
Unsafe Supervision this analysis of pilot error, there are no Pilot Error Classifications The unsafe supervision level is divided errors in this category. into four categories: inadequate Unsafe Pilot Error Analysis supervision supervision, such as failure to provide Unsafe 7.8% preconditions Organizational training, failure to provide opera- Most narratives in the NTSB accident 0.8% influences tional doctrine and failure to provide database include causal factor state- 0.0% oversight; planned inappropriate ments that use key words and phrases operations, such as failure to pro- described in the HFACS, but a sig- vide correct data, failure to provide nificant number of narratives lack sufficient personnel and failure to sufficient detail to allow indisputable Unsafe acts provide the opportunity for adequate classification. As a result, in the follow- 91.3% crew rest; failure to correct a known ing accident analysis, some educated problem, such as failure to initiate judgments were necessary. Determi- corrective action and failure to report nation of error type and category was Note: Does not total 100 percent because of unsafe tendencies; and supervisory based on the accident investigators’ full rounding.
violations, such as authorizing an narratives, with emphasis on the initial Source: Clarence E. Rash unnecessary hazard and failure to causal factor in the accident sequence. Figure 3 enforce rules and regulations. A summary of the classification analysis using the four top levels of the (Table 1). Accidents in other categories Organizational Influences human-related failure HFACS scheme were recorded in far fewer numbers. The organizational influences level is is presented in Figure 3. Unsafe acts ac- Throughout the decade, the percentages divided into three categories: resource/ counted for 91.3 percent, 7.8 percent were for each failure type are fairly consistent; acquisition management, including lack classified as unsafe supervision, and 0.8 this implies that the human factors at the of funding, poor equipment design and percent were classified as preconditions root of each error type have not changed insufficient manpower; organizational for unsafe acts. As expected, the HFACS over time. climate, including policies on drugs analysis of only pilot error meant that no and alcohol, value and belief culture, accidents were placed in the organiza- Unsafe Acts and chain-of-command structure; tional influences classification. In the unsafe acts category, errors (83.4 and organizational process, including An examination of the decade per- percent) greatly exceeded violations (7.9 quality of safety programs, influence centages for all failure types shows that percent) for the decade. Within the errors of time pressure and the presence or an overwhelming number of accidents category, skill-based errors (53.1 percent) absence of clearly defined objectives. In each year are classified as unsafe acts exceeded decision errors (25.6 percent)
Summary of Pilot Error Accidents, 2001–2010, Classified as Unsafe Acts
Unsafe Acts 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2001–2010 Errors 85.5% 81.1% 82.7% 88.6% 84.7% 87.4% 86.7% 74.7% 80.2% 80.8% 83.4% Decision errors 26.5% 26.5% 21.6% 30.7% 27.7% 26.2% 26.7% 24.2% 24.8% 19.2% 25.6% Skill-based errors 53.0% 49.2% 57.6% 50.0% 54.0% 55.3% 59.2% 40.4% 52.5% 60.3% 53.1% Perceptual errors 6.0% 5.3% 3.6% 7.9% 2.9% 5.8% 0.8% 10.1% 3.0% 1.4% 4.7% Violations 7.7% 11.4% 10.8% 2.6% 2.2% 5.8% 5.0% 14.1% 10.9% 11.0% 7.9% Routine 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% Exceptional 7.7% 11.4% 10.8% 2.6% 2.2% 5.8% 5.0% 14.1% 10.9% 11.0% 7.9% Total 93.2% 92.5% 93.5% 91.2% 86.9% 93.2% 91.7% 88.8% 91.1% 91.8% 91.3%
Source: Clarence E. Rash
Table 1
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by a factor of two. Perceptual errors aver- percent) was used almost exclusively to Notes aged a relatively low 4.7 percent; however, characterize failures of instructor pilots 1. Another 4 percent were attributed to perceptual errors are the most difficult to maintain adequate supervision of maintenance error; and less than 1 percent type to discern, and their incidence most student pilots during training or of rated involved errors attributed to manufacturer, ground or control tower personnel. likely is underrepresented. pilots during check rides. The NTSB As would be expected, most skill- accident narratives repeatedly cited 2. Felciano, R.M. Human Error: Designing for Error in Medical Information Systems. based errors were failures by the pilot improper supervision or failure to take Stanford University. 1995. to perform at the subconscious skill corrective action as the causal factor. 3. Adams, C. What is Human Error?
New FAA programs find and fix hidden risks.
BY JOSEPH TEIXEIRA
n the United States, 99.998 percent of air Without waiting for accidents or incidents traffic operations take place according to to occur, the FAA has found a way to identify the U.S. Federal Aviation Administration’s and correct potential risks. Two FAA voluntary (FAA’s) strict safety guidelines. However, safety reporting programs for front-line employ- Iwith controllers guiding as many as 7,000 flights ees already are producing results. at any one time, even a fraction of a percent of The confidential, nonpunitive programs Jon Ross/U.S. Federal Aviation Administration Aviation Federal Jon Ross/U.S. Straight to the deviation can put an aircraft at risk. draw information from the men and women
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who guide the nation’s airplanes and maintain control facility in Norfolk, Virginia, said she and the equipment necessary to keep the National other front-line managers were worried at first Airspace System (NAS) running. One program that controllers would use ATSAP’s non-punitive was designed to engage air traffic control- element as an opportunity to take less care when lers, and the other was designed for technical performing their duties. Instead, the program operations specialists; both were developed in has had the opposite effect, she said. Controllers partnership with their respective unions. are reading the program’s regular briefing sheets The programs go to the source for advanced (which do not include information that could knowledge. The FAA trusts its front-line em- identify the reporter) and learning from col- ployees to be our greatest resource to eliminate leagues’ experiences. risk in the NAS. “The briefing sheets make the controller know that the things he or she is doing at the Getting Results point of decision aren’t isolated,” Moses said. The controllers’ Air Traffic Safety Action Pro- “Other controllers are experiencing the same gram (ATSAP) is attracting substantial partici- kinds of breakdowns, and we need to get to the pation. More than 60 percent of controllers have point that we’re not setting ourselves up for it to voluntarily submitted at least one ATSAP report happen again. The information is helping con- — more than 48,000 total — since the program trollers watch for those things and correct those was implemented in 2008. things early, rather than waiting for something to Most importantly, the program gets results. happen and filing an ATSAP report afterward.” After reviewing ATSAP reports, safety panels The fact that the reports are written by comprising representatives from the FAA’s Air fellow controllers enhances the likelihood that Traffic Organization (ATO) and Air Traffic Safety the information will be compelling and re- Oversight Service, and the National Air Traffic Con- membered. Controllers hear the language and trollers Association (NATCA) have asked for cor- terminology used by other controllers, and it rections that have been implemented in 150 cases. resonates with them much more than anything Thanks to ATSAP, pilots now get better in- an outsider could tell them. formation about runways that have been short- Moses has been able to use the informa- ened for construction, trees have been removed tion from the briefing sheets to help guide new to improve coverage of an airport surveillance controllers through training and prepare them radar system, and condensation that obstructed to handle air traffic on their own. “With the controllers’ vision has been cleared from tower information from ATSAP, I can see early trends cab windowpanes. with new controllers,” she said. “And we can help The FAA sees another safety benefit from people who struggle in training break some of ATSAP: It encourages reflection that leads to the bad habits that may eventually lead to bigger learning. Reporting a safety event requires a issues. I hope it becomes entrenched in the op- controller to describe what happened and what eration. I hope we stop calling it a program, and The FAA said that the should have happened. it just becomes part of how we do things.” success of a safety The sheer act of explaining what you did As it becomes entrenched, ATSAP will reporting program and why you did it is the fundamental tenet of continue to help solve safety issues that have for controllers voluntary safety reporting. That’s how you learn, nothing to do with the performance of people. has prompted and that learning often extends beyond the In most safety situations, it is not the human be- demonstration of a individual who files the report. ing who is the hazard; it is the policy, procedure, similar program for training or situation. technical operations Managers See Value Along those lines, ATSAP reports have helped specialists. Nysei Moses, a front-line manager at the airport identify and resolve issues with computer-based traffic control tower and terminal radar approach instruction, a restricted area over Washington,
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D.C., and a policy issue that resulted from com- Report Gets a WINKK bining sectors at a major terminal radar approach control facility.
s a result of an Air Traffic Safety Action Program (ATSAP) report, Controllers See Value pilots flying between two busy Northeast U.S. airports now can Ause a route that they readily can program into their flight man- Resolving systemic issues, some of which have been agement systems, making it easier for controllers to issue the route problems for years, encourages more controllers to clearance and reducing pilot-controller communications. use the program. When controllers see that ATSAP Before the change, the route between Philadelphia International is an effective means to resolve long-standing Airport and John F. Kennedy International Airport in New York issues, they become strong advocates for the included a turn at the intersection of an airway and a radial from a nearby navaid. Pilots often had difficulty programming the intersec- program, said Lisa Cyr, a controller at Albuquerque tion into their on-board computers and sometimes said they could not (New Mexico) Center and NATCA national lead accept the clearance. With no other available routing, controllers at for the FAA’s recurrent training program. Philadelphia had to issue radar vectors as part of the clearance, which As part of implementing the recurrent required coordination with controllers at New York Center. training program, which draws much of its On most days, that was not a big deal. Only a few scheduled flights teaching material from ATSAP reports, Cyr operate from Philadelphia to Kennedy. But when thunderstorms or other impediments impacted the region’s airspace, it got compli- traveled to nearly a dozen air traffic facilities cated. When weather or other issues prevent airplanes from landing and talked to 300 controllers and managers at Kennedy, the flights often are diverted to Philadelphia. Once the from all over the country. She heard many problem clears, the diverted planes head back toward Kennedy. stories about how ATSAP’s effectiveness won Many of the diverted pilots work for international carriers or have over front-line employees who were suspicious flown across the country. During that long flight, they may have faced of the program when it first was introduced. weather-related problems, endured holding, had to divert and encoun- tered unfamiliar airspace. If a controller does not issue a straightforward One example came from her control area route, all those factors create risk. But because a controller filed an at Albuquerque Center. After controllers who ATSAP report, the risk is now reduced and the route is more efficient. initially were doubtful about ATSAP saw that it The controller’s report recommended a new area navigation fix at the resolved some minor safety issues at the facility, intersection of the airway and the radial. After local and national safety they began to file regular reports on a major experts studied the issue, the U.S. Federal Aviation Administration created problem. Two of the area’s sectors, one that the new fix, called WINKK, on an accelerated schedule. Controllers can now issue a simple route, and pilots can focus on other duties. handled high-altitude traffic and another that — JT handled very-high-altitude traffic, often had trouble with radio frequencies. The clarity of transmissions on the frequen- cies was bad and getting worse, Cyr said. As a result of several ATSAP reports on the problem, the frequencies are being fixed. Now, controllers who initially were skeptical of the program are some of its most vocal proponents at the facility, Cyr said. (WINKK) In its development of a safety culture, the FAA wants to create an environment in which employees can report safety events without fear of punishment. “We presume the good intent of U.S. Federal Aviation Administration Aviation Federal U.S. our controllers and are more interested in the free flow of information than we are in punish- A controller’s report of a difficult intersection between Philadelphia ing for errors,” ATO Chief Operating Officer and New York prompted the creation of a new waypoint: WINKK. David Grizzle said. “This allows us to identify and address systemic risk.”
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Tech Ops Signs Up Republic Air Holdings airlines, and they will Thanks in large part to ATSAP, the FAA has begin actively participating soon. CISP gives collected 10 times more data in the last three the FAA and the airlines access to information years than it used to receive through traditional they otherwise would not have, elevating man- reporting systems. The agency expects similar agers’ awareness of safety issues and providing success with the voluntary safety reporting pro- a more complete picture of safety incidents. gram created for its technical operations (tech According to Mike Blake, NATCA lead rep- ops) specialists. resentative for CISP, the program has identified The Technical Operations Safety Program, several issues, and efforts are currently under or T-SAP, is currently in its demonstration phase way to resolve them. In one instance, a contra- in the FAA’s Central Service Area. The ATO diction between an approach plate and a letter would like to extend the 18-month demonstra- of agreement between two facilities brought tion phase, which began in October 2011, for airplanes across a navigation fix at unexpected one year, and the program will expand to the altitudes. Pilots filed Aviation Safety Action other two service areas. Program (ASAP) reports on the issue, and those The program already is showing positive were shared with the FAA through CISP. The results. More than 2,200 employees are eligible letter of agreement is being modified. to submit reports, and 74 reports have been FAA analysts review 50 to 100 CISP reports InSight is a forum for submitted, several of which have resulted in each week that provide a huge chunk of data expressing personal positive changes. that the FAA aggregates to identify and resolve opinions about issues of One report alerted officials that computer systemic issues. The FAA currently is organizing importance to aviation safety and for stimulating screen savers could interfere with the monitor- data as part of an effort to study issues brought constructive discussion, ing of airport surface detection equipment used up by pilot reports on tail wind landings and pro and con, about the by air traffic controllers. The problem could security measures around special events, such as expressed opinions. Send delay a technician’s response to a malfunction- NASCAR races and VIP travel. your comments to Frank ing system, increasing the chances of a runway The airlines frequently share “lessons Jackman, director of incursion. A maintenance alert was issued, learned” from ATSAP reports with their pilot publications, Flight Safety Foundation, 801 N. Fairfax allowing sites to set up the screen savers prop- groups, and ATSAP has published (with per- St., Suite 400, Alexandria erly, and a national change proposal has been mission) information from pilot reports as well, VA 22314-1774 USA or submitted to disable automatic screen savers. shedding light on the root causes for certain [email protected]. miscommunications or misunderstandings. Airlines Trade Data There is no lack of interest in the program on ATSAP and T-SAP are based on the voluntary the part of system users. Twenty-seven airlines safety reporting programs in use at several airlines. have expressed a desire to participate. Nearly 100 aviation companies have operated such programs, and their origin can be traced back to Reducing Risk the early 1970s, when United Airlines began using The airlines’ enthusiasm for sharing data and a voluntary safety reporting program. voluntary safety reporting is reflected in the way Now, one of the biggest opportunities to controllers, tech ops specialists and managers are improve understanding and communication embracing ATSAP and T-SAP as a means to address on safety issues has been realized by linking FAA safety issues long before lives are put at risk. the FAA’s ATSAP with the airlines’ Air Safety “The FAA has never been better positioned Action Programs. to embrace every opportunity to identify, under- So far, three airlines are connected through stand, correct and communicate the root causes the Confidential Information Sharing Pro- of risk in the system,” Grizzle said. grams (CISP): American, Southwest and Joseph Teixeira is vice president for safety and technical United. The FAA has agreements in place with training at the FAA Air Traffic Organization. flightsafety.org | AeroSafetyWorld | August 2012 | 43 GROUNDOPS
ast year’s Paris Air Show was particularly given the airline industry’s that 27,000 ramp accidents and inci- marked by an event that received razor-thin profit margin. dents — one per 1,000 departures — wide media coverage: The right Flight Safety Foundation several occur worldwide annually.1 wingtip of an Airbus A380 struck years ago estimated that “ramp acci- Many definitions of ground damage La building at Le Bourget airport as dents cost major airlines worldwide at are offered by regulators and indus- the aircraft was maneuvering on the least $10 billion a year. These accidents try trade associations. Perhaps the ground. Most ground damage incidents affect airport operations, result in most relevant is in Chapter 660 of the receive little, if any, public attention, personnel injuries and damage aircraft, International Air Transport Associa- but ground damage is a significant facilities and ground-support equip- tion (IATA) Airport Handling Manual financial, operational and safety issue, ment.” The Foundation also estimated (AHM).2 The definition includes the
A ground accident program, ground damage database and revised ground handling services agreement promise to reduce ground damage.
Covering the Ground © Alastair Gardiner/Airliners.net
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terminology most commonly used in insur- and less experienced personnel, unfamiliar with ance policies that cover the cost of damage. The the aircraft they are servicing and less familiar AHM distinguishes between the costs of aircraft with the equipment they are operating.” physical damage and consequential losses. He added, however, that major operators A Fokker F-27-500 Aircraft physical damage includes labor costs; such as FedEx and UPS staff their own opera- engine was damaged material costs; handling fees for parts and materi- tions, their management is experienced in night in a collision with a als used for repair; aircraft finance costs and cost of operations, their teams are permanent and they towed ground power capital while the aircraft is out of service; tem- have established safety programs and staff. unit at Edinburgh porary leasing costs of aircraft spare parts when IATA recently launched the Ground Damage Airport, Scotland. replacements and repairs are not readily available Database, the industry’s first repository specifi- to ensure aircraft serviceability; costs to ferry the cally for the collection and analysis of ground damaged aircraft to a repair station or base station; damage occurrences worldwide. Concerning the extra parking costs, including overtime and securi- most common forms of damage based on data ty for the damaged aircraft at the current location; available to IATA, it is “too early to say, as we have and external survey/claims administrative costs. only just started gathering industry data; howev- Consequential losses include costs related to er, preliminary analysis indicates the majority of passengers and crew incurred within 72 hours damage is to hold compartments and doors,” said of the event, including the cost of transportation Guenther Matschnigg, IATA senior vice presi- on other carriers; compensation associated with dent, safety, operations and infrastructure. non-passenger revenue (cargo, mail, etc.); the internal cost of investigation/claims administra- Safety Risks tion; delay of services (other stations); revenue Ground damage is associated with safety risks loss; aircraft delay costs, including sub-charter that cannot be underestimated. About 243,000 on flights other than the one involved; opera- people are injured each year in ground occur- tional disruption; loss of priority payload due to rence accidents and incidents; the injury rate is 9 aircraft change; catering costs; and crew changes per 1,000 departures. and rescheduling/interruption. Accidents involving ramp events are increas- ing as a percentage of all accidents (Figure 1, p. Risks During Ground Operations 46).3 The figure does not tell the whole story — During airline ground operations, risks are “con- it does not include incidents as defined by the centrated in the movement, control, guiding and International Civil Aviation Organization. synchronization of ground equipment with other Why are so many risks associated with ground pieces of equipment or other vendors working operations? More important, why are ramp events around the aircraft,” said Bill Johnson, a consul- increasing as a proportion of all accidents? Ivar tant in airline operations, fuel efficiency and cost Busk, who has been head of airside safety at SAS management. “Furthermore, training and supervi- since 1982 and manager of SAS Group Insurance sion also represent a very important area of risk. since 2004, lists the main reasons: time pressure “Cargo operations are typically more vulner- on ground personnel, increased production and able because of the extent of damage caused by therefore congestion of airports, technology and large, solid, heavy objects. Also, cargo operations change management, training and education of are frequently not as well supervised in that there ground personnel, and human factors. are fewer people around the aircraft, and they “The ever-increasing demand for quick aircraft are frequently night operations when company turnaround puts considerable pressure on people management is often limited in presence and ex- working on the ramp,” said Busk. “There is not BY MARIO PIEROBON perience. In addition, as cargo operations are by only an airline’s management-enforced policy of nature sporadic, work crews are often character- quick turnarounds, but I personally know of sev- ized by high turnover, supplemented by part-time eral examples of ground incidents directly linked
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above deductibles (the insurers’ pre- ARC, RAMP and CFIT Accidents, EASA Member State Airlines, 2001–2010 mium being equal to average claims
25 plus administration costs plus profits). ARC Refunds for ground damage caused by 20 RAMP CFIT ground handling companies are nor- 15 mally included in turnaround charges
10 to airlines. The whole cost of ground damage is paid directly or indirectly by 5 the world’s airlines. 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 One reason airlines bear the whole cost is that “after privatization, airlines ARC = abnormal runway contact; CFIT = controlled flight into terrain; EASA = European Aviation Safety set about horizontally integrating and Agency; RAMP = ground handling thus divesting themselves of their Source: European Aviation Safety Agency cleaning, catering and other ground Figure 1 handling divisions,” said Andrew Dixon, owner of Aviation Recovery and with time pressure exercised by pilots, can learn to manage new technology formerly accident recovery manager at ATC [air traffic control], etc., on ground safely and proactively. British Airways. “This was in pursuit personnel,” said Busk. “The ground operations industry of economies of scale and to focus on “Most of the world’s big hubs have does not lack high quality standards, what they do best through simplifying more flights today than ever, but they like the IATA AHM, but the training of their business model. Whilst regulatory have grown without appropriate invest- personnel is a real problem — during hurdles slowed airline integration, the ments in their capacity. Airports struggle turnarounds standards are not fol- same cannot be said for their former for efficient and effective space manage- lowed as strictly and professionally as divisions. These handling divisions ment and many incidents are linked to they are followed in the cockpit during amalgamated at great speed and have insufficient maneuvering space. The flight operations. The root cause more formed companies that are now often congestion of airports is also associated often than not lies at the budgeting and larger than the flag carriers that used to with a frequent alternation of gates be- business planning phases, because in- control them. Where the engineering tween narrow-bodied and wide-bodied vestments in training are always easily departments are now separate compa- aircraft. This is one of the leading causes postponed to the following year. nies, the airlines now get real invoices of confusion to ground personnel, which “Very often, there are a number for damage repairs. The balance of can be the basis of ground damage, of human factors reasons behind a power has moved away from airlines. especially during peak times.” damage incident, and if the relevant These giant handling companies now investigation is not carried out in include internal insurance companies Technology and Change Management detail, the conclusion often is that the and have become very sophisticated. New technology increases production, person did not follow the procedure, “It is a more difficult problem for but it also can have negative conse- and instead of going deeper into the the airlines, and with the insurers quences, Busk said: “Some towbarless case to find the root causes, the case raising the deductibles at the airlines’ (TBL) tractors now operate like fly-by- is closed. Even on the ground, human behest, the amounts at stake are wire (steer-by-wire), and airbridges also factors need to be taken seriously into increasing. The larger airlines have are becoming increasingly sophisti- consideration as a leading cause of generally risen well to this task and cated, some operating nearly automati- equipment damage.” have skilled and experienced teams cally. If there is a crash in the computer chasing recoveries, but the smaller system, huge damage can result. It is Cost of Ground Damage airlines are at a disadvantage, as they very important at the time of new tech- Airlines normally pay directly for any simply don’t have enough volume of nology implementation to train ground ground damage below deductibles and activity to build up sufficient experi- personnel appropriately so that they underwriters pay for ground damage ence and expertise.”
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New Risks in the Equation those] employed on metallic airplanes. (By de- While ground damage threatens safety on the sign, bolted repairs in composite structure can ramp or taxiways, it is less likely to represent an be permanent and damage tolerant, just as they immediate flight safety threat because harm to can be on a metal structure.) aircraft structural integrity is often detected before “In addition, airlines have the option to takeoff, partly because normal operating proce- perform bonded composite repairs, which offer dures dictate visual checks of airframe and engine improved aerodynamic and aesthetic finish. surfaces before flight. The relative ease in detecting These repairs are permanent, damage tolerant, ground damage may not be here to stay, however. and do not require an autoclave.”4 The increasing use of composite materials in aircraft manufacturing may pose a new threat Increasing Maintenance Costs because often, after being hit, a composite sur- The repair of composite surfaces will be a major face returns to its original shape and the damage step for most maintenance, repair and overhaul underneath is invisible. organizations (MROs). “Composite repairs “Safety occurrences have been attributed to demand new techniques and technologies that the fact that the defect of composite material are not yet used by most MROs,” said Reichen. surfaces was missed during daily and weekly “This could cause a concentration of repair sta- checks,” said Philipp Reichen, an aerospace and tions with the required capabilities and increase aviation consultant and contractor specializing the repair cost for structural damages associated in engineering and maintenance. “A simple ‘tap’ with ground occurrences, as the investments in test might not detect delaminations at early the new technologies are substantial.” A truck driver was stages or in specific areas. According to Busk, “In the new technol- pinned inside the “Some of the most abused aircraft surfaces ogy of ground operations, the maintenance of cab until rescued by while on the ground are cargo and passenger sometimes very complicated pieces of equip- firefighters following doors, which might be hit several times a day by ment (such as automated airbridges and modern a collision with a ground service equipment and can therefore be TBL tractors) creates the need for new types of Gulfstream II at exposed to minor delaminations, which in turn maintenance skills that could increase the costs Seattle King County could lead to problems sometime in the future.” of ground damage.” International Airport. The Boeing Co., with re- gard to the use of composites in the airframe and primary structure of the 787, says that “in addition to using a robust structural design in damage- prone areas, such as pas- senger and cargo doors, the 787 has been designed from the start with the capability to be repaired in exactly the same manner that airlines would repair an airplane today — with bolted repairs. The ability to perform bolted repairs in composite structure is service-proven on the 777 and [requires] comparable
© Jeremy Dwyer-Lindgren/NYCAviation © Jeremy repair times and skills [to
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Ground safety needs commitment cultures, attaining a consolidated ap- do today when ground damage occurs,” of resources by airline management, proach and pinpointing exact causes of said Busk. “Is it fair that airlines have but what tools are available for ground ground damage. The Ground Damage to reimburse their stranded passengers damage mitigation? More important, Database is designed to answer these as per the European Union passengers’ what should an industrywide effort to difficulties. IGOM establishes core bill of rights when damage is caused reduce ground damage concentrate on? ground handling procedures, AHM by a third party? Is it fair that airlines provides standards, ISAGO audits suffering ground damage are refunded Ground Accident Prevention Program ground operations which currently use by their service providers only the cost Flight Safety Foundation was one of the AHM standards as guidance and will of physical damage, which is only a first organizations to become proac- include IGOM procedures in the near minor fraction of the total damage cost tive in addressing ground safety issues. future. Based on the Ground Damage incurred? There is no other industry In 2003, the Foundation launched the Database outputs, the standards/proce- with such strict liability limits when Ground Accident Prevention (GAP) dures of AHM/IGOM and ISAGO will somebody damages another party. program in response to industry re- be assessed for their abilities to reduce “Ground handlers tend to as- quests. “The GAP program developed damages and potential risks.” sume that a change in the SGHA will information and products in a practical be followed by an increase in the format — ‘e-tools’ — designed to elimi- Ground Handling Agreement premium charges they will have to nate accidents and incidents on airport The most commonly used ground pay to their underwriters, and there- ramps (aprons) and adjacent taxiways, handling services agreement is IATA’s fore an overall increase in the aircraft and during the movement of aircraft Standard Ground Handling Agree- turnaround charges to airlines, but by into and out of hangars,” the Foundation ment (SGHA). amending the SGHA we should aim at says. According to Article 8 of the SGHA, an improvement in the overall effi- The e-tools on the Foundation’s web- the ground handling company “shall in- ciency and safety awareness of ground site include a ground accident prevention demnify the carrier against any physical operations, so that the cost of ground cost model, a set of videos illustrating loss of or damage to the carrier’s aircraft damage to the industry is reduced. safe aircraft towing, ground accident caused by the handling company’s neg- This will not increase premiums.”
prevention leadership tip sheets and a ligent act or omission, provided always Mario Pierobon works in business development template outlining ramp operational that the handling company’s liability and project support at Great Circle Services in safety procedures. “The document is in- shall be limited to any such loss of or Lucerne, Switzerland, and was formerly at the In- tended to assist ramp supervisors in the damage to the carrier’s aircraft in an ternational Air Transport Association in Montreal. development or improvement of their amount not exceeding the level of de- Notes organizations’ written SOPs,” the Foun- ductible under the carrier’s hull all-risk dation says. “The template is presented policy which shall not, in any event, ex- 1. Flight Safety Foundation (FSF). Ground in Microsoft Word format to facilitate ceed USD $1,500,000 except that loss or Accident Prevention (GAP).
48 | flight safety foundation | AeroSafetyWorld | August 2012 DataLink
BY RICK DARBY Progress Report The accident statistics for 2011 offer encouraging signs.
f there can be such a thing as a (Table 1, p. 50). On-board fatalities Fatal accidents in passenger operations good year for accidents, 2011 was have dropped as well: 175 last year, during the 10-year period 2002–2011 that year in worldwide commercial compared with 555 in 2010 and 413 in numbered 63 (Table 2, p. 51). The jet aviation. 2009. Fluctuations in annual fatal- comparable number for 2001–2010 was I The 2011 record showed reductions ity numbers, however, are partially 69. On-board fatalities in passenger in two of the most serious accident influenced by chance — an accident operations in the most recent 10-year types, runway excursions and approach involving the same basic aircraft type period totaled 4,486; in the previous 10 and landing accidents. Runway excur- might kill two people, the pilots, on a years, 4,711. sions — veer-offs and overruns — oc- cargo flight and several hundred on a In scheduled passenger service, curred in 25 percent of the 36 accidents passenger flight. One 2011 fatal crash, there were 60 fatal accidents in 2002– last year, compared with 33 percent in fact, did involve a scheduled cargo- 2011, compared with 67 in 2001–2010. of the 40 accidents in 2010. Approach carrying Boeing 747-400 that crashed However, all accidents in passenger and landing accidents represented 58 into the sea while the flight crew was operations increased from 308 to 317 percent of the total in 2011, versus 65 diverting because of an on-board fire, in the most recent 10-year period. Ac- percent the previous year. with the loss of the two pilots, the only cidents in cargo operations decreased Absolute numbers of these types crewmembers. from 80 to 74 in the most recent period. of accidents were lower as well: nine Four of the 36 accidents in 2011 (11 The fatal accident rate in 2002 overruns in 2011, 13 in 2010; 21 ap- percent) involved at least one on-board through 2011 for scheduled commer- proach and landing accidents in 2011, fatality, versus eight of 40 in 2010 (20 cial passenger operations was 0.34 per 26 in 2010. The data are derived from percent) and nine of 62 (15 percent) in million departures, and 0.62 for other Boeing Commercial Airplanes’ an- 2009. Seven of the 2011 accidents (19 types of operations, including chartered nual statistical summary.1,2 Airplanes percent) were major accidents, accord- passenger, scheduled cargo, chartered manufactured in the Soviet Union or ing to U.S. National Transportation cargo and maintenance testing. The the Commonwealth of Independent Safety Board terminology.3 Comparable equivalent rates for 2001–2010 were States are excluded for lack of opera- percentages were 28 percent in 2010 0.40 and 0.67, respectively, for improve- tional data. and 21 percent in 2009. ments of 15 percent and 7 percent. Total accident numbers have been In its accident data, Boeing empha- The 79 fatal accidents from 2002 declining, down from 62 in 2009 sizes time frames longer than a year. through 2011 represented 20 percent flightsafety.org | AeroSafetyWorld | August 2012 | 49 DataLink
2011 Airplane Accidents, Worldwide Jet Fleet
On-board Fatalities/ Occupants Event Phase Damage (External Major Date Airline Model Accident Location of Flight Description Category Fatalities) Accident? Jan. 3 American Airlines 737-800 Los Angeles Takeoff Tail strike Substantial Jan. 9 Iran Air 727 (Near) Urumiyeh, Iran Final approach Missed approach at night Destroyed 78/105 (0) Jan. 10 AirAsia A320 Kuching, Malaysia Landing Runway veer-off Substantial Jan. 10 Africa Charter Airline 737-200 Hoedspruit, South Africa Taxi Rolled off the side of a taxiway Substantial Jan. 13 American Airlines 757 Los Angeles Takeoff Tail strike Substantial Feb. 16 Saudi Arabian Airlines 747-300 Madinah, Saudi Arabia Landing Runway veer-off Substantial Feb. 24 US Airways ERJ-190 New York Landing Galley cart struck a passenger’s ankle March 27 Hapag-Lloyd Flug 737-800 Tenerife, Spain Takeoff Tail strike Substantial March 30 Northern Air Cargo 737-300 Dayton, Ohio, U.S. Initial climb Pallet jack in the cargo hold Substantial fractured a structural frame April 11 Comair CRJ-700 New York Taxi Vertical stabilizer struck by a Substantial taxiing aircraft April 13 Air France A330 Caracas, Venezuela Landing Hard landing Substantial April 17 China Cargo 777 Copenhagen, Denmark Landing Tail strike Substantial May 6 Continental Airlines 737-800 Greenville, Taxi Taxiway tarmac collapsed under Substantial Mississippi, U.S. landing gear May 18 Omega Air 707 Point Mugu, Initial climb Engine and pylon separated from Destroyed California, U.S. the wing; veer-off May 28 SBA Airlines 767 Caracas, Venezuela Landing Hard landing Substantial June 25 Malev Hungarian Airlines 737-800 Heraklion, Greece Landing Tail strike Substantial July 8 Hewa Bora Airways 727 Kisangani, Congo DR Final approach Crashed short of the runway on Destroyed 83/118 (0) final approach July 14 Delta Connection CRJ-900 Boston Taxi Taxiway collision Substantial July 28 Asiana Airlines 747-400 East China Sea near Cruise Cargo fire Destroyed 2/2 (0) Jeju Island, South Korea July 29 EgyptAir 777 Cairo Load/unload Smoke and fire on the flight deck Substantial July 30 Caribbean Airlines 737-800 Georgetown, Guyana Landing Runway overrun Destroyed Limited Aug. 20 First Air 737-200 Resolute Bay, Canada Final approach Struck hill and broke apart Destroyed 12/15 (0)
Aug. 29 Gulf Air A320 Cochin, India Landing Runway veer-off Substantial Sept. 2 Turkish Airlines A340 Mumbai, India Landing Runway veer-off Substantial Sept. 3 Mahan Air A300-600 Mashad, Iran Landing Runway veer-off Substantial Sept. 16 TAME EMB-190 Quito, Ecuador Landing Runway overrun Destroyed Sept. 26 Aeropostal DC-9 Puerto Ordaz, Venezuela Landing Hard landing Substantial Oct. 7 Delta Air Lines MD-88 Atlanta Tow Collision with tug Substantial Oct. 10 Sky Airlines 737-400 Antalya, Turkey Landing No flaps, landing gear collapse Substantial
Oct. 18 Iran Air 727 Tehran, Iran Landing Gear-up landing Substantial Nov. 1 LOT Polish Airlines 767 Warsaw Landing Gear-up landing Substantial Nov. 10 SA-Airlink RJ-85 Johannesburg, Landing Gear-up landing Substantial South Africa Dec. 14 Air Canada A321 Fort Lauderdale, Taxi Stopped abruptly during taxi Florida, U.S. because of potential collision Dec. 20 Sriwijaya Air 737-300 Yogyakarta, Indonesia Landing Landing overrun Substantial Dec. 23 Austrian Airlines A321 Manchester, England Go-around Wind shear and tail strike Substantial Dec. 25 AMC Airlines MD-83 Karachi, Pakistan Landing Nose landing gear up Substantial Total accidents: 36 Totals: 175 (0) 7
Source: Boeing Commercial Airplanes
Table 1
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Accidents, Worldwide Commercial Jet Fleet, by Type of Operation
On-board Fatalities All Accidents Fatal Accidents (External Fatalities)* Hull Loss Accidents Type of operation 1959–2011 2002–2011 1959–2011 2002–2011 1959–2011 2002–2011 1959–2011 2002–2011 Passenger 1,424 317 483 63 28,553 (777) 4,486 (142) 680 129 Scheduled 1,307 294 437 60 24,427 4,470 611 122 Charter 117 23 46 3 4,126 16 69 7 Cargo 252 74 76 13 264 (330) 44 (72) 169 44 Maintenance test, ferry, positioning, 122 13 44 3 208 (66) 17 (0) 74 8 training and demonstration Totals 1,798 404 603 79 29,025 (1,173) 4,547 (214) 923 181 U.S. and Canadian operators 555 78 180 11 6,193 (381) 17 (8) 222 26 Rest of the world 1,243 326 423 68 22,832 (792) 4,530 (206) 701 155 Totals 1,798 404 603 79 29,025 (1,173) 4,547 (214) 923 181 *External fatalities include ground fatalities and fatalities on other aircraft involved, such as helicopters or small general aviation airplanes, that are excluded.
Source: Boeing Commercial Airplanes
Table 2 of the total accidents Accidents, by Injury and Damage, Worldwide Commercial Jet Fleet (Figure 1). The 87 fatal accidents from 1959 through 2011 Total 1,798 603 fatal accidents 1,195 non-fatal accidents 2001 through 2010 (34% of total) (66% of total) were slightly more 487 accidents with hull loss 432 hull loss accidents of the total, at 22 25 accidents with 702 substantial damage percent. A more strik- substantial damage accidents without accidents without substantial ing difference can be substantial damage damage (but with serious injuries) seen in comparing the latest 10-year period 0 100 200 300 400 500 600 700 800 900 1,000 1,100 1,200 1,300 1,400 1,500 1,600 1,700 1,800 Number of accidents with the 53-year peri- 2002 through 2011 Total 404 od that began in 1959, 79 fatal accidents 325 non-fatal accidents (20% of total) (80% of total) around the beginning 69 accidents hull loss 112 hull loss without fatalities of commercial jet 1 fatal accident with aviation. In that span, substantial damage 196 substantial damage without fatalities fatal accidents were 34 9 accidents without 17 accidents without substantial substantial damage percent of the total. damage (but with serious injuries) Ideally, design 0 100 200 300 400 improvements should Number of accidents result in a larger Source: Boeing Commercial Airplanes percentage of substan- Figure 1 tial damage accidents without fatalities. Boeing examined fatal accidents using the Little change is evident, however. From 2002 standardized taxonomy of the U.S. Commercial through 2011, the rate was 60 percent; from Aviation Safety Team/International Civil Avia- 1959 through 2011, it was 59 percent. The total tion Organization (CAST/ICAO).4 For some period includes recent years, so a comparison of 10-year periods, “loss of control–in flight” the most recent decades with the most distant (LOC-I) has resulted in the most fatalities (Fig- might tell a different story. ure 2, p. 52). In the 2002–2011 period, LOC-I
flightsafety.org | AeroSafetyWorld | August 2012 | 51 DataLink
fatalities as a percent- Fatalities by CAST/ICAO Taxonomy Accident Category, age of all fatalities Worldwide Commercial Jet Fleet, 2001–2010 were reduced. Among on-board fatalities, 2,000 On-board fatalities [Total 4,547] 1,493 of a total 4,547, 1,800 , | External fatalities [Total 214] or 33 percent, were in 1,600 the LOC-I category. 1,400 1,200 | In 2001–2010, it had , 1,000 | been 1,765 of 4,774, Fatalities 800 or 37 percent. 600 | The number of 400 156|69 | | 200 | | fatal LOC-I accidents, | | | | 0 18, was reduced LOC-I CFIT RE UNK MAC SCF-NP RE OTHR WSTRW FUEL RAMP F-NI SCF-PP in the most recent (Landing) + (Takeo ) ARC + USOS period from the pre- Number of fatal accidents vious 20. (79 total) 18 18 15 4 2 1 5 2 1 1 8 2 2 Controlled CAST = U.S. Commercial Aviation Safety Team; ICAO = International Civil Aviation Organization; ARC = abnormal runway flight into terrain contact; CFIT = controlled flight into terrain; F-NI = fire/smoke (non-impact); FUEL = fuel related; LOC-I = loss of control – (CFIT) claimed a in flight; MAC = midair/near midair collision; OTHR = other; RAMP = ground handling; RE = runway excursion; SCF-NP = system/ component failure or malfunction (non-powerplant); SCF-PP = system/component failure or malfunction (powerplant); higher percentage UNK = unknown or undetermined; USOS = undershoot/overshoot; WSTRW = wind shear or thunderstorm. of lives among the No accidents were noted in the following principal categories: aerodrome, abrupt maneuver, air traffic management/ communications, navigation, surveillance, bird strikes, cabin safety events, evacuation, fire/smoke (post-impact), ground total in 2002–2011, collision, icing, low altitude operations, loss of control – ground, runway incursion – animal, runway incursion – vehicle, aircraft 24 percent, compared or person, security related or turbulence encounter. with 21 percent in Note: Principal categories are as assigned by CAST. Airplanes manufactured in the Russian Federation or the Soviet Union are excluded because of lack of operational data. Commercial airplanes used in military service are also excluded. the previous 10-year Source: Boeing Commercial Airplanes stretch. There was one more CFIT accident Figure 2 in 2002–2011 than in Operations 1959–2011.
52 | flight safety foundation | AeroSafetyWorld | August 2012 help us make flying safer.
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After Shock An uncontained engine failure began an in-flight drama to save Qantas Flight 32.
BY RICK DARBY
BOOKS “The huge Rolls-Royce Trent 900 engine was destroyed. The extent of damage was Epic Fail unprecedented in Airbus’s history. Two heavy QF 32 chunks tore through the wing, traveling at De Crespigny, Richard. Sydney, Australia: Pan Macmillan Australia, approximately two times the speed of sound. 2012. 358 pp. Photographs, appendixes. The fan blades and chunks acted like the ex- n Nov. 4, 2010, and the following day, plosive core of a hand grenade, ripping wing jaws dropped all over the world as facts panels into shrapnel that sprayed like mis- Oof the accident involving Qantas Flight sile fragments over the fuselage as far as the 32 — QF32 — became known. The near disaster massive tail sections. One chunk also ripped and its successful resolution were the stuff of through the aircraft’s belly, severing hundreds compelling drama. of wires. The flight began when Richard Champion “Over 600 wires were cut, causing almost de Crespigny, a Qantas captain and pilot-in- every aircraft system to become degraded. ... command of QF32, signed for Nancy-Bird- The hydraulics, electrics, brakes, fuel, flight Walton, an Airbus A380, the world’s largest control and landing gear systems were all passenger aircraft. The doors were closed compromised.” and the airplane was now “his.” Four minutes Understandably, many readers could be after a routine takeoff from Changi Airport tempted to skip directly to the later chapters de- in Singapore, headed for Sydney with 469 scribing the accident and the efforts of the flight people aboard, the no. 2 engine (left inboard) crew to return the airplane safely to Changi was ruptured by an explosive failure while the while the cabin crew worked to calm passengers airplane was climbing through 7,400 ft. De and prepare for a possible evacuation. Crespigny describes what happened immedi- But if they skip earlier chapters, readers will ately afterward: miss something important. The biographical
54 | flight safety foundation | AEROSafetyWorld | August 2012 InfoScan
background de Crespigny relates played an im- for every checklist, rather than just relying on portant part in the story; it made him the man computer displays.” he is and contributed to his ability as a team When, as a Qantas pilot, he transitioned leader in the cockpit when every action was from the Boeing 747 to the Airbus A330 — the critical and so many lives were at risk. aircraft he flew before the A380 — he had a De Crespigny came by his aristocratic huge task of knowledge replacement: “I went name from noble Huguenot ancestors in the through all the manuals, and I phoned engineers reign of French King Louis XIV in the 17th and I questioned designers and talked to test century. That family’s mansion survives, up pilots until I fully understood what I was about ‘There was shock the road from Omaha Beach of Normandy to take control of.” invasion fame. Several of his ancestors were Shortly after 1000 local time on Nov. 4, around me as the distinguished in various ways, including during QF32’s climbout, two booming noises other pilots waited eccentricity. The Rev. Heaton de Crespigny startled the flight crew and shook the airplane. fought a pistol duel in 1828 (“he was later De Crespigny selected “altitude hold” and pulled for me to speak.’ defrocked and died in the Australian gold back the thrust levers. He soon realized that the fields”). In 1883, Sir Claude de Crespigny autothrust system had failed. tried to travel from England to France in a “There was shock around me as the other balloon, found himself at 17,000 ft, decided pilots waited for me to speak,” he says. “With discretion was the better part of valor and the aircraft flying straight and level, and at a crash landed in Holland. He also became the constant speed, I now focused on the engine assistant executioner for the English county and warning display, the top display in the of Essex. middle of the instrument panel. Engine [no.] Richard de Crespigny’s account of his young 2 looked very sick. All of the [indications] self suggests he was something of a “Wright for thrust, temperature and pressures were brothers” type, fascinated with mechanical replaced with crosses telling us that there was devices from an early age. He learned to rebuild no data to display. It appeared that all the sen- a motorbike or car engine and start it working sors had been blown off that engine. This was a again. “The time bashing around on those bikes catastrophic failure.” and fixing them gave me a respect for ma- As bad as the situation was — and de chinery that I took into my aviation career,” de Crespigny did not yet know how bad — the air- Crespigny says. plane could fly and was controllable in cruise. It’s a long way from a bike to an A380 with The captain was fortunate to have four four engines each normally producing 70,000 lb other pilots in the cockpit for task sharing: First (31,752 kg) maximum thrust, 52 flight control Officer Matthew Hicks; Second Officer Mark surfaces, 16 wheels, and fly-by-wire systems. Johnson; and two check pilots, Capt. David Still, it’s likely that de Crespigny’s keenness to Evans and Capt. Harry Wubben. understand the workings of equipment was a Fuel was available to fly a holding pattern, positive factor when he met the supreme test of assess the situation and plan the landing. But his flying career. even plentiful fuel turned out to be a mixed “I have to learn the machine from the blessing, because the jettison valves and pumps ground up, not from the buttons and check- were inoperable. There was no way to dump lists down,” he says. “I don’t like controlling fuel, which would necessitate a seriously over- machinery I don’t fully understand … . I need weight landing. to understand the philosophy of how the The Airbus’s electronic centralized aircraft machine is designed and assembled so I can monitoring (ECAM) system tells the pilots understand the limits and standard operat- what is wrong and presents checklists designed ing procedures. I have to know the purpose to deal with it. “The ECAM checklists started flightsafety.org | AEROSafetyWorld | August 2012 | 55 InfoScan
with engines, hydraulics, flight controls, then suspenseful story. The book fills in details that fuel, each of them with a series of fixes we had news reports could not convey at the time, not to perform to see if we could get the problem only of technical issues but about crew resource under control,” de Crespigny says. “The explo- management. sions had obviously started a fire and disabled The cabin crewmembers, headed by an engine, which we’d shut down, hopefully customer service manager Michael von Reth, containing or extinguishing the fire. But the prepared for an emergency evacuation while, By the time the fix for the fire in engine [no.] 2 was only the perhaps more difficult under the circumstanc- beginning of it: engines [nos.] 1, 3 and 4 were es, calming and reassuring the passengers. flight was an hour degraded in different forms, the fuel system This involved identifying any passengers who was in a total mess, the hydraulics and electrics showed signs of losing control, which could old, the ECAM had and pneumatics were plundered, and even our have initiated contagious panic throughout
identified about 100 flight controls were compromised.” the back of the plane. Von Reth had to give By the time the flight was an hour old, the special care to a few passengers, but only significant faults ECAM had identified about 100 significant a few. faults and checklists. QF32 shows occasional signs of hasty prep- and checklists. De Crespigny says, “The aircraft was so aration, such as some repeated information. injured, and so many of the 250,000 sensors But with a series of events of such complexity, were complaining, that I had reached the limit even that may help the reader understand the of my ability to absorb them all. The ECAM big picture. De Crespigny mentions the awards threw up so many failures, degradations and the crew received, including the Flight Safety checklists — especially in the fuel system — Foundation Professionalism Award. “This that I could not evaluate all the interactions last award is remarkable because it included and consequences of the cascading failures. I Michael von Reth in the citation, the first time just wasn’t confident how much of the aircraft a cabin crewmember had ever been recognized we had left.” in the FSF’s 65-year history,” he says. Actually, The turning point came, he says, when he the Foundation has given a different award, for decided to concentrate on what was working. heroism, to several cabin crewmembers includ- As everyone knows, the landing involved no ing Richard DeMary, the lead flight attendant injuries, but that wasn’t the end of the ordeal; who risked his life to help rescue passengers leaking fuel in the vicinity of brakes heated to from the burning cabin of USAir Flight 1016 500 degrees C (932 degrees F) by the land- following a crash in 1994. ing speed and overweight condition created a In any case, there was indeed plenty fire hazard that prevented the passengers and of credit to go around. As for Richard de crew from exiting the plane. It was another Crespigny, he sums up the attitude that helped 52 minutes before disembarkation was judged him in his role during the emergency: “I’m safe and the first passenger descended the old school in this respect: On board, I believe airstairs. The no. 1 engine would not shut the pilot’s job is exactly as written in the fed- down, even with water sprayed directly into it. eral laws; pilots are ‘responsible for the safety It continued turning for three and a half hours of the passengers and crew’ regardless of what after the landing. stands between them and disaster. Whether The author’s description of the calcula- it’s a fly-by-wire computer or a few cables tion of landing parameters, discussion (and connected to your rudder pedals, your job is sometimes disagreement) among the flight to know your plane, be unafraid of the plane crewmembers, contact with air traffic control, and to fly the plane.” announcements to the passengers and fur- FSF video interviews with de Crespigny and von Reth can ther automated warnings makes a grippingly be accessed at
56 | flight safety foundation | AEROSafetyWorld | August 2012 OnRecord Long Float Leads to Overrun Light, variable winds were reported, but an 11-kt tail wind was encountered.
BY MARK LACAGNINA
The following information provides an aware- Chakeri Airfield is a joint military/civilian ness of problems that might be avoided in the airport with one runway, which is 9,000 ft (2,743 future. The information is based on final reports m) long. “Since it is an air force airfield, it has by official investigative authorities on aircraft arrestor barriers [nets] and a soft-ground area accidents and incidents. on either side of the runway to stop [an] aircraft in case of an overrun,” the report said. The CRJ’s JETS quick reference handbook indicated that the aircraft could be landed within about 5,000 ft Standing Water on Runway (1,524 m) on the wet runway. Bombardier CRJ700. Substantial damage. No injuries. The commander, the pilot flying, later told bout 45 minutes after departing from investigators that the approach was stabilized Delhi, India, for a scheduled flight to and that the copilot made all standard callouts. AKanpur the morning of July 20, 2011, “Both the cockpit crew stated that they saw the flight crew asked an air traffic controller the runway at decision altitude and continued at Kanpur’s Chakeri Airfield for the current for landing,” the report said. “The commander weather conditions. The controller said in part further stated that approximately 43 ft [above that the surface winds were variable at 5 kt, vis- the runway], he retarded the throttle levers and ibility was 2,000 m (1 1/4 mi) in thundershow- round-off for landing was initiated.” ers and the runway was wet. Recorded flight data indicated that the The CRJ was nearing the airport when the aircraft’s airspeed was 135 kt, or 7 kt above the
controller advised that visibility had decreased reference landing speed (VREF), and ground- to 800 m (1/2 mi), which was below the mini- speed was 146 kt when the commander began mum of 1,200 m (3/4 mi) required to conduct the landing flare. The report said that this the instrument landing system (ILS) approach “implies that at the time of landing the tail wind to Runway 27, according to the report by the component was around 11 kt.” Indian Directorate General of Civil Aviation The CRJ floated above the runway for about (DGCA). The crew decided to enter a holding 10 seconds before the commander “had to de- pattern and wait for the visibility to improve. liberately put down the aircraft,” the report said. They told the controller that they had sufficient Touchdown occurred with about 4,235 ft (1,291 fuel to hold for 20 minutes before they would m) of runway remaining. The speed brakes and have to divert the flight to their alternate airport. thrust reversers were deployed, and the com- The aircraft had been in a holding pat- mander applied maximum wheel braking. How- tern for nearly 20 minutes when the controller ever, “the remaining runway was not enough to advised that visibility had improved to 1,200 m. stop the aircraft … under the prevailing rainy The controller cleared the crew to conduct the conditions,” the report said. ILS approach to Runway 27 and advised that The aircraft overran the runway at 44 kt and there were patches of water on the runway. rolled about 200 ft (61 m) before coming to a flightsafety.org | AEROSafetyWorld | August 2012 | 57 OnRecord
stop with the landing gear mired in soft ground. to increase momentarily to 0.87 Mach (maxi- The left wing struck the localizer antenna, mum operating speed is 0.86 Mach). which tore a 3-in (8-cm) hole in the leading The pilots said that they were surprised edge. There was no fire, and none of the 55 pas- when the master warning light illuminated sengers and four crewmembers was injured. and the aural overspeed warning sounded. “After the aircraft came to a complete halt, The copilot, the pilot not flying (PNF), manu- the commander informed ATC [air traffic ally disengaged the autopilot by pressing the control] that they [had] gone off the runway and takeover pushbutton on his sidestick. Moreover, required assistance,” the report said. “The pas- “a pitch-up input on the PNF’s sidestick going as sengers were deplaned normally.” far as three-quarters to the stop was recorded for Among recommendations based on the six seconds,” the report said. “This input was ac- findings of the investigation, the DGCA said companied by an input to bank to the right then that airlines should place more emphasis on left. The PNF stated that he did not remember wet/contaminated runway landings during these inputs.” recurrent training and proficiency checks, and The report said that the control inputs should publish a nonpunitive go-around policy likely were reflexive actions that resulted from in training and operations manuals. the “startle effect” produced by the overspeed warning. “Sometimes this effect sparks primal ‘Startle Effect’ Cited in Upset instinctive reaction, instant and inadequate Airbus A340-313. No damage. No injuries. motor responses,” the report said. “These basic nvestigators said that the flight crew did not reflexes may prove to be incorrect and difficult have their weather radar and navigation dis- to correct under time pressure and may affect Iplays adjusted properly to show a small line of the pilot’s decision-making ability.” cumulus clouds that had built quickly to 38,000 The continuous sounding of the overspeed ft over the Atlantic during a flight from Caracas, warning likely masked the aural alert that was Venezuela, to Paris the night of July 22, 2011. generated when the autopilot was disengaged. “It should be noted that this type of iso- The captain, the pilot flying (PF), deployed the lated cloud in an inter-tropical zone is beyond speed brakes in reaction to the overspeed warn- forecasting abilities other than immediate or ing. “The PF indicated that in the seconds that very short-term forecasts,” said the report by the followed, he switched on the lights and noticed French Bureau d’Enquêtes et d’Analyses (BEA). being in IMC [instrument meteorological condi- The pilots said that The A340 was in cruise flight at 0.83 Mach and tions] and that there was precipitation,” the report Flight Level (FL) 350 (approximately 35,000 ft), said. “He also indicated that he turned around to they were surprised with the ranges on both navigation displays set put his meal tray on the seat behind him.” to 320 nm (593 km) and the weather radar tilt set The pilots said that they did not hear the when the master between minus 0.5 degree and minus 1.0 degree. aural altitude alert activate when the aircraft The report said that, at the low tilt settings, the climbed through 35,200 ft at 1,950 fpm. The warning light radar was scanning a portion of the clouds that speed brakes retracted automatically as the illuminated and the consisted primarily of ice crystals, which have very aircraft’s angle-of-attack exceeded the designed low reflectivity. The report also noted that the threshold. Pitch attitude increased to 12 degrees aural overspeed recommended display ranges for weather avoid- as the aircraft climbed through FL 360. “Vertical ance are 80 nm (148 km) and 160 nm (296 km). speed reached a maximum of 5,700 fpm,” the warning sounded. Both pilots told investigators that they saw report said. “The crew was not aware of this.” no areas of precipitation on the navigation The A340 was climbing through 37,950 ft displays before the aircraft skirted the edge of at 0.66 Mach when the captain disengaged the the line of clouds and encountered moderate autothrottle and moved the thrust levers to the turbulence. A strong wind gust caused airspeed takeoff/go-around position. “The PF stated that
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he noted with surprise that altitude was 38,000,” of thrust causes the engine fan blades to twist the report said. and shed any accumulated ice. The aircraft then began to descend with When the crew retarded the left thrust lever, a high nose-up pitch attitude. “The PF then however, the vibration level suddenly and unex- became aware of the disengagement of the AP pectedly increased to the maximum value. The The left engine had [autopilot] and made a pitch-down input on his crew responded by moving the lever forward, begun to surge or sidestick,” the report said. “Pitch attitude began without the required five-second pause. The to decrease two seconds later.” result was that EPR increased only slightly, while stall during the The crew returned the aircraft to stable flight exhaust gas temperature (EGT) increased almost at FL 350 and landed without further incident to the limit. The lever was retarded again to bring interrupted fan ice about eight hours later in Paris. None of the the vibration level and the EGT within limits. 270 passengers and 14 crewmembers had been The crew decided to divert the flight to removal procedure. injured during the upset, and there was no dam- Nouakchott, Mauritania. During the descent, age to the aircraft. the left engine began again to respond normally BEA concluded that “this serious incident to thrust lever movement, and the aircraft was was due to inadequate monitoring of the flight landed in Nouakchott without further incident. parameters, which led to the failure to notice “Subsequent examination of both engines on the AP disengagement and the level bust [assigned ground, both externally and internally, did not altitude deviation], following a reflex action reveal any damage,” the report said. on the controls.” The report noted that if the Investigators determined that the left engine autopilot had remained engaged, the incident had begun to surge or stall during the inter- likely would have comprised only the 200-ft rupted fan ice removal procedure. “The vibra- altitude deviation. tion condition was attributed by the engine manufacturer [Rolls-Royce] to an asymmetric Engine Vibration Prompts Diversion ice buildup under the [engine] spinner fairings,” Boeing 757-200. No damage. No injuries. the report said. he aircraft was at FL 370, en route with 96 Rolls-Royce in 2001 had issued a service passengers and seven crewmembers from bulletin, revised in 2006, requiring the instal- TSierra Leone to London the night of Aug. 25, lation of seals between the engine spinners and 2010, when the flight crew noticed an increase in the spinner fairings to prevent moisture from engine vibration levels. In accordance with the entering the spinner cavities and freezing. The quick reference handbook procedure, they acti- report said that the spinners on the incident vated the engine anti-icing systems, but the vibra- aircraft had not been modified according to the tion levels continued to increase, said the report service bulletin, which calls for compliance by by the U.K. Air Accidents Investigation Branch. March 2015. “The vibration could now be felt through the airframe by both the flight crew and the cabin Oil Tube Fractures on Takeoff crew,” the report said. “The commander decided McDonnell Douglas MD-90-30. Substantial damage. No injuries. to perform the manufacturer’s ‘Fan Ice Removal’ he MD-90, with 111 people aboard, was procedure detailed in their OM [operations on initial climb when ATC told the flight manual] in an attempt to reduce the vibration.” Tcrew that white smoke had been observed The OM said that the procedure is to be from the right engine as the aircraft was rolling followed for one engine at a time by quickly for takeoff from Sendai (Japan) Airport the moving the thrust lever to idle and waiting afternoon of Aug. 15, 2010. The captain, the five seconds for the engine to stabilize before pilot monitoring, noticed an indication of low advancing the lever to attain the desired engine oil pressure and received clearance from ATC pressure ratio (EPR). The initial rapid reduction to stop the climb at 6,000 ft and proceed to an flightsafety.org | AEROSafetyWorld | August 2012 | 59 OnRecord
area south of the airport, where the problem The Premier pilot was not aware that the Cub could be diagnosed. was going to make an angled departure, and he The aircraft was climbing through 5,500 ft became concerned about a potential conflict with shortly thereafter when the engine fire warning the smaller airplane, said the report by the U.S. activated, said the report by the Japan Transport National Transportation Safety Board (NTSB). Safety Board (JTSB). The captain declared an The report said that as the light jet made a emergency and assumed control of the aircraft. continuous left turn from downwind to short The crew then shut down the right engine, acti- final, the bank angle varied between 32 and 43 vated the fire-extinguishing system and returned degrees. The enhanced ground-proximity warn- to the airport, where a single-engine landing ing system aboard the Premier generated five was completed without further incident. “bank angle” warnings. Investigators found that the no. 4 bearing scav- The pilot “stated that he overshot the enge tube had fractured, spraying oil that ignited runway centerline during his turn from base on contact with the engine’s hot section. The tube, to final and, when he completed the turn, his located inside the engine case, returns oil used to airplane was offset to the right of the runway,” lubricate and cool the aft bearing on the high- the report said. The Premier was 37 ft above pressure rotor shaft to the oil tank. The report said the ground when the pilot radioed that he was that stresses imposed by temperature and pressure going around. changes inside the tube likely had caused a fatigue “The pilot reported that he initiated a go- crack to form at a bend in the tube. around, increasing engine power slightly but The report noted that a heat shield precludes not to takeoff power as he looked for additional a visual check of the tube during maintenance traffic to avoid,” the report said. “He estimated inspections. As a result of the investigation, the that he advanced the throttle levers ‘probably a JTSB recommended that the U.S. Federal Avia- third of the way to the stop’ and, as he looked for tion Administration require the engine manufac- traffic, the stall warning stick-shaker and stick- turer, International Aero Engines (IAE), to review pusher systems activated almost simultaneously the tube design and inspection procedures. as the right wing stalled.” The report, issued in June, noted that IAE The airplane was in a nose-down and right- believes the fracture was caused partly by as- wing-low attitude when it struck a grass drain- sembly stresses and has revised the installation age ditch about 4,300 ft (1,311 m) north of the procedures. departure end of the runway. The pilot and his passenger were seriously injured, but no one on Stall on Go-Around the ground was hurt. Hawker Beechcraft 390. Substantial damage. Two serious injuries. pecial ATC procedures were in effect for a TURBOPROPS high volume of traffic at a major air show Sin Oshkosh, Wisconsin, U.S., the afternoon Prop Overspeed Causes Control Loss of July 27, 2010. Arrivals and departures were Bombardier DHC-8-103. Substantial damage. No injuries. being handled by different controllers on differ- he flight crew had turned on the seat belt ent radio frequencies. An arrivals controller had sign, expecting turbulence during the cleared the pilot of the Premier 1A to turn onto Tdescent over mountainous terrain to Sørkjo- a base leg about the same time that a departures sen (Norway) Airport the night of Feb. 21, 2006. controller cleared the pilot of a Piper Cub, which When the aircraft encountered “heavy” turbu- was holding on the runway, for an immediate lence at about 9,000 ft, the commander moved takeoff and to make an “angled departure” — the power levers toward flight idle, intending that is a slight left turn after liftoff to clear the to decrease airspeed from 225 kt to 180 kt, the runway for the light jet. maximum speed for flying in turbulence.
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However, the commander inadvertently turbulence increased, and the airplane entered lifted the tabs beneath the power lever knobs an uncommanded left roll and dive,” the report that release the locks that prevent the levers from said. “The autopilot disengaged, and the pilot’s being moved past the flight idle gate and into the electrically driven attitude indicator tumbled. Examination of the beta range, said the report issued by the Accident The flight crew reduced the engine power levers Investigation Board Norway in June 2012. to idle and were able to recover utilizing the airplane revealed “Unintentionally, both power levers ended copilot’s vacuum-driven attitude indicator. The that the outboard up aft of the flight idle gate,” the report said. “As airplane was returned to straight-and-level flight a result, both propellers overspeeded.” Possibly at an altitude of 8,000 ft; however, flight control one-third of the because the right power lever was moved farther instability persisted.” into beta than the left power lever, the right The crew diverted the flight to Blountville, left elevator had propeller entered an uncontrollably high rotation Tennessee, and landed the King Air without separated in flight. speed and caused severe internal engine damage. further incident. Examination of the airplane re- The drag produced by the right propeller vealed that the outboard one-third of the left el- caused a momentary loss of control. The Dash evator had separated in flight and the outboard 8 pitched 20 degrees nose-down, entered a section of the right elevator was bent downward. 58-degree right bank and descended about 1,000 “In addition, the horizontal stabilizer bulkhead ft before the crew was able to level the aircraft, frame was fractured, and the aft portion of the feather the propeller using the alternate feather- airframe sustained several areas of deformation,” ing system and shut down the engine. None of the report said. the 17 passengers or three crewmembers was injured. The crew decided to return to Tromsø, Takeoff Rejected Too Late where a single-engine landing was conducted Cessna 208B. Destroyed. One fatality, eight minor injuries. without further incident. he pilot was familiar with the airport in The report noted that the aircraft had Pukatawagan, Manitoba, Canada, and, not received a service bulletin modification Thaving conducted two scheduled flights preventing the power levers from being moved there earlier in the day on July 4, 2011, likely into beta unless the weight-on-wheels sensing was aware of several soft spots caused by recent system is activated. rainfall on the 3,000-ft (914-m) gravel runway. With eight passengers, baggage and 900 lb (408 Icing, Turbulence Trigger Upset kg) of fuel aboard, the Caravan was about 1,000 Beech King Air A100. Substantial damage. No injuries. lb (454 kg) below its maximum takeoff weight, he airplane was on a positioning flight from and the center of gravity was within limits, said Bridgewater, Virginia, U.S., to Wichita, the report by the Transportation Safety Board TKansas, the afternoon of June 15, 2011. of Canada. The pilots said that the ride in IMC at FL 200 The pilot began the takeoff from the ap- over Tennessee was smooth, but the weather proach end of Runway 33, with 20 degrees of radar system showed a large area of moderate flaps per the company’s standard operating to extreme precipitation about 30 nm (56 km) procedure. Groundspeed stagnated when the northwest. aircraft encountered soft spots about halfway “Meteorological and radar data revealed that down the runway. “One or both of the main the airplane entered an area of rapidly intensify- landing gear wheels lifted off the ground ing convective activity [that] developed along momentarily, but the aircraft was unable to the airplane’s flight path,” the NTSB report said. fly away,” the report said. “This indicates that The King Air encountered moderate turbu- either the aircraft was rotated too early or a lence and severe icing conditions, and the pilot significant degree of rotation occurred before altered course 40 degrees south. “However, the liftoff speed was attained.” flightsafety.org | AEROSafetyWorld | August 2012 | 61 OnRecord
The report said that the aircraft’s takeoff After the airplane was landed in Sacramento, performance might have been affected by an un- investigators found that the right wing flap expected wind shift or wind shear. The surface extension cable had failed where it contacts a winds were estimated as from 280 degrees at 12 pulley — a cable section that cannot be in- kt, gusting to 22 kt. spected for damage unless the cable is removed, The pilot rejected the takeoff with about the report said. The cable was installed when 600 ft (183 m) of runway remaining, which was the airplane was manufactured in 1975 and had insufficient to stop the aircraft, the report said. accumulated over 4,830 flight hours. The Caravan overran the runway, rolled down a steep 20-ft (6-m) slope into a ravine and caught Brake Failure Leads to Ramp Overrun fire. One passenger, who was not wearing a Lockheed P2V-5 Neptune. Substantial damage. No injuries. shoulder harness, was rendered unconscious he air tanker was returning to its base in by severe head wounds. The pilot and another Broomfield, Colorado, U.S., the afternoon passenger tried to extricate the unconscious pas- Tof June 26, 2010, when the flight crew senger but were forced away from the aircraft by discovered that the main hydraulic system had the increasing heat and smoke. The passenger failed — a fault later attributed to a ruptured died of smoke inhalation. hydraulic line. The copilot used emergency systems to extend the landing gear. However, PISTON AIRPLANES she inadvertently returned the emergency nose gear selector to the “bypass” position, rather Split-Flap Condition than to the “normal” position, which isolated Cessna 421B. Minor damage. No Injuries. emergency hydraulic system pressure from the he airplane was about 1,000 ft above the emergency brakes. designated pattern altitude when it en- There was enough residual accumulator Ttered the downwind leg at Truckee-Tahoe pressure to engage the brakes during land- (California, U.S.) Airport during an emergency ing, and the captain exited the runway on a medical services positioning flight the afternoon high-speed turn-off onto a taxiway leading to of May 2, 2011. When the pilot extended the the tanker ramp. However, when he tried to landing gear and flaps to facilitate a descent, he stop the airplane on the ramp, the brakes did heard a “popping sound,” and the 421 banked 80 not respond. The P2V crossed the ramp, rolled degrees right, the NTSB report said. through the airport perimeter fence and down The pilot attempted to retract the flaps, but an embankment, and came to a stop on a road. the left flap remained fully extended, and the The report noted that the airplane flight pilot had to use full left aileron control and trim manual procedure for a hydraulic failure is to to keep the wings level. He circled the airport stop and shut down the airplane on the runway and cycled the flap selector several times, but after landing, pin the landing gear and have the the split-flap condition persisted. airplane towed to parking. “He was able to accomplish left turns with about 5 degrees of bank, and although right Multiple Modifications Blur VMCA turns could be performed, recovery to wings- Beech 58 Baron. Substantial damage. Two fatalities. level was slower than normal,” the report said. he pilot had recently purchased the “Due to terrain and wind concerns, he decided airplane, which had been modified ac- to divert back to [Sacramento, California]. For Tcording to a supplemental type certificate the remaining 35 minutes of flight, the pilot (STC) with vortex generators that decreased employed the assistance of a medical crewmem- the minimum single-engine control speed
ber to help with maintaining left aileron control (VMCA) from 81 kt to 74 kt and under another deflection.” STC with more powerful engines and different
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propellers. The STC for the latter modification had struck and destroyed the tail rotor. “The
specified a VMCA of 87 kt. original location of the clipboard and how it Because no flight testing had been per- became free could not be determined,” the formed to determine the interrelationship of the report said. two STCs, which had been obtained by different companies, “the actual performance data for the Rotor Stalls on Approach Robinson R22 Beta. Destroyed. Two fatalities. airplane, including the VMCA, were unknown,”
the NTSB report said. “However, the VMCA … he pilot was returning to a helipad in Ya-
likely was higher than the 74-knot VMCA marked maga, Japan, after a route-familiarization on the airspeed indicator.” Tflight the afternoon of Aug. 1, 2010. A The pilot was receiving an instrument witness saw the R22 cross utility lines and competency check the morning of Aug. 7, 2010, then enter a steep, descending right turn. Both when the airplane stalled, entered a spin and occupants were killed when the helicopter struck a house in Saltsburg, Pennsylvania. The crashed in a paddy about 160 m (525 ft) from pilot and flight instructor were killed, but no the helipad. one on the ground was hurt. The JTSB report said that the helicopter Investigators determined that the pilot likely likely had been descending with a relatively high
lost control of the Baron during a VMCA dem- approach speed and a low main rotor speed onstration. “Because the airplane was equipped when the pilot increased collective control to with only a throw-over control yoke, the [flight stay above the power lines. Main rotor speed instructor] had limited ability to assist in the continued to decrease until the rotor blades recovery of the airplane,” the report said. stalled, resulting in the loss of control, according to the report. HELICOPTERS Bent Pneumatic Line Fractures Clipboard Strikes Tail Rotor Hughes 500D. Minor damage. No injuries. Hiller UH-12E. Substantial damage. Three fatalities. he helicopter was descending to land at he pilot stowed most of the passengers’ McGrath, Alaska, U.S., during a charter equipment and personal effects in the Tflight the evening of July 4, 2011, when the Thelicopter’s external racks before departing engine noise abruptly changed and the aural and from Clarkston, Washington, U.S., for a wildlife- visual engine failure warnings activated. The survey flight the morning of Aug. 31, 2010. pilot initiated autorotative flight and conducted About 40 minutes later, the pilot radioed an emergency landing on uneven tundra. The that he was diverting the flight to Kamiah, main rotor blades were damaged when they Idaho, which was about 35 nm (65 km) short struck several small trees during the emergency of the planned destination, but gave no reason landing, but the pilot and her two passengers for the diversion. “No further transmissions escaped injury. were received from the helicopter,” the NTSB “A post-accident inspection revealed a fa- report said. “Several witnesses … heard un- tigue fracture in the engine Pc line that provides usual noises emanating from the helicopter compressed air to operate the engine governor and observed objects separating or falling and fuel control units,” the NTSB report said. from it. [They] reported that it was rotating as “The Pc line met the metallurgical material it descended.” specifications, but there was a bend in a nor- The Hiller crashed out of control on a mally straight portion of the line.” The bend, driveway in a residential area near Kamiah. which was of unknown origin, created material Investigators determined that a metal clip- stress and fatigue that eventually caused the line board belonging to one of the passengers to fracture. flightsafety.org | AEROSafetyWorld | August 2012 | 63 OnRecord
Preliminary Reports, June 2012
Date Location Aircraft Type Aircraft Damage Injuries
June 1 Pontianak, Indonesia Boeing 737-400 substantial 163 minor/none Visibility was 600 m (3/8 mi) in heavy rain, and surface winds were from 230 degrees at 22 kt when the 737 veered off the left side of Runway 15 while landing. June 2 Accra, Ghana Boeing 727-200F destroyed 12 fatal, 4 minor/none A thunderstorm was overhead when the 727 overran the 3,400-m (11,155-ft) runway during a night landing, rolled through the airport perimeter fence and struck two vehicles on a road. Twelve people on the ground were killed. June 3 Lagos, Nigeria McDonnell Douglas MD-83 destroyed 163 fatal The MD-83 was 11 nm (20 km) from the airport when the flight crew declared an emergency because of a loss of power from both engines. The aircraft then struck a power line and crashed in a residential area. All 153 people aboard the aircraft and 10 people on the ground were killed. June 3 Modena, Utah, U.S. Lockheed P2V-7 Neptune substantial 2 fatal The air tanker struck terrain while turning onto final approach to drop retardant on a forest fire at the bottom of a narrow valley. June 4 Indiantown, Florida, U.S. Bell 427 substantial 5 minor The helicopter was in cruise flight at 800 ft when several large birds struck the main rotor head. The pilot said that the 427 began to shake violently and became difficult to control. The helicopter rolled over after striking the ground hard during the emergency landing. Recovered bird remains were sent to the Smithsonian Institution for identification. June 6 Rio de la Plata, Uruguay Swearingen Metro III (missing) NA The Metro is presumed to have crashed, and the four crewmembers killed, shortly after departing from Montevideo, Uruguay, for a cargo flight to Buenos Aires, Argentina. June 7 Lake Wales, Florida, U.S. Pilatus PC-12/47 destroyed 6 fatal The airplane was in instrument meteorological conditions, climbing through 25,000 ft and deviating from course to avoid an area of moderate to extreme precipitation, when it departed from controlled flight and broke up. Witnesses saw the PC-12 emerge from the clouds in a spin. June 9 Prague, Czech Republic ATR 42-500 destroyed 1 NA A mechanic was injured when an explosion occurred and the ATR 42 caught fire inside a maintenance hangar. June 9 Teisendorf, Germany Robinson R44 destroyed 4 fatal Visual meteorological conditions (VMC) prevailed when the R44 struck mountainous terrain during a flight from Worms, Germany, to Salzburg, Austria. June 10 Kiev, Ukraine Let 410UVP destroyed 5 fatal, 15 minor/none The skydiving aircraft was returning to the airport because of an approaching rainstorm when it crashed in a field. June 18 Atlanta, Georgia, U.S. Beech 400A Beechjet substantial 2 serious, 2 minor Witnesses said that the Beechjet touched down at DeKalb-Peachtree Airport with about 3,000 ft (914 m) of the 4,800-ft (1,463-m) runway remaining. The airplane overran the runway and rolled down an embankment. June 19 Ceduna, South Australia, Australia Eurocopter AS 350-BA destroyed 2 none The pilot conducted a precautionary landing after detecting fuel fumes. The helicopter caught fire after the landing. June 20 Pweto, Democratic Republic of Congo Grumman Gulfstream 1 destroyed 5 minor/none The Gulfstream touched down hard, bounced 20 ft and overran the runway onto a rocky embankment. June 20 Tokyo, Japan Boeing 767-300 substantial 193 none Winds were from 220 at 14 kt, gusting to 27 kt, when the 767 touched down hard on Narita’s Runway 16R and bounced twice. June 22 Morgantown, West Virginia, U.S. Beech King Air C90GT substantial 1 fatal The King Air struck a communications tower and crashed about 7.5 nm (14 km) from the airport during a positioning flight in VMC.
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 | August 2012 The Foundation would like to give special recognition to our BARS Benefactors, Benefactor and Patron members. We value your membership and your high levels of commitment to the world of safety. Without your support, the Foundation’s mission of the continuous improvement of global aviation safety would not be possible.
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Presented by Flight Safety Foundation and Latin American and Caribbean Air Transport Association (ALTA) Hosted by Directorate General of Civil Aviation of Chile Sheraton Santiago Hotel and Convention Center, Santiago, Chile