AeroSafety world
THERMAL RUNAWAY RISK MANAGEMENT Lithium battery cabin hazards Corporate flight following MAINTENANCE HUMAN FACTORS PILOT CERTIFICATION Survey shows programs’ importance Seeking revised standards CRIMINALIZATION FIGHTING THE URGE TO PROSECUTE
TheFlight Journal Safety of FFoundationlight Safety Foundation MARCH 2008
President’sMessage Keeping It Credible
dvocating safety in this remarkably safe change will be from overwhelming to robust. industry isn’t easy, as the people who read China already has been trying to slow the nation’s this magazine know. It is tough to stand overheated aviation growth because of the safety up every day and suggest fixes for prob- threat; a downturn will ease the Chinese task. lemsA that haven’t happened yet. It is even worse India has not controlled growth, and today if you have to convince someone to spend money it faces a serious shortfall in skilled aviation pro- on a “risk” that doesn’t seem real to them. fessionals and supporting infrastructure. Even a To do that job well, you have to do your home- substantial slowdown will not relieve India’s need work and have a lot of conversations with yourself, to catch up; six months ago the situation looked asking if the risk you are attacking is real, or are impossible, six months from now it may improve you overstating the case? Just one overblown claim to really difficult. can compromise the credibility that is essential I have been asking airline and manufacturing to our job. executives what they think. They are not seeing Over the past year and a half, I have been a slowdown yet. Europe looks solid, and even working hard to make the case that all is not the U.S., as of February, is not seeing a big traffic well in our aviation world. There are, in fact, big dropoff. Manufacturers have all achieved record- risks out there. That was a pretty easy position setting backlogs and those numbers are holding. to justify when all the indicators were pointing However, air freight, a reliable leading indicator, toward record-setting growth that was overtaking is showing some softness. the people and infrastructure that are essential So my conclusion is simple. We may catch a to safety. little bit of a break, but it will be brief and slight. But what about now? Global financial markets History has shown that aviation growth rebounds have taken a pounding, and all the signs in the quickly from economic setbacks. We need to use United States point toward recession. Do we still this time to build the base of people and infra- have a problem? structure that can support that expansion. It is a I am not an economist, but when I do my tougher sell today, but it is still the right message. homework and ask the hard questions, this is Look at the numbers yourself and make up your where I come out: The world is definitely going own mind. During the coming difficult times we to notice a U.S. downturn, but not the way it used must keep the message credible and focused. to. Many areas around the world experiencing rapid growth have either a lot of oil or a lot of people. Oil dollars will continue to fuel expansion in places like the Middle East, Russia, West Africa and Indonesia. In India and China, growth of the middle class William R. Voss has been driving transportation demand, and it President and CEO is not going away. Growth may slow a bit, but the Flight Safety Foundation www.flightsafety.org | AeroSafetyWorld | March 2008 | 1 AeroSafetyWorld
contents March2008 Vol 3 Issue 3 features
12 CoverStory | Deterring Criminalization
19 FlightOps | Real Time Risk Management
12 24 InSight | Quality Control for Pilots
29 CausalFactors | Close Call in Khartoum
34 MaintenanceMatters | Human Factors in Maintenance
42 CabinSafety | Thermal Runaway
19 departments 1 President’sMessage | Keeping It Credible
24 5 EditorialPage | Lingering Pain
6 SafetyCalendar | Industry Events
8 InBrief | Safety News
2 | flight safety foundation | AeroSafetyWorld | March 2008 29
34 42
AeroSafetyWORLD telephone: +1 703.739.6700 49 DataLink | Kiwi Count William R. Voss, publisher, FSF president and CEO [email protected], ext. 108 53 | Traffic Jam InfoScan J.A. Donoghue, editor-in-chief, FSF director of publications 57 OnRecord | Runway Deficit [email protected], ext. 116 Mark Lacagnina, senior editor [email protected], ext. 114 Wayne Rosenkrans, senior editor [email protected], ext. 115 Linda Werfelman, senior editor [email protected], ext. 122 Rick Darby, associate editor [email protected], ext. 113 Karen K. Ehrlich, web and print production coordinator [email protected], ext. 117 Ann L. Mullikin, art director and designer [email protected], ext. 120 Susan D. Reed, production specialist About the Cover [email protected], ext. 123 Learning from accident investigations is threatened by criminal prosecutions. Patricia Setze, librarian Photo Illustration: © Chris Sorensen Photography [email protected], ext. 103
Editorial Advisory Board We Encourage Reprints (For permissions, go to
Editorialpage Lingering Pain
elf-inflicted injuries always seem And that is what many feared NAOMS The situation was made worse when to hurt more, the pain exacerbated would become — just a massive collec- NASA, trying to explain its decision not to by the frustration that once again tion of unverified war stories that might do more with the data, sounded like it was you’ve failed to maintain control or might not be skewed by each pilot’s purposefully hiding bad news. This had andS let things get so far out of whack that personal reference framework. We just the effect of throwing gasoline on a fire. injury was the result. The subsequent don’t know, and that is the baseline fact. Trying to do the right thing for its healing process becomes a succession of And while all data have problems, this study subjects, and remembering the very reminders of your mistake. bunch seems too burdened with unknow- bad experience of several years ago when Perhaps that’s why the recent kerfuffle able variables for researchers to bother Dutch researchers had to divulge identi- over data from the National Aviation Op- trying to adjust the data to get a clear fications it had pledged to protect, NASA erational Monitoring Service (NAOMS), picture of an environment already fairly on New Year’s Eve released a package of put together to develop new methods for well described through other methods. data that went the extra mile to protect aviation system safety analysis by the U.S. But another error was made. The the participants. National Aeronautics and Space Admin- researchers promised those who partici- Sadly, this is an election year in the istration (NASA), is so grating. pated in the study that their contributions United States, and members of Congress From birth, the study’s basic concept would remain anonymous. It makes are getting attention by continuing to beat had credibility problems. That good, perfect sense to do so; the Aviation Safety on the issue. Last month, the chairman quantifiable data would come from Reporting System that collects volun- of the U.S. House Committee on Science 25,000 telephone interviews with pilots teered incident reports grants anonymity and Technology, Bart Gordon (D-Tenn.), is a premise that many in the business of to its participants. Although the program joined with some committee members to serious research question. is serviced by NASA, it is a Federal Avia- request that the Government Account- If two pilots report a runway incursion tion Administration (FAA) program, and ability Office, an arm of Congress, take incident, were there two incidents or are Congress has granted FAA the right to over the original data and analyze it. they both reporting the same event? If a shield that sort of information against Looks like this self-inflicted wound will pilot’s union is engaged in wrangling with disclosure due to a request based on the take a while to heal. management over flight and duty time Freedom of Information Act (FOIA), a limits, might the pilot be just a little more right that NASA regrettably lacks. likely to identify fatigue in the cockpit as Several years after the project was a major safety risk? And even if he does mercifully laid to rest, a news organiza- exaggerate, he still might be right in his as- tion got to wondering what happened J.A. Donoghue sertion; it’s just that there is no supporting with NAOMS and filed an FOIA request, Editor-in-Chief data other than his individual war story. and NASA’s problem became clear. AeroSafety World www.flightsafety.org | AeroSafetyWorld | March 2008 | 5 safetycalendar
MARCH 5–7 ➤ Airport Wildlife Management MARCH 25 ➤ Aerospace Medicine: APRIL 29–MAY 1 ➤ 53rd annual Seminar. Embry-Riddle Aeronautical University. Survival Following Aircraft Incidents. Corporate Aviation Safety Seminar (CASS). Dallas/Fort Worth International Airport. Allen R. Royal Aeronautical Society and IET. London. Flight Safety Foundation and National Business Newman,
6 | flight safety foundation | AeroSafetyWorld | March 2008 Serving Aviation Safety Interests for More Than 60 Years
light Safety Foundation is an international membership organization dedicated to Officers and Staff the continuous improvement of aviation safety. Nonprofit and independent, the Chairman, Board of Governors Amb. Edward W. FFoundation was launched officially in 1947 in response to the aviation industry’s need Stimpson for a neutral clearinghouse to disseminate objective safety information, and for a credible President and CEO William R. Voss and knowledgeable body that would identify threats to safety, analyze the problems and Executive Vice President Robert H. Vandel recommend practical solutions to them. Since its beginning, the Foundation has acted in the General Counsel and Secretary Kenneth P. Quinn, Esq. public interest to produce positive influence on aviation safety. Today, the Foundation provides Treasurer David J. Barger leadership to more than 1,170 individuals and member organizations in 142 countries. Administrative Manager, MemberGuide Support Services Linda Crowley Horger Flight Safety Foundation 601 Madison Street, Suite 300, Alexandria, VA, 22314-1756 USA Financial tel: +1 703.739.6700 fax: +1 703.739.6708 Chief Financial Officer Penny Young www.flightsafety.org Membership Director, Membership and Development Ann Hill Membership Services Coordinator Namratha Apparao Membership Services Coordinator Ahlam Wahdan
Communications Director of Communications Emily McGee
Technical Director of Member enrollment ext. 105 Technical Programs James M. Burin Ann Hill, director, membership and development [email protected] Technical Specialist/ Seminar registration ext. 101 Safety Auditor Robert Feeler Namratha Apparao, membership services coordinator [email protected] Manager of Seminar sponsorships ext. 105 Aviation Safety Audits Darol V. Holsman Ann Hill, director, membership and development [email protected] Exhibitor opportunities ext. 105 Past President Stuart Matthews Ann Hill, director, membership and development [email protected] Founder Jerome Lederer FSF awards programs ext. 105 1902–2004 Ann Hill, director, membership and development [email protected] Technical product orders ext. 101 Namratha Apparao, membership services coordinator [email protected] Library services/seminar proceedings ext. 103 Patricia Setze, librarian [email protected] Web Site ext. 117 Karen Ehrlich, web and print production coordinator [email protected]
www.flightsafety.org | AeroSafetyWorld | March 2008 SINCE 1947 | 7 inBrief Safety News Outdated Instrumentation?
he primary cockpit instrumenta- required for RNP flight, tion in many aircraft is outdated and information re- Tand inadequate for the required quired to monitor system navigation performance (RNP) environ- performance for flight ment, which requires a high degree of procedures is scattered accuracy in navigation, the Interna- throughout the flight deck, tional Federation of Air Line Pilots’ IFALPA said. In addition, Associations (IFALPA) says. the PFD does not provide IFALPA criticized the design of the position information — or primary flight display (PFD) and naviga- situation information — tion display (ND), which are based on and as a result, the crew’s analog “clocks and dials” used in earlier situational awareness is navigation instruments. inadequate, IFALPA said. © Honeywell “In the days of straight courses, Flight crews today re- This integrated primary flight display gives pilots situational airways, approach and departure pro- quire information displays awareness of the flight path, terrain and navigational environment. cedures, all with relatively large safety with “an accurate and intui- margins, these indicators, together with tive presentation, without in the sky, combined with a flight path flight director (FD) guidance technology, the need to use more than one display to predictor, may be the best way to optimize [were] sufficient to enable pilots to safely access the relevant data,” IFALPA said. the display of all the requirements for safe monitor the progress of a flight as well “There is an immediate need to and accurate flight in the RNP environ- as to keep flight technical errors within update the capabilities of the avionics ment, thus allowing crews the facility to required margins when flying manually,” displays in order that they become equal manually operate (or hand fly) the aircraft IFALPA said in a position statement. to the task,” IFALPA said. through complex approach, departure However, the depiction scale on to- The organization suggested that “de- and missed approach procedures or dur- day’s NDs does not provide the resolution velopment of a [three-dimensional] path ing non-normal operations.”
Runway Warning Lights
ew runway light systems being tested at two U.S. Runway status lights (RWSL), which are being tested at airports for their effectiveness in averting runway airports in the Dallas–Fort Worth area and in San Diego, are Nincursions have proved effective and should be in- automated “surveillance-driven” lights that are installed at run- stalled at airports nationwide, according to a report by the way and taxiway intersections and at runway departure points; U.S. Department of Transportation Office of the Inspector they illuminate to indicate it is unsafe to cross or depart from a General. runway. “RWSL is a viable and important technology for reduc- ing runway incursions,” the report said. “Pilots, pilot union officials, air traffic management and the airport operator at [Dallas–Fort Worth International Airport] all agreed that RWSL works as intended and has no known negative impact on capacity, communication or safety.” In addition, the report said that the U.S. National Transportation Safety Board (NTSB) considers RWSL a promising technology for addressing an NTSB recom- mendation that pilots receive direct warnings of potential runway conflicts. The U.S. Federal Aviation Administration said, in a re- sponse included in the report, that it agreed with several report recommendations, including one that called for the accelerated deployment of RWSL. © Igor Marx/iStockphoto.com
8 | flight safety foundation | AeroSafetyWorld | March 2008 inBrief
VLJ Integration
urocontrol has established a new forum to seek recom- mendations for integrating very light jets (VLJs) into the EEuropean air traffic system. The European VLJs Integration Platform is intended to ensure the safe, efficient increase in the number of VLJs in European skies. That number is expected to total about 700 by 2015; of these, most are expected to be used in air taxi operations, resulting in an increase of 200 to 300 flights per day, Eurocontrol said. “The growth in VLJs adds a significant extra dimension to the complexity of air traffic in Europe,” said Alex Hendriks, Eu- © Spectrum Aeronautical rocontrol deputy director of air traffic management strategies. “VLJs have very different speeds and cruising levels from cur- takeoff and en route portions of flight, as well as the technical rent commercial jet aircraft, so we need to conduct an impact requirements of VLJ on-board systems because of the possibil- assessment to see how they will affect the network as a whole.” ity of “difficulties in adapting some of the fully integrated avi- Eurocontrol said that the assessment would examine the onics systems currently employed in certain VLJs to particular likely impact of VLJs on air traffic control services during navigation requirements.”
Special Regulations for MU-2Bs Aid to Indonesia
he U.S. Federal Aviation Admin- said Nick Sabatini, FAA associate fficials from Australia and Indo- istration (FAA) says it will require administrator for aviation safety. nesia have signed a three-year co- Tadditional training, experi- “When we saw the rising accident Ooperative agreement to improve ence and operating requirements to rate for the MU-2B, we decided to transport safety in Indonesia, including improve operational safety for the take appropriate actions to bring the training for up to 40 Indonesian air- Mitsubishi MU-2B (ASW, 1/07, p. 32). plane up to an acceptable level of worthiness inspectors each year. The FAA has finalized a special safety.” The agreement, signed late in Janu- federal aviation regulation (SFAR) that The increase in accidents and ary, also calls for Australia to provide mandates a comprehensive standardized incidents was recorded in 2004 and mentoring and training for personnel pilot training program. The SFAR also re- 2005, the FAA said, and a subsequent in Indonesian air traffic management quires pilots to use a standardized check- evaluation of the airplane concluded services, as well as guidance in the con- list and the current airplane flight manual that changes were required in training duct of transport safety investigations. and, in most cases, to have a working and operating requirements. These measures were among several autopilot installed in the airplane. MU-2B operators must comply that were identified by the Indonesian “The FAA studies enormous with the SFAR within one year of its government as key safety priorities. amounts of data looking for trends,” publication. Australian Transport Minister Anthony Albanese said that the agree- ment calls for expansion of the exist- ing cooperative relationship between the two countries. “It is essential the traveling public of both countries [has] confidence that transport safety is a priority and that lessons from previous transport accidents are being acted upon,” Albanese said. “Australia’s assistance will complement the substantial efforts that the government of the Republic of Indonesia has already taken to improve the safety of their transport services.”
© Mitsubishi Heavy Industries
www.flightsafety.org | AeroSafetyWorld | March 2008 | 9 inBrief
Runway Safety Goals Caution on Corrosion
he U.S. aviation perators of older small aircraft — industry has and the maintenance personnel Ttaken significant Owho work on them — should add short-term actions corrosion detection to their mainte- to improve airport nance plans, the Australian Civil Avia- safety, but additional tion Safety Authority (CASA) says. steps must be taken “Corrosion is a real problem, and to reduce risks of … all corrosion, regardless of sever- runway incursions ity, requires rectification,” a CASA and wrong-runway airworthiness bulletin says. “Several departures, the U.S. reports have been received by CASA Federal Aviation Ad- indicating that severe corrosion has ministration (FAA) been detected in several models and © Christoph Ermel/iStockphoto.com says. types of older small aircraft. In some Acting FAA Administrator Robert A. Sturgell said that 53 of the nation’s 75 instances, this has led to major repairs busiest airports have upgraded airport markings, 20 large airports have completed and has resulted in a few aircraft being runway safety reviews, and 385 of the nation’s 569 certificated airports now require beyond economic repair.” annual recurrent training for airport employees with access to movement areas. The airworthiness bulletin said In addition, all 112 active air carriers have told the FAA that they have that the problem has arisen, in part, complied with directives to include ground scenarios in pilots’ simulator training because many small aircraft have and to review cockpit procedures to address matters that distract pilots dur- remained in service longer than their ing taxi, the FAA said. The FAA is developing a DVD for distribution to the air manufacturers had expected. carriers for use in training non-pilot employees who operate vehicles or aircraft “In many instances, the manufac- at airports and also has agreed to work with the National Air Traffic Controllers turers did not consider the problems Association to develop an aviation safety action program (ASAP) — or voluntary, associated with older aircraft fleets,” nonpunitive safety reporting system — for air traffic controllers. CASA said. “Some are only now con- sidering corrosion detection and pre- vention programs and aging aircraft maintenance requirements.” In Other News … CASA recommended that all cost-benefit analysis is being planning. The NTSB cited six general registered operators of small aircraft conducted for the Australian aviation CFIT accidents in a recent incorporate corrosion detection, Civil Aviation Safety Author- three-year period in which the aircraft rectification and prevention into their A maintenance plans and ensure that all ity to evaluate instrument approaches struck terrain either soon after takeoff with vertical guidance. Among the ap- or during descent while preparing to corrosion is rectified as soon as pos- proaches being studied are the Japanese land. … The U.S. Federal Aviation sible after detection. multi-function transport satellite-based Administration (FAA) has issued augmentation system (MSAS) and the a safety alert for operators warning U.S. wide area augmentation system of the hazards of an air conditioning (WAAS). … The U.S. National Trans- (A/C) cart pressurizing an airplane portation Safety Board (NTSB) has cabin if the cart is used while airplane issued a safety alert to warn general doors are closed. The FAA cited a 2005
aviation pilots of the increased risks of accident in which a flight attendant on Baker/Dreamstime.com © Darren controlled flight into terrain (CFIT) a Bombardier CRJ200 suffered serious during night visual meteorological con- injuries after opening the galley door ditions, caution them against compla- while an A/C cart was connected to cency, and urge increased altitude and the airplane and being ejected from the position awareness and better preflight galley service door (ASW, 1/08, p. 10).
Compiled and edited by Linda Werfelman.
10 | flight safety foundation | AeroSafetyWorld | March 2008 $O YOU FULLY UNDERSTAND YOUR OPERATION
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02-11-08_ASW_ad.indd 1 2/12/08 1:58:32 PM Coverstory © Christine Balderas/iStockphoto
Deterring Criminalization Aviation safety leaders face a growing challenge in dissuading prosecutors from filing criminal charges against pilots, controllers and others involved in aircraft accidents.
BY LINDA WERFELMAN
12 | flight safety foundation | AeroSafetyWorld | March 2008 coverStory
riminal prosecutors are becom- Safety Foundation President and CEO sources of information and jeopardize ing increasingly eager to press William R. Voss. safety.” charges against pilots, air traffic “The safety of the traveling public In addition to major cases that have controllers and other aviation depends on encouraging a climate of generated worldwide attention — for professionalsC involved in aircraft ac- openness and cooperation following example, the Air France Concorde that cidents, and that eagerness is a grow- accidents,” Voss said. “Overzealous crashed into a hotel after takeoff from ing threat to flight safety, says Flight prosecutions threaten to dry up vital Charles de Gaulle Airport in Paris in Photo IllustrationPhoto © Chris Photography Sorensen
www.flightsafety.org | AeroSafetyWorld | March 2008 | 13 Coverstory
1/08, p. 42). The Indonesian National Transporta- tion Safety Committee (NTSC), in its final report on the accident, said that the causes were inef- fective flight crew communication and coordina- tion, the crew’s failure to reject the unstabilized approach, the captain’s failure to act on both his copilot’s calls for a go-around and repeated alerts from the airplane’s ground-proximity warn- ing system (GPWS), the copilot’s failure to take control of the airplane, and the absence of pilot training by the airline on required responses to GPWS alerts and warnings. The captain could be sentenced to up to seven years in prison if he is convicted of the charges against him, including manslaugh- ter and violating aviation law. His arrest was denounced by the Garuda pilots association as “unlawful.”1,2 The Garuda pilots group, along with the International Federation of Air Line Pilots’ Associations (IFALPA), said that, although the NTSC had issued what it called a final report, the report was incomplete and that further in- vestigation is required to identify all factors that contributed to the accident. “Unless this is done, there is little possibility that aviation safety in the area of crew perfor- mance can be improved by the lessons of this accident,” IFALPA said. “Clearly, a criminal prosecution at this time may well foreclose fur- ther investigation for safety purposes.” © Chris Bernard/iStockphoto Published reports have said that Indonesian police have been conducting a criminal investi- 2000 and the Gol Linhas Aéreas Boeing 737-800 gation that has not relied on the findings of the “On one hand, that crashed in the Amazon after a midair col- NTSC report, issued late in 2007. The reports we’ve got to be lision with a business jet in 2006 (see “Cases of said that, when the case goes to trial, NTSC Criminalization”) — dozens of lesser known officials could be called to testify as expert wit- vigorous about cases also have been developed in jurisdictions nesses but that the accident report cannot be around the world, he said. used in court.3 protecting safety “Every time you ask, there are two or three Voss said that proponents of aviation safety
information, but on more cases,” Voss said. “can’t say, just because it’s aviation, that the The most recent high-profile case involves the justice department doesn’t have the right to the other hand, we arrest in early February of the captain of a Garuda pursue an independent investigation, as long as Indonesia 737 that overran the runway on land- it doesn’t compromise safety processes or critical can’t put ourselves ing in Yogyakarta and burned on March 7, 2007, safety information. killing 21 of the 140 people in the airplane and “On one hand, we’ve got to be vigorous ahead of justice.” leaving 12 others with serious injuries (ASW, about protecting safety information, but on
14 | flight safety foundation | AeroSafetyWorld | March 2008 coverStory
Cases of Criminalization
he following are examples of dozens of cases in which crew and four people on the ground. The French Bureau pilots, air traffic controllers, civil aviation regulators and d’Enquêtes et d’Analyses (BEA) said that the probable causes Tofficials of aviation companies have been accused or of the crash were the passage of a Concorde tire over a part convicted of criminal activity in connection with an aviation lost by an aircraft that had departed earlier, the “ripping out” accident: of a large piece of the fuel tank and the ignition of the leak- 5 Jan. 20, 1992 — An Air Inter Airbus A320 was being flown ing fuel. on a VOR/DME (VHF omnidirectional radio/distance measur- In 2006, France’s highest court refused to dismiss criminal ing equipment) instrument approach to Strasbourg, France, charges against a former official of the French civil avia- in night instrument meteorological conditions when it struck tion authority and two former officials of Aerospatiale, the company that built the Concorde. Aerospatiale was one of a snow-covered mountain ridge.1 The impact was just below three companies that merged in 2000 to form the European the top of the ridge and on the extended runway centerline. Aeronautic Defence and Space Co. (EADS). Continental There was no indication of any problem before the crash, and Airlines, the operator of the DC-10 that investigators said the flight crew had complied with standard procedures until dropped a titanium metal strip on the runway, also has the airplane began descending at 3,300 fpm — instead of been placed under investigation in the matter.6 700 fpm — to the Strasbourg VORTAC, 2 nm (4 km) from the A trial is not airport. expected before 2009. In 2006, one air traffic controller and five current and Sept. 29, 2006 — A Gol Linhas Aéreas Boeing 737-800 retired aviation officials of Airbus, the French civil aviation crashed into the Amazon after a midair collision with an authority and Air Inter — a subsidiary of Air France that ExcelAire Embraer Legacy 600 business jet.7 since has been incorporated into the airline — were tried in All 154 people in the 737 were killed, and the airplane criminal court on charges of involuntary manslaughter and was destroyed. The Legacy’s crew maintained control of their acquitted. Airbus and Air France were found liable for the damaged airplane and conducted an emergency landing at pain and suffering of the victims’ families, but the court did a Brazilian air base; none of the seven people in the busi- not determine how much the two companies should pay, ness jet was injured. A Brazilian military investigation of the leaving that decision to a subsequent trial.2 accident was continuing, but preliminary findings indicated May 11, 1996 — A ValuJet Douglas DC-9 crashed in Florida’s that the two airplanes had been assigned to the same flight Everglades about 10 minutes after takeoff from Miami level and that air traffic control (ATC) stopped receiving sig- International Airport, killing all 110 people in the airplane. nals from the Legacy’s transponder nearly an hour before the The U.S. National Transportation Safety Board said that collision. Radio communications between the Legacy and the accident resulted from a cargo compartment fire that ATC had been interrupted until about four minutes before began with the actuation of oxygen generators that were the accident, when the crew heard an ATC call telling them to improperly carried as non-revenue cargo. Probable causes change radio frequencies but received no response to their were the failure of a contract maintenance firm to properly request for clarification. package and identify the oxygen generators, ValuJet’s failure The Legacy pilots were detained in Brazil for two to properly oversee its contract maintenance program for months after the accident. In June 2007, the pilots and four compliance with hazardous materials practices and the U.S. air traffic controllers were ordered to stand trial for “expos- 8 Federal Aviation Administration’s failure to require smoke ing an aircraft to danger.” At press time, the trial had not detectors and fire suppression systems in Class D cargo begun. A subsequent report by the military investigators compartments.3 said that five military controllers were among those respon- Two months after the accident, SabreTech, the contract sible for the crash and that “crimes were committed” that maintenance firm that had handled the oxygen genera- could result in the controllers’ imprisonment, suspension tors, and three of its employees were indicted on criminal or discharge. The report also criticized the Legacy pilots for 9 charges. A jury acquitted the three mechanics; SabreTech “contributing to the accident by action or omission.” was convicted and ordered to pay US$2.9 million in fines — LW and restitution. An appeals court overturned the convic- Notes tions in 2005.4 1. Airclaims. Major Loss Record. Volume 2, Issue 161, 2007. July 25, 2000 — An Air France Concorde burst into flames during takeoff from Charles de Gaulle Airport in Paris and 2. Clark, Nicola; Phillips, Don. “6 Acquitted in Crash of French Jet in crashed into a nearby hotel, killing all 109 passengers and 1992.” International Herald Tribune. Nov. 7, 2006.
www.flightsafety.org | AeroSafetyWorld | March 2008 | 15 Coverstory
3. U.S. National Transportation Safety Board. Aircraft Accident 6. Associated Press. “Paris Court Paves Way for Concorde Trial.” AP Report: In-Flight Fire and Impact With Terrain, ValuJet Airlines Online. Sept. 22, 2006. Flight 592, DC-9-32, N904VJ, Everglades, Near Miami, Florida, May 11, 1996. NTSB/AAR-97/06. 7. U.S. National Transportation Safety Board. Factual report no. DCA06RA076A. 4. Prentice, Stephen P. “Justice Delayed: USA vs. Sabre Tech.” AMT Online. Aug. 24, 2005.
the other hand, we can’t put ourselves future passengers depend on the vital become less likely to file charges against ahead of justice.” safety information that is gathered dur- “people on the line,” Voss said. Instead, Capt. Stephanus Geraldus, presi- ing an accident investigation. If there the emphasis appears to have shifted dent of the Garuda pilots association, is fear of prosecution, then the parties to managers who were accountable for agreed, adding, “We are not against involved will be less inclined to be open failed systems, he said. holding pilots accountable if there is a during this investigation process.” “This is more consistent with what case to answer. But we want everything The same sentiments were ex- we talk about in good safety prac- to follow international standards.” That pressed in an October 2006 resolution tices — the concept of accountable is “not the case here,” he said.4 approved by Flight Safety Founda- executives,” he said. “However, it does Standards set forth by the Inter- tion, the Royal Aeronautical Society, still have a little bit of a chilling effect national Civil Aviation Organization the Académie Nationale de l’Air et de because it makes people in executive (ICAO) say that discipline or punish- l’Espace and the Civil Air Navigation positions uncomfortable. … It’s a thing ment for people involved in an aviation Services Organisation. that’s hard to celebrate, but you also accident or incident is appropriate only The resolution said, “The para- have to acknowledge that it probably if evidence shows that the occurrence mount consideration in an aviation reflects an emerging understanding of “was caused by an act considered, in accident investigation should be to safety issues on the part of prosecutors.” accordance with the law, to be conduct determine the probable cause of and In addition, he noted that the with intent to cause damage, or conduct contributing factors in the accident, not government agencies that investigate with knowledge that damage would to punish criminally flight crews, main- accidents have become increasingly probably result, equivalent to reckless tenance employees, airline or manu- likely in recent years to cite weak safety conduct, gross negligence or willful facturer executives, regulatory officials practices or safety cultures within avia- misconduct.”5 or air traffic controllers. By identifying tion organizations among the causes, or ICAO also says that the only the ‘what’ and the ‘why’ of an accident, contributing factors, of accidents. objective of an accident or incident aviation safety professionals will be Capt. Paul McCarthy, IFALPA’s investigation should be to prevent better equipped to address accident representative to ICAO, said that in future accidents and incidents, not to prevention for the future. Criminal cases in which aviation personnel have determine blame or liability of anyone investigations can and do hinder the been prosecuted for negligence, judges involved in the occurrence — and, critical information-gathering por- and juries often have been reluctant to international aviation leaders say, not to tions of an accident investigation, and convict. supply data to criminal prosecutors. subsequently interfere with successful “There is recognition that it is fun- “In situations of gross negligence prevention of future aviation industry damentally wrong to convict someone or malfeasance, the judicial authori- accidents.”6 criminally for trying to do their job,” ties need to pursue their own, separate In the months since approval of the McCarthy said. “We have several exam- investigation,” Voss said. “The lives of resolution, prosecutors generally have ples where pilots have been acquitted.
16 | flight safety foundation | AeroSafetyWorld | March 2008 coverStory
In each case, the pilot was attempting seminar, the public likely will continue just talk to prosecutors so that they can to respond to either a malfunction or to demand punishment of aviation pro- do a better job of balancing the rights highly unusual circumstance and got it fessionals who are involved in accidents of individuals that are compromised as wrong. Where there have been convic- and incidents. Nevertheless, the public a result of an accident versus the needs tions, the circumstances have been far sentiment cannot be permitted to over- of the public.” ● more political than legal.” ride “the fundamental principle that Nevertheless, prosecutors often punishment does not improve safety” Notes respond to the public’s calls for retribu- because the threat of punishment — 1. Fitzpatrick, Stephen. “Garuda Crash Pilot tion after an accident, he said. which may deter intentional acts — has Facing Jail.” The Australian. Feb. 5, 2008.
Voss theorized that this trend may no effect on unintentional errors that 2. International Federation of Air Line Pilots’ be associated with the public’s increased lead to accidents, he said. Associations (IFALPA). IFALPA Daily desire for accountability in many areas Actions that do improve safety News. Feb. 5, 2008. of industry — not just in aviation. include accident investigations, manda- 3. Fitzpatrick. “The whole issue of corporate ac- tory safety reporting schemes, vol- countability, both in the United States untary reporting schemes, and flight 4. IFALPA. and in Europe, has become very large operational quality assurance (FOQA) 5. International Civil Aviation Organization in the public psyche, and I think that’s programs and similar data analysis (ICAO). Annex 13, Attachment E. partially feeding some of this,” Voss programs, all predicated on a “just cul- 6. “Joint Resolution Regarding said. ture” — defined by ICAO as a culture Criminalization of Aviation Accidents.” For example, a Swiss court in Sep- that recognizes that personnel should AeroSafety World Volume 2 (January tember 2007 convicted four middle- freely share critical safety information 2007): 13–14. level managers of Skyguide, the Swiss without fear of punishment while also 7. International Federation of Air Traffic air navigation services provider, of accepting that, in some instances, there Controllers’ Associations. Press Release. negligent homicide in the midair col- may be a need for punitive action. Sept. 17, 2007.
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CONVECTIVE SIGMET 55C VALID UNTIL 2255Z TX OK FROM 40SE MLC-40ENE AUS LINE SEV TS 20 NM WIDE MOV FROM 27025KT. TOPS A major opportunity to improve safety. TO FL400. TORNADOES...HAIL TO 2 IN... BY PETER V. AGUR JR. WIND GUSTS TO 60KT POSS. ost of the time, two heads are better Dominating their risk assessment that day than one. Sometimes, however, two was a dry, high-energy cold front that would pass heads are not enough. When trip through the White Plains area during their arrival conditions are changing rapidly or window. They agreed to pay particular attention theM situation is far outside the norm, additional to the automatic terminal information system information and ideas that are timely and digest- (ATIS) for White Plains and pull in other weather ible can make the difference in effective risk reports as they neared the New York area. management. Unknown to the pilots, while they were en About a year ago, a corporate flight crew de- route, at least six commercial and corporate parted from Detroit for White Plains, New York, flight crews aborted takeoffs or landings at the U.S., in their large-cabin aircraft. They had a team Newark and Teterboro airports in nearby New of their company’s top executives aboard. Because Jersey due to extreme winds, wind shear condi- neither Detroit nor White Plains was their home tions and strong low-level turbulence. base, the crew did what most corporate aviation As the pilots neared the White Plains air- crews do every day — they self-dispatched. port, the ATIS was reporting that the surface Their aviation department was certified as winds were gusty but less than 20 kt from about meeting the International Standard for Busi- 60 degrees off runway heading. During their ness Aircraft Operations (IS‑BAO). As was their entry onto final approach, they noted that the custom, the flight crew followed the format of winds at the outer marker were nearly 50 kt. At the department’s safety management system the middle marker, they asked for a wind check. (SMS). They conducted a preflight analysis that The wind conditions reported by the tower con- included identification and assessment of risks troller were the same as the ATIS broadcast. for the trip, and development of risk-mitigation As they flared for touchdown, severe
strategies and tactics. turbulence caused the aircraft to roll both left Risk Management Real Time
www.flightsafety.org | AeroSafetyWorld | March 2008 | 19 FlightOPS
and right, requiring concerns that led to the emergence in the 1970s full aileron input to of crew resource management (CRM). recover. Although it A few business aviation departments have was a rough landing, discovered the power of additional support no passengers were in their risk-mitigation and trip-management injured; they were all processes. Cox Enterprises in Atlanta is one of belted in, and their them. During a visit to their facilities last spring, gear was properly I had the opportunity to see firsthand how they stowed. However, do it. One of their Hawkers was returning home during the postflight from the Washington area. It was mid-morning, walk-around, the crew and lines of convective weather associated with a discovered that they moist cold front were developing rapidly over the had damaged a wing aircraft’s route. Their licensed dispatcher, Dave tip by ground contact Small, was tracking the flight and the weather on during the landing. his high-definition display. He called the crew to The pilots consid- recommend a routing change that would take the © Chris Sorensen Photography ered themselves lucky Hawker around the trailing edge of the weather. that their surprise last-minute encounter with The crew readily accepted the suggestion. It severe turbulence had not had more dire conse- wasn’t long before the original route became a quences. But, if their department had been using mess, with other crews asking to divert due to a real time risk management program, the crew severe turbulence and heavy precipitation. The likely would have been advised of the severe Hawker crew reported that they completed the turbulence — and they might not have needed trip without a ripple. The Cox team had effec- any luck at all. tively identified a significant risk and mitigated it, in real time. Borrowing a Page Real time risk management programs have been Home-Based Help used for decades by the airlines. Professional Following my observations of the Cox Enter- dispatchers constantly track weather and other prises processes, I talked with numerous mem- critical variables that can adversely affect their bers of other aviation departments about the use flights. When conditions warrant, the dispatch- of home-based staff to support trip risk identi- ers contact the flight crews to alert them to what fication and mitigation. In general, two camps is happening, describe the potential risks and emerged: Those who wholeheartedly endorsed Professional suggest mitigating options. immediate implementation of the concept, and Many business aviation pilots take pride those who made excuses as to why it could not dispatchers in the fact that they are not coddled like their work in their departments because of the lack of
constantly track airline counterparts. They aren’t handed a brief- staff. ing and a flight plan that tell them what to do Certainly, not every aviation department has weather and other and how to do it. Most business aviation pilots a scheduler or a dispatcher. And many schedul- consider themselves problem solvers and jacks- ers are not trained to interpret weather data critical variables of-all-trades. effectively. But most departments have pilots Indeed, the vast majority of business avia- who are. that can adversely tion flight crews are on their own. They do For example, there is a department in affect their flights. their own preflight planning and preparation. Naples, Florida, that operates a single long-range They might even believe that they are ready for aircraft without the services of a scheduler or whatever comes their way. That sense of supe- dispatcher. But, for years, George Adams, the riority and independence sounds like the gist of department’s director of aviation, has acted as a
20 | flight safety foundation | AeroSafetyWorld | March 2008 in support of crews during trips. Although Small based Cox aviation team could be a powerful tool aheightenedSmall awareness of how home- the system shutdown aftermath inthe of 9/11.It gave dispatcher support of trip crews was ATC the communication links. digital and voice ground-to-air and displays weather digital tracking, flight time real information office their systems to include upgraded have also They dispatchers. licensed are schedulers their instance, For initiatives. through avarietyof training and education people their of capabilities the improving ing implemented anumber of changes, includ- practices or better.” have Since they then, “best to standards operating their elevate dispatcher, didnot. He had authority the to doit. Small, asenior much implementing difficulty his program. As director the of aviation, Adams didnot have positive impacthas on avery trip outcomes. have that recognized blending CRMand SMS George Adams, Dave andothers Small several Best orBetter plan for next the leg. crew’s flight the workload by flight their filing collaborative reduces decision, he further then their on Based early. quits it call to or limits toward maximum their allowable duty day continue should they whether decide them help to conditions operating trip and cycle rest previous times, duty crew’s the assesses He site. stop technical the at place in are ments that customs and quick-turn arrange fuel - confirms Adams instance, for Europe, from optionsthem to consider. knowlet them whatas well as to to give expect, with voice crew the via and messaging digital to of atrip. safetythe or service He communicates issues, as well as anything that else may affect (ATC) routing patterns, crew duty and workload routinely monitors weather, control air traffic resource to are his crew they when air. inthe He www. The impetus for Cox’s decision to provide to decided department Cox’s 1999, In When crew the is making areturn trip flightsafety.org |
orld World AeroSafety | March 2008 March
© Chris Sorensen Photography challenges were faced they people-related. And, things related like all to safety, biggest the modest investments inhardware and software. efficiency. Implementing programs the required have resulted inimproved safety, and service byused business aviation departments, but they that Adams and implemented Small are rarely for flight’s the decisions remains with crew. the entire Cox team that ultimate the responsibility alternatives. Nevertheless, clear to the is very dispatchers’their information and suggested encounter. will they have They come to value crew enroute about them to alert conditions and planning. their patterns and other factors that could impact trips at locations their or destinations, ATC routing about projected the of arrival thunderstorms the director of aviation, he began to warn crews did not. Nevertheless, with the endorsement of the beginning, some of the department’s captains clearly understood opportunity the right away, in souls were won over. ning. But, over time, most eventhe independent litely- begin inthe declinedhis offers of service department.the Some “old school” captains- po trips underporting way was not shared by in all The real risk time management programs Today, it is normal for to Small contact a Small admitsSmall that his enthusiasm for sup- their dispatchers’ and suggested FlightOPS come to value alternatives. information Pilots have |
21
FlightOPS
Safety Investment set of opportunities. Is he or she appropriately During conversations with leaders and manag- trained and experienced to assess developing ers of aviation departments about the concept weather patterns? If not, you can arrange to and practice of real time risk management, I have a certified meteorologist come to your have found a substantial number to be less than department and provide a half day or more of enthusiastic. The most often stated barrier was: introductory training on weather depiction “We don’t have the people.” technology and suggested sources of up-to-date But, if you have a scheduler/dispatcher, you information. do have the people. If you have a pilot who is Some of the questions and concerns about real time risk management that I have heard are more administrative than substantive: “How are you going to get a pilot to do this on his day off?” “Won’t we be interfering with the off-duty crewmember’s rest cycle?” The answer to the first question is rela- tively easy. Certainly, additional duties must be assigned equitably. As to the second ques- tion, quality of work/life does deserve strong consideration. The hierarchy of benefits to the department and its customers must be considered when establishing administrative processes that assure crew work/life balance. According to Adams, this is relatively simple in a smaller department operating one aircraft because there is only one trip at a time. Using his laptop computer and BlackBerry, he finds U.S. National Oceanic and Atmospheric Administration it easy to track the progress of a trip and to not directly involved with a trip, you do have the communicate with the crew while they are on people. If you don’t have a scheduler or a non- the ground or in the air. Adams says that these You can arrange trip pilot, then you need even stronger on-board tasks do not take much away from work or technology, such as an XM satellite weather personal time. to have a certified uplink, to get every edge you can. Real time risk management improves the
meteorologist come And if you do have the bodies, you need to quality of operational safety and service. The make certain that their heads and hearts are biggest investment for most business aviation to your department in the right places. Many schedulers are hired departments — whether managed or internal to be the customer’s link with the department. — is time. Those involved in business avia- and provide a half They may not need any in-depth aeronautical tion should take a hard look at how real time knowledge and expertise when hired. But, if risk management can be implemented in their day or more of you have attended a National Business Aviation department. When it comes to safety, there is introductory training Association (NBAA) Schedulers and Dispatch- no better time than now. ● ers Conference, you know that these aviation Peter v. Agur Jr. is managing director and founder of on weather depiction. professionals typically are bright, enthusiastic The VanAllen Group, a management consulting firm to people on a quest to find ways to help their business aviation with expertise in safety and security. He is a member of the Flight Safety Foundation Corporate departments and their customers succeed. Real Advisory Committee and the NBAA Corporate Aviation time risk management is right up their alley. Management Committee, and is an NBAA Certified If you use a non-trip pilot as your risk iden- Aviation Manager. Agur holds an airline transport pilot tifier and solution adviser, you have a different certificate and an MBA.
22 | flight safety foundation | AeroSafetyWorld | March 2008 Aviation
For ICAO compliance Available March 2008
Henry Emery & Andy Roberts
In compliance with ICAO language requirements The new course from Macmillan Education to help pilots and air traffic controllers achieve and maintain ‘operational’ level 4 according to ICAO language requirements.
Authors Henry Emery and Andy Roberts - speakers at the second ICAO Aviation Language Symposium 2007, Montreal. www.macmillanenglish.com/aviationenglish For more information please contact Charlotte Ellis at [email protected] Insight © FlightSafety International © FlightSafety
Quality Control
An independent organization aims to set for high, industrywide standards for new pilots.
BY CONSTANCE BOVIER
y now, virtually the entire aviation As the industryPilots wrestles with this Six different training paths now industry has heard the Interna- dilemma, the Professional Avia- deliver pilots into commercial and busi- tional Air Transport Association’s tion Board of Certification (PABC; ness aviation cockpits (Figure 1, p. 26): estimate that the global demand see sidebar) is proposing that pilot • The military; forB new commercial pilots will average preparedness be tackled head-on by • U.S. Federal Aviation Administra- 17,000 per year for the next 20 years. creating a globally accepted standard tion (FAA)/Industry Training This figure far exceeds the current annual for training entry-level professional Standards (FITS); number of pilots who earn a commer- pilots.1 PABC Executive Director Pe- cial license with an instrument rating, ter Wolfe explains that to be effective, • Traditional; the minimum credentials required to such an international standard must • Bridge; fly for hire. As Flight Safety Foundation be consistent with the new multi-crew • Ab initio; and, President and CEO William R. Voss pilot license (MPL) requirements noted in his article about the Foundation’s (ASW, 12/07, p. 38) and be adapt- • MPL. realigned priorities (ASW, 12/07, p. 16), able for use by the current extensive The MPL is the most recent, compre- the growing shortage of qualified person- network of training programs that will hensive, entry-level professional pilot nel is emerging as a significant risk to the continue to supply the industry for training standard, created and approved safety of the aviation system. the foreseeable future. by a large cross-section of international
24 | flight safety foundation | AEroSafetyWorld | March 2008 Insight
industry stakeholders. The other five unaddressed subjects and skills needed Military services around the world training paths share no common to fly commercial and business aircraft. produce well-trained, experienced avia- standard, resulting in graduates whose Today, a number of bridge programs tors who often transition into civilian knowledge, skills and competencies introduce aspects of commercial and flying careers. In the United States, range from excellent to unacceptable. business aviation during the licensing military pilots receive FAA commercial Until the 1970s, most civilian- phases. Generally — certainly in the and instrument certificates when they trained pilots followed the traditional United States — pilots are self-funded pass a written competence examination. path — especially in the United States, from the beginning of licensing courses Figure 1 shows how most military, Canada and Australia — which enabled through the completion of bridge pro- FITS, bridge and ab initio paths now them to earn their private and com- grams, which increase candidate appeal offer supplementary courses to dimin- mercial licenses, with instrument and to prospective employers and improve ish the training gap and better meet multi-engine ratings, so they would their ability to succeed in employers’ industry needs. be competitive when applying for the demanding new-hire training. Employers want pilot candidates entry-level flying jobs of that era. Upon who can begin classes already able to graduation, these new aviators typically FITS and Starts aviate, navigate and communicate, with added a flight instructor certificate The FITS program, launched by the a firm grasp of weather, the air traffic to their résumés and flew any and all FAA in 2002, is the newest U.S. training system, jet aircraft, high altitude and equipment to help build hours in their path by which pilots can fulfill basic cer- commercial flight operations, critical logbooks and accelerate their climb up tification requirements. Like MPL, FITS thinking skills, crew resource manage- the career ladder. Over time, however, encourages trainers to use the most ment, and threat and error management. a gap developed between the four advanced educational methods to turn Given the absence of stakeholder- licenses and ratings of the traditional out graduates who are highly competent defined and -approved standards, most track and the evolving needs of the in- in required flying skills and in general training providers have been left to rely dustry. Recognition of this gap spurred airmanship. Although FITS is in the on their own judgment in selecting development of other training paths, all early stages of development, it appears topics and determining their relative of which, except MPL, are derivatives of capable of delivering well-prepared importance when designing courses. the original traditional model. applicants to the ranks of professional The irresistible attraction of the Ab initio — a Latin term meaning pilots, when training is augmented by latest flight deck avionics for today’s “from the beginning” — was the first courses addressing jet aircraft and com- computer-gaming youth explains why training method to include airline prac- mercial/business operations. many vendors have emphasized this tices and procedures from the earliest stages. Ab initio courses introduce a Professional Aviation Board of Certification wide range of air carrier operations while students earn commercial, instru- he Professional Aviation Board of Certification (PABC) is a nonprofit U.S.- ment and multi-engine pilot qualifica- based corporation created to ensure the preparedness of pilots seeking tions. In most cases, these courses offer Tprofessional careers in commercial and business aviation. This concept, carrier- and type-specific training in rooted in discussions held in the mid-1990s by the Air Transport Association’s Operations Council, has been developed as an independent initiative without support of a particular airline. formal affiliation with any commercial or regulatory body. This frees PABC to Bridge programs emerged in the address the overall interests of the aviation industry as its primary concern. mid-1980s to meet the increasing de- PABC Executive Director Peter Wolfe is a retired commercial and U.S. Air mand for pilots created by regional air- Force pilot and former airline executive and pilot trainer. The PABC board of lines. At first, bridge programs filled the directors and advisory council include representatives from seven stakehold- gap between licensing — commercial, er groups: employers, educators, pilots, government agencies, insurers, man- ufacturers and service providers, and the public. instrument and multi-engine certifi- The board and council are currently expanding cates — and the needs of the industry to reflect PABC’s international perspective. by introducing supplementary training, — CB consisting of a broad array of previously www.flightsafety.org | AeroSafetyWorld | March 2008 | 25 Insight
Six Paths to Flying Careers
Military FITS Traditional Bridge Ab initio MPL
New hire New hire New hire New hire New hire
ATPw ATP/ATPLw ATP/ATPLw ATP/ATPLw ATP/ATPLw Jet and CBO Jet and CBO Jet and CBO Jet and CBO MPL Phase 4 Commercial Commercial Commercial Commercial ATPLw Multi-engine Multi-engine Multi-engine Multi-engine Phase 3 MIL COMP Instrument Instrument Instrument Instrument Phase 2 Private Private Private Private Phase 1
Company and type speci c Pilot flies for hire with air transport category aircraft
Generic Pilot flies for hire with non-transport category aircraft
No introduction to carrier operations
New hire = aircraft and line qualification training provided by employer ATP/ATPLw = successful completion of written tests required by the U.S. Federal Aviation Administration (FAA) for issuance of its airline transport pilot certificate and/or by International Civil Aviation Organization (ICAO) contracting states for issuance of their airline transport pilot licenses Jet and CBO = jet aircraft and commercial and business flight operations course MPL = multi-crew pilot license Commercial = commercial pilot license Multi-engine = multi-engine rating Instrument = instrument rating Private = private pilot license MIL COMP = military competency: an FAA exam to earn commercial certificate and instrument rating FITS = U.S. Federal Aviation Administration Industry Training Standards
Source: Professional Aviation Board of Certification
Figure 1
aspect of training in their curricula International Civil Aviation Organi- sector — say that the failure rate among and marketing strategies. Employers, zation (ICAO), the International Air new hires has risen as the flight experi- however, report an unbalanced result, Transport Association, the Interna- ence of new hires has been reduced. Over with new hires often over-trained in tional Federation of Air Line Pilots’ the years, the failure rate hovered around advanced avionics yet lacking basic air- Associations, Transport Canada, the 5 to 10 percent, but today the rate at some manship and instrument flying skills. FAA, Airbus, Boeing, Alteon, CAE, regional airlines has topped 20 percent. “We must confront these issues Flight Safety Foundation, FlightSafety Yet looking at failures shows by creating a global training standard International, the Royal Aeronautical only part of the story, because can- that is common among all training Society, airlines and collegiate aviation didates with a great attitude who paths,” says Wolfe. “PABC also believes programs. struggle because of shortfalls in their that developing and maintaining such pre-employment preparation are often a standard should be a collaborative Failure Rate Up given extra training rather than being effort by government agencies and Training managers from several U.S. washed out. Extra training, like wash- industry stakeholders.” organizations — who will speak only off outs, is costly to employers. Wolfe says that numerous aviation the record, concerned that their remarks Because airlines have not estab- experts share this outlook, including will erode customer confidence or alarm lished an industry-defined specification executives, staff and members of the the public about the regional airline Continued on p. 28
26 | flight safety foundation | AEroSafetyWorld | March 2008 CEOs on Training A SERIES
“At Amway safety is our top priority. That’s why we’ve insisted on FlightSafety’s professional training for more than 30 years.”
RICH DEVOS Amway co-founder, NBA Orlando Magic owner and chairman
Rich DeVos co-founded Amway Corp. in 1959 and acquired with his family the Orlando Magic in 1991. He continues to serve on his company’s board and travel to deliver his inspirational messages to independent Amway distributors and other audiences. He is the author of Believe!, Compassionate Capitalism and Hope From My Heart: Ten Lessons for Life, which was inspired by his heart transplant at the age of 71 in 1997.
fter more than 80 years, Rich DeVos still looks The company’s belief in the many benefits and forward to each day with the same “can do” attitude advantages of business aviation and the passion DeVos A that propelled him to become one of the world’s most has for aviation continue today. He may have retired successful entrepreneurs. He was barely out of high school from the day-to-day responsibilities of running Amway, but when he returned from overseas after service in World War II his retirement hasn’t slowed him down. When he flies – to start an aviation business with his friend Jay Van Andel. which he does often as a business leader, philanthropist That business and other ventures together took off, and and speaker – his flight crews are FlightSafety trained. they eventually founded Amway from their homes in 1959. As far as he’s concerned, it’s the only way to go. Amway within a few years was a household name, known for pioneering the sales of products through independent distributors. Today the company records over $6 billion in annual sales in more than 80 countries. Serving a growing global operation required fast, efficient world travel. Amway established a flight department and turned to FlightSafety for aviation training. “We’ve been fortunate that Amway has enjoyed tremendous
success,” DeVos says. “Success requires confidence and For more information, please contact any of our Learning Centers or call persistence and demanding the best of ourselves and others. Scott Fera: 636.532.5933. Our headquarters are at the Marine Air Terminal, LaGuardia Airport, New York 11371-1061. Email: [email protected] That’s why our flight department insists on FlightSafety’s professional, safety-focused training for our jets and helicopters.” flightsafety.com
FLIGHTSAFETY DEVOS_AMWAY CEO AD Bleed: 8-3/4” x 11-1/4” Trim: 8-1/2” x 11” HIRES PDF VERIS COLOR PROOF Insight
for pre-employment training courses, distributed such a standard to training vendors, or created any sort of quality control mechanism, the range of course Peter Wolfe, quality is wide. Some so-called bridge PABC executive courses simply “teach the test” — how director (left), with to pass an employer’s interview and FSF president flight check — while some others are and CEO poorly designed, taught or managed. William R. Voss. The creation of a new baseline training J.A. Donoghue standard will enable vendors, employ- ers and students to compare cost and is a poor measure of actual prepared- depth are expected to be greater than quality of course offerings against the ness. “To be realistic, we’ll always have many of today’s licensing tests, and it performance of graduates. to look at flight hours, because experi- will be upgraded regularly to keep up MPL represents the most extensive ence plays an important role in this, but with changes in the industry. It will update of pre-employment pilot train- we have to pay attention to what really involve solving a number of scenario- ing standards in over 40 years. MPL matters — the competencies that we’re based problems to assess the candi- students do not earn private, instru- trying to measure,” Voss says. “I think dates’ ability to apply their knowledge ment, multi-engine and commercial we’re much better now at developing in practical situations. The resulting credentials. Instead, graduates must the strategies to measure competencies credential will also help employers successfully complete a series of per- than we were in the past, and we should screen applicants, while the underlying formance checks using various train- go straight after that.” performance standards will support ing devices and simulators, and must As one part of such a system, PABC the design of new-hire training cur- pass the airline transport pilot license proposes that the ICAO standards and ricula for non-MPL pilots. written exam (ATPLw) or an equivalent recommended practices (SARPs) be “The pilot shortage doesn’t necessar- test approved by the national aviation revised to encourage graduates of non- ily create a safety problem by itself unless authority issuing the MPL license. MPL training programs to take a com- we allow the shortage to compromise the Until MPL programs are written, mon written exam to verify competence level of competency that we require to approved and implemented worldwide, in prescribed subject areas. operate an aircraft,” says Voss. “We must the industry remains heavily dependent proactively oversee the industry to make on the other five pilot career paths to Entry-Level Certificate sure that pilot demand is not forcing fill work force requirements. Voss and PABC’s first goal is to create a global standards below a safe level. There is no Wolfe see an excellent opportunity for training standard consistent with the reason that industry can’t come together synergy during this transition, because outcomes prescribed for MPL gradu- to deliver a proposal to ICAO.” both MPL and PABC support outcome ates. As the pool of pilot applicants Such cooperative efforts, Wolfe and standards for measuring the perfor- continues to be fed by hundreds of Voss believe, could greatly shorten the mance of pilot candidates. training vendors, an independent cer- time to bring about essential changes The traditional metric for pilot eval- tification exam for graduates becomes needed to ensure the quality of the pilot uation, the flight logbook, while useful, critical to attaining and supporting a work force for global air transport of the predictable, quantifiable performance future. ● InSight is a forum for expressing personal opinions standard. Constance Bovier is a longtime aviation writer about issues of importance to aviation safety and PABC envisions a common cre- for stimulating constructive discussion, pro and con, with special interests in pilot training and career about the expressed opinions. Send your comments dentialing exam by which pilots prove development. to J.A. Donoghue, director of publications, Flight that they have attained the entry-level Safety Foundation, 601 Madison St., Suite 300, standards for knowledge and com- Note Alexandria VA 22314-1756 USA or donoghue@ petency that are defined by industry flightsafety.org. 1. The organization’s Web site address is stakeholders. The exam’s scope and
28 | flight safety foundation | AEroSafetyWorld | March 2008 causalfactors
navigation fix that was not where the The report said that if the go-around had flight crew thought it was, omission been initiated six seconds later, the aircraft likely of standard callouts and a mix-up in would have struck the ground 1.5 nm (2.8 km) communication about sighting the ap- from the runway threshold. The TAWS warning Aproach lights were among the factors involved occurred between 3.4 and 5.1 seconds after the in an unstabilized approach that was continued go-around was initiated. below the minimum descent altitude (MDA) in “Given that procedural triggers to go around nighttime instrument meteorological conditions had not been effective, it is of concern that the (IMC) at Khartoum, Sudan, on March 11, 2005. warning system may not have provided suf- The Airbus A321 “came hazardously close ficient alert time to prevent an impact with the to the ground” before the crew realized their ground,” the report said. mistake and initiated a go-around, said the U.K. The TAWS was found to have functioned Air Accidents Investigation Branch (AAIB) in according to applicable design and installation its final report on the serious incident. A few standards. The system received position infor- seconds later, when the aircraft was 125 ft above mation from the A321’s flight management and ground level (AGL), the terrain awareness and guidance system (FMGS) based on multi-sensor warning system (TAWS) generated a “TER- area navigation calculations.1 The report said RAIN, PULL UP” warning. that position information received directly from Close Call in
BY MARK LACAGNINA KhartoumConfusion reigned when an A321 was flown below minimums in a sandstorm.
© Erich Ball
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an on-board global positioning system (GPS) “In essence, the CFIT protection technology receiver is more accurate and results in more has improved, but the required minimum TAWS timely warnings. standards have not. Thus, significant improve- Without a direct GPS feed, TAWS sensitivity ments in aviation safety in this area are available “CFIT protection is reduced when the aircraft is near the runway to but not mandated.” prevent nuisance warnings that might be caused Among recommendations based on the technology has by less accurate position information. If the system incident investigation, AAIB urged the European
improved, but the in the incident aircraft had received position Aviation Safety Agency to work with industry information directly from the on-board GPS and on a review of TAWS design and installation stan- required minimum incorporated the latest software changes, a “TOO dards “with particular emphasis on the timeliness LOW, TERRAIN” warning likely would have been of alerting when close to the runway.” AAIB said, TAWS standards generated when the aircraft was at 240 ft AGL. “Revisions to these standards arising from this “The current TAWS standards undoubtedly review should apply [retroactively] to all aircraft have not.” were appropriate at the time of implementation, currently covered by the TAWS mandate.” and statistics show that they have significantly reduced the CFIT [controlled flight into terrain] Sandstorm risks, most likely saving many lives,” the report The British Mediterranean Airways flight had said. “However, operational experience of indi- originated in Amman, Jordan, at 2130 coordi- rect GPS installations that do not directly feed nated universal time (UTC; 2330 local time) GPS quality data to the TAWS … has highlight- with 19 passengers and eight crewmembers.2 ed problems that have been addressed by the The commander, 46, had 7,400 flight hours, TAWS manufacturers but that are not required including 3,700 flight hours in type. The copilot, to be implemented. 39, had 4,700 flight hours, including 3,200 flight hours in type. “The weather forecast for Khartoum, obtained Airbus A321-200 before departure, had reported gusting northerly winds and reduced visibility in blowing sand,” the report said. “During the cruise, and once they were in Sudanese airspace, the copilot asked ATC [air traffic control] for the latest weather report for Khartoum.” The controller said that the surface winds were from the north at 20 kt and visibility was 1,000 m (5/8 mi) in blowing sand. Runway 36 was in use. A notice to airmen advised that the instrument landing system (ILS) was not in service. The commander decided to conduct the VHF omnidirectional © Adrian Pingstone/wikipedia.org radio/distance measuring equipment (VOR/ DME) approach. The Khartoum VOR/DME he A321 is a stretched version of the A320. The A321‑200 has more (KTM) is 0.6 nm (1.1 km) south of the Runway fuel capacity, a higher takeoff weight and greater range than the -100. The incident airplane is an A321‑231 that was built in 2002; 36 approach threshold. T “Neither pilot had previously operated in it has International Aero Engines V2533‑A5s rated at 146.8 kN (33,000 lb thrust), a maximum takeoff weight of 89,000 kg (196,209 lb) and a blowing sand, and both were concerned about maximum landing weight of 79,000 kg (174,163 lb). the possible implications,” the report said. The Source: Jane’s All the World’s Aircraft pilots found no information about blowing sand in the airline’s operations manual and used information about volcanic ash for guidance.
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“As a result, the pilots discussed various pos- Charted Approach Profile sible actions, and the commander chose to select continuous ignition on both engines for the IAF approach,” the report said. HASAN JEBRA KTM KTM 5d KTM 10d Although reported as blowing sand, the meteorological condition at Khartoum had the 4000 2740 characteristics of a sandstorm. “Blowing sand 358° is associated with strong winds which raise the 2900 particles above ground level but no higher than 1640 358° 2 m [7 ft],” the report said. “Sandstorms are usu- MAP at KTM ally associated with strong or turbulent winds THR Elev 1260 that raise particles much higher.” The operations 0 1 2 3 4 5 10 manual recommended that pilots avoid flying in KTM = Khartoum VOR/DME (VHF omnidirectional radio/distance measuring equipment); a sandstorm whenever possible. d = DME distance (nm) from KTM; IAF = initial approach fix; THR Elev = Runway 36 approach threshold elevation; MAP = missed approach point Managed Approach Source: U.K. Air Accidents Investigation Branch Another check with ATC on weather condi- Figure 1 tions at the airport indicated that visibility had improved to 3,000 m (2 mi). The commander The pilots were not aware that a discrep- decided to conduct a managed nonprecision ancy existed between the location of the final approach (MNPA) to Runway 36. “This type approach fix (FAF) depicted on their approach of approach requires the autopilot to follow an chart and the location programmed in the approach path defined by parameters stored in FMGS database. Approach charts and FMGS the aircraft’s commercially supplied [FMGS] database updates were provided by different navigation database,” the report said. commercial vendors. The chart depicted the At the time, however, the airline was in the FAF, called HASAN, at “KTM 5d” — that is, process of developing MNPA procedures and 5.0 nm DME from KTM (Figure 1). The report had received authorization from a U.K. Civil said that this location resulted from the 2002 Aviation Authority (CAA) flight operations Sudanese Aeronautical Information Publication inspector to conduct managed approaches only (AIP), which placed the FAF 5.0 nm from both in visual meteorological conditions. the runway threshold and KTM. “By interpolat- The commander had conducted managed ing the depicted final approach gradient, the The pilots were approaches while flying for another airline. [chart vendor] determined that HASAN was not aware that a “Therefore, [he] did not consider it would be actually 5.6 nm from the runway threshold,” the a problem, despite the fact that the reported report said. “This coincided with the KTM 5 discrepancy existed visibility was below VFR [visual flight rules] DME position.” limits,” the report said. “The copilot’s acceptance The FMGS database included a 2004 amend- between their of this decision illustrates that neither pilot ment to the AIP that placed the FAF 5.0 nm [realized] that not all the necessary safeguards from the runway threshold and 4.4 nm DME approach chart and were in place to conduct such approaches safely from KTM. the FMGS database. in IMC.” “The pilots were unaware of [the] significant While setting up for the approach, the crew discrepancy between the approach param- revised the MDA programmed in the FMGS eters on the approach chart and those within database to 1,650 ft because the airline’s stan- the navigation database because they had not dard operating procedures for a nonprecision compared the two data sets before commencing approach required 50 ft to be added to the the approach,” the report said, noting that this published MDA. omission was partly the result of the absence www.flightsafety.org | AeroSafetyWorld | March 2008 | 31 causalfactors
of a formal U.K. CAA policy and clear guid- The managed approach was being con- ance by the airline on how to conduct managed ducted correctly by the autopilot based on the approaches. FMGS data. Thus, the aircraft did not begin the final descent at 5.0 DME, as the pilots expected ‘Late’ Descent (Figure 2). “The aircraft began its final descent The commander’s The report said, “The pilots commenced the 0.6 nm later than the pilots were expecting,” the approach with the autopilot engaged in man- report said. “Believing the aircraft was high on input caused aged modes — that is, the approach profile the approach, the handling pilot [the com-
the autopilot being determined by the FMGS instead of pilot mander] changed the autopilot mode in order to selections.” select an increased rate of descent.” to command a At 0025 UTC (0325 local time), the aircraft The commander intended to establish the crossed the initial approach fix, JEBRA, at 4,000 ft, A321 on a 3.0-degree vertical flight path angle, descent rate of and then completed the procedure turn to the final which was equivalent to a descent rate of about approach course. During this time, the crew asked 800 fpm at the selected airspeed. He mistakenly 300 fpm, rather ATC for the current visibility and were told that it believed that the autopilot was in the track/ than a 3.0-degree was between 1,000 m and 1,200 m (3/4 mi). flight path angle mode. The autopilot actually The crew said that the A321 was fully was in the heading/vertical speed mode, and flight path angle. configured for landing and stabilized at the ap- the commander’s input caused the autopilot to propriate airspeed when it crossed the 5.0 DME command a descent rate of 300 fpm, rather than location for HASAN depicted on the approach a 3.0-degree flight path angle. chart at 2,900 ft, the published minimum alti- As the aircraft descended on final approach, tude for crossing the FAF. it entered the sandstorm, and the crew’s forward visibility decreased rapidly. “The com- A321 Flight Path mander described the effect of the sand 4,200 Initial approach x Not to scale 4,000 as like watching iron 3,800 filings flying past 3,600 the windscreen,” the 3,400 report said. He also 3,200 FAF according to noted that the visual 3,000 the navigation database effect of the landing 2,800 Final approach x (FAF) light reflecting off the 2,600 according to the chart sand was disorienting. 2,400 Autopilot mode changed Altitude (ft)Altitude The copilot 2,200 conducted a distance/ 2,000 altitude check at 4.0 1,800 Company incremented MDA 1,650 ft 1,600 MDA 1,600 ft DME and found 1,400 that the aircraft was Runway elevation 1,260 ft 1,200 about 200 ft above the 1,000 descent profile shown 11 10 9 8 7 6 5 4 3 2 1 0 Distance to Runway 36 (nm) on the approach chart. KTM VOR/DME location “The commander stated that as the KTM = Khartoum VOR/DME (VHF omnidirectional radio/distance measuring equipment); MDA = minimum descent altitude Source: U.K. Air Accidents Investigation Branch aircraft approached 3.0 DME, it became Figure 2 apparent that it was
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not closing with the vertical profile, and The misidentified lights and the KTM, and another missed approach so he increased the rate of descent to disorienting effect of the blowing sand was conducted at 0049 UTC. “While about 2,000 fpm,” the report said. A few prompted the commander to initiate the carrying out the go-around, the com- seconds later, he reduced the selected go-around at about 180 ft AGL — 210 mander could make out the running rate of descent to 1,200 fpm. “The ft below the MDA. He advanced the strobe lights below and stated that the pilot’s selections resulted in a varying throttles to the takeoff/go-around power aircraft passed slightly to the right of flight path angle that averaged about setting, which automatically engaged them,” the report said. 4.5 degrees,” the report said. the autopilot go-around mode. During The pilots told investigators they this process, the aircraft sank to 125 became aware that the crew of an- Lights in Sight? ft AGL, where the TAWS “TERRAIN, other aircraft had conducted the ILS The cockpit voice recorder (CVR) PULL UP” warning was generated. “The approach and landed on Runway 36. recording of the verbal communication commander reported that he noted the However, when they tuned the ILS fre- between the pilots during the approach aircraft’s attitude was 5 degrees nose- quency, they found that a test code was subsequently was overwritten. “It has up, so he pulled back on his sidestick being transmitted, indicating that the not been possible to establish exactly with sufficient force to disengage the ILS must not be used for an approach. what was said between the pilots at this autopilot and increase the pitch attitude The crew decided to conduct another time,” the report said. “However, it is to between 17 degrees and 20 degrees VOR/DME approach. apparent that at some stage late in the nose-up,” the report said. “While maneuvering, they heard approach, the commander asked the The commander pulled the sides- the pilots of another inbound aircraft copilot if he could see the approach tick about halfway back, instead of all ask Khartoum Tower to confirm that lights. The copilot mistook this ques- the way back, as required by the emer- the visibility was now 200 m [1/8 mi],” tion to be the commander stating that gency procedure for responding to the the report said. “When this reported he could see the lights. As a result, the TAWS warning. He told investigators visibility was confirmed, the copilot copilot informed ATC that they could that he believed he already was “over- immediately questioned the tower see the approach lights and requested pitching the aircraft.” Nevertheless, the controller about the current visibility confirmation that they were cleared to report said, “By nature, any [TAWS] at Khartoum. The initial reply from the land. The commander, hearing the co- terrain warning requires prompt and controller was that the visibility was pilot’s transmission, took this to mean decisive action, and the protections 900 m [between 1/2 and 5/8 mi], fol- that the copilot had got the approach built into the aircraft’s flight control lowed quickly by a correction to 800 m lights in sight.” system allow for the application and [1/2 mi] and then a further correction Standard callouts were omitted, and maintenance of full back sidestick until by the controller to 200 m.” neither pilot had the required visual the warning ceases.” The commander broke off the ap- references in sight as the A321 descend- proach at 4,000 ft and diverted to Port ed below 1,650 ft — about 390 ft AGL. Two More Tries Sudan, where the aircraft was landed “Had appropriate calls been made at the During the missed approach, the com- without further incident at 0214 UTC critical moments, they would have al- mander briefed the copilot for another (0514 local time). ● most certainly prevented the confusion approach. He decided not to conduct This article is based on U.K. AAIB Aircraft that allowed the aircraft to continue another managed approach but to use Incident Report No. 5/2007 (EW/C2005/03/02). below MDA without the required visual raw data and selected autopilot modes. references,” the report said. “The pilots also decided to leave the Notes
The commander looked up and landing lights off for this second ap- 1. FMGS is an Airbus term. Flight manage- saw lights at the one o’clock position proach to prevent the disorienting ment system (FMS) is another term used but realized that they were not the ap- effect of light scattering off the sand,” to describe the equipment. proach lights. A note on the approach the report said. 2. British Mediterranean Airways was chart cautions pilots against “confusing During the second approach, the founded in 1994 and operated as a British local street and bridge lighting with ap- pilots did not have the approach lights Airways franchise until 2007, when it was proach and runway lights.” in sight at the missed approach point, acquired by the U.K. airline bmi. www.flightsafety.org | AeroSafetyWorld | March 2008 | 33 MaintenanceMatters Human Factors in Maintenance Surveys reveal the importance of regulations mandating human factors programs.
By William B. Johnson and Carla Hackworth
espite the existence of human factors and 2007, the U.S. Federal Aviation Administra- programs in aviation maintenance since tion (FAA) conducted two large-scale surveys the late 1980s, such programs are not that gave the international maintenance com- required throughout the world, and those munity and FAA aviation safety inspectors (ASIs) thatD do exist are far from standardized. In 2006 an opportunity to report progress and identify
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the human factors issues that need immediate training for all maintenance personnel. At the attention. High response rates and frank answers same time, the FAA continued its human factors R to the surveys gave a clear view of the status and and D, publishing extensive human factors guid- Continental Airlines showed the direction future work should take. ance materials for U.S. domestic and international in 1989 became During the 1980s, many flight organiza- applications. The FAA also initiated human factors tions were enhancing safety by adopting cockpit training for all of its nearly 1,800 ASIs. An expand- the first to expand resource management (CRM) programs. Flight ed version of that training continues today. Yet, in crews were finding means to ensure and improve spite of the extensive R and D, guidance material CRM and human safety by focusing on teamwork, communication and internal employee training, the FAA has not and developing operating procedures. The term issued a regulation requiring the industry to pro- factors principles evolved to become “crew” resource management vide training for human factors in maintenance. to maintenance and and expanded to include a variety of human factors that affect performance and safety, such Regulatory Differences engineering. as fitness for duty, fatigue, nutrition and health, Meanwhile, TC, EASA, the Civil Aviation Safety safety culture, and much more. There is no ques- Authority of Australia and other regulatory tion that CRM has improved the safety of flight. agencies have adopted regulations for main- In 1988, the Aloha Boeing 737 fuselage- tenance human factors programs. That situa- failure accident was the first of a number of tion prompted the authors to assess the status significant events that focused attention on of human factors programs in maintenance human factors in maintenance. That year, the organizations and airlines throughout the world. U.S. Congress passed the Aviation Safety Act, In addition, the FAA wanted to understand © Tomas Bercic/iStockphoto Tomas © which directed the FAA to conduct research on maintenance human factors in the United States all aspects of human performance in aviation, as viewed by its ASI work force. including maintenance, launching the devel- Both surveys, developed in cooperation with opment of FAA’s maintenance human factors the EASA’s European Human Factors Working research programs that continue today. Group, were Web-based, and respondents’ answers Continental Airlines in 1989 became the first were anonymous.1 The industry questionnaire to expand CRM and human factors principles contained 78 items; the FAA survey had 45 ques- to maintenance and engineering, introducing its tions. For the most part the surveys used five-point Crew Coordination Concepts program. By the rating scales and provided open-ended opportuni- early 1990s, US Airways, with significant FAA ties for comments. The surveys discussed here are research and development (R and D) participa- more fully described separately. 2, 3, 4 tion, began its Maintenance Resource Manage- The goals of the industry survey were to ment effort. Both programs continued for years, assess the current status of human factors pro- but without regulatory requirements to con- grams, including: tinue, they faded away when lean times arrived • Training; for the U.S. carriers. By the mid-1990s, Transport Canada (TC), the • Fatigue management; U.K. Civil Aviation Authority and the FAA started • Leadership commitment; an annual conference titled “Human Factors in Maintenance and Inspection.” That conference • Error report systems; provided excellent information exchange until • Use of technical documentation; and, 2002, when it took a hiatus until 2006. During that • Program cost justification. period, both TC and the Joint Aviation Authorities — now being replaced by the European Aviation And, most importantly, the survey was designed Safety Agency (EASA) — enacted regulations to assess the differences between mandatory and requiring initial and continuing human factors voluntary programs.
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The international industry respondents had While these responses reflect positively on a lot to say. The invitation was sent to more than the industry, results from this question likely were 600 valid e-mail addresses. Responses numbered skewed by the high percentage of FAA-regulated 414, an unusually high 66 percent response respondents, who are not required to have a rate, and included input from management, program. However, answers to further questions quality control, training and labor representa- showed that those who had to comply with regula- tives in 54 countries. The highest percentage tions indicated their programs were more robust, of respondents — 40 percent — worked within provided better training for instructors and trained the United States. Some of the other countries higher percentages of staff. included Canada, 9 percent; United Kingdom, 7 But human factors programs go beyond percent; and Australia, Norway and Singapore, regulations. The survey inquired about many all 3 percent. aspects of a total human factors program, in- The survey sample spanned the entire cluding topics such as use of error management aircraft maintenance industry, with more than systems, fatigue management and training, cost one-third from an airline maintenance depart- justification of human factors programs and ment, 27 percent from repair stations, 9 percent technical documentation systems. in a general aviation/business operation, and 6 Some 55 percent of the respondents reported percent at a training that error data were stored in a database, and Employment of Respondents facility or mainte- less than half of all those responding said their nance school. While database was reviewed in a proactive manner. In School/training facility Other specific respondent this day of increased attention to safety man- 5.6% 10.1% affiliation was secure agement systems (SMS), a data-driven process, Military/government Airline and anonymous, it that number is not high enough. The response 8.2% maintenance 35.0% is estimated that ap- indicates that there is plenty of opportunity for General aviation/business proximately 200 orga- improvement and reinforces the idea that the col- 8.9% Repair station nizations responded lection of data, while challenging, is easier than Manufacturing 27.3% (Figure 1). data analysis. The SMS challenge is to discover 4.8% FAA-regulated what the data are telling us.
Source: William B. Johnson and Carla Hackworth maintenance op- Fatigue is a safety issue in maintenance, erations were the most according to 82 percent of the respondents. How- Figure 1 numerous, followed ever, only 25 percent had a fatigue management by those governed by system, and just 36 percent covered fatigue in the Respondents’ Primary Regulatory Authority EASA rules (Figure 2). training program. This discontinuity between Regulations that recognizing the fatigue threat and establishing Other national aviation authorities require human factors barriers is alarming, and it was repeated in the 17.8% programs make a dif- inspector survey. Civil Aviation ference, respondents Less than 10 percent of respondents reported Safety Authority (Australia) U.S. Federal said. To a question that an effort had been made to show a return 4.7% Aviation Administration regarding the motiva- on investment in human factors programs even Transport Canada 45.0% 8.9% tion for human factors though 51 percent said such information was programs, the two important. Clearly, the industry must improve responses most fre- methods to assess the financial return on human European Aviation quently selected were factors programs if such programs are to flourish Safety Agency 23.5% flight safety and worker and expand beyond minimum regulatory require- protection, followed by ments. The lack of justifications helps explain why Source: William B. Johnson and Carla Hackworth regulatory compliance the apparently successful voluntary programs from Figure 2 and cost control. the early 1990s became victims of hard financial
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times. Those programs “felt” good, but did not The inspectors capital- take the time to prove their financial worth. ized on the opportu- Aviation Safety Inspector Specialty Mix More than 70 percent of respondents’ com- nity, and the survey Airworthiness certi cation panies had a formal or informal policy to apply obtained approximate- 1% FAA safety team Manufacturing inspector human factors considerations to the develop- ly 180 open-ended 2% 1% ment or modification of documentation. comments. General aviation avionics 12% Proper use of technical documentation As with the indus- remains a very high priority for the industry. try survey, there was a Failure to follow procedures is the no. 1 cause of high response rate. The Air carrier Air carrier avionics 37% most negative events, and human factors issues voluntary participa- 16% are often a root cause of documentation events. tion by more than 800 General aviation When people do not use documents correctly, ASIs meant that nearly 31% event investigations must drill down to discover 45 percent of FAA’s the reasons, not just assign blame. Effective use inspectors participated. Source: William B. Johnson and Carla Hackworth of error reporting systems is a very good way to The inspectors raise human factors-related attention to techni- generally were evenly Figure 3 cal documentation and procedures. divided between the The industry survey indicates that the fol- airlines and general aviation, with the airline lowing are the best opportunities for improving group slightly larger (Figure 3). More than 80 how human factors are handled in maintenance: percent of the respondents performed surveil- lance as part of their job and had maintenance • Use of event reporting data, creation of a experience in excess of 20 years. Some 44 percent fatigue management program; of the inspectors reported that the companies Failure to follow they oversee comply with EASA rules with • Increased use of data to provide cost justi- procedures is fication of human factors programs; and, respect to human factors. Thus, the FAA ASIs are seeing a lot of human factors programs, but not the no. 1 cause • Greater attention to the human factors because of FAA regulations. aspects during the development and A high percentage of FAA inspectors, 64 of most negative use of technical documentation and percent, said the human error investigations procedures. they see in the U.S. industry tend to be informal. events, and human In a separate item, 12 percent of the ASIs said factors issues are Inspectors and Human Factors their operators had implemented human factors The second survey, completed in 2007, focused practices to “a considerable extent” or “a great often a root cause on the FAA inspector work force. The FAA survey extent.” The informality of the programs may be had these goals: reasonable because good programs are not neces- of documentation sarily highly structured. Instead, they should be • To gather opinions regarding the per- designed to fit the company culture and require- events. ceived level of human factors knowledge ments derived from error reporting systems. among the ASI work force; The 12 most common causes of human error • To assess the level of human factors sup- in maintenance, named the “Dirty Dozen” by port for ASIs; Canadian safety specialist Gordon Dupont, were presented for inspectors to rank the challenges • To obtain an inspector’s view of human (Figure 4, p. 39). The top three for maintenance factors programs in the industry; and, were pressure, complacency and the use of • To identify workplace challenges both for norms — that is, the use of unwritten practices. the aviation maintenance industry and The combination of these top-rated causes of er- the FAA. ror can contribute to the failure to use technical www.flightsafety.org | AeroSafetyWorld | March 2008 | 37 AP-ATS-2858x2233 6/02/08 14:52 Page 1
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sensors, real-time Gordon Dupont’s Dirty Dozen human performance modeling, advanced The most common causes of human error: technology sched- uling practices, • Lack of communication • Lack of awareness economics of • Lack of teamwork • Lack of resources maintenance worker • Norms • Distraction compensation prac- • Pressure • Assertiveness tices and accident • Complacency • Fatigue investigation analysis • Lack of knowledge • Stress related to fatigue. The FAA’s three- Source: William B. Johnson day employee course, Figure 4 “Human Factors in Aviation Mainte- documentation, which surprisingly was rated nance,” is now required training; half of all air- only as the fifth on the inspectors’ rating of worthiness ASIs attended the previous two-day challenges despite the fact that documentation class. Two-thirds of the respondents indicated issues are unarguably the leading contributor to that they want biennial recurrent training in hu- maintenance error. man factors; EASA requires biennial recurrent FAA inspectors rated the important attri- training for its certificate holders. butes/programs for a quality maintenance orga- During 2006 and 2007, FAA released two nization and overwhelmingly identified a positive operator’s manuals for human factors, one for safety culture — 91 percent — and an SMS — 82 maintenance that received the FAA Adminis- percent — as the most important (Figure 5). FAA trator’s Plain Language Award for 2006, and management, especially from the Aviation Safety the other a report for airport operations.6 ASIs office (AVS), has been “walking the walk” with respect to safety culture and SMS, evidenced by Ranking Importance of Maintenance Safety Programs the organization’s recent ISO9000 certification and establishment of a new office dedicated to gathering, analyzing and sharing data. Positive safety culture Fatigue is a concern for the aviation indus- try.5 Nearly 40 percent of ASIs responded that Safety management system maintenance employee fatigue is a safety issue for the operators they oversee. Airline inspec- Error reporting system tors saw this as a greater issue — 43 percent — than did general aviation (GA) inspectors — 35 Human factors training percent. Both categories of inspectors reported Fatigue management a need for regulations related to fatigue issues in maintenance, 91 percent for airline ASIs and Formal human factors program 75 percent for GA inspectors. The FAA has ongoing research initiatives that are providing 0 20 40 60 80 100 guidance and procedures to address fatigue Percent in the maintenance workplace. This R and D Note: Results from survey of FAA safety inspectors involves a planned mix of approaches ad- Source: William B. Johnson and Carla Hackworth dressing issues including the science of fatigue and sleep, applications for nano-technology Figure 5 www.flightsafety.org | AeroSafetyWorld | March 2008 | 39 MaintenanceMatters
indicated a limited familiarity with an understanding of the impact of hu- lose focus on the most important link the maintenance operator’s manual, man factors programs in maintenance in the safety chain, the human. ● suggesting that the FAA must not only organizations. Many of the comments publish guidance materials but also originated from the ASI’s past em- William B. Johnson, Ph.D., is chief scientific tech- promote them both internally and ployment in the airline maintenance nical adviser, human factors in aircraft mainte- externally. industry. nance systems, FAA, and Carla Hackworth, Ph.D., Inspectors used the “Dirty Dozen” There was general agreement is an engineering research psychologist, FAA. to rate their own job challenges, and se- between the two surveys that the no. lected distraction, lack of resources and 1 challenge is fatigue in maintenance. Notes pressure as their greatest challenges. Throughout the world, the rules ad- 1. Nearly 1,500 safety professionals world- There were many comments providing dressing fatigue are not strict. There wide contributed to these surveys. The re- positive suggestions to improve inspec- are exceptions, usually due to national search was a joint effort of the FAA Civil tors working efficiency. Inspectors labor law. That leaves the responsibility Aerospace Medical Institute (CAMI) at the Mike Monroney Aeronautical recognized the emerging requirement of addressing fatigue challenges with Institute, Oklahoma City, Oklahoma, for additional oversight of domestic companies, labor organizations and U.S., and the Maintenance Division of the and international repair stations and individuals. Flight Standards Service, Washington, said they knew that inspectors face a A strict regulation regarding duty D.C. Flight Standards participants were workload that is growing faster than the time may not be the best solution for John J. Hiles and David Cann. CAMI work force. everyone. The issue crosses a variety team participants were Kali Holcomb, Joy Banks, Melanie Dennis and David Inspectors said that there should of domains, including but not limited Schroeder. be an FAA regulation for human to science, health, fitness for duty and factors programs, with 80 percent of safety, plus significant corporate and 2. Hackworth, C.; Holcomb, K.; Dennis, airline inspectors and 72 percent of personal economic issues. One size M.; Goldman, S.; Bates, C.; Schroeder, D.; Johnson, W. (2007a). “Survey of GA inspectors backing the idea. Their does not fit all. Maintenance Human Factors Programs positions were reinforced by numer- The industry must not wait for Across the World.” The International ous comments that generally said that regulators to issue a mandate. Tools Journal of Applied Aviation Studies, airline maintenance organizations are are available that organizations can use Volume 7, Number 2, 212–31. driven by regulations and will invest to assess the potential impact of their 3. Hackworth, C.; Holcomb, K.; Dennis, M.; resources to follow the rules. When scheduling practices on fatigue and Goldman, S.; Bates, C.; Schroeder, D.; there are human factors regulations, performance. Industry must step up Johnson, W. (2007b). An International there will be compliance by all. Until to professional reviews of scheduling Survey of Maintenance Human Factors then, human factors programs will exist patterns, managing shifts and tracking Programs (Report No. 07/25). Oklahoma only where there are EASA certificates duty time, plus beginning to recognize City, Oklahoma: FAA CAMI. and/or enlightened U.S. maintenance fatigue as a valid reason to miss or stop 4. Hackworth, C.A.; Banks, J.O.; Holcomb, organizations. work. K.A.; Johnson, W.B.; Hiles, J.J. (2007c). Additional opportunities for Aviation Safety Inspectors’ (ASIs) Maintenance Human Factors Survey, Combining Survey Data improvement, depending on company (Memorandum Internal FAA Report). The high rate of response to both vol- and country, may include the following: Oklahoma City, Oklahoma: FAA CAMI. untary surveys was evidence of a high increased use of error reporting system interest in maintenance human factors. data; application of systems and data to 5. U.S. National Transportation Safety Board (2006). Most Wanted Transportation Safety Respondents had positive attitudes and cost-justify human factors programs; Improvements, Federal Issues. Aviation: reported what they believed were the improved training for human factors Reduce Accidents and Incidents Caused best opportunities for improvement. trainers; improved systems for technical by Human Fatigue.
40 | flight safety foundation | AeroSafetyWorld | March 2008 CASS 53rd annual Corporate Aviation Safety Seminar
April 29–May 1, 2008 p a l m h a r b o r , f l o r i d a
To receive agenda and registration information, contact Namratha Apparao, tel: +1 703.739.6700, ext. 101; e-mail: [email protected]. To sponsor an event, or to exhibit at the seminar, contact Ann Hill, ext. 105; e-mail: [email protected]. CABINSafety
he proliferation of portable it is considered that the likelihood of an incident — “My reason for this report electronic devices that passen- incident (i.e., smoke, fire or explosion) in- is a needed change to the ‘Cabin Smoke gers carry aboard airliners would volving a portable electronic device with a From An Unknown Source’ checklist. increase the risk of in-flight fires, it lithium-ion battery pack is relatively low. We obviously isolated the situation [a wasT thought, but airline pilots and flight However, [if there were such a fire,] the lithium-ion battery in a laptop computer attendants in the United Kingdom since fire extinguishers available to the flight overheated during in-flight charging 2003 have been reassured that the extin- [crew] and cabin crew have been shown from an in-seat power supply port] by guishing agents normally aboard their by test to be effective in extinguishing the turning off the power ports as part of the aircraft would be up to this firefighting f i re .” 1 Although lithium battery–specific checklist. My concern is that if a laptop task. However, recent experience and firefighting techniques were not covered, [computer] is in the overhead bin and research seem to indicate that the “all’s this report built a foundation for the spontaneously combusts, we will never well” take of the underlying research updated techniques expected later in know [that the source of smoke/fire] is report issued by U.K. Civil Aviation Au- 2008 from a joint effort by the CAA, U.S. not the airplane. The flight attendants’ thority (CAA) is not entirely justified. Federal Aviation Administration (FAA) [checklist] or our checklist should have The report said in part, “Based on and three other civil aviation authorities.2 a place to require all passengers with the information, design knowledge and A few airline crewmembers have battery-powered devices of any kind to expertise provided by [the research reported their need for such enhanced locate them and inspect them during an contractor] regarding the in-built safety guidance. A Boeing 737 captain said emergency of this type.”33 devices used in lithium-ion battery packs, in March 2007 — after conducting a Another airline pilot, traveling together with past in-service experience, diversion and landing without further in June 2007 as a passenger, used a
U.S. Federal Aviation Administration
By Wayne Rosenkrans Thermal
New guidance for extinguishing lithium-battery fires is on the way. U.S. Federal Aviation Administration Aviation Federal U.S.
42 | flight safety foundation | AeroSafetyWorld | March 2008 CABINSAFETY
magazine when asked to handle a nearby pas- senger’s 9-volt battery, which the pilot believed to be an “alkaline battery … [with increasing] heat of an intensity which would blister skin,” placed the battery in a cup of ice in the aft galley and notified the aircraft captain by interphone. The pilot-passenger later said, “Passengers carrying on batteries which have overheated have become a cabin safety issue. A large laptop [computer battery] overheating could present increased problems. Question: Is there adequate flight crew guidance available in pilot and flight attendant U.S. Federal Aviation Administration manuals on procedures to handle an overheating battery in the cabin? Is placing the battery in ice the proper procedure?”4 Despite no passenger airliner accident caused in the intervening years by a lithium-battery fire, the U.S. National Transportation Safety Board (NTSB) has reiterated concerns based on its inves- tigation of the UPS Flight 1307 accident, in which the airplane was destroyed by fire after landing and three flight crewmembers received minor injuries during evacuation, and its awareness of incomplete and inconsistent aviation battery-incident data.5
Thermal U.S. National Transportation Safety Board
NTSB’s work since 2006 has torpedoed a few requirements [by PHMSA effective in Janu- Left, overheated comfortable assumptions: that the probability ary 2008] demonstrate the growing awareness lithium-ion cell of such fires is low because of the safety systems and concern within the DOT and the airline releases flaming designed into most of these batteries; that passen- industry over the air transportation of primary electrolyte; six cells gers heed battery makers’ safety warnings against [nonrechargeable] and secondary [recharge- burned in a carry- battery misuse/abuse and comply with applicable able] lithium batteries and electronic equip- on spare laptop regulations; that extinguishing agents can put ment containing such batteries,” NTSB said in battery. Above, a out equally all types of lithium-battery fires; and the final accident report (Table 1, p. 44). thermal runaway that flight attendants can respond proficiently charred a JetBlue to a potential or actual thermal runaway — the Lithium Battery Basics Airways overhead characteristic of special concern in these fires. Lithium-ion battery refers to a rechargeable type compartment; one of “The issuance of the safety alerts and that contains lithium as one element of chemi- the laptops shipped advisories [by the Pipeline and Hazardous cal compounds but no metallic lithium in its on UPS Flight 1307. Materials Safety Administration (PHMSA) elemental form. Lithium-ion batteries typically of the U.S. Department of Transportation power consumer electronics such as laptop com- (DOT) and FAA] and the new, more stringent puters, mobile telephones, music/video players,
www.flightsafety.org | AeroSafetyWorld | March 2008 | 43 CABINSafety
A Growing Understanding of Lithium Battery Risks to Airliners
Date Battery Occurrence/Report Significance 1976–1983 Lithium After adopting approved battery designs first Launched in 1982, the Navy’s Lithium Battery Safety (unspecified) marketed in 1970, the U.S. Navy reported six Program currently provides a technical manual of injuries and one death. specifications and procedures, safety-performance testing requirements for cell/battery approval, safety- data packages and training. May 1994 Lithium-metal Loose button-size batteries in a box emitted The U.K. Civil Aviation Authority (CAA) noted that these smoke and showed fire damage during transport batteries were destined for shipment as cargo on a by truck. passenger flight from London Heathrow Airport; the resulting safety focus was on the absence of protection against short-circuiting. April 1999 Lithium-metal A total 120,000 batteries on two cargo pallets Airline employees’ initial attempts to extinguish the fires burned after being removed from a passenger with portable fire extinguishers and a fire hose failed; flight and then mishandled/dropped on the apron flare-ups recurred each time the fire appeared to be at Los Angeles International Airport. extinguished. No external ignition source was found. The U.S. National Transportation Safety Board (NTSB) called for evaluation of lithium battery issues and appropriate measures to protect passengers and aircraft. July 2003 Lithium-ion U.K. researchers tested some of the most common The report for U.K. CAA found “the likelihood of an battery packs used in portable electronic devices incident (i.e., smoke, fire or explosion) … is relatively carried into aircraft cabins. low.” The test results “verified the effectiveness of existing fire-extinguishing agents in coping with a lithium-ion battery fire.” August 2004 Lithium-ion Smelling smoke during loading, handlers NTSB said the probable cause was the failure of repositioned a cargo container from a freighter to unapproved packaging, which was inadequate to protect the ground; one of two 136-cell battery modules the modules from short circuits during transportation. soon ignited. This 2005 report cited 16 other U.S. and non-U.S. events as relevant for regulatory review. September 2006 Lithium-ion The U.S. Federal Aviation Administration (FAA) Individual cells and bulk-packed cells packaged for released a study of fire-related characteristics of shipment on cargo and passenger aircraft were tested. the most common type of cell used inside laptop FAA found in part that Halon 1301, the only FAA-certified computer batteries. fire-suppressant agent for systems permitted in cargo compartments of passenger aircraft, is effective for fires but not in sufficiently cooling overheated cells to prevent them from explosively releasing flaming liquid electrolyte seconds to minutes after its application. January 2008 Lithium-metal A final U.S. Department of Transportation (DOT) Reasons included evidence from FAA research that heat rule, effective on an interim basis in December from a smoldering cargo fire could ignite a lithium-metal 2004, prohibited cargo shipments of specified battery fire, fire propagation between these batteries was lithium-metal batteries on passenger aircraft. likely, and burning batteries could not be extinguished by Halon 1301. January 2008 Lithium-ion and A DOT rule prohibited airline passengers from The rule allowed carrying batteries of specified sizes and lithium-metal carrying loose batteries in checked luggage; quantities only if installed in portable electronic devices monitoring of safety issues continued. in checked luggage or carry-on bags, or packed as spares in carry-on luggage with protection against short- circuiting by enclosure in original packaging or other acceptable methods. February 2008 Lithium-ion NTSB released the final report on the UPS Although lithium-ion battery packs in laptop Flight 1307 accident in Philadelphia. computers were among cargo burned in the early stages of the fire, the fire origin was undetermined. As part of this investigation, NTSB issued additional safety recommendations related to lithium-ion and lithium-metal batteries carried in cargo and passenger operations.
Sources: DOT, FAA, NTSB, U.S. Navy
Table 1
44 | flight safety foundation | AeroSafetyWorld | March 2008 CABINSAFETY
digital cameras and video camcorders. Lithium- challenge for the cabin crew in responding to metal battery refers to a nonrechargeable type thermal runaways then is determining when the that does contain lithium as a distinct element. process has ended so that the battery or device Lithium-metal batteries typically power film can be handled without anyone being burned by cameras, high-intensity flashlights, remote con- the device/battery itself or flying debris, or sus- trol devices, toys and many other devices that taining smoke/fume inhalation or an eye injury.6 take batteries of small standard sizes. To reduce the risk of a thermal runaway, Distinguishing between these types is impor- PHMSA — the lead agency in the United States tant because of different characteristic fire behav- responsible for determining how to regulate ior and how cabin fire extinguishers perform. For lithium batteries and whether restrictions example, the chemical components in lithium- actually protect the traveling public — recom- metal batteries responsible for the batteries’ supe- mended these safety measures on its compre- rior energy density compared with conventional hensive Web site at
By January 2008, however, NTSB had issued Another argument was advanced in a Novem- two safety recommendations urging PHMSA, ber 2007 presentation to the Dangerous Goods FAA and the airline and battery industries to Panel of the International Civil Aviation Organiza- take further steps to ensure passenger and crew- tion (ICAO) by the Portable Rechargeable Battery member awareness of the risks of improper use Association (PRBA), which said that some inci- of lithium batteries inside aircraft cabins, and to dents cited from FAA’s battery-incident database measure and publish the results of communica- lack sufficient detail for useful safety analysis.12 tion campaigns.9 “While there appear to be several reasons for these incidents, the majority of incidents were Scope of Problem Debated caused by non-compliance with the current Interpretation of the sparse U.S. data about lith- regulations that govern the transport of lithium ium-battery fires on passenger flights has been a batteries and equipment powered by them, and
Airlines rely on continuing point of contention (see “Crew Expe- passengers who failed to protect batteries from aircraft occupants riences”). According to a 2005 study by the U.S. damage and short circuits,” the association said. to obey Institute of Standards and Technology, “About “Therefore, PRBA does not believe significant regulations and five safety incidents involving notebook com- revisions to the current lithium battery dangerous heed warnings puters [including those in aviation] occurred in goods regulations are necessary. … However, it is on use of lithium 2002. Cell production was in the range of 770 important to recognize that what is missing from battery–powered million units, of which roughly 40 percent (350 this [FAA] list of incidents is any meaningful devices such as million) were for installation in [battery packs ‘root cause’ analysis of the purported incidents.” high-intensity of] notebook computers. This translated into PRBA also said that some of the incidents in flashlights. five incidents in 308 million, or slightly more FAA’s database involved batteries or devices that than one [incident per] 61 million cells.”10 could have been subject to recall, damaged or Counting lithium battery incidents in avia- counterfeited — yet such root causes could not tion without categorizing them also has been be determined without failure analyses, which contentious. From Feb. 1, 1996, through July 25, typically did not occur. In its comments on a 2007, FAA’s battery-incident database showed letter to NTSB from the Air Line Pilots Associa- 14 incidents involving lithium-ion batteries — tion, International (ALPA) concerning the UPS six involving checked baggage and carry-on Flight 1307 accident, PRBA also said, “There items intended for passenger flights — and 13 have been fewer than 50 incidents of [battery involving lithium-metal batteries, according packs worldwide] overheating — fewer than 10 to an NTSB analysis. “Of the seven incidents of which have involved flames — during a peri- involving passenger aircraft, two occurred in od in which over 5 billion lithium-ion cells have flight, one causing the flight crew to divert; been produced. The [2006] Sony recall, which three occurred on board before takeoff; and two has received the most notoriety, has involved occurred in the airports before boarding the only a subset of this handful of incidents, even aircraft,” NTSB said.11 though apparently over 9 million battery packs Lithium-metal batteries were involved in six were in service that may have contained cells incidents involving carry-on items intended for from the same production runs.”13 Safety devices passenger flights, and two incidents involved within each lithium-ion cell are designed to packages shipped as cargo on passenger flights. power off the cell if an internal cell short-circuit “Of the eight incidents involving passenger and spontaneous overheating occur because flights, four occurred in flight, two causing the of contamination of parts of the cell by micro- flight crew to divert or land; two occurred or scopic metal particles during manufacturing were detected postflight, either during unloading — which prompted, for example, the 2006 recall or sorting operations; and two occurred before of Sony cells built into various laptop computer boarding the aircraft,” NTSB said. manufacturers’ battery packs. Wayne Rosenkrans
46 | flight safety foundation | AeroSafetyWorld | March 2008 CABINSAFETY
Crew Experiences
.S. government investigations of cabin fires linked to a pack inside a passenger’s laptop computer, which had lithium-ion or lithium-metal battery typically find it dif- been recharging from an in-seat power supply port.4 Uficult or impossible to obtain complete factual details • A flight attendant notified the captain during an and produce optimal analyses in the absence of standardized international flight that a battery of unknown type reporting, some aviation safety specialists say. The following had exploded in the coach section of the widebody summaries reflect issues that crewmembers have encoun- transport airplane. The crew continued to the destina- tered in the relatively few situations in public records: tion after the captain determined that no injuries had • Flight attendants preparing for the departure of a occurred, smoke had dissipated without further in- Boeing 767 smelled fumes, then saw smoke from a dication of fire, one seat cushion had been damaged passenger’s carry-on bag by opening an overhead and only a few pieces of the battery could be found. bin. Removed to the airbridge, the bag contained No passenger would take responsibility for owning scorched/melted clothing packed around an extremely the battery.5 hot video camcorder battery of unspecified type; a • During cruise, the flight crew of an A320 identified maintenance technician received a thermal injury to the source of a loud popping sound and acrid burn- 1 his hand while removing the battery. ing odor as an explosion involving the xenon lamp • The flight crew of a chartered 727 returned to the de- and lens in the captain’s high-intensity flashlight, parture airport and landed without further incident which had been used during the preflight inspec- after flight attendants and federal security agents tion. After donning oxygen masks and clearing the extinguished a passenger-seat fire ignited after odor from the cockpit, the crew found that this the explosion of a 9-volt lithium-ion video camera flashlight was hotter than normal and its lithium- battery as it was being handled by a news media metal batteries were charred.6 videographer.2 —WR • During boarding and baggage loading, fire in a checked bag was discovered by a baggage handler Notes who saw flames. Firefighters later told a crewmember 1. U.S. National Aeronautics and Space Administration (NASA) of the Airbus aircraft that the fire had been ignited by Aviation Safety Reporting System (ASRS) report no. 440497, a lithium-ion battery pack, designed for a handheld June 1999. video game player, which had been packed loosely 2. U.S. Federal Aviation Administration Accident/Incident Data 3 among wires and cables. System report no. 20041029028789c, Oct. 29, 2004. • The flight crew diverted a 737 and landed without 3. NASA ASRS report no. 730630, March 2007. further incident after passengers and a flight attendant smelled electrical smoke, which at first seemed to have 4. NASA ASRS report no. 731104, March 2007. dissipated after completion of emergency-checklist 5. NASA ASRS report no. 732079, March 2007. items. Firefighters within 30 seconds of entry located smoke still being emitted by an extremely hot battery 6. NASA ASRS report no. 760318, November 2007.
Dramatic Video Demonstrations then overpressures, releasing flammable liquid Though not released as official guidance, the electrolyte,” FAA said. “Cells may explode.” FAA’s draft firefighting videos have been pre- This draft video shows scenarios of thermal sented in public forums and posted to a Web site runaways, induced during tests by external heat- for industry comment. The draft video showing ing with either an electric hot plate or alcohol laptop computers, positioned as used on a cabin flame. Extinguishing options discussed include tray table, said that any installed battery pack Halon 1211 fire extinguishers, water fire extin- may malfunction and overheat, often during the guishers, and bottles or pitchers of water, juice, charging process, causing the pack to ignite. “A soda, carbonated drinks and other nonalcoholic cell, in a thermal runaway, gets extremely hot, liquids typically found on a beverage service cart. www.flightsafety.org | AeroSafetyWorld | March 2008 | 47 CABINSafety
“The objective is to extinguish the the laptop, making it more likely BlakeFirefightingVideo1.wmv>. The CSRTG fire and cool the battery pack, pre- that more cells will reach thermal comprises representatives of Agência venting additional cells from reaching runaway.” Nacional de Aviação Civil of Brazil, U.K. CAA, Direction Générale de l’Aviation Civile thermal runaway,” FAA said. “Wa- of France, the FAA and Transport Canada. ter fire extinguishers are effective at In May 2007, ALPA suggested ways 3. U.S. National Aeronautics and Space extinguishing the fire and cooling the that airlines can supplement the guid- Administration (NASA) Aviation Safety battery pack. Halon 1211 fire extin- ance in FAA Advisory Circular 120-80, Reporting System (ASRS) report no. guisher followed by the available water In-Flight Fires until the next revision. 731104, March 2007. source [was the second-best option in “Once ignited, a [lithium] battery fire 4. NASA ASRS report no. 740664, June 2007. tests because] Halon 1211 extinguishes may … have many characteristics the fire and water cools the battery that are not traditionally covered in 5. NTSB. “Inflight Cargo Fire, United Parcel Service Company Flight 1307, McDonnell pack. [The third-best option was] using firefighting training for crewmembers,” Douglas DC-8-71F, N748UP, Philadelphia, a Halon 1211 fire extinguisher alone, ALPA said. “Once the fire appears to Pennsylvania, February 7, 2006.” Accident which extinguished the fire and pre- have been extinguished, consider mov- Report no. NTSB/AAR-07/07. Dec. 4, 2007.
vented spread of fire as the battery cells ing the [portable electronic] device to 6. FAA. “Extinguishing In-Flight Laptop consumed themselves [but] Halon 1211 an area without flammable material, Computer Fires.” October 2007. This did not prevent additional cells from such as a galley oven (if not adjacent draft video was posted by Advanced reaching thermal runaway. Avoid using to the cockpit); the device should not Imaging, Operations Planning, FAA Air ice or smothering substances that act be moved if it is still on fire, or if it is Traffic Organization, for airline industry review and comment at
the fire and prevent spread to 1. Lain, M.J.; Teagle, D.A.; Cullen, J.; Dass, V. 11. NTSB. Accident Report no. NTSB/ adjacent flammable materials. “Dealing With In-Flight Lithium Battery AAR-07/07. Follow this [action] by dousing Fires In Portable Electronic Devices.” 12. Portable Rechargeable Battery Association. the laptop with water or other Safety Regulation Group, CAA. CAA “Analysis of ‘Known or Suspected’ nonalcoholic liquids from the Paper 2003/4. July 30, 2003. Battery Incidents and Update on Industry Activities Addressing Issues Related to drink cart or any other source. 2. Cabin Safety Research Technical Group the Transport of Lithium Batteries.” ICAO (CSRTG). “Aircraft In-Flight Firefighting.” Dangerous Goods Panel Working Paper October 2007. This draft video was posted no. DGP/21-WP/42. Nov. 9, 2007. • “Avoid the use of ice or other cov- for airline industry review and comment ering materials [to cool or suffo- at 48 | flight safety foundation | AeroSafetyWorld | March 2008 DataLink © iStockphoto.com Kiwi Count Quarterly data from New Zealand show decreased incident numbers for Part 121 operations. BY RICK DARBY he latest published data from the Civil accidents — serve as a proxy for assessing risk Aviation Authority of New Zealand management. (CAA) show that in the third quar- The data show that numbers of incidents, ter, from July 1 to Sept. 30, 2007, the airspace incidents and defect incidents for Tnumber of accidents involving large and large airplanes decreased in the third quar- medium-sized airplanes was unchanged from ter of 2007 compared with a year earlier. But the equivalent period in 2006, namely, zero.1 the long-term incident rates, especially for When there are no accidents to analyze, inci- large and medium airplanes, are not notably dents — which can be thought of as potential improving. New Zealand Aircraft Incidents, Second and Third Quarters, 2006–2007 Second Second Third Third Quarter Quarter Quarter Quarter Aircraft Category 2006 2007 Change 2006 2007 Change Airplanes that must be operated under CAR Part 121 111 85 –26 120 80 –40 Airplanes that must be operated under at least CAR Part 125 9 13 +4 9 23 +14 Other airplanes with a standard airworthiness certificate 28 30 +2 23 52 +29 Helicopters with a standard category airworthiness certificate 15 10 –5 13 9 –4 CAR = New Zealand Civil Aviation Rules Source: Civil Aviation Authority of New Zealand Table 1 www.flightsafety.org | AeroSafetyWorld | March 2008 | 49 DataLink The number of air carrier incidents, involv- New Zealand Aircraft Incidents, Large and Medium Airplanes ing large airplanes that must be operated under 200 Civil Aviation Rules (CAR) Part 121, decreased Airplanes that must be operated under CAR Part 121 Airplanes that must be operated under at least CAR Part 125 2 er to 80 in the quarter, from 120 (Table 1, p. 49). p 150 s t n That marked a drop of 33 percent, greater than e d i ight hours ight c l 100 f n the year-to-year 23 percent decrease in the i ft 000 000 , second quarter. rcra 50 i 100 A The data were somewhat less encouraging 0 4th 1st 2nd 3rd 4th 1st 2nd 3rd 4th 1st 2nd 3rd in other categories. For medium-size air- 2004 2005 2005 2005 2005 2006 2006 2006 2006 2007 2007 2007 Quarter planes in air transport that must be operated under at least CAR Part 125, the year-over- CAR = New Zealand Civil Aviation Rules year incident totals were up in the second and Note: Lines represent 12-month moving averages. third quarters.3,4 For other airplanes with a Source: Civil Aviation Authority of New Zealand standard airworthiness certificate — exclud- Figure 1 ing airplanes used for agricultural operations or in sport — incidents increased 126 percent New Zealand Aircraft Incidents, Airplanes With in third quarter of 2007 over the third quarter Standard Airworthiness Certificate and Helicopters With of 2006. Standard Airworthiness Certificate Part 121 airplanes had a higher incident 60 rate since the fourth quarter of 2004 than Other airplanes with standard airworthiness certi cate those operated under at least Part 125. The er 50 Helicopters with standard category airworthiness certi cate p s t n 40 incident rates, as 12-month moving averages, e d i ight hours ight c l 30 f n are shown in Figure 1. The incident rate for i ft 000 000 20 , “other airplanes” has been gradually rising rcra i 100 A 10 (Figure 2). 0 4th 1st 2nd 3rd 4th 1st 2nd 3rd 4th 1st 2nd 3rd The CAA classifies incidents as critical, 2004 2005 2005 2005 2005 2006 2006 2006 2006 2007 2007 2007 major and minor.5 No incidents in the “airplanes Quarter that must be operated under Part 121” or “air- Note: Lines represent 12-month moving averages. planes that must be operated under at least Part Source: Civil Aviation Authority of New Zealand 125” categories were classified as critical in the Figure 2 second quarter or third quarter of either 2006 or 2007. Rates of airspace incidents trended higher New Zealand Airspace Incidents, Large and Medium Airplanes for both airplanes operated under at least Part 125 Airplanes that must be operated under CAR Part 121 125 and those in Part 121 operations in the 6 er Airplanes that must be operated under at least CAR Part 125 p same period (Figure 3). “Other airplanes” had 100 s t n e a higher rate of airspace incidents than heli- d 75 i ight hours ight c l n f i 50 copters with a standard category airworthiness 000 000 , certificate (Figure 4). rspace i 25 100 A 0 Airspace incidents decreased year-over- 4th 1st 2nd 3rd 4th 1st 2nd 3rd 4th 1st 2nd 3rd year in the second and third quarters for Part 2004 2005 2005 2005 2005 2006 2006 2006 2006 2007 2007 2007 Quarter 121 operations, but increased in the “other airplanes” category, with 51 percent more CAR = New Zealand Civil Aviation Rules recorded in the third quarter comparison. Note: Lines represent 12-month moving averages. The airspace incidents are shown for the Source: Civil Aviation Authority of New Zealand second and third quarters of 2006 and 2007 in Figure 3 Table 2. 50 | flight safety foundation | AeroSafetyWorld | March 2008 DataLink New Zealand Airspace Incidents, Second and Third Quarters, 2006–2007 Second Second Third Third Quarter Quarter Quarter Quarter Aircraft Category 2006 2007 Change 2006 2007 Change Airplanes that must be operated under CAR Part 121 47 40 –7 47 39 –8 Airplanes that must be operated under at least CAR Part 125 19 18 –1 16 17 +1 Other airplanes with a standard airworthiness certificate 54 81 +27 45 68 +23 Helicopters with a standard category airworthiness certificate 7 13 +6 3 7 +4 CAR = New Zealand Civil Aviation Rules Source: Civil Aviation Authority of New Zealand Table 2 Defect incidents7 occurred at a higher rate New Zealand Airspace Incidents, Airplanes With in Part 121 operations than for those involv- Standard Airworthiness Certificate and Helicopters With ing airplanes operated under at least Part Standard Airworthiness Certificate 125 from the 2004 fourth quarter to the 2007 third quarter (Figure 5). 125 Other airplanes with standard airworthiness certi cate er Helicopters with standard category airworthiness certi cate Rates of defect incidents were similar in a p 100 s t n side-by-side comparison of helicopters with e d 75 i ight hours ight c l n f a standard category airworthiness certificate i 50 000 000 and the “other airplanes” data category in this , rspace i 25 100 period (Figure 6, page 52). A 0 The numbers of defect incidents declined 4th 1st 2nd 3rd 4th 1st 2nd 3rd 4th 1st 2nd 3rd 2004 2005 2005 2005 2005 2006 2006 2006 2006 2007 2007 2007 year-over-year in the second and third quar- Quarter ters of 2006 and 2007 for all these airplanes. Defect incidents involving Part 121 opera- Note: Lines represent 12-month moving averages. tions were down 36 percent from the second Source: Civil Aviation Authority of New Zealand quarter of 2006 to the second quarter of 2007, Figure 4 and declined 10 percent for the respective third quarters. Table 3 (page 52) shows the numbers. New Zealand Defect Incidents, Large and Medium Airplanes Bird hazard monitoring through March 31, 2007, indicated that eight of the 18 monitored 250 er 200 p airports had bird strike rates above the “trigger s t n e 150 level” that calls for CAA action. d ight hours ight i l c f n “One aerodrome exhibited a strike rate in the i 100 000 000 , 50 Defect Defect high-risk category of the CAA standard (above 100 Airplanes that must be operated under CAR Part 121 10.0 bird strikes per 10,000 aircraft movements),” 0 Airplanes that must be operated under at least CAR Part 125 4th 1st 2nd 3rd 4th 1st 2nd 3rd 4th 1st 2nd 3rd the report says. Six fell into the medium-risk 2004 2005 2005 2005 2005 2006 2006 2006 2006 2007 2007 2007 category, and 11 were in the low-risk category. ● Quarter CAR = New Zealand Civil Aviation Rules Notes Note: Lines represent 12-month moving averages. 1. CAA. Aviation Safety Summary Report: 1 July to 30 Source: Civil Aviation Authority of New Zealand September 2007. Available via the Internet at New Zealand Defect Incidents, Second and Third Quarters, 2006–2007 Second Second Third Third Quarter Quarter Quarter Quarter Aircraft Category 2006 2007 Change 2006 2007 Change Airplanes that must be operated under CAR Part 121 176 113 –63 146 131 –15 Airplanes that must be operated under at least CAR Part 125 23 11 –12 20 13 –7 Other airplanes with a standard airworthiness certificate 55 41 –14 38 32 –6 Helicopters with a standard category airworthiness certificate 28 45 +17 28 29 +1 CAR = New Zealand Civil Aviation Rules Source: Civil Aviation Authority of New Zealand Table 3 (considered equivalent to 12,500 lb), or with a single New Zealand Defect Incidents, Airplanes With engine and carrying passengers under instrument Standard Airworthiness Certificate and Helicopters With flight rules. Standard Airworthiness Certificate 4. In response to a query by AeroSafety World about the 200 meaning of the phrase “operated under at least CAR Other airplanes with standard airworthiness certi cate Part 125,” the CAA said, “We take the view that an er Helicopters with standard category airworthiness certi cate p 150 s operator of an airplane that could be operated under t n e Part 125 can operate that airplane to the higher d ight hours ight i l c 100 f n i specification of Part 121.” 000 000 , 50 Defect Defect 100 5. A critical incident causes, or on its own has the 0 potential to cause, loss of life or limb. 4th 1st 2nd 3rd 4th 1st 2nd 3rd 4th 1st 2nd 3rd 2004 2005 2005 2005 2005 2006 2006 2006 2006 2007 2007 2007 A major incident involves a major system that causes, Quarter or has the potential to cause, significant problems to the function or effectiveness of that system. Note: Lines represent 12-month moving averages. Source: Civil Aviation Authority of New Zealand A minor incident is an isolated occurrence or deficiency not indicative of a significant system Figure 6 problem. 2. Part 121, Air Operations — Large Aeroplanes, 6. An airspace incident involves deviation from, or fall- applies to airplanes with more than 30 passenger ing short of, the procedures or rules for avoiding a seats or a payload capacity of more than 3,410 kg collision between aircraft or avoiding a collision be- (7,518 lb). tween aircraft and other obstacles when the aircraft is under air traffic control. 3. Part 125, Air Operations — Medium Aeroplanes, ap- plies to airplanes with 10 to 30 passenger seats, or a 7. A defect incident involves failure or malfunction of payload capacity of 3,410 kg or less and a maximum an aircraft or aircraft component, whether found in certificated takeoff weight greater than 5,700 kg flight or on the ground. 52 | flight safety foundation | AeroSafetyWorld | March 2008 InfoScan Traffic Jam Europe is upgrading its air traffic management, but safety information flow within the system is held back by fears of legal repercussions. BOOKS In a chapter titled “ATM and Society — De- mands and Expectations,” contributor Nadine European Air Traffic Management: Pilon says that current forecasts predict a Principles, Practice and Research doubling of air traffic in Europe by 2025. “This Cook, Andrew (editor). Aldershot, England, and Burlington, Vermont, U.S.: predicted growth of flights may produce more Ashgate, 2007. 277 pp. Figures, tables, appendix, bibliography, index. incidents in absolute numbers, and increases the s part of the future air ATC/ATM [air risk of collision,” she says. “In order to maintain its traffic control/air traffic management] adequate level of safety, the air transport industry, “A service for Europe, aircraft will be and in particular ATM, implements continuous controlled accurately and with high integrity in reinforcements of safety assurances, but this has four dimensions [latitude, longitude, altitude little repercussion on the perception of risk.” and time] with the aid of on-board and satellite The development of land for housing and navigation and communications technologies,” business in ever-growing areas around cities says one contributor to this book, an across-the- may also increase the perception of risk because board look at European ATM. “Each aircraft will of accidents during takeoff or approach. The negotiate and re-negotiate a 4D [four-dimensional] two most dramatic accidents that resulted in flight plan in real time with the ground-based people on the ground being killed were the El ATM system. This will provide airborne au- Al 747 accident in Amsterdam in 1992 and the tonomous separation to give conflict-free tracks Concorde accident at Roissy, near Paris Charles between origin and destination in the form of 4D de Gaulle Airport, in 2000. profiles to be accurately adhered to by aircraft.” “It appears that society could be becom- That will be then; this is now. Although ATC ing more sensitive to, and more aware of, air will arguably change more radically than any transport safety risks and/or environmental other part of the aviation system in the coming impacts, and possibly becoming less tolerant of years, for the moment it remains largely in the operational errors,” Pilon says. “An illustration is hands of traditional controllers operating on the case of the Linate [Airport, Milan] accident the basis of radar coverage and voice or datalink where a runway incursion resulted in a collision, radio communication. with fatalities, in 2001. Both the judicial inves- European ATM must accommodate a tigation and the technical investigation were growth in demand for air transport while heavily reported in the press, in particular in the maintaining or improving current safety levels. regional newspapers. The trial resulted in eight Technical innovations, such as reduced vertical ATM personnel (from front-line operations separation minima, and administrative initia- to top management) being jailed. The way in tives, such as the Single European Sky legislation which this, and a number of similar cases, were adopted in 2004 to reorganize air navigation reported in the press and handled in the courts service providers into functional sectors inde- … identifies a lack of support by society for air pendent of national boundaries, are helping to traffic management. There remains a tendency increase capacity, the book says. for these cases to be addressed not only through www.flightsafety.org | AEROSafetyWorld | March 2008 | 53 InfoScan changes in the system but, additionally, by estab- the way safety analyses, investigations and lishing culpability and punishment on the basis improvement measures are carried out, of personal liability. This poses the question of some may see certain confidentiality clauses whether such cases point to a trend where, in as being over-restrictive, however. A delicate modern societies, air transport is considered a issue to resolve.” mature industry in which failures of that system are less and less tolerated.” • “In the case of a legal inquiry, any re- Concern about ATM-related accidents natu- quested data or file will be released to the rally leads to calls for measuring the system’s judicial authority, regardless of any confi- safety. But European ATM, Pilon says, is “not dentiality agreement. In certain countries providing at the European level a satisfactory in Europe, even when no accident has indication of the level of safety it produces, as actually occurred, staff may still be pros- stated by the Performance Review Commission ecuted because of a safety incident.” [of Eurocontrol in a 2006 report].” To counteract inhibitions about reporting Safety cannot easily be measured by the safety information, the ATM community and number of ATM-related accidents, which is Eurocontrol, for example, through the SAFREP quite low overall, so that a single major accident [Safety Data Reporting and Data Flow] task can cause a huge spike in the rate. “That is the force, are promoting the idea of “just culture” in reason why reporting on safety occurrences and ATM. Eurocontrol says that “the SAFREP task incidents is required: In some cases, a safety force found that punishing air traffic controllers occurrence may indicate that safety has been or pilots with fines or license suspension, as well compromised and therefore lead to improve- as biased press reports, has led to a reduction in ments,” Pilon says. “However, this genuine the reporting of incidents and sharing of safety demand for transparency may, in some cases, information. It also recognized that the need cause difficulties for air traffic management on for a culture that encourages honest reporting is account of the safety culture, confidentiality and not yet reconciled with the judicial system and even legal issues.” legislators. It warns that the situation may get Pilon says that the flow of incident informa- worse if no immediate action is taken.” tion can be limited for several reasons: REPORTS • “In organizations such as ATC, team is- sues play an important role, and a strong An Overview of Spatial Disorientation as a safety culture is crucial for safety. Efficient Factor in Aviation Accidents and Incidents safety reporting is based on trust and therefore takes a long time to become fully Newman, David G. Australian Transport Safety Bureau (ATSB) Aviation Research and Analysis Report B2007/0063. Final report. December embedded in the organization — and can 2007. 42 pp. Figures, references. Available via the Internet at 54 | flight safety foundation | AEROSafetyWorld | March 2008 InfoScan of reference,” the report says. “It is a very com- inner ear; others visual, which can occur even in mon problem, and it has been estimated that the visual meteorological conditions and are often chance of a pilot experiencing SD during [his or based on expectations that override what the her] career is in the order of 90 to 100 percent. pilot actually sees. The results of several international studies show Possible contributors to SD include pilot fac- that SD accounts for some 6 to 32 percent of tors, such as flying while experiencing an illness major accidents, and some 15 percent to 26 that affects the vestibular system, or while taking percent of fatal accidents.” medication with a similar effect; aircraft factors, for The report describes three types of SD: example, lack of an autopilot or the presence of a malfunctioning autopilot; operational factors, such • Unrecognized. “The pilot, unaware of the as inadvertent entry into instrument meteorological problem, continues to fly the aircraft as conditions (IMC) by pilots without an instrument normal. This is particularly dangerous, as rating, or prolonged acceleration; and environmen- the pilot will not take any appropriate cor- tal factors, including the lack of visual cues, as rective action, since [he does] not perceive when an approach is flown at night over water that there is in fact a problem. … This form — prompting the “black hole” illusion that gives of SD is clearly dangerous, and accounts for a false mental picture of altitude above terrain. the majority of SD accidents and fatalities.” “The chances of an SD event occurring in • Recognized. “The pilot becomes aware that flight can be reduced by a series of simple preven- there is a problem. While the pilot may or tive measures, many of which can be attended may not be aware that the problem is SD, to before flight,” the report says. “These include in this form of disorientation [he is] aware flying when fit and well … , not flying under the that something is not quite right, that [his] influence of alcohol or medications, avoiding sensory system is giving information that [flying under] visual flight rules into IMC, [and] does not agree with the information avail- increasing awareness of SD illusions and planning able from the instruments, or that things just for their possible appearance at different stages of don’t add up. … If this is successfully dealt flight in the preflight planning process. with, an SD accident does not tend to result. “It is vitally important that pilots are aware The pilot may then have received a valuable that SD happens to normal pilots. It can affect lesson on SD and how to recover from it.” any pilot, any time, anywhere, in any aircraft, on • Incapacitating. “The pilot may be aware any flight, depending on the prevailing circum- of the disorientation, but is mentally and stances. Furthermore, experience of SD does not physically overwhelmed to the point mean it will not ever happen again. Awareness where [he is] unable to successfully recov- and preparedness are key elements in preventing er from the situation. The pilot may fight an SD accident.” the aircraft all the way to ground impact, WEB SITES never once achieving controlled flight. Such forms of disorientation are a result of Centers for Disease Control and Prevention, information with the (drinking and recreational exposure); protection public. from insects and arthropods, principally spiders; Sections of the site and health tips and vaccination requirements for focus on health and global travelers. safety information of Literature references and Web site links to interest to flight and related information appear within documents cabin crewmembers and on the CDC site. and the aviation indus- try. The CDC provides Asociación Latinoamericana de Aeronáutica, instructional and guid- 56 | flight safety foundation | AEROSafetyWorld | March 2008 OnRecord Runway Deficit The pilots saw vehicles ahead and realized something was amiss. BY MARK LACAGNINA The following information provides an aware- would be made available temporarily for long- ness of problems in the hope that they can be haul international aircraft. As the 777 neared avoided in the future. The information is based Auckland, the full length of the runway was on final reports by official investigative authori- made available for the departure of an aircraft ties on aircraft accidents and incidents. bound for Singapore. “For traffic sequencing, the aerodrome controller held the Singapore- JETS bound aircraft at the runway holding point and cleared the [777] pilots to land their aircraft Reduced Thrust Set for Takeoff first,” the report said. “Because the full length Boeing 777-300ER. No damage. No injuries. of the runway was temporarily available, the he flight crew began the takeoff from aerodrome controller advised the pilots that Runway 05R at Auckland (New Zealand) the full length of the runway was available for TInternational Airport the afternoon of their landing.” The crew landed the 777 and March 22, 2007, believing that the full length — taxied to the gate. 3,230 m (10,598 ft) — was available. Flaps and There were 357 passengers and 18 crew- engine thrust had been set accordingly. “Dur- members aboard for the return flight to Sydney. ing the takeoff, they saw work vehicles in the The airport ground controller told the crew to distance on the runway and, realizing something taxi to Runway 05R and to hold on Taxiway was amiss, immediately applied full engine A10 for departure. The crew did not request thrust and got airborne,” said the report by the clearance to back-taxi on the western runway New Zealand Transport Accident Investigation extension, which would have added 393 m Commission (TAIC). The 777 passed 92 ft over (1,289 ft) to the available takeoff distance. To the vehicles. ensure that the crew knew about the reduced The aircraft had arrived in Auckland about runway length, the controller said, “Confirm two hours earlier on a flight from Sydney, Aus- you will depart from alpha ten reduced length?” tralia. Before departing from Sydney, the crew The crew confirmed that they would begin the read a notice to airmen (NOTAM) advising that takeoff from A10, believing that the full length available takeoff and landing distance on Run- of the runway was available and misunderstand- way 05R had been reduced to 2,320 m (7,612 ft) ing the controller’s reference to “reduced length” due to work in progress on the eastern portion as meaning the western runway extension that of the runway. The crew therefore planned to they were not planning to use. conduct a reduced-length landing at Auckland. “The first officer was the pilot flying, and the The NOTAM also said that, with 45 min- pilots set the thrust that they had determined was utes’ prior notice, the full length of the runway necessary for a reduced-thrust departure using www.flightsafety.org | AEROSafetyWorld | March 2008 | 57 OnRecord the full length of the runway from intersection as closely as possible to ICAO-recommended A10,” the report said. An N1 — fan speed — set- standards.” ting of 86.4 percent and a flaps 5 setting were used. The proper settings for the reduced takeoff Undetected Damage Blamed for Rudder Loss Airbus A310-300. Substantial damage. One minor injury. distance were 94.6 percent N1 and flaps 20. The 777 was about halfway down the re-existing damage within the rudder runway when the pilots saw the work vehicles, worsened after the aircraft departed from which included a rubber-removal truck and the PVaradero, Cuba, for a flight to Quebec City airport safety officer’s utility vehicle. The captain the morning of March 6, 2005, and eventually immediately applied takeoff/go-around thrust caused the rudder to separate in flight, said the — 104.8 percent N1. “The recorded airspeed at Transportation Safety Board of Canada (TSB). the time was 149 knots,” the report said. “Within There were 262 passengers and nine crewmem- 4 seconds, the aircraft accelerated to the pilots’ bers aboard the aircraft. predetermined takeoff decision speed (V1) of The A310 was cruising at Flight Level (FL) 161 knots. The first officer later said that imme- 350 (approximately 35,000 ft) 90 nm (167 km) diately after reaching V1, the captain called ‘ro- south of Miami when the flight crew heard a tate’ when the rotation speed (VR) of 163 knots loud bang and felt a vibration. The aircraft then was achieved. The aircraft became airborne entered a Dutch roll. “Cabin crewmembers approximately 190 m [623 ft] before the end of located in the back of the aircraft were thrown the reduced runway and climbed away steeply.” to the floor, and unsecured galley carts moved The crew landed the aircraft in Sydney about freely,” the TSB report said. One cabin crew- three hours later. member received a minor back injury. The pilots told investigators that because the The crew disengaged the no. 1 autopilot, full runway length was available for their land- believing that it was the source of the problem. The pilots told ing, they believed that it also was available for However, when the no. 2 autopilot was engaged, takeoff. They said that this belief was reinforced the Dutch roll intensified. The autopilot was dis- investigators that by the words “active runway mode normal engaged, and the captain hand-flew the aircraft. operations” at the beginning of the automatic The crew requested and received clearance to because the full terminal information service (ATIS) broadcasts descend, and they prepared to divert the flight runway length they had received. The report said that these to Fort Lauderdale, Florida, U.S. words meant only that the approach threshold of “Throughout the event, there was no ECAM was available for Runway 05R was not displaced. The pilots said [electronic centralized aircraft monitor] message that they had overlooked information provided relating to the control problem … and there were their landing, they later in the ATIS broadcasts about the reduced no warning lights or cockpit indications of an believed that it runway length. aircraft malfunction,” the report said. “Even with The report noted that the ATIS broadcasts limited clues as to the cause of the Dutch roll, the also was available for Auckland were twice the length recom- crew knew that descending to a lower altitude mended by the International Civil Aviation might lessen or stop the Dutch roll motion.” for takeoff. Organization (ICAO) and were cluttered with The Dutch roll motion decreased during the noncritical “permanent” information. Among descent and stopped at FL 280. The A310 was recommendations based on the findings of the abeam Miami when the crew decided to return incident investigation, TAIC said that the New to Varadero. Their first indication that the rudder Zealand Civil Aviation Authority should “ensure was the cause of the control problem came when that ATIS broadcasts … have clear word and they were unable to correct a slightly crabbed at- sentence structures, are unambiguous, never titude with rudder inputs during final approach. imply that things are normal when they are not, Nevertheless, they landed the aircraft without fur- contain no permanent information and conform ther incident. “After shutdown, it was discovered 58 | flight safety foundation | AEROSafetyWorld | March 2008 OnRecord that [only] small pieces of the rudder were still The 717’s main fuel switches are on the attached to the vertical stabilizer,” the report said. center console, below the throttle levers. After The accident aircraft first flew in 1991 the incident, the aircraft operator issued a safety and had accumulated 49,225 flight hours alert to its 717 crews advising that the main fuel and 13,444 flight cycles. The rudder basically switches could be moved to the “ON” posi- The main fuel comprises carbon-fiber-reinforced plastic tion without correctly engaging the locking side panels bonded with resin to a composite detent. “That alert also warned flight crew of switches could be honeycomb core. Investigators determined the possibility of inadvertent in-flight selection moved to the “ON” that some disbonding of a side panel or a core of the switches to ‘OFF’ by catching wristbands fracture likely existed when the A310 departed or long-sleeve shirt cuffs,” the report said. “In position without from Varadero and that the damage worsened addition, flight crew were advised to not pass to the point that it caused the rudder to flutter technical manuals or other similar items across correctly engaging and fail during the flight. the throttle quadrant in the vicinity of the main the locking detent. “The manufacturer’s recommended inspec- fuel switches.” tion program for the aircraft was not adequate to detect all rudder defects,” the report said. “The Ice Crystals Cause Dual Flameout damage may have been present for many flights Raytheon Beechjet 400A. No damage. No injuries. before the occurrence flight.” Based on this find- oon after beginning a descent from FL 410 ing, the TSB recommended that the European in instrument meteorological conditions Aviation Safety Agency work with the industry to S(IMC) on July 12, 2004, the flight crew “develop and implement an inspection program felt a jolt, heard a bang and noticed that cabin that will allow early and consistent detection of pressure was decreasing. The airplane, with nine damage to [composite] rudder assemblies.” people aboard, was over the Gulf of Mexico, about 100 nm (185 km) west of Sarasota, Switch Movement Cited in Shutdown Florida, U.S., en route from Duncan, Oklahoma, Boeing 717-200. No damage. No injuries. to Fort Myers, Florida. There was convective he flight crew was beginning the descent activity in the area. from FL 330 during a flight from Perth, “The [pilots] donned their oxygen masks, TWestern Australia, to Karratha on Sept. 6, declared an emergency and went through the 2006, when the right engine lost power soon emergency descent checklist,” said the report by after the autothrottle system commanded a the U.S. National Transportation Safety Board thrust reduction. “During the completion of the (NTSB). “They noticed that every warning light relevant non-normal checklist items, the crew in the cockpit was illuminated and that the noticed that the main fuel switch for the right engines were not operating. After several unsuc- engine was selected to ‘OFF,’” said the report by cessful attempts to restart the engines, the pilots the Australian Transport Safety Bureau (ATSB). were able to get the right engine restarted as the The crew restarted the engine as the aircraft airplane descended through 10,000 feet.” descended through FL 160 and landed without The crew diverted the flight to Sarasota further incident in Karratha. and landed without further incident. Tests of ATSB determined from recorded flight data the engines revealed no discrepancies. The fuel that the main fuel switch had been moved to the remaining in the Beechjet met Jet‑A specifica- “OFF” position when the descent was begun. tions, but the concentration of icing inhibitor, a “The means for that switch movement could not fuel additive, was only 0.02 percent; concentra- be determined,” the report said. A possibility tions of 0.10 to 0.15 percent are specified by the was that the switch had not been locked in the airplane flight manual. “ON” position and had moved to the “OFF” po- NTSB determined that the probable cause of sition due to vibration or unintentional contact. the incident was “high-altitude ice crystals that www.flightsafety.org | AEROSafetyWorld | March 2008 | 59 OnRecord had accreted on the compressor vanes and were from Luton and 20 nm (37 km) from Heathrow. ingested into the high-pressure compressor “Concerned with the physical effort required when the pilots retarded the power levers [for to fly the aircraft manually, the commander the descent], causing compressor surges and decided to divert to Heathrow,” the report said. flameouts of both engines.” Contributing fac- A passenger, an off-duty employee of the tors were “the lack of training on the hazards of company who held a pilot’s license, assisted the high-altitude ice crystals to gas turbine engines crew by manipulating the throttles. The ap- and guidance to the pilots to activate the engine proach and landing at Heathrow were conduct- anti-ice system in conditions where high- ed without further incident. altitude ice crystals may exist,” the report said. The incident aircraft was manufactured in 2004 and had accumulated 202 flight hours. Trim Control Loss Traced to Condensation Initial examination revealed no pre-existing Bombardier Challenger 604. No damage. No injuries. defects. The report cited several previous pitch- bout 4 1/2 hours after departing from trim incidents that involved moisture contami- Lagos, Nigeria, to fly to Farnborough, Eng- nation of the horizontal stabilizer trim control Aland, on Nov. 11, 2005, the autopilot pitch unit motherboards in Challengers and their trim system failed. About 30 minutes later, both regional jet derivatives. These incidents were be- the primary and secondary manual pitch-trim lieved to have been caused by water entering the systems failed. The manual systems are acti- control unit, which is located beneath the floor vated by switches on the control columns. The near the cabin door and galley. The response Challenger does not have a backup mechanical was to require protective tape to be installed on pitch-trim system, said the U.K. Air Accidents portions of the motherboard. Investigation Branch (AAIB) report. However, AAIB determined that the Novem- “The pilots elected to descend to a lower ber 2005 incident likely was caused by condensa- level, believing that ‘cold soaking’ of the aircraft tion on the Challenger’s motherboard. Laboratory in the very low temperatures at FL 400 could tests showed that moisture contamination be a cause of the trim system faults,” the report occurred during prolonged exposure to a hot and said. However, pitch trim ran to almost full humid environment, followed by exposure to a nose-down despite manual application of nose- cold environment. “Faults appeared after about up trim commands. five hours due to the cold external wiring cooling “Consequently, although the commander the motherboard and allowing condensate to remained the handling pilot, it was necessary for build up, due to the humid air,” the report said. the copilot to assist him by applying aft pressure The faults caused by the moisture contamination to the control column,” the report said. “There included multiple intermittent short circuits. is no indication that the crew attempted to dis- connect the system through the stabilizer trim TURBOPROPS disconnect switches.” Although the checklist for landing with a Unfeathered Prop Causes Control Problems stabilizer trim failure called for use of 20 degrees Bombardier DHC-8/Q400. No damage. No injuries. of flap, the commander decided to keep the he aircraft was on a scheduled flight with flaps retracted, to avoid increasing the nose- four crewmembers and 69 passengers from down pitch. The runway at Farnborough was TStockholm to Kalmar, Sweden, on April 6, not long enough for a no-flap landing, so the 2006. During descent for the initial approach in crew requested and received clearance to divert visual meteorological conditions (VMC), an over- to London Stansted Airport. The air traffic con- speed of the right propeller occurred. “According troller advised the crew that the Challenger was to the emergency checklist, a number of actions 65 nm (120 km) from Stansted, 25 nm (46 km) are to be taken, ending with feathering the faulty 60 | flight safety foundation | AEROSafetyWorld | March 2008 OnRecord propeller and switching off the engine to reduce the Q400 in level flight at a very low height the air resistance (drag) of the propeller,” said — 200 to 300 ft AGL — about 1 nm (2 km) the report by the Swedish Accident Investigation from the runway threshold. “The controller Board. was convinced that there would be an accident The commander decided, however, not to and therefore said to the emergency services, “At the same time, feather the propeller and to keep the engine ‘Come out with all you’ve got. He’s going to operating at flight idle. He increased power crash,’” the report said. the automatic from the left engine from flight idle to 40 Recorded flight data showed that full rud- percent torque. The first officer asked whether der and aileron control were used during the ‘up-trim’ system in she should secure the right engine. “The com- approach. The aircraft passed 15–20 ft over the the engine increased mander rejected this proposal, referring to the runway threshold and touched down about 20 fact that the approach had now begun and that m (66 ft) beyond the threshold. “Roll-out on the power from the he understood that, in this situation, one should the runway took place with no further prob- not start a shutdown sequence but continue the lems,” the report said. “The rescue vehicles left engine to 100 approach and land,” the report said. followed the aircraft to its parking place on the The commander increased left-engine apron.” percent torque.” power to 90 percent to level off at 2,000 ft. “The The commander told investigators that he first officer once again asked the commander did not complete the propeller overspeed check- if she should secure the right engine but again list, by feathering the propeller and shutting received a negative answer,” the report said. “At down the engine, because “he thought the Q400 this stage, the autopilot automatically discon- had so much power that this was not neces- nected due to the increased asymmetric power, sary,” the report said. “During the approach, he and the aircraft had to be flown manually. At the found that controlling the aircraft became more same time, the automatic ‘up-trim’ system in the and more difficult … and found it difficult to engine increased the power from the left engine understand why.” to 100 percent torque.” The 125 percent torque setting had been The Q400 began to sink rapidly. The terrain maintained for 1 minute and 15 seconds, and awareness and warning system (TAWS) gener- did not cause any damage to the left engine. ated a “TERRAIN, PULL UP” warning and sev- The propeller overspeed was traced to contact eral “SINK RATE” warnings when the aircraft between a sensor and a bus bar on the propeller was 1,200 ft above ground level (AGL), sinking hub that produced sparks and electromagnetic at 3,700 fpm and in a right turn, away from interference with the propeller electronic control the airport. The commander increased left- unit. engine power to 125 percent, which is beyond In the two-year period preceding the inci- the torque limit, and began a climbing left turn dent, six propeller overspeeds had occurred dur- toward the final approach course. ing the airline’s operations. “The QRH [quick The airport air traffic controller noticed on reference handbook] emergency checklist was his radar screen that the aircraft was off course not followed in any of these cases,” the report and 800 ft low. At the same time, the first officer said. “Instead, the crews had either carried out reported that they had an engine problem. The only part of the list or not followed it at all. … controller asked if they needed assistance, and Several explanations were given for not complet- the first officer replied, “We don’t need any as- ing the checklist in these situations.” sistance. It will be a normal landing.” Among actions taken by the airline after “At this stage, the air traffic controller the April 2006 incident were a revision of the decided that the situation really was serious emergency checklist to improve its clarity and and set off the alarm,” the report said. While implementation of propeller overspeed training calling emergency services, the controller saw during simulator checks. www.flightsafety.org | AEROSafetyWorld | March 2008 | 61 OnRecord Airspeed, Turbulence Cited in Breakup he was attempting a forced landing on a logging Aero Commander 690A. Destroyed. Four fatalities. road. “The aircraft struck trees during a steep he airplane was about 1,038 lb (471 kg) right-hand turn and crashed,” the report said. over its maximum takeoff weight when The pilot and two passengers were killed. Tit departed from Oklahoma City to fly to Orlando, Florida, U.S., the afternoon of Oct. 15, PISTON AIRPLANES 2006. About 37 minutes later, while cruising at FL 230, the pilot was told by air traffic control Aileron Rigging Error Missed on Preflight (ATC) that radar showed the airplane entering De Havilland DHC-2. Substantial damage. No injuries. an area of heavy precipitation, the NTSB report he pilot said that both he and the mainte- said. The pilot acknowledged the information. nance technician who had rebuilt the Bea- The Aero Commander was being flown 15 Tver checked the engine and flight controls to 20 kt above its turbulence-penetration speed before attempting the first flight following the when moderate turbulence was encountered. rebuild on April 17, 2007. Winds were from ATC radar indicated that the airplane made a 150 degrees at 16 kt, gusting to 22 kt, when 180-degree turn while descending at about 13,500 the airplane departed from Runway 14 at Ted fpm. The wreckage was found the next day, Stevens Anchorage (Alaska, U.S.) International scattered over a densely wooded area in Antlers, Airport. The Beaver was about 150 ft AGL on Oklahoma. “An examination of the airframe initial climb when it suddenly rolled right about revealed that the airplane’s design limits had been 90 degrees, the NTSB report said. exceeded and that the examined fractures were “The pilot applied left aileron and left rud- due to overload failure,” the report said. der control, but the airplane did not respond,” the report said. “He retarded the engine power Engine Fails During Flight Over Mountains to idle and pushed forward on the control yoke Cessna 208B. Destroyed. Three fatalities, five serious injuries. to maintain airspeed.” The right wing, then the he Caravan was over a designated moun- left wing struck the runway, and the airplane tainous area at 9,000 ft, during a flight from touched down hard on the main landing gear, TTofino, British Columbia, Canada, to Van- departed the runway and struck a ditch. couver, on Jan. 21, 2006, when the engine failed. “A postaccident examination of the airplane “A compressor turbine blade failed as a result of and flight controls revealed that the chain con- the overstress extension of a fatigue-generated trol linkage within the control yoke was mis- crack,” the TSB report said. “The subsequent routed at the base of the control column, thereby internal damage to the engine was immediate reversing the aileron activation,” the report said. and catastrophic.” NTSB said that the rigging error and the pilot’s The pilot turned toward Port Alberni Regional inadequate preflight inspection were the prob- Airport, about 17 nm (31 km) away. “The pilot was able causes of the accident. in VMC, but he would have to enter cloud dur- ing the descent,” the report said. “The pilot then Fuel Injectors Blocked by Rust Particles requested navigational information to help keep Piper Aztec. Destroyed. One fatality. the aircraft clear of the mountains. … There is no he aircraft had been stored outside at Bagby capability for air traffic controllers to provide such Airfield near Thirkelby Hall, England, with navigational guidance.” The aircraft did not have, Tno engine runs conducted, for nearly five and was not required to have, a TAWS. years before the pilot bought it in February ATC lost radio communication with the 2006, the AAIB report said. Water was found in pilot when the aircraft descended through 7,000 the fuel system during maintenance and inspec- ft. Pilots of other aircraft in the area heard the tions conducted before the sale; the system was Caravan pilot declare an emergency and say that flushed, and the fuel filters were cleaned. 62 | flight safety foundation | AEROSafetyWorld | March 2008 OnRecord The pilot flew the Aztec a little more than The PIC told the first officer to descend “and three hours before returning it to Bagby Airfield stay just a bit below” the glideslope. The report for an annual maintenance inspection. A fuel said that he likely expected that this would has- injector in the left engine was found blocked; ten their acquisition of the approach lights and all the fuel injectors were cleaned, and the fuel reduce the possibility of a go-around. system again was flushed. The helicopter was about 250 ft over the Winds were from 250 degrees at 5–8 kt when Waddenzee when the PIC noticed that airspeed the pilot arrived at the airfield to pick up the air- had decreased to 20 kt and the helicopter was plane on June 29, 2006. Bagby is an unlicensed descending rapidly. He applied full power and airfield with two grass runways. The main run- maximum aft collective. The descent was arrest- way, 06/24, is 710 m (2,330 ft) long, and Runway ed, but the S‑61 touched the water before it began 24 has a nearly 3-degree downslope. to climb. It then was landed at the airport without Witnesses saw smoke emerging from both en- further incident. The water contact had caused gines as the Aztec departed from Runway 24. The no damage, but the gearbox had been overloaded pilot radioed that the aircraft was not climbing during the recovery and required replacement. properly and then flew a tight pattern to return The report said that the failure of both pilots to for a landing on Runway 24. The aircraft touched promptly notice and correct the decreasing air- down hard and bounced several times before the speed and increasing descent rate likely was caused pilot conducted a go-around. The aircraft was by fatigue, neglect of standard operating procedures observed climbing slowly before it banked steeply and checklists, preoccupation with an autopilot left, stalled and spun to the ground. problem and lack of recent experience in the S‑61. “The examination of the engines revealed that two different types of corrosion debris had Tail Rotor Control Lost During Landing affected many of the fuel injector nozzles,” the Bell 206L-3. Substantial damage. Two minor injuries. report said. One of the fuel injectors on the left he news helicopter was engaged in filming engine was totally blocked, and those on the a rescue operation at 12,500 ft in mountain- right engine had flow rates reduced by 55 to Tous terrain near Taos, New Mexico, U.S., on 91 percent. The report said this indicated “that July 12, 2006. After circling an open landing area despite the cleaning and flushing of the fuel three times, the pilot attempted a run-on landing. system, not all of the corrosion debris had been The LongRanger began to yaw right about 30 ft removed from the system.” AGL, and the pilot was not able to correct the yaw, the NTSB report said. The helicopter struck HELICOPTERS the ground and rolled onto its left side. “The pilot reported that the wind was calm Water Contact During Go-Around and the temperature was approximately 70 de- Sikorsky S-61N. Minor damage. No injuries. grees F [21 degrees C],” the report said. “The pilot he helicopter was returning with 12 passen- stated that he did not complete any performance gers to Den Helder (Netherlands) Airport calculations prior to the flight.” NTSB said that Tfrom a North Sea platform on Nov. 30, the probable cause of the accident was loss of tail 2004. IMC prevailed at the airport, and visibility rotor effectiveness during the attempted landing was deteriorating in fog. The first officer, the in the high-density-altitude conditions. pilot flying, told the pilot-in-command (PIC) “When operating at high altitudes and high that he would conduct the instrument landing gross weight, tail rotor thrust may not be suffi- system (ILS) approach at 70 kt, rather than the cient to maintain directional control,” the report standard 100 kt, to provide “ample time to ob- said. “In these conditions, gross weight needs to serve everything,” said the report by the Dutch be reduced and/or operations need to be limited Safety Board. to lower density altitudes.” ● www.flightsafety.org | AEROSafetyWorld | March 2008 | 63 OnRecord Preliminary Reports Date Location Aircraft Type Aircraft Damage Injuries Jan. 2, 2008 Tehran, Iran Fokker 100 destroyed 59 none Snow was falling when the Fokker skidded off the runway during takeoff. Jan. 2, 2008 Masbate, Philippines NAMC YS-11A substantial 47 NA Winds were reported from 040 degrees at 10 kt, gusting to 14 kt, when the airplane overran Runway 21 on landing and struck a concrete fence. Jan. 3, 2008 Bahía Piña, Panama Britten-Norman Islander destroyed 2 serious The flight crew reported an engine problem before the Islander stalled and crashed on approach. Jan. 3, 2008 Deauville, France Boeing 737-400 minor 174 none The 737 ran off the runway during landing. Jan. 3, 2008 Oklahoma City Pilatus PC-12/45 none 1 fatal The pilot was shutting down the engine after landing with seven passengers when a line technician walked into the propeller and was killed. Jan. 4, 2008 Los Roques, Venezuela LET 410VP destroyed 14 fatal During descent, the pilot reported that both engines had failed. The airplane crashed while being ditched. Jan. 5, 2008 Kodiak, Alaska, U.S. Piper Chieftain substantial 6 fatal, 3 serious, 1 minor A passenger said that the baggage door opened during takeoff. The pilot lost control while attempting to return to the airport, and the Chieftain crashed into the ocean. Jan. 7, 2008 Bangkok, Thailand Boeing 747-400 none 334 none All four generator control units failed about 30 minutes after the 747 departed from Bangkok. The crew returned to the airport using standby power and instruments. Jan. 9, 2008 Detroit Airbus A319-100 substantial 73 none The no. 2 engine fan cowling separated during approach and struck the horizontal stabilizer. Engine maintenance had been performed before the flight. Jan. 11, 2008 Windhoek, Namibia Cessna 210M destroyed 6 fatal The airplane crashed in a residential area after losing power during takeoff for a charter flight. Jan. 14, 2008 Lihue, Hawaii, U.S. Beech 1900C destroyed 1 fatal The airplane crashed in the ocean during a night cargo flight to Lihue from Honolulu. Jan. 15, 2008 Port Saïd, Egypt Beech King Air C90B destroyed 2 fatal The King Air crashed on takeoff during a training flight. Jan. 16, 2008 Cleveland Beech 58 Baron substantial 1 fatal The Baron crashed in Lake Erie during takeoff from Burke Lakefront Airport for a positioning flight. Jan. 16, 2008 Tulsa, Oklahoma, U.S. Aero Commander 500B substantial 1 fatal The airplane was departing in night instrument meteorological conditions (IMC) for a cargo flight when the pilot reported gyro problems. The pilot lost control while attempting to return to the airport. Jan. 17, 2008 London Boeing 777-200ER substantial 2 minor, 191 none Both engines lost power and did not respond to throttle inputs during final approach. The 777 touched down in a grassy area short of the runway. Jan. 19, 2008 Huambo, Angola Beech Super King Air 200 destroyed 13 fatal The King Air crashed into a mountain during an approach in night IMC. Jan. 22, 2008 Ochopee, Florida, U.S. Robinson R44 substantial 2 fatal The helicopter was seen maneuvering erratically before it crashed during a training flight. Jan. 23, 2008 Miroslawiec, Poland CASA C-295M destroyed 20 fatal The Polish Air Force airplane crashed in a forest during final approach. Jan. 25, 2008 Pointe Noire, Congo Antonov An-12 destroyed 2 serious The Antonov struck a 727-200 after its brakes failed during taxi. Both airplanes reportedly were damaged beyond economic repair. Jan. 26, 2008 Malinau, Borneo CASA 212-200 destroyed 3 fatal The airplane crashed during a cargo flight from Tarakan to Long Apung, Indonesia. Jan. 26, 2008 Los Angeles Robinson R44 destroyed 1 fatal The helicopter struck power lines and crashed on a highway. Jan. 30, 2008 Sugapa, Indonesia de Havilland Canada DHC-6 substantial 1 fatal, 2 serious, 18 none The Twin Otter skidded off the runway while landing and struck several people, killing one and injuring two others. Jan. 31, 2008 West Palm Beach, Florida, U.S. Boeing 757 none NA The crew declared an emergency because of smoke in the cockpit and cabin. After landing, six occupants were transported to a hospital with unknown injuries. 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 | March 2008 22-24 April 2008 Rosen Shingle Creek Resort Orlando, Florida EARLY BIRD DISCOUNTS AVAILABLE Organised by: MEET THE BEST IN THE BUSINESS AT WATS 2008 the premier aviation training business forum WATS 2008 – the world’s biggest gathering of aviation training professionals – will address airline training requirements through the expertise of its presenters, exhibitors and delegates. Every major aircraft manufacturer will be on-site and some will be conducting workshops for new aircraft and emerging technologies. Close to 1000 delegates representing almost 100 air carriers will attend for a concentrated three days of training, networking and business. Tel. US: +1 (407) 322 5605 • RoW: +44 (0)1252 532000 • Email:[email protected] www.halldale.com/wats A Halldale Media Group Event SPON S ORED BY Corporate Flight Operational Quality Assurance C-FOQA A cost-effective way to measure and improve training, procedures and safety Using actual performance data to improve safety • Appropriate use of stabilized-approach procedures; by identifying: and • Ineffective or improper training; • Risks not previously recognized. • Inadequate SOPs; • Inappropriate published procedures; Likely reduces maintenance and repair costs. • Trends in approach and landing operations; Accomplishes a critical Safety Management System step For more information, contact: • Non-compliance with or divergence from SOPs; and assists in achieving IS-BAO compliance. Jim Burin Director of Technical Programs E-mail: [email protected] Tel: +1 703.739.6700, ext. 106