AeroSafety WORLD
NO RUNWAY TO SPARE Rejected takeoff considerations RUNWAY FRICTION Water’s role in excursions PRESSURE POINTS Continuing VFR into IMC
HAZARDS ACCOMPANY TAXIWAY PROJECTS OPEN FOR CONSTRUCTION
THE JOURNAL OF FLIGHT SAFETY FOUNDATION AUGUST 2013 MULTIPLE AVIATION INDUSTRY SEGMENTS. ONE MESSAGE: SAFETY.
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FSF13002m_HouseAd.indd 2 2/7/13 9:08 AM PRESIDENT’SMESSAGE
JETLINER ADVANCES BOOST Survivability
nyone seeing the pictures of the withstand 16 times the force of gravity, It appears that in this crash the pas- smoldering wreckage of Asiana immediately come to mind. sengers mainly exited through the four Flight 214 on a San Francisco After a terrible collision of two air- doors on the left side of the aircraft, runway [on July 6] and hearing liners on the ground in 1991 at Los showing the importance of paying atten- Athe terrifying passenger stories had to Angeles International that led to 34 tion to the cabin crew during the safety wonder how anyone could have survived. deaths by fire and smoke inhalation, briefing and following all instructions Yet only two passengers were killed of the the National Transportation Safety during an emergency. 307 people aboard. (Editor’s note: A third Board (NTSB) reiterated past recom- We take aviation safety for granted passenger died several days later.) mendations for fire resistant materials now, but accidents can still happen. Ap- We have seen a number of frightening in the cabin. proaches and landings rank in the top aviation incidents over the past few years The NTSB started calling for seats three areas of accidents worldwide. But as — such as Air France Flight 358 in 2008 that are designed to withstand a 16g we can see from this accident and others in Toronto, British Airways Flight 38 in impact in the 1970s after investigating like it, approach and landing accidents 2011 in London, and most recently Lion accidents where this was a major factor. are also very survivable. Air Flight 904 last April in Indonesia — in The normal and emergency exit doors We have no answers yet about Asiana which every passenger survived. on aircraft also have been made to operate 214. The NTSB has just started what will It’s not a miracle that passengers walk more easily and will spring out of the way be a thorough investigation. But one away from accidents such as these. Avia- to allow a faster escape. thing we can be certain of is that as the tion safety professionals, both in the indus- NTSB determines the actual cause and try and with the government, have worked Good record makes official suggestions to mitigate for decades not only to mitigate the risk The Boeing 777 was first put into service future risk, improving passenger surviv- of an accident, but also to make those in 1995 and has had a stellar safety re- ability will be a top priority.
accidents which occur more survivable. cord. It incorporates all of the technolog- (This column first appeared in USA Today and They have taken what has been ical advances that have been developed is reprinted here with permission.) learned from past accidents and worked over the years that were designed with closely with the aircraft manufactur- passenger survival in mind. ers to build into the design safety im- According to the Federal Aviation provements that will increase passenger Administration’s regulations, in order survivability. for an aircraft to be certified for flight, the manufacturer must show that all Safety Changes the passengers are able to evacuate Capt. Kevin L. Hiatt Fire-resistant materials in the cabin, in 90 seconds with half of the exits President and CEO along with seats that are designed to blocked. Flight Safety Foundation
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | AUGUST 2013 | 1 AeroSafetyWORLD
contents August 2013 Vol 8 Issue 7 features
12 CoverStory | Construction During Runway Operations 12 17 FlightOps | Continued Takeoffs 22 ThreatAnalysis | Runway Excursion Weather
26 AviationMedicine | Medically Related Diversions
31 SafetyRegulations | SMS Compliance Assessment
34 FlightOps | Upset Prevention Up Close 17 40 HelicopterSafety | VFR Into IMC Pressure Points departments
1 President’sMessage | Jetliner Advances Boost Survivability
5 EditorialPage | Be Prepared 22 7 SafetyCalendar | Industry Events
2 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | AUGUST 2013 34
26 40
AeroSafetyWORLD 8 InBrief | Safety News telephone: +1 703.739.6700
Capt. Kevin L. Hiatt, publisher, 44 DataLink | European Safety FSF president and CEO [email protected]
48 InfoScan | Canadian Year in Review Frank Jackman, editor-in-chief, FSF director of publications [email protected], ext. 116 51 OnRecord | Bird Scare Leads to Overrun Wayne Rosenkrans, senior editor [email protected], ext. 115
Linda Werfelman, senior editor [email protected], ext. 122
Rick Darby, contributing editor [email protected]
Mark Lacagnina, contributing editor
Jennifer Moore, art director [email protected] About the Cover Openness to best practices enhanced safety during Paris Charles de Gaulle Airport construction. Susan D. Reed, production specialist [email protected], ext. 123
© Aéroports de Paris S.A. Editorial Advisory Board
David North, EAB chairman, consultant We Encourage Reprints (For permissions, go to
| | FLIGHTSAFETY.ORG AEROSAFETYWORLD AUGUST 2013 | 3 ARGUS PROS Your IOSA Experts
ARGUS PROS is the leading audit organization for air carriers around the world. As a founding member and participant in the design and development of the IOSA program in 2002, ARGUS PROS has more on-site experience than any other certified IOSA auditing organization. Thinking about IOSA? Think ARGUS PROS. • Truly independent, not affiliated with any airline • Over 10 years of IOSA auditing experience • Over 400 IOSA’s performed worldwide • Authorized IOSA Auditor Training (IAT) provider
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BE Prepared
xpect the unexpected. Plan for the worst. Be parameters,” the report said, adding that the man- prepared. These are all variations on a theme agement of tasks during the approach deteriorated running through much of the material that very quickly. In other words, he was distracted by has crossed my desk recently. the unexpected. EIn last month’s AeroSafety World (ASW), Mark In “Continued Takeoffs” in this issue of ASW Lacagnina’s cover story examined the May 2010 (p. 17), Wayne Rosenkrans writes about takeoff crash of an Afriqiyah Airways Airbus A330-200 risk factors and runway excursions. In his ar- while on approach to Tripoli, Libya, the airline’s ticle, he quotes from a training aid published home base, on a flight from Johannesburg, South a few years ago by the U.S. Federal Aviation Africa. All but one of the 104 passengers and crew Administration that says, “The infrequency of died as a result of the accident. [rejected takeoff events] may lead to compla- In its report on the accident, the Libyan Civil cency about maintaining sharp decision-making Aviation Authority (CAA) said the crew con- skills and procedural effectiveness. … In spite ducted an approach briefing that covered some of the equipment reliability, every pilot must be details, but that other “essential points” were not prepared to make the correct go/no go decision discussed. “The fact that the approach briefing on every takeoff — just in case. … For optimum was incomplete indicates that … the crew did crew effectiveness, [pilots] should share a com- not anticipate any special difficulty in the con- mon perception — a mental image — of what is duct and management of the approach,” the CAA happening and what is planned [based on] com- report said. munications, situational awareness, workload As with most accidents, there were numer- distribution, cross-checking and monitoring” ous causal and contributing factors. The report (emphasis added). says the copilot may have inadvertently entered In other words, know your options before the incorrect data into the flight management system, unexpected happens so you are better prepared causing the aircraft to begin its descent too early. when it does. Hesitation in taking corrective action was cited, as were possible fatigue and spatial disorienta- tion. But what struck me was that a report of fog from another flight crew likely surprised the crew and “led the captain to focus his attention on the Frank Jackman outside to acquire visual reference points, rather Editor-in-Chief than on coordinating and monitoring the flight AeroSafety World
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | AUGUST 2013 | 5 Serving Aviation Safety Interests for More Than 65 Years OFFICERS AND STAFF ince 1947, Flight Safety Foundation has helped save lives around the world. The Chairman Board of Governors David McMillan Foundation is an international non-profit organization whose sole purpose is to President and CEO Capt. Kevin L. Hiatt Sprovide impartial, independent, expert safety guidance and resources for the General Counsel aviation and aerospace industry. The Foundation is in a unique position to identify and Secretary Kenneth P. Quinn, Esq. global safety issues, set priorities and serve as a catalyst to address the issues through Treasurer David J. Barger data collection and information sharing, education, advocacy and communications. The
ADMINISTRATIVE Foundation’s effectiveness in bridging cultural and political differences in the common Manager of cause of safety has earned worldwide respect. Today, membership includes more than Support Services and 1,000 organizations and individuals in 150 countries. Executive Assistant Stephanie Mack FINANCIAL MemberGuide Financial Operations Manager Jaime Northington Flight Safety Foundation 801 N. Fairfax St., Suite 400, Alexandria VA 22314-1774 USA tel +1 703.739.6700 fax +1 703.739.6708 flightsafety.org MEMBERSHIP AND BUSINESS DEVELOPMENT Member enrollment ext. 102 Senior Director of Ahlam Wahdan, membership services coordinator [email protected] Membership and Seminar registration ext. 101 Business Development Susan M. Lausch Namratha Apparao, seminar and exhibit coordinator [email protected] Director of Events Seminar sponsorships/Exhibitor opportunities ext. 105 and Seminars Kelcey Mitchell Kelcey Mitchell, director of events and seminars [email protected] Seminar and Donations/Endowments ext. 112 Exhibit Coordinator Namratha Apparao Susan M. Lausch, senior director of membership and development [email protected] Membership FSF awards programs ext. 105 Services Coordinator Ahlam Wahdan Kelcey Mitchell, director of events and seminars [email protected] Consultant, Student Technical product orders ext. 101 Chapters and Projects Caren Waddell Namratha Apparao, seminar and exhibit coordinator [email protected] Seminar proceedings ext. 101 COMMUNICATIONS Namratha Apparao, seminar and exhibit coordinator [email protected] Director of Website ext. 126 Communications Emily McGee Emily McGee, director of communications [email protected] Basic Aviation Risk Standard GLOBAL PROGRAMS Greg Marshall, BARS managing director [email protected] BARS Program Office: Level 6, 278 Collins Street, Melbourne, Victoria 3000 Australia Director of Global Programs Rudy Quevedo tel +61 1300.557.162 fax +61 1300.557.182 Foundation Fellow James M. Burin
BASIC AVIATION RISK STANDARD BARS Managing Director Greg Marshall
facebook.com/flightsafetyfoundation Past President William R. Voss @flightsafety Founder Jerome Lederer 1902–2004 www.linkedin.com/groups?gid=1804478
FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | AUGUST 2013 ➤ SAFETYCALENDAR
JULY 29–AUG. 2 ➤ Fire and Explosion OCT. 10 ➤ ACAS Monitoring Dissemination OCT. 29–31 ➤ 66th International Air Safety Investigation. Southern California Safety Institute. Workshop (SESAR Project 15.04.03). Summit. Flight Safety Foundation. Washington, San Pedro, California, U.S. Denise Davalloo,
SEPT. 29–OCT. 1 ➤ SMS/QA Symposium. DTI OCT. 22–24 ➤ 2013 NBAA Business Aviation Be sure to include a phone number and/ Training Consortium. Disney World, Florida, U.S. Convention & Exhibition. National Business or an email address for readers to contact
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | AUGUST 2013 | 7 INBRIEF Safety News Asiana Crash
n Asiana Airlines Boeing 777- 200 crashed short of the landing Arunway at San Francisco Interna- tional Airport after a flight from Seoul, South Korea. Three of the 307 people in the airplane were killed and dozens were injured in the July 6 accident, and the airplane was destroyed. The U.S. National Transportation Safety Board’s (NTSB’s) investigation of the accident was continuing. Preliminary NTSB findings noted that, in the seconds before the air- plane struck a sea wall just short of the runway, its airspeed dropped to about 30 kt below the target threshold speed of 137 kt. The airplane was being flown by an experienced 747 pilot undergoing © Eugene Anthony Rah/Reuters initial operating experience in the 777, under the supervision of an instructor pilot who was conducting his first trip in that capacity, the NTSB said. It was the first accident involving an airliner in the United States since Feb. 12, 2009, when a Colgan Air Bombardier Q400 crashed during approach to Buffalo Niagara (New York, U.S.) International Airport, killing all 49 people in the airplane and one person on the ground (ASW, 3/10, p. 20). It also was the first crash of a major airline’s aircraft in the United States since Nov. 12, 2001, when an American Airlines Airbus A300 crashed after takeoff from Kennedy International Airport in New York, killing all 260 people in the airplane and five people on the ground.
Separation Standards
iting five recent incidents in which air carrier aircraft the intersection, passed the intersection or has crossed over on go-arounds came dangerously close to other landing the departure runway.” Cor departing aircraft, the U.S. National Transportation Requirements also call for timed separation intervals Safety Board (NTSB) recommended new requirements to behind heavy aircraft. ensure safe aircraft separation. “However … there is no requirement for controllers to The NTSB said, in a safety recommendation letter to provide the same protections for the potential go-around the U.S. Federal Aviation Administration (FAA), that it flight path of a landing aircraft even though, in the event was “concerned that existing FAA separation standards and of a go-around, the arriving aircraft effectively becomes a operating procedures are inadequate to prevent such events departure. … There appears to be no safety justification for and need to be revised.” treating the situations differently,” the NTSB said. The FAA should establish new separation standards In the five incidents cited by the NTSB, the “nature of similar to those governing aircraft departing from intersect- the geometry of the encounters and the unexpected nature ing runways or on intersecting flight paths, the NTSB said. of the go-arounds” made it impossible for controllers to pro- FAA requirements specify that air traffic controllers vide effective instructions to the pilots to ensure that the air- must separate aircraft that depart from intersecting runways craft would avoid each other. Instead, the pilots performed or on intersecting flight paths “by ensuring that the depar- “impromptu evasive maneuvers … during critical phases of ture does not begin takeoff roll until … the preceding air- flight,” the NTSB said. craft has departed and passed the intersection, has crossed Four of the five incidents cited occurred between April the departure runway or is turning to avert any conflict [or] and July 2012; the fifth occurred in January 2006. No inju- a preceding arriving aircraft is clear of the landing runway, ries were reported in any of the incidents, and none of the completed the landing roll and will hold short of airplanes was damaged.
8 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | AUGUST 2013 INBRIEF
Runway Safety Campaign Investigating the Investigators
he Civil Air Navigation Services Organisation (CANSO) ustralian lawmakers, challenging the Australian has begun a new campaign — focusing on airport per- Transport Safety Bureau’s (ATSB’s) conclusion that Tsonnel and air navigation service providers (ANSPs) — Athe Nov. 18, to improve runway safety by reducing unstable approaches. 2009, ditching of an The campaign offers runway safety checklists for airports emergency medi- and ANSPs, and recommendations for pilots and air traffic cal services flight controllers. The Runway Safety Maturity Checklist — intend- resulted primarily ed for use by ANSPs, airlines, airport operators, regulators from the pilot’s ac- and aeronautical telecommunication and radio navigation tions, has asked the providers — is designed to help “benchmark their levels ATSB to re-open its of maturity with regard to managing runway safety risks,” investigation. CANSO said. “The checklist identifies key elements of risk The Australian control and uses a series of questions to assess the maturity of Senate’s Rural and an organization against each element.” Regional Affairs CANSO cited data from the International Air Transport and Transport Association that showed that an unstable approach was cited References Com- as a contributing factor in 17 percent of accidents between mittee said, in a 2008 and 2012. report released “Air traffic control plays an important role in contribut- in May, that the ing to safe, stable approaches and reducing the risk of runway ATSB has defend- excursions,” said CANSO Director General Jeff Poole. “This ed its conclusions includes ensuring that controllers appreciate what is re- “without … a solid evidentiary base.” quired for a pilot to achieve a stabilized approach, issuing The report added, “The ATSB repeatedly deflected sug- proper clearances and providing timely and accurate weather gestions that significant deficiencies with both the operator information.” [Pel-Air], … and CASA’s [the Civil Aviation Safety Author- An earlier campaign to promote runway safety — the ity’s] oversight of Pel-Air … contributed to the accident. The Runway Safety Initiative, involving about 20 organizations in committee takes a different view and believes that ATSB the worldwide aviation community and coordinated by Flight processes have become deficient.” Safety Foundation — produced sets of countermeasures to ad- The crew of the Israel Aircraft Industries Westwind dress veer-offs and overruns and emphasized the importance 1124A ditched the airplane off Norfolk Island — where they of stabilized approaches. The Runway Safety Initiative’s final had planned a refueling stop during their trip from Apia, report, Reducing the Risk of Runway Excursions, was released Samoa, to Melbourne, Australia — rather than risk a flame- in 2009 (see “Continued Takeoffs,” p. 17). out while attempting another approach in darkness and deteriorating weather. All six occupants survived the impact and escaped from the Westwind before it sank (ASW, 10/12, p. 38). The Senate committee said in its report that members were “surprised by the [ATSB’s] near-exclusive focus on the actions of the pilot and lack of analysis or detail of factors that would assist the wider aviation industry” and “troubled by allegations that agencies whose role it is to protect and enhance aviation safety were acting in ways which could compromise that safety.” The report also said that the committee had “strong concerns about the methodology the ATSB uses to attribute risk.” That methodology “appears to defy common sense by not asking whether the many issues that were presented to the committee in evidence but not included in the report” could add to understanding of the crew’s actions, offer lessons for the aviation industry and help prevent a similar incident in the future. Aero Club/Wikimedia Commons
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | AUGUST 2013 | 9 INBRIEF
EC225 Repairs
he European Aviation Safety Agency (EASA), citing the 2012 ditching of two Eurocopter EC225 Super Pumas in the North Sea, has issued an Tairworthiness directive (AD) calling for action to prevent failures of the main gear box (MGB) bevel gear vertical shaft. AD 2013-0138-E describes what the EASA calls “a set of modifications and inspections which aim at monitoring and detecting vertical shaft crack conditions and reducing the likelihood of any shaft crack initiation.”
The new AD follows an emergency AD issued in November 2012 in calflier001/Wikimedia Commons response to a May 2012 ditching that occurred after a warning indication of a loss of MGB oil pressure and an additional alarm indicating problems with the MGB emergency lubrication system. Subsequent inspections revealed a crack in the lower vertical shaft of the MGB bevel gear; the crack caused the vertical shaft to stop driving the main oil pump and its backup, the EASA said. The crack was traced to “an oxidation pit found in the chamber of the vertical shaft welding stop hole,” the EASA said.
Capacity Problems Flight Training Proposals
n increasing number of European airports will be operating pplicants for an air transport pilot license or a at or near capacity by 2035, causing not only an increase position as a pilot in multi-crew operations would Ain delays but also an inability to accommodate 1.9 million Abe required to complete training in “multi-crew flights — 12 percent of total demand, Eurocontrol says. cooperation,” according to a proposed change in Austra- In its fourth Challenges of Growth study, Eurocontrol said lia’s Civil Aviation Safety Regulations. that, under the most likely scenario, more than 20 European The Civil Aviation Safety Authority (CASA) includ- airports would be operating at 80 percent or more of capacity for ed the new requirement in its proposed revision of Part at least six hours a day in 2035. In comparison, three airports fell 61 standards for flight crew licensing, which specify the into that category in 2012. flight training and knowledge required for all licenses, The study ratings and endorsements. Proficiency checks for ratings suggested and English language proficiency requirements also are several steps to included. ease the prob- CASA says that, in addition to the proposed multi- lem, including crew cooperation training, the draft calls for two other adjusting flight significant changes in existing requirements. One change schedules, con- would require flight tests as a prerequisite for an air struction of new transport pilot license, low-level rating or night vision runways and imaging system rating. The other change would require other infrastruc- pilots seeking a private or commercial pilot license with a ture, and the helicopter rating to complete basic instrument training. increased use of CASA planned to accept comments on the proposals larger airplanes. until Aug. 2 and to issue final regulations late this year. Jnpet/Wikimedia Commons
In Other News …
The European Commission (EC) is proposing to extend until 2024 the mandate of the Single European Sky Air Traffic Management Research (SESAR) Joint Undertaking — a move the EC says is intended to demonstrate its commitment to the Single European Sky project. … The U.K. Civil Aviation Authority has begun reviewing fire protection at helicopter landing sites to determine whether current requirements are appropriate and to harmonize requirements aimed at airports, temporary helicopter landing ar- eas, offshore helidecks and hospital landing sites. CAA Chief Executive Andrew Haines says the goal is “to assess all potential risks and take account of the availability of new technology for detecting and controlling fires.”
Compiled and edited by Linda Werfelman.
10 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | AUGUST 2013 ©2011 Oshkosh Corporation. Oshkosh, the Oshkosh logo, Striker and the Striker logo are registered trademarks of Oshkosh Corporation, Oshkosh WI, USA.
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Safety risk management and a collaborative approach mitigate the risks.
BY GAËL LE BRIS
onstruction projects in an airport required balancing safety standards, compliance movement area introduce numerous with certification specifications, preservation of hazards and complexities, as illustrated the operational robustness, and limiting con- by a case study at Paris Charles de straints on the construction project. CGaulle Airport (CDG). To increase the safety and capacity of strategic Safety and Performance Challenges taxiways crossing the southwest part of the air- Due to the size of the project and the nature of side, more than 7.0 acres (2.8 hectares) of pave- the construction, it was not realistic to complete ment are being reconstructed at CDG through a the work at night with the runway closed. Only four-year, six-phase program that started in 2010. two options were available: closing Runway The project included modifying the design of the 08L/26R during the entire Phase 2, or operating entrance taxiways of Runway 08L (THR08) along the runway with a displaced threshold to make the runway more than 2,400 ft (732 m) from the available a sufficient area to perform a large threshold. This operation was undertaken from majority of the work, especially stages that can- April to June 2012 in a unique phase (called not conveniently be interrupted (e.g., pouring THR08 Reconstruction Program Phase 2), which concrete with slip forms).
12 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | AUGUST 2013 © Aéroports de Paris S.A. national Aviation Civil Organization (ICAO), management support, prime the contractor control air the ed traffic tower (ATCT), project before construction. the The work group includ- acomplexeffect and modification. critical (SRM), for Phase which 2was an opportunity to a mature process of safety risk management and airside the 2, CDG community developed sixyears the During preceding THR08Phase on safety of any change operations. to airport regulation necessitates assessing impacts the mandatory inFrance in2008.The related SMS safety management systems (SMS) became Following recommendations the of Inter the Analysis Formal Risk runways system. cantly operational the degrade robustness of the cated to takeoffs. closure of one of two the long runways- dedi departures was not compatible with alengthy al andal safety requirements. Runway 08L/26R—could operation both meet - emergency return just after takeoff. many airliners crews flight requested iftheir an (2,700-m) outer runways would short too for be weight. And finally, two the remaining 8,860-ft not able be to off take at required their takeoff addition, heaviest the long-haul would flights than required to accommodate daily In flights. capacityairfield would dramatically be lower on (4,200-m)runway, second the 13,780-ft the tion of averification program for safety assurance. definition of an implementation plan, and prepara- determination of appropriate mitigation measures, and risks, assessment of risks’ the acceptability, into five main steps: identification of hazards human into factors process. the expertise creation of aPilots-for-SRM Pool that brought operator. Airlines were involved later, with the tions and Facilities Department of airport the and different of activities - Airside the Opera FLIGHTSAFETY.ORG The formal SRM of Phase one 2started year Moreover, a24/7closure- would signifi The large number of airplane arrivals and So only secondSo the option —ashortened A comprehensive SRM airport divided can be |
WORLD AEROSAFETY 1 Indeed, of incase any incident | AUGUST 2013 3 -
2
edge of Taxiway parallel the Tango northward. Runwaysouthern the 26Rwestward,to and an area at risk that beyond runs RESAof the data from two runway these excursions revealed runway protections at The addition CDG. of the instrumentthe landing system (ILS)Category I a lateral excursion 747-200beyond by a Boeing RESA. The of second, in2000,was trajectory the 2005 that stopped beyond a hypothetical ICAO at Toronto Pearson International in Airport a longitudinal overrun of an Airbus A340-600 tworevealed extreme trajectories. The first was sions after landing or after takeoff arejected of was Ahistory assessed. RESAalso excur the available. runway that offtake believing full the is could sibility must considered be that any crew flight low overflew fences. the Therefore,- pos the separator delineating runway the end and then off from Runway with plastic 27L,collided the runwaytakeoff available (TORA), took they crewflight to into take account shortened the rated from construction the area by blast fences. remaining available length of runway the - was sepa (1,234 m)to allow for resurfacing. The apartial 09R was temporarily displaced by 4,050ft threshold the 2008 at when for CDG, Runway events during used risk analysis the in occurred protectedthe approach slopes. One of key the (RESA) and of construction activity penetrating after overrunning runway the end safety area aircraft colliding with construction equipment for Phase 2comprises addressing risks of the an reducing most the risks. critical for inputs from other to in succeed airports explain,we will it often is also relevant to search (e.g., air transportation safety organizations). As other accessible resources like databases external risk manager missing inthe has to data fill using commonbe onlyto years seven ago. safety the So a couple of years, practice started this because recordsthese usually donot date back more than about safety on events all airfield, the occurring The possibility of an aircraft overrunning of failure the Because 737-800 of aBoeing of riskAn mitigation overview performed If SMS the acquires and archives information COVERSTORY - |
13 14 | COVERSTORY and might include only of afew types accidents, events are, fortunately, rare at asingle airport for more-critical events. Indeed, catastrophic to assessused minor are risks, they inadequate dents worldwide. records Although local can be informationlected about incidents and acci- April 2011, safety personnel at have CDG col- studythe of safety events outside Since of CDG. signage as areminder of shortened the TORA. R1 with prefix the “WORKS” and installation of publication designation (AIP),the of Taxiway forced by an illustrated aeronautical information TORA. Pilots’ situational awareness was rein- first one (Taxiway offered R1),which longest the entries to Runway 26Rwere except closed the crews.flight For taxiway the that all purpose, larly miscommunication of information to the sible accident and incident precursors,- particu situationgency necessitated alanding). moved beyond Taxiway Tango an (incase emer until workers the and mobile machines were suspension of landings on Runway 08L/26R it when was operational, section) closed the and and human activity on runway the (including end of Runwayrary banning of 26R, obstacles tation of (240-m)RESAat a787-ft tempo the - analysis for risk were critical this implemen the - As noted, risk analysis the from benefited In addition, aprevention plan mitigated- pos Finally, resulting the countermeasures of the - decision-making (CDM) standards implementation of collaborative airport the risks wethe faced. of interactions these and develop responses to how we could improve quality the and efficiency interact. helped This us effort to also understand and practices to understand how we work and morelook closely into eachother’s procedures operational performance. together to ensure highest the level of safety and es as a strength, and having working partners all to need reachthe consensus, using differenc the complexity of Phase 2made more challenging organizational cultures and points of view. The with opposite interests and often with different a large number of stakeholders, sometimes The THR08Reconstruction Program involved The Collaborative Approach precursors that have we might otherwise missed. proach allowed us to risks and identify easily were integrated into risk analysis. the This ap- than 200events were considered, and adozen ate abenchmark study. case For Phase 2,more requiring addition the of exogenous to cre cases - ment, taught which entities all to share inthe productivity practices inairport best manage- ATCT, operator airport the and airlines, the and All ofAll preceding the was facilitated by the requiredPhase 2also stakeholders the to FLIGHT FOUNDATION SAFETY |
WORLD AEROSAFETY 4 between the the between | AUGUST 2013 -
© Aéroports de Paris S.A. COVERSTORY
decisions. Phase 2 also was an opportunity to to the outer runway through lighted corridors bring the project management support and the across Runway 08L/26R, preventing the align- prime contractor more into the SMS. Their direct ment of an aircraft on the wrong runway. To involvement in SRM meetings enhanced their reinforce the visual information, plans were put comprehension of the safety objectives, and of in place for extra lighted crosses after the last our goals and constraints for the project. Today, corridor. This procedure was not activated at the these stakeholders even propose mitigation time, but we use it now as a standard risk miti- measures. gation for prolonged inner runway closures.
Operations Management Limits of Aeronautical Information At CDG, the Airside Control Center (PCR) is The airport operator and the ATCT made con- responsible for monitoring operations on the siderable efforts to communicate to the flight movement area, and for overseeing the tem- crews, going beyond the regulatory require- porary operational changes. So the PCR is the ments. An AIP supplement including temporary key to real-time safety assurance, performing ground movement control maps was published inspections of the construction area activities. and then activated by a notice to airmen. Pilot During Phase 2, the airside operations special- briefings were performed and a reminder was
The construction ists faced an exceptional number of mitigation included on the automatic terminal informa- area at CDG was measures to be verified. In addition, they had tion service messages. Complementary materials entirely closed, to monitor other major projects, including the were provided on the website portal of CDG’s with particular extension of the centralized deicing facilities airport operations community. Finally, a special attention paid to and the completion of a new concourse. This controller-pilot phraseology was used from runway interfaces. situation required a briefing of the staff on duty, preflight to takeoff alignment. All paved accesses and the addition of special supplements to the Despite these measures, the Safety Assess- were indicated certification deviations inspection sheet. ment of Foreign Aircraft inspections by the by a continuous During the nights when the installation and national Civil Aviation Safety Directorate line of frangible deconstruction of Phase 2 occurred, the PCR found that more than a fourth of the flight plastic separators. staffing was doubled, with one team dedicated crews inspected did not have the information to the usual duties and a second one dedicated provided by the AIP supplement around the to Phase 2. This was overseen by the activation first day of the threshold displacement. The of the CDM Command Center (or CDM Cell) controllers stopped three incursions on Run- in which the airport operator, the ATCT and way 26R via the closed-entry taxiways, despite the airlines decided together how to manage the having cleared the aircraft crews involved for irregular operations and adverse conditions. R1 WORKS. The risk awareness of the controllers was “Plan B” increased by special briefings and a local tempo- “Plan B” contingency actions were defined to rary operational order. However, these incidents guarantee the operational robustness of the run- revealed that the regular aeronautical informa- way during the work. For instance, the risk that tion alone, as defined by international standards the reduced-length Runway 08L/26R would not and national or regional regulations, is not suffi- be reopened on time was anticipated through a cient to guarantee correct and effective diffusion recovery procedure based on the shorter parallel from the airport operator to the cockpit. Runway 08R/26L. Recalling the 747-400 takeoff collision with Beyond Phase 2 construction barriers and equipment at Chiang Phase 2 of the TH08 Reconstruction Program Kai-Shek International Airport, Taiwan, in 2000, demonstrated the force of formal SRM as the procedure called for the aircraft to proceed the main tool in managing airside changes
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | AUGUST 2013 | 15 16 | COVERSTORY at CDG. Program Phase 2 Reconstruction during THR08 closed taxiways 08L/26R with shortened Runway Temporarily RWY 26Rlandinglimit RWY DTHR08L RWY 26Rtakeo limit RWY For we developed collaborations purpose, this adding exogenous events to risk analysis. the communitypractices inside airport the and exchanging and management experiences best movementmodified area. was followed by amultiple-party approval of the andbeginning end the of construction. the It ATCTthe acceptance inthe inspections at the One simple, CDM efficient action was involving derstanding for of each participant. difficulties informationthe sharing and reciprocal the un- among stakeholders the significantly facilitated sive action plans). and risk mitigation (coherent and comprehen - (complementary of approaches) both aspects ing (no redundancies), hazards identification Phase 2,created valuable synergies sav intime - ATCT’s risk analysis, at determined after CDG insufficiency. is not updated after asafety event reveals an cannot deployed be and or verified, plan ifthis Indeed, arisk mitigation plan is useless ifit and operations. the theory the loop between conduct their study ina continual feedback of risk mitigation, safety risk managers may pragmatic way. To achieve intended the level groundthe and inaproactive designed and ment. This process was inspired by reality on as amajor tool of project airport manageand - Finally, Phase relevance 2highlighted the of For project management, CDM the spirit The merger of operator’s airport the and For departures For arrivals Taxiways notavailable 26R for lineuponRWY Areas closed 5. priority of our industry. — proof, that ifneeded, safety is common the 4. 3. 2. 1. Notes tion with the North American airport community. department, with aspecial focus on establishing collabora- activity of economic and technical benchmarking for his de Paris at He CDG. safety is risk manager and leads the Gaël airside Bris Le is development manager for Aéroports es spontaneously appeared at airports both that infacing same the hazards, similar respons- International In Airport. particular, we agreed shortened runways at and Chicago CDG O’Hare sons from learned operations on temporarily (ACAC), with whom we compared les- the Advisory Construction Council of Airport the North America. with other and airports institutions, in especially
port CDMport Implementation Manual of Eurocontrol. 2012. For details about further A-CDM, Air the see sion Making (A-CDM) certification by Eurocontrol in ized throughized two divisions of parent the company. plexes of two runways. parallel Rosenkrans, Wayne.Rosenkrans, 2005. Design and Operations, Chapter 9.3.November AeroSafety World Volume 7(July 2012),pp. 16–19. CDG was granted CollaborativeCDG Airport the Deci At Aéroports deParis, functions are these internal ICAO. Amendment of Annex 14,Volume 1, has two independentCDG northand south com We met in2012with Jim Krieger, chairman FLIGHT FOUNDATION SAFETY RWY =runwayRWY “ What’s on Your Runway?” |
WORLD AEROSAFETY | AUGUST 2013 Airport Airport 5
- - - -
© Aéroports de Paris S.A. © Danijel Jovanovic/AirTeamImages.com A 2013 by accident investigation boards. cording reports issued to final the inearly aware of non-normal circumstances, ac- tinue suddenly after takeoffs became they FLIGHTSAFETY.ORG FLIGHTSAFETY.ORG every pilot mustevery prepared be to make “In spite of equipment the reliability, FAA Takeoff Safety Training Aid says. andskills procedural effectiveness,” the maintaining sharp decision making may to lead complacency about of (RTO) takeoff rejected events. Aviation Administration (FAA) analysis siderations,” p. 18),such as U.S. Federal “Guidance Takeoff on Rejected - Con emphasized by safety (see specialists nant risks and causal factors previously outside some generic lists of predomi- In circumstances exact the eachcase, fell “The infrequency of infrequency RTO“The events the flight crews’ flight the decisions to con- commercial had incommon jet incident involving alarge serious business accident jet and a | AEROSAFETY BY WAYNE ROSENKRANS WORLD WORLD | AUGUST 2013 AUGUST 1,2
Airways Boeing 737-800on Runway Boeing Airways lot during flying of takeoff the a Qantas In Australia, was pi the first officer the - Tailwind Incident ference success between and disaster.” andtakeoff RTO can often mean dif- the regarding anon-normal situation during communication,ingful however brief, before–engine review. start) …Mean- appropriatebe for before-takeoff (or control are examples of what might configuration warning or transfer of of actions for ablown tire, high-speed checking and monitoring. …Areview awareness, workload distribution, cross- on] communications,[based situational what is happening and what is planned of — perception —amental image [pilots]ness,should share a common —justtakeoff incase. correctthe go/no go decision on every “For optimum crew- effective speeds monitoring. 4,2012.The captainDec. was pilot the atoccurred about on time 1618local injuries were reported event the when Noas 2,163m(7,096ft). damage or Perth Runway Airport 06/24length Airservices Australia sheet lists fact the of distance takeoff the required. An from priorexpected calculation runway without margin the of safety to become airborne near end the of the to atailwind that caused airplane the direction suddenly and changed speed wind the Latelia. run, takeoff inthe 06 at Perth Western Airport, Austra- the navigationthe display was showing a captain noticed that wind vector the on Transporttralian Safety Bureau. “The seconds,” said report the by Aus the - not increasing start again for several airspeed stoppedthe increasing and did Two flightcrews suddenlyhad “Approaching reference takeoff the little ornorunwaytospare. 3 of V of 1 and V and R [rotation speed], FLIGHTOPS |
17 FLIGHTOPS
tailwind of about 20–25 kt. The captain told investigators that windsock 2 also anemometer experienced a significant disconnected the auto-throttle and had indicated a headwind component. wind change at 1618 that would have ‘fire-walled’ the thrust levers [selected Neither pilot was able to observe any of resulted in tailwind conditions at least maximum thrust]. the airport’s three windsocks from the near the northern part of Runway 06,” “During the initial climb, the Runway 06 threshold (Figure 1, p. 19). the report said. Investigators’ computa- first officer performed a wind shear The temperature was 37 degrees tions showed that the crew otherwise escape manoeuvre. … Just after the C (99 degrees F), and visual meteo- should have been able to safely conduct aircraft became airborne, the wind rological conditions prevailed. “The a takeoff on Runway 06. was recorded at 282 (degrees true) and 25 kt. No wind shear warnings were Guidance on Rejected Takeoff Considerations recorded. Recorded latitude, longitude and radio altitude data showed that the light Safety Foundation, as coordinator, and the International Air Transport aircraft passed over the end of Runway Association published in July 2009 the findings and recommendations of 06 (threshold of Runway 24) at a height the Runway Safety Initiative (ASW, 8/08, p. 12) based partly on excursion F 1 of about 10 ft above ground level. … data from 1995 through March 2008. Only about one-fourth as many excur- As the performance calculations had sions occurred during takeoff — 63 percent of them overruns — as occurred assumed nil [zero] wind for takeoff, the during landing. Turboprops accounted for 41 percent of these takeoff excur- aircraft failed to achieve the predicted sions, jet transports for 36 percent, business jets for 17 percent and other fleets for 6 percent. The most common risk factor in takeoff excursions was a rejected takeoff performance.” takeoff (RTO) initiated at a speed greater than V1 (see definition in “Continued Analysis of quick access recorder Takeoffs,” Note 3, p. 21). Loss of directional control by the pilot was the next data for the flight “showed that the most common risk factor, followed by rejecting the takeoff before V1. airspeed stagnated at 134 kt for 3-4 Other takeoff risk factors ranked as significant by the initiative were: The flight crew fails to consider rejecting the takeoff; the crew performs an RTO seconds just below the V1 speed of 137 kt, the auto-throttle was disconnected with inadequate time to avoid a veer-off; premature rotation occurs (that is, prior to reaching V ); rotation is not attempted; no rotation occurs because V is and maximum thrust was set.” R R not reached; the pilot is unable to rotate the airplane; rotation occurs above VR; Investigators determined that at piloting technique fails to counteract crosswind; the flight crew fails to comply the time of the takeoff, cumulonimbus with standard operating procedures; improper checklist use occurs; the pilot- cloud activity was present about 20–30 in-command fails in supervision of the first officer; a failure of crew resource nm [37–56 km] north of the airport, management occurs; the aircraft weight calculation is incorrect; sudden engine and also found there were “no indica- power loss occurs; degraded engine performance occurs; tire failure occurs; and/or thrust asymmetry occurs. tions of an impending wind change Earlier insights about when and how to safely conduct RTOs were based on before takeoff.” The flight crew during data from airline operations compiled by the U.S. Federal Aviation Administra- climb advised air traffic control (ATC) tion (FAA).2 For the period 1959–2003, the FAA’s estimates from the available about the tailwind component that they data were that 143,000 RTOs occurred in worldwide airline operations — 6,000 had seen displayed. “Takeoffs were then a year — and that in 97 cases, or about four per year, the outcome was an ac- temporarily suspended from Runway cident or incident. The conclusion was that RTOs were uncommon, with typical operations resulting in one RTO per 3,000 takeoffs and one runway overrun 06 and aircraft departed using Runway accident or incident during takeoff per 4.5 million takeoffs. 03,” the report said. — WR The flight crew had monitored the current automatic terminal informa- Notes:
tion service message, issued about five 1. Flight Safety Foundation. “Reducing the Risk of Runway Excursions: Report of the minutes before lineup for takeoff. It re- Runway Safety Initiative.” May 2009. ported wind from 060 degrees magnet- 2. FAA. “Pilot Guide to Takeoff Safety.” Section 2, Takeoff Safety Training Aid, 1994 ic at 8 kt — that is, a direct headwind. (last update February 2008). The other sections include “Takeoff Safety Overview Before lining up for takeoff, the captain for Management,” “Example Takeoff Safety Training Program,” “Takeoff Safety observed that windsock 1 indicated a Background Data” and an optional video. headwind component. The first officer
18 | FLIGHTFLIGHT SAFETY SAFETY FOUNDATION FOUNDATION || AEROSAFETYAEROSAFETYWORLD || AUGUSTAUGUST 2013 FLIGHTOPS
A reactive wind shear–detection Sudden Tailwind During Takeoff Run system, incorporated in the 737’s ground-proximity warning system, began at rotation to detect whether it was actually experiencing wind shear. A predictive wind shear–detection system, incorporated in the airplane’s weather radar system, began scanning when the thrust levers were set for takeoff. “New warnings were inhibited after the aircraft reached 100 kt until it was over 50 ft above ground level,” the report said. “This incident serves as a reminder to pilots that significant wind changes can occur during take- off, can be difficult to predict, and can occur in the absence of thunderstorm activity. The wind conditions at each end of a runway may differ significant- ly so that headwind conditions can exist at one end and tailwind condi- BoM = Australian Bureau of Meteorology tions at the other end. Although it did Note: None of the windsocks could be seen by the Boeing 737 flight crew from the Runway 06 threshold. not assist in this case, it is important The airfield anemometer at Perth Airport, Western Australia, registered a significant wind change during to monitor the available windsocks their takeoff run. Source: Australian Transport Safety Bureau before takeoff as it is the final oppor- tunity to detect wind changes before Figure 1 the takeoff roll begins.” The report recommended review subsequently landed safely at a dif- light rain, cloud vertical visibility 200 ft of one briefing note on wind shear ferent airport. above the ground, temperature and dew
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | AUGUST 2013 | 19 FLIGHTOPS
The ATC officer saw the Citation Takeoff Continued After Runway Overrun entering the runway and amended the initial clearance, instructing the crew to hold on the runway for takeoff clearance because the runway inspection was still in progress. “In view of the expected de- lay, the commander then set the parking brake,” the report said. At 0853:43, the takeoff clearance was issued, updating wind data to 060 degrees at 6 kt. “The commander then switched on the pitot heater and landing lights, pushed the thrust levers forward and handed control over to the copilot.
He instructed the copilot, in view of the Note: Accident investigators found traces of locked brakes (1) at the departure end of the runway, reduced visibility, to carry out a so-called that the Citation had damaged a runway-end identifier light (2) and that its wheel tracks (3) indicated crossing of a meadow and stream bed before liftoff. standing takeoff. At a power setting Source: Aviation Division, Swiss Accident Investigation Board with a low-pressure compressor speed N1 of approximately 90 percent of the Figure 2 rated speed, the copilot took his feet off the brake pedals, set takeoff thrust and on the meadow. “The copilot, according strobe lights. Then she made sure on steered the aircraft on the runway center- to his statement, had the feeling that it the radar screen that [the airplane] had line. The set takeoff thrust was checked was no longer possible to continue the actually lifted off.” by both crewmembers.” takeoff and briefly reduced power,” the Following normal climb procedure, The commander “had the impres- report said. “But at approximately the the commander next reduced power to sion that the aircraft’s acceleration was same time, the copilot noted that [the the maximum continuous thrust setting lower than usual,” the report said. “[The Citation] had already lifted off and ap- and retracted the flaps. “Then the crew Citation] attained a speed of 80 kt before plied full power again. realised that the parking brake was still Taxiway E1 … i.e., rather late, but still “At the same time, he asked the set,” the report said. within a framework which seemed ac- commander whether the takeoff pro- During his attempt to retract the ceptable to the commander. On reaching cess should continue. The [command- landing gear, however, the commander
[VR], in the copilot’s estimation approxi- er] answered the copilot’s question observed a red gear-warning light. Ex- mately 250 m [820 ft] before the end of in the affirmative, with the consid- tending the gear again resulted in three the runway, the commander called out eration that they would perhaps still green indicator lights, so the crew left ‘Rotate,’ whereupon the copilot pulled have a chance to get the aircraft into the gear extended for the remainder of on the control column. the air.” the flight. After being handed off to an “Both crewmembers immediately Investigators’ analysis of this stage approach controller at about 3,500 ft, noticed that the nose of the aircraft was determined that “a few seconds” had the flight crew requested and received not lifting. After a repeated callout by elapsed from the point of runway over- IFR clearance to Zurich, their IFR the commander, he, too, pulled on the run — then more than 100 m (328 ft) alternate airport, where they landed control column. On overshooting the across the meadow and stream bed — uneventfully. end of the runway, the right main land- to the liftoff (Figure 2). “Structural damage was found in ing gear … struck a light, which was “The [ATC officer] heard a click on the area of the nose gear and main gear, perceived by the crew as a distinctly the radio frequency as [the Citation] as well as to both rear wing spars,” the noticeable impact.” approached the end of the runway,” the report said. “Also, a certain asymmetry Leaving the runway pavement, the report said. “She took up the binoculars was ascertained in the dimensions of landing gear wheels continued to roll and was still able to see the aircraft’s the aircraft.”
20 | FLIGHTFLIGHT SAFETY SAFETY FOUNDATION FOUNDATION || AEROSAFETYAEROSAFETYWORLD || AUGUSTAUGUST 2013 FLIGHTOPS
Investigators used the accident reasonable to assume that on handing Notes airplane’s flight management system to over control to the copilot, the com- 1. ATSB. “Significant wind change during replicate the pilots’ calculated take- mander was no longer aware of the set takeoff involving Boeing 737, VH-VZL off field length for the conditions at parking brake. Possibly, also, the delay Perth Airport, Western Australia, 4 Grenchen, obtaining 2,808 ft (856 m) due to the runway inspection may December 2012.” ATSB Transport Safety as the result. “It is apparent that with have played a part in this.” Report, Aviation Occurrence Investigation AO-2012-168, May 17, 2013. 124 m [407 ft], the crew basically had Because of their significant experi- a small safety margin available,” the ence, both pilots had a mental picture 2. Aviation Division, SAIB. “Final Report No. 2156 of the Swiss Accident Investigation report said. “There is no evidence of of the normal acceleration of the Board SAIB concerning the accident the existence of any technical defects or accident airplane at Grenchen, the involving the C525 aircraft, registration limitations which could have caused or report said, noting, “On a takeoff on a HB-VOV on 16 February 2011 at Grenchen influenced the accident.” relatively short runway, preconceived regional airport (LSZG).” April 25, 2013. The operator’s preflight check- decisions and thus the willingness to 3. V1 means the maximum speed in the takeoff list for this airplane did not refer to abort takeoff roll early at the merest at which the pilot must take the first action releasing the parking brake except hint of a failure or adverse [effect] is (e.g., apply brakes, reduce thrust, deploy just before taxiing from the parking essential.” speed brakes) to stop the airplane within stand. From 1997 to 2011, 11 incidents The SAIB’s safety recommendations the accelerate-stop distance. V1 also means the minimum speed in the takeoff, follow- occurred involving takeoffs with the in part addressed the need for a retrofit ing a failure of the critical engine at VEF , at parking brake set, according to the technical solution to warn flight crews which the pilot can continue the takeoff and airframe manufacturer’s data for the when the takeoff roll is initiated with achieve the required height above the takeoff aircraft type, the report said. “It seems the parking brake set. surface within the takeoff distance.
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FLIGHTSAFETY.ORG | AEROSAFETYWORLD | AUGUST 2013 | 21 THREATANALYSIS
BY ED BROTAK
22 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | AUGUST 2013 THREATANALYSIS
unway excursions (REs) are among devices for decision making by air traffic control the most common event categories of and, in some countries, advice to pilots. The re- accidents in air transport operations. Ac- sulting so-called Mu (coefficient of friction) value cording to the European Aviation Safety generated can range from 100 (U.S. value) or 1.00 Agency’sR (EASA’s) latest safety review, “There (International Civil Aviation Organization value) were 100 runway excursion accidents and seri- for the highest friction to 0 for the lowest friction. ous incidents at EASA aerodromes between Any value less than 40 on an operational runway 2008 and 2012.” should be recorded and the information passed These are events in which an aircraft either along to incoming aircraft pilots. veers off the runway surface or overruns the end Values less than 20 would result in closing of the runway. Most REs are caused by improper the runway. More commonly, runway braking approaches that lead to aircraft control issues action is reported by pilots who already have after touchdown. landed; this is usually considered the most reli- The threshold crossing height, airspeed, de- able indicator of runway conditions at the time scent rate and angle on the approach are usually of landing. A pilot who deems that the “braking involved. Sometimes strong, gusty crosswinds, action conditions” are less than good is expected tail wind and/or runway friction are involved to fill out a runway condition report and provide (ASW, 7/13, p. 43). Once the aircraft touches a pilot report. down, its deceleration capability and flight crew Pilots should keep in mind that runway fric- actions also play a role. So most REs are associ- tion can change very quickly when precipitation ated with multiple factors. is occurring, sometimes within minutes. A major If you change one factor, an RE might be problem in reporting runway conditions by pilots avoided. Runway conditions, although not a is their subjective nature. Last year, the U.S. Fed- primary cause of REs, are often a contributing eral Aviation Administration (FAA) also stopped factor. Compromised runway conditions make recommending that airports provide runway it more difficult for the flight crew to overcome friction measurements to pilots when snow or the problems produced by an unstable approach. ice is on the runway, citing inconsistencies in the A recent study by Boeing (ASW, 11/12, p. 8) measurement process (ASW, 11/12, p. 13). indicated that 94 percent of REs occurred on Finally, at some locations, airport personnel non-dry runways. themselves have been authorized to make the After the tire tread on the landing gear makes determination of runway friction and pass the effective contact with the surface of the runway, information along to pilots. friction between the two allows the pilots to To further assist pilots in assessing U.S. decelerate the aircraft while maintaining control. runway conditions, the FAA classifies runways Any “contaminant” that gets between the tire as being “dry,” “wet” or “contaminated.” “Dry” and the runway surface can lessen the frictional would seem self-explanatory, but a damp runway, bond. This leads to longer stopping distances and, one which appears discolored but not reflective, at worst, runway excursions. Any type of debris, is considered “dry.” Damp runways often are the such as rubber particle buildup from tires, can be result of dew or very light rain, or represent the problematic. Water from rain is one of the most final drying stage of a previously wet runway. Airports and ATC common contaminants. In colder climates, winter A “wet” runway is sufficiently moist to appear struggle to estimate weather elements such as frost, snow, slush and reflective, but is still not considered “contami- and maximize runway ice can also greatly affect runway friction. nated.” Braking action is reduced, but conditions How winter runway conditions are deter- are still acceptable. A 1/8-in (3-mm) depth of friction in a variety of mined and reported to pilots remains a focus of water is considered the threshold for “hydroplan- weather conditions. ongoing study and debate. Many airports periodi- ing” or “aquaplaning,” in which a layer of water
cally measure runway friction with specialized comes between the tire and the pavement surface, Susan Reed; illustration: Photo © Jakub Gojda/Dreamstime.com base photo:
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | AUGUST 2013 | 23 THREATANALYSIS
factors — crosswinds and rainfall intensity. The direction of the wind can help or hinder water flow off the runway. But one of the most important factors is the inten- sity of the rainfall. The key question for airport engineers is, at what rainfall rate would the drainage capacity of a runway be overwhelmed and the water level on the pavement exceed the texture depth of the This Embraer 190 and loss of directional control can result. Keep in surface, leading to standing water? slid off a wet runway mind that water depths less than 1/8 in can still Unfortunately, with all of the variables, there while landing at Santa reduce friction and increase stopping distance is no way to directly correlate specific rainfall Maria, Colombia, even without loss of control. Also, sometimes rates with resulting runway conditions. We can, after a flight from runways can be described as “flooded.” In these however, make some general statements. Cali in July 2007. cases, large areas of standing water are visible. Convective showers or thunderstorms can Because rainwater is a common contaminant generate rainfall rates that compromise run- of runways, a number of methods are used to re- way conditions. An inch (25 mm) of rain in 15 duce its negative impact on friction. The asphalt minutes or less is not that unusual. The critical or concrete used for the runway is specially tex- 1/8 in of water can fall within a minute or two. tured. The primary purpose of the macrotexture Convection associated with tropical cyclones or roughness of the runway surface is to provide a also is known for producing excessive amounts path for water to escape from beneath the tires. of rain. The more typical winter storms and Pavement texture makes a significant dif- fronts without convection usually are associated ference in the friction of a wet surface. A rough with rainfall rates of less than 1 in per hour. macrotexture provides much better friction in Weather radar is useful in determining rain- wet conditions. The microtexture, the fine-scale fall rates because the colors used on the meteo- roughness or feel of the surface, helps break rologist’s standard radar display represent the through the residual water film left. Grooves strength of the signal return, which is directly also are often cut into the runway surface to fa- related to rainfall intensity. Green areas indicate cilitate drainage. The FAA standard groove is ¼ less than 0.1 in (2.5 mm) per hour. Yellow areas in (6 mm) deep and ¼ in wide, and the grooves mean up to 0.5 in (12.7 mm). Orange shows 1 in are spaced 1½ in (38 mm) apart. Runways also or more. Reds and then purples indicate rainfall are sloped or crowned for better drainage. rates of 2 in (5 cm) or more per hour. The goal is to keep water levels on the Winter-type precipitation in the higher lati- runway below the height of the textured surface, tudes is even worse in terms of contaminating a thus eliminating standing water. The drainage runway. According to the FAA, “a contaminated ability of a runway is affected by the cross slope, runway has more than 1/8 in of slush, snow, or
the surface texture, wheel ruts and two weather compacted snow, ice, or frost covering more Smith/Reuters P. © Andrew
24 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | AUGUST 2013 THREATANALYSIS
than 25 percent of the required length above freezing, the snow on the ground rotary steel bristle brushes remove and width of its surface.” It takes very can contain a percentage of liquid water remaining snow. Unfortunately, these little time, sometimes only minutes, that produces slush. Slush also greatly are very labor intensive and often slow for 1/8 in of frozen precipitation to reduces friction. processes. And if snowfall rates are too accumulate. And unlike rainwater, Snowfall rates are important in great, it becomes physically impossible frozen precipitation will not drain off. determining how fast the coefficient of to remove the snow fast enough to keep The methods used to drain water from friction of a runway can be affected. In the runways clear and the airport must runways will be of little use in these convective snow events (ASW, 10/10, p. close until the snowfall lessens. situations. Only air or ground surface 18), snowfall rates can approach 4 in (102 In icing situations, runways may temperatures above freezing will create mm) per hour. At this intensity, a runway be treated with sand, like highways. melting from below and runoff. can be compromised within minutes. Or deicing/anti-icing chemicals can Although frost is included among Snowfall rates also are critical in marginal be sprayed on runways just as they are runway contaminants, its typical depth, situations when air temperatures are near, sprayed on aircraft to remove ice and/ less than 0.04 in (1 mm), is usually less or even above, freezing and/or when the or temporarily prevent surface icing. of a problem. Frost also differs from runway surface itself has above-freezing Some airports opt to treat runways other cold weather contaminants be- temperatures. In these situations, snow ahead of time with “freezing-point cause, technically, it’s not precipitation can still accumulate if the fall rate exceeds depressant” chemicals to prevent ice ac- that falls from clouds. Frost is a frozen the melting rate. In other words, when cumulation. The cost of the chemicals deposit of water vapor as ice crystals on the snow is piling up on top faster than it and environmental concerns are factors a surface that occurs when the surface is melting from below, it can accumulate in their availability as a mitigation, temperature falls to freezing and reaches regardless of temperature. however. Easily the most ambitious the dewpoint. It usually occurs under Sleet, which is composed of small ice recent attempt at solving the winter clear skies and light to calm winds. Rime pellets, can accumulate quickly, but its precipitation problem is with a heated ice, which is deposited when clouds granular nature makes it less of a problem runway system such as the one at the with below-freezing temperatures move for aircraft deceleration. Denver International Airport. Geother- across a surface, is similar. Clearly, the worst winter precipita- mal energy also shows promise. Winter precipitation types include tion for runway excursion risk is freezing Edward Brotak, Ph.D., retired in 2007 after 25 snow, sleet and freezing rain. Each has its rain or glaze. In this case, liquid water years as a professor and program director in own unique properties. Snow comprises droplets fall to earth and freeze on con- the Department of Atmospheric Sciences at the ice crystals. The consistency of snow is a tact with any surface that has tempera- University of North Carolina, Asheville. function of temperature. With tempera- tures below 32 degrees F (0 degrees C). References tures near freezing, the snow is usually This can leave a layer of sheer ice on any wet and heavy, the good packing snow paved surface. Often the layer of ice has Daniels, Jeffrey M. “Aircraft Performance of snowballs and snowmen. At colder some water on top of it. and Flight Deck Basics.” Presented at the 23rd Annual Schedulers and Dispatchers temperatures, the snow becomes lighter Studies have shown that wet ice Conference, San Diego, California, U.S. and drier and not as compactable. produces the most dangerous runway January 2012. As any skier can tell you, the consis- surface conditions. Four or five times International Civil Aviation Organization. tency of the snow affects how the sur- the stopping distance that would be re- Runway Surface Condition Assessment, face of the ski moves over it. Skiers use quired on dry pavement can be needed. Measurement, and Reporting. 2008. different waxes on the bottom of their Wet ice on a runway often leads to International Federation of Air Line Pilots’ skis to go faster in different conditions. unacceptable braking conditions and Associations. Runway Safety Manual. 2009. This same principle applies to snow closing the runway. on runways. Cold, dry snow has more To deal with winter precipitation, Roginski, Michael. “Manufacturers Perspective — Runway Friction and Aircraft Performance.” grip, at times becoming almost sticky. airports utilize a number of tools. For Presented at Asociación Latino Americana Wet, mushy snow has a higher water snow, old-fashioned snowplows and y Caribeña de Pavimentos Aeroportuarios content and greatly reduces traction. snowblowers help keep runways open. Seminar of Airport Pavements, Panama City, When temperatures on the ground are In addition, runway sweepers with Florida, U.S., September 2012.
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BY LINDA WERFELMAN
Studies of in-flight medical emergencies aim to identify strategies for deciding when diversions are appropriate.
nhanced guidelines for evaluating ground resources and the availability diversions,” the document said, noting, and managing the symptoms of ail- of resources on board,” the document “Flight diversions are not only costly ing airline passengers and increased added. “This decision [on whether to but also pose increased risks to the awareness of high-risk groups could divert a flight] requires more special- other passengers.” Ereduce the number of “futile diversions,” ized training for cabin crew [and] These increased risks come as the medical researchers say.1 medical professionals and enhanced flight crew travels to an unexpected A study published in the May issue tools for communication with ground- destination and conducts what may be of Aviation, Space, and Environmental based medical advice services.” an unfamiliar instrument approach. Medicine (ASEM) also recommended The study examined data from In addition to safety risks, flight crews the prescreening of some passengers 4,068 in-flight medical events that may need to dump excess fuel before recently discharged from hospitals, occurred at a large Hong Kong com- an emergency landing, which can post-operative patients and people with mercial airline from December 2003 damage the environment and increase specific terminal illnesses. through November 2008 and found fuel consumption; and a diversion may “Formulation of specific man- that medical volunteers participated result in costly delays for passengers agement guidelines for different in 1,439 (35.4 percent) of the cases, in- and the operator. symptom-based categories, grounded cluding 39 (84.8 percent) of the 46 cases Records allowed for further review on evidence-based results, is the next that resulted in an aircraft diversion. of 36 of the 39 diversions, and of that step to establish specific action plans Medical volunteers — who, in 77 per- number, 12 passengers were released, for flight attendants,” the study said. cent of the cases, were doctors who had 16 were hospitalized, and eight died “Actions should be clearly delineated, been flying as passengers — were more during the flight (Figure 1). Of those and the role of coordination of available likely to be involved when the events were who were hospitalized, half were sus- medical volunteers and the ground- serious, the study said, noting that the air- pected of having had a stroke, two had based physicians clarified.” line’s policy was to call for volunteers only chest pain and two went into labor. In-flight medical kits with detailed if recommended by MedLink, a ground- Of seven diversions handled guidelines on when and how to use based medical advisory service, or if the without medical volunteers, three pas- specific medications and medical passenger was obviously critically ill. sengers were released after emergency equipment also would aid both flight The study was designed to de- room evaluation, three were hospital- attendants and medical volunteers, the termine how medical volunteers ized, and one died during flight. Of report said. functioned during in-flight medical those who were hospitalized, one each “The need for medical diversion emergencies and to identify strategies experienced pain, “nonspecific” symp-
is a balance between the proximity of that might result in “more appropriate toms and bleeding with no injury. © Bailey/AirTeamImages Illustration: Susan Reed; photo:
26 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | AUGUST 2013 AVIATIONMEDICINE Diverted
The study’s authors said they In cases of chest pain, limited di- In the third category, “death,” all five “cannot conclude that the presence agnostic equipment is available during diversions were diagnosed as cases of car- of medical volunteers leads to more flight, and treatment focuses on providing diac arrest. The study questioned whether medical diversions. This remains an oxygen, aspirin and other medications to a flight diversion is wise for patients who association, and there is no evidence stabilize the passenger’s condition. experience cardiac arrest during flight. to infer that volunteers directly cause more diversions.” Symptom-Based Categorization of Diversions They added that the ratio of “ap- propriate diversions” was the same for Cases without volunteer (7) patients on flights that were diverted after the intervention of medical volun- Released after Admitted to Died (1) teers and for those on flights where the evaluation (3) hospital (3) Chest pain (1) decision to divert was made without a Nausea/vomiting/diarrhea (1) Pain (1) volunteer’s input. Convulsion (1) Nonspeci c (1) Overall, suspected strokes (catego- Di culty breathing (1) Bleeding, no injury (1) rized as “nonspecific”) accounted for 25.6 percent of diversions, more than any other category, followed by chest Cases with volunteer (36) pain (18.6 percent) and death (11.6 percent; Table 1, p. 28). Released after Admitted to Died (8) Therefore, the study said, “it may evaluation (12) hospital (16) Death (5) be useful to incorporate simple pre- Chest pain (4) Nonspeci c (8) Chest pain (1) hospital stroke scales … into the training Nonspeci c (2) Chest pain (2) Bleeding, no injury (1) of the cabin crew.” Such assessment Pain (2) In labor/delivery (2) Di culty breathing (1) Injuries (1) Convulsion (1) scales typically call for a simple evalu- Convulsion (1) Pain (1) ation of whether both sides of the face Allergy/skin (1) Nausea/vomiting/diarrhea (1) move equally or one side does not move, Bleeding, no injury (1) Di culty breathing (1) whether both arms can be moved equally or one arm drifts down, and whether Source: Hung, Kevin K.C.; Cocks, Robert A.; Poon, W.K. et al. “Medical Volunteers in Commercial Flight Medical Diversions.” Aviation, Space, and Environmental Medicine Volume 84 (May 2013): 491–497. speech is correct or the words are garbled or the passenger cannot speak. Figure 1
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Symptoms Associated With Medical Flight Diversions
Frequency Symptom Category Diagnosis (Percent) Strategies Nonspecific Stroke 11 (25.6) Stroke assessment, glucose test, conscious-level assessment Chest pain Acute coronary syndrome 8 (18.6) Diagnosis, treatment of coronary artery disease Death Cardiac arrest 5 (11.6) Cardiopulmonary resuscitation, use of automated external defibrillator, diversion protocol for cardiac arrest cases Pain Intracranial hemorrhage (1), Back pain (1), 4 (9.3) Diagnosis and pain management Kidney stone (1), Ectopic pregnancy (1) Convulsion Convulsion 3 (7) First aid, glucose test Difficulty breathing Asthma (1), Cancer (1), Cyanosis (1) 3 (7) Use of oxygen, asthma treatment, monitor Bleeding, no injury Epistaxis (1), Antepartum hemorrhage (1), 3 (7) First aid Vaginal bleeding (1) Nausea/vomiting/diarrhea Diabetic ketoacidosis (1), Vomiting (1) 2 (4.7) First aid, glucose test Labor/delivery Labor 2 (4.7) Basic delivery Allergic/skin Peanut/tomato allergy 1 (2.3) First aid Injuries Head injury 1 (2.3) First aid, conscious-level assessment Excluded for categorization 3 Total 46 (100)*
* Percentages do not total 100 because of rounding.
Source: Hung, Kevin K.C.; Cocks, Robert A.; Poon, W.K. et al. “Medical Volunteers in Commercial Flight Medical Diversions.” Aviation, Space, and Environmental Medicine Volume 84 (May 2013): 491–497.
Table 1
“The chances of a successful re- percent; respiratory symptoms, 12.1 emergency medical services (EMS) pro- suscitation in non-VF [cardiac arrest percent; and nausea or vomiting, 9.5 viders in 4.4 percent, and other health not involving ventricular fibrillation] percent.2 care professionals in 3.7 percent of cases. out-of-hospital arrest are extremely Hospitalizations most often were “Aircraft diversion and hospitaliza- low, even on the ground, and therefore attributed to cardiac arrest, strokelike tion rates differed according to the type the decision to medically divert should symptoms, obstetrical or gynecological of medical volunteer,” the report added, be taken very carefully,” the study symptoms and cardiac symptoms. noting that, by a very slight margin, said. “Considering the time it will take The study examined in-flight physicians had the highest diversion for the passenger to be taken to the medical emergencies that prompted rates — 9.4 percent. In comparison, hospital, diversion is only medically crewmembers to consult with medical diversion rates for EMS providers were warranted if the patient responds to re- experts on the ground — a situation 9.3 percent; for nurses, 6.2 percent; and suscitation, and not for every passenger that occurred at a rate of about 16 per for crewmembers, 3.8 percent. with cardiac arrest.” 1 million passengers — or about one Hospitalization rates were highest time in every 604 flights.3 The 11,920 for EMS providers — 10.2 percent — Second Study calls, made from Jan. 1, 2008, through compared with 9.3 percent for physi- A separate study, published in the May Oct. 31, 2010, to experts on the ground, cians, 8.7 percent for nurses and 4.7 30 issue of the New England Journal of resulted in aircraft diversions in 875 percent for flight crewmembers. Medicine, reviewed 34 months of calls (7.3 percent) of the cases. In-flight treatment most frequently from five airlines to an unidentified involved providing oxygen (in 49.9 medical communications center and Medical Volunteers percent of cases), intravenous saline found that the most frequent medical In 48.1 percent of cases, medical as- solution (in 5.2 percent) and aspirin (in problems experienced by passengers sistance came from physicians who 5.0 percent), the study said. were syncope (fainting) or presyncope were traveling as passengers. Nurses Aircraft diversion was most closely (lightheadedness and weakness), 37.4 volunteered in 20.1 percent of cases, associated with use of an automated
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external defibrillator (AED) and assis- Records showed that 36 of the Challenges tance from an EMS provider, the study 10,914 passengers died, including 30 Providing medical treatment dur- added, noting that records showed who died during flight. ing flight can be challenging, in part that AEDs were applied to 137 patients Overall, the study estimated that because of the limited availability of (1.3 percent). For the 134 patients 44,000 in-flight medical emergencies space and medical equipment, the with medical records detailed enough occur every year. Most of these are study said. to allow further analysis, researchers “self-limiting or are effectively evalu- Nevertheless, the document added, determined that AEDs were used when ated and treated without disruption of “diversion of a commercial airliner to the primary symptoms were syncope the planned route of flight,” the study an unscheduled destination for an ill or presyncope, and chest pain; they said. “Serious illness is infrequent, and passenger requires consideration of also were applied in 24 cases of cardiac death is rare.” both medical and operational issues. arrest. Of these, a shock was delivered The potential medical benefit should to five patients. In nine cardiac arrest Consultations be assessed on the basis of the condi- cases, cardiac activity resumed while Like the ASEM report, the Journal study tion and its time sensitivity, the ability the AED was being used, and all but noted that some airlines require flight to stabilize the patient’s condition with one of the nine survived long enough to attendants to consult with a ground- available supplies and the likely time be admitted to a hospital. Eighty-four based physician before using the emer- savings with consideration of the time of the 134 patients treated with AEDs gency medical kit in the airplane. needed to land and the proximity of had lost consciousness. “Passengers’ symptoms can often medical resources to specific airports. In 42.1 percent of cardiac arrest be managed in collaboration with the Immediate operational factors that cases, the flight was not diverted, the flight attendants, who are well versed may contribute to variability in airline study said; in some of these cases, an in the equipment that the airplanes practices include weather, fuel load immediate diversion was not pos- carry and in operational procedures,” and the potential need to drop fuel be- sible because the airplane was on a the study said. “When the need for fore landing, the availability of specific transoceanic flight or near its planned evaluation or intervention exceeds aircraft services at airports and air destination. their capabilities, flight attendants traffic control.” Follow-up information was avail- may seek health care professionals on The study called for the “systematic able for 10,914 patients, indicating that the flight.” tracking of all in-flight medical emer- 3,402 (31.2 percent) needed no ad- The study recommended establish- gencies, including subsequent hospital ditional care after landing. Emergency ing step-by-step procedures for coping care and other outcomes, to better medical services personnel were sum- with the most common in-flight medi- guide interventions in this sequestered moned for 7,508 patients, including cal emergencies — syncope, respiratory population.” 2,804 (37.3 percent) who were taken to symptoms, nausea or vomiting, and Notes a hospital emergency room; of those cardiac symptoms. for whom follow-up information was For example, the study said that pa- 1. Hung, Kevin K.C.; Cocks, Robert A.; available, 901 patients (8.6 percent) tients with syncope, who may initially Poon, W.K. et al. “Medical Volunteers in were admitted to the hospital or left be unresponsive and have low blood Commercial Flight Medical Diversions.” Aviation, Space, and Environmental the emergency room against the advice pressure, usually improve in about Medicine Volume 84 (May 2013): 491–497. of medical personnel. 15 minutes with no treatment other than fluids, administered by mouth or 2. Peterson, Drew C.; Martin-Gill, Christian; Guyette, Francis X. et al. “Outcomes of Reasons for Hospitalization intravenously. Medical Emergencies on Commercial The most common reasons for admis- Cases of heart attack, stroke or Airline Flights.” New England Journal of sion, the study said, were cardiac arrest; “other factors that raise concern about Medicine Volume 368 (May 30, 2013): stroke symptoms; obstetrical or gyne- time-sensitive conditions,” including 2075–2083. cological symptoms, most often bleed- passengers with “persistently altered 3. Participating airlines accounted for about ing that signaled a possible miscarriage; mental status,” should prompt the crew 10 percent of passenger flight volume and other cardiac symptoms. to consider a diversion, the study said. worldwide for the time period studied.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | AUGUST 2013 | 29 e Foundation would like to give special recognition to our BARS Benefactors, Benefactor and Patron members. We value your membership and your high levels of commitment to the world of safety. Without your support, the Foundation’s mission of the continuous improvement of global aviation safety would not be possible.
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patrons SAFETYREGULATION NEW ROLE FOR THE Regulator BY SIMON ROBERTS AND THE SAFETY MANAGEMENT INTERNATIONAL COLLABORATION GROUP
Inspection and compliance assessment are being enhanced to help organizations maximize SMS effectiveness. © User:retrorocket/iStockphoto
tate and regional civil aviation authorities are changing their approach to regulatory oversight with the evolution of safety management systems (SMS), and some have struggled with confusion and inconsistencies. Rec- ognizing this, the Safety Management International Collaboration Group S(SM ICG), a group of regulators, has responded with experience-based advice about the transition.
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Members of the SM ICG have begun shar- how they meet the regulations but also at the ing experiences and lessons learned to provide effectiveness of the safety barriers they control better guidance on the interpretation of safety and knowing the safety risks that could be management requirements. One key objective is transferred onto others. Important conversa- to deliver guidance on how to implement a state tions on risk should take place between these safety program (SSP) and SMS at both the state organizations. Many of the risks and operator levels. Essential to the successful An effective SMS has to bring organiza- implementation of SMS is the realization that tions together, as the management of risk often sit in the gaps and SMS builds on years of prescriptive require- is shared. It also should bring the regulator ments written as a result of lessons learned and the regulated together in a collaborative interfaces between from past events (reactively). This has produced relationship as part of the state safety program. different parts a safe industry, but we must also ensure that The International Civil Aviation Organization we do not become complacent as the aviation (ICAO) SMS framework was a good starting of the system. system changes. point, but now that we understand SMS better, SMS continues our shared journey toward one question arises: Are the current regulations an even safer industry, in which prescriptive still fit for purpose? rules do not fit every organization or opera- More and more states are recognizing the tion. However, if SMS is misinterpreted, this can need to address the total system rather than create its own safety risk rather than the safety provide oversight to isolated parts. Indeed, benefits intended. many of the risks sit in the gaps and interfaces As former Flight Safety Foundation Presi- between different parts of the system. Safety dent and CEO William R. Voss wrote in a recent management of the individual parts does not article (ASW, 5/13, p. 7), SMS does not have to necessarily equal the safety management of the be complicated. At the same time, regulators whole system. need to protect the public while industry has a SMS requires a change of approach from responsibility to offer safe products and ser- industry and the regulators. As regulators, we vices. Together, we must provide the right level want to see organizations implement an effective of safety assurance in a proportionate manner SMS that is adding safety value. This includes that reflects the size, nature, inherent risk and organizations having a better risk picture and a complexity of the organization. means to monitor their safety performance, so SMS at the operator level is about managing they know that they are taking the right actions risk — current, future and third-party. Within for the risks they face. We also want to see the the operator’s system, third parties are exten- industry reduce its safety risks and get a return sively used for safety-critical services such as on its investment. contracted maintenance, ground handling, fuel- One of the greatest challenges for every- ing, deicing and aircraft loading. one is the shift in organizational cultures. The surveillance and oversight of these An SMS will not be effective without the third-party organizations are paramount for right safety culture, but this key point is states and operators, as such organizations missing from most SMS regulations. This is not only generate risks but also manage and because culture is subjective and difficult to control some of the risks faced by the primary regulate. However, this should not stop the organization. This involves not only looking at regulator from assessing safety culture (even
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subjectively) and providing that indepen- judge the performance and effectiveness of an dent view to the organization’s accountable SMS. They will need to acquire new skills and a executive and senior management. Moreover, shift in the culture of the inspection staff, which this assessment should contribute to deter- will take time. mining the level of surveillance needed for Furthermore, the ICAO SSP/SMS frame- performance-based oversight. works have been around for a while, and there As regulators move toward risk-based are still areas of confusion and inconsistent oversight or performance-based oversight, they interpretation. We need to make sure that other need to consider not only how well an orga- states learn from those that have already been nization complies with regulations but also on the SMS journey and have uncovered issues how well it understands and manages its safety and pitfalls on the way so others don’t make the risks and monitors its safety performance. As same mistakes. This was one key reason that the regulators, our confidence in the organization SM ICG was established. to manage safety is also based on our view of its The state safety program, in conjunc- safety culture. tion with the cumulative effects of individual It is not just the regulated organizations that organizations’ SMS, can provide that extra layer need to ensure they have the right culture to of safety. However, this will only happen if it enable their SMS to deliver. Each regulator is on meets the original intent and doesn’t get lost in its own journey, too. Inspectors need to consider unnecessary complexity and language that not the performance and effectiveness of the SMS in everyone understands. We need to avoid the jar- Inspectors are now addition to compliance. gon of SMS and communicate so that everyone This requires a different way of thinking on understands what safety management is trying being required to the part of the inspector. Having a well-crafted to achieve. understand risk, safety management manual and delivering SMS We need to consolidate our understand- training won’t itself produce an effective SMS. ing and our application of safety management safety performance, It is how the organization manages safety in before we move on to something new. We are practice that adds most value. a long way from reaping the full rewards of ef- safety culture and Does it do what it says it does? Are these fective safety management. That doesn’t mean human factors, strategies effective? How does the inspector we should give up, it just means we should evaluate the effectiveness? It starts with the manage our expectations about progress and and judge the organization’s risk register and focuses on the celebrate each critical step forward on the biggest risks. Do they reflect the same risks that SMS journey. performance and the state has identified in its own SSP, and do The Safety Management International Col- they reflect those of similar organizations in the laboration Group (SM ICG) is a joint partnership effectiveness same sector? Has the organization identified its of many regulatory authorities for promoting a of an SMS. risks correctly? This is where the SSP feeds into common understanding of safety management the SMS oversight and the SMS oversight feeds principles and requirements and facilitating their back into the SSP. implementation across the international avia- The competencies expected of the regulatory tion community. Further information regarding inspector are changing. Inspectors are now be- SM ICG can be located at
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ontinuing to build upon the late-1990s glowing responses from pilots who have com- legacy of knowledge, intensive efforts in pleted this training. the past four years have propelled airplane Presenters and attendees filled in details upset prevention and recovery training of these developments, cited a few points of C(UPRT) from the milieu of a few subject matter controversy and highlighted next steps on their experts to finalizing international standards and agendas during the World Aviation Training guidance for commercial air transport (ASW, Conference and Tradeshow (WATS 2013) in 7/13, p. 27). April in Orlando, Florida, U.S. What’s new is increased experience among “Stall training [has] been required, for a pri- airlines that — after working closely with vate pilot license through type ratings, forever,” other stakeholders to stem the risk of loss of said Paul Kolisch, a captain at Pinnacle Airlines. control–in flight (LOC–I) — have become vol- “Nonetheless, we continue to lose airplanes in
Worth the Wait untary early adopters of UPRT, some receiving the commercial fleet, and most [such accidents]
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Upset prevention and recovery training are following stall events and the loss of control– gains endorsements from airline pilots. in flight. [Pilots] didn’t need to get upside down or even close to it. But the airplane wasn’t flying. BY WAYNE ROSENKRANS And the pilots didn’t recognize it. … We have to use our imaginations and be open to new possibilities that really, virtually, violate our traditional stall training.” Despite consensus recommendations of industry specialists behind the U.S. Federal Aviation Administration’s (FAA’s) August 2012 publication of Advisory Circular 120-109, “Stall and Stick Pusher Training,” Kolisch said he still encounters skepticism and distrust about UPRT-related changes. “There are still people out there who say ‘They don’t apply to us,’” he told the conference. “Well, wings apply to you. And if they stop flying, they’re a problem for you.” A significant discrepancy has endured, he said, between the 5,000-ft to 10,000-ft altitudes traditionally used in approach-to-stall training for airline pilots and the altitudes where actual stalls occurred in recent LOC–I accidents. Moreover, the traditional training had failed to emphasize that typical pilots instinctively react to a startle/surprise affecting their flight path with immediate control input to increase pitch. UPRT instructors address this response, telling simulator students, “That’s what you’re going to do; now here’s how you recover,” Kolisch said. “In current practices, approach to stall is a © TNO scripted maneuver; it’s limited to non-realistic © L-3 Link Simulation & Training scenarios and it’s typically hand-flown,” he said. “I call it choreography.” Updates to regulatory standards, official guidance and practical test standards overcome such weaknesses. There- fore, stall prevention, recognition and recovery can be accomplished today before an anomaly deteriorates to a violent, possibly unrecoverable, airplane upset, he said. “The first thing you do is get the nose down,” Kolisch said, paraphrasing the key mes- sage adopted by various stall and UPRT work- ing groups. “If you don’t get the nose down, the wings aren’t flying long enough to level them. … [Training requirements also] should not mandate a predetermined value for altitude
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loss, nor mandate attaining an altitude going through high-altitude and involves flight crews hearing “PULL during recovery.” low-altitude stall training — most of UP” alerts from the terrain aware- Pinnacle Airlines is an example of it starting on the autopilot [to be] real- ness and warning system at the same the airlines that have opted to imple- istic,” Kolisch said. One point of poten- time that stall recovery requires them ment the latest best practices. “No one tial confusion that must be overcome to reduce angle-of-attack to reattach comes out of our training without in low-altitude stall training, he said, airflow to the wings so that responding
Preview of UPRT Enhancements to Instructor Operating Stations
mminent flight simulation training of these displays has been to “dispel inputs that otherwise cannot be as- device (FSTD) enhancements for the myth … that simulators are not an sessed by the instructor, such as rudder Iteaching pilots upset recovery in effective tool for upset prevention and pedal displacement and control forces); large commercial jets include several recovery training [UPRT].” and a method to inform the instructor currently under review by the U.S. The four new IOS displays are tools of the relationship between the ma- Federal Aviation Administration (FAA) that an instructor will use to provide neuver and aircraft operational limits. and already described in FAA interim feedback to the student during and after The latter typically would be a V-n dia- guidance. An example of the technol- six standardized UPRT maneuver sce- gram3 showing how these limitations ogy being finalized within the flight narios. The interim FAA guidance speci- may affect the maneuver. Ideally, the simulation industry provides upgraded fies that this feedback must indicate the FAA suggests, operators should install feedback to instructors/evaluators fidelity of the simulation, the magnitude capability to record and play back all via four new displays intended for of student control inputs, and the aircraft these dynamic parameters. instructor operating stations (IOS) and operational limits that could affect the “Our graphs should give the debriefing rooms,1 says Lou Németh, success of one or more maneuvers. instructor enough information to chief safety officer and captain, CAE. The FAA’s three minimum require- show whether or not the airplane During one session at the World ments for any FSTD used for this was recovered within the airplane Aviation Training Conference and purpose (Figure 1) are a simulator structural limits and the limitations as Tradeshow (WATS 2013), he presented validation envelope (the alpha/beta they’re defined by the Airplane Upset designers’ concepts of what this IOS crossplot2 on the IOS or equivalent Recovery Training Aid [ASW, 7/13, p. 30],” feedback may look like and how it will alternate method); IOS display of flight Németh said. “The instructor has to work. So far, Németh said, one purpose control inputs while the student is look at all four of these” alongside data for giving the airline industry previews performing maneuvers (especially any from flight control positions and flight Figure 1 instrument indications. CAE predicts that typically these IOS upgrade tools will replay and freeze moments or frame sequences during debriefing animations of flight crew maneuvers/aircraft performance, and help simulator students under- stand the safe/unsafe outcomes. “When you are doing UPRT, there’s so much going on over a short period of time that you need to be able to stop and look at it almost frame-by- frame to understand and show pilot performance and properly debrief the student,” Németh said. “Recorded data may be replayed because it’s so rich, and it happens so fast. The instructor can stop at the IOS and retrace the dots across the screen to see what © CAE
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to the alerts becomes possible. While Stick Pusher Training encounters the shaker or other indica- showing a video of an airline crew’s For operators of stick pusher–equipped tors of stick pusher activation (firing) is simulator session in this scenario, he airplanes, UPRT elements should be to pull the control column. said, “The GPWS [ground-proximity implemented to avoid negative train- Simulator instructors tasked with warning system] was telling them ing, Kolisch said. Without this train- inducing surprises can tell you, “Don’t ‘PULL UP.’ Pulling up kills you.” ing, the typical response of a pilot who pull, don’t pull, don’t pull — and you’ll
as the good recovery example. This pilot is in and out of the stall during the recovery. We can represent the difference — or the margin of safety — between where this pilot was and the safe recovery of the airplane as per the previous slide. There is no margin of safety, and he is in and out of the stick shaker in the recovery.” © CAE Simply counting dots on the display of the alpha-beta plot tells the story. happened, to see where the flight con- The differences among safe, unsafe The unsafe-maneuver pilot was in a stall trols were in every part of the maneu- and unsurvivable performance quickly for 15 seconds. “I know that because ver on a second-by-second scroll.” become apparent when these feed- I can see that he was on the stall line For example, capturing the alpha- back data immediately are available. on the V-n diagram, and he was in this beta plot readily depicts the aerody- The CAE presentation focused on two red region on the alpha-beta plot,” he namic status of the airplane inside pilots’ recovery performance during said. Moreover, this pilot’s unsafe effort and/or outside the normal (green) one of six standardized UPRT simulator even exceeded the simulator validation aerodynamic envelope. “I maintain that scenarios, the nose-up maneuver. envelope — that is, the known range of a good upset recovery will stay inside In one slide, the UPRT-trained fidelity to the actual airplane — of the that green envelope,” Németh said. pilot’s “maneuver started at just slightly FSTD’s approved aerodynamic database. Similarly, the V-n diagram shows under 2 g,” Németh said. “The nose — WR that as a pilot’s maneuver increases pitches up, the pilot unloads, moves Notes aerodynamic load in relation to the the airplane toward the center of the known structural limits, the stall speed envelope and then starts a dive recov- 1. FAA National Simulator Program (NSP). “FSTD Evaluation Recommendations increases along the diagram’s coefficient ery until the end of the recording. Each for Upset Recovery Training of lift/drag curve. Plotting maneuver dot represents one second. The margin Maneuvers.” Flight Simulation Training data as green, yellow and red dots between where the pilot was and the Device Qualification Guidance 11-05. traced over the V-n diagram helps the positive-g stall is very important; this NSP Guidance Bulletin, Dec. 20, 2011. instructor and student to visualize and shows a good recovery. This shows that 2. An alpha-beta plot graphs the wing grasp the complex interaction of aero- the pilot understood the relationship angle-of-attack in degrees (alpha) dynamic parameters. between g and stall, unloaded the on the vertical axis and the airplane On one of the new IOS displays, airplane and moved the airplane away sideslip in degrees (beta) on the horizontal axis. Flight envelope the control positions and primary from the danger zones.” boundaries are overlaid based on flight display are supplemented He compared the preceding safe flight test data, wind tunnel data and by data for speed-trim status, trim performance on this maneuver with data from engineers’ extrapolations. indicator, speed brake status, rudder that of a similar type-rated airline In Figure 1 and Figure 2, the irregular pedal deflection (percentage and the pilot who had not completed UPRT. green-outlined shape is the approved aerodynamic envelope of the amount of force applied), g-meter (a “The green dots at about 1.8 g are simulator incorporating flight test device indicating aerodynamic load the start of the maneuver,” Németh data under license from the airframe relative to standard acceleration of said, showing the corresponding slide manufacturer. gravity [g]), autopilot on/off status, (Figure 2). “The airplane is pitched up 3. A V-n diagram shows the normal load autothrottle status, and landing gear in the nose-high recovery maneuver factor and airspeed limits of a specific up/down status. and the unload is not as significant aircraft type.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | AUGUST 2013 | 37 FLIGHTOPS
pull,” he said. “But if you practice it a few The airline industry absolutely situation. The initial critiques from times, then you’ll release it. … Release, must “avoid negative training, but at [ALPA-represented] pilots that have put the nose down, and you’ll recover.” the same time, we shouldn’t be afraid to gone through that training have been Lou Németh, chief safety officer use our simulators because they’re not extremely positive … a tremendous and a captain, CAE, cited a potential exactly perfect,” Cheeseman said. ALPA confidence-builder. I happen to be source of confusion. “You’re sitting in recently has joined follow-on activities, one of them.” the cockpit of a stick pusher–equipped including a search for ways to enhance airplane, and the preflight procedures the “difficult skill of pilot monitoring” Other Pilot Reports require you to hang on to the stick and redouble its effectiveness. As part of its advanced qualification pusher and fight through the stick ALPA urges the U.S. airline indus- program for pilots, UPS Air Cargo has pressure,” he said. “So every preflight, try not to attempt to circumvent full designed programs to teach low-altitude, you’re sitting there holding onto this UPRT — specifically, the training re- low-speed stalls and high-altitude, low- thing, and you’re doing absolutely the quirements included in U.S. law1 — by speed stalls in FSTDs, said attendee Jeff opposite of what you should do if the not exposing pilots to full aerodynam- Ryan, a UPS captain, Boeing 767 check stick pusher fires in flight. … We want ic stalls and recoveries in approved airman and simulator instructor. to demonstrate the stick pusher, and flight simulation training devices “Having gone through it, I will tell we want to see the pilot demonstrate (FSTDs). “We don’t understand why you that it was extremely eye-opening,” proficiency in respecting the stick this is a big discussion in the United he said. “First, [practicing recovery pusher when it fires in flight.” Németh States,” he said. from] a low-altitude, low-speed stall, was chairman of the Stick Pusher and Airbus and Boeing representa- initially dropping the nose, the airplane Adverse Weather Aviation Rulemak- tives at the conference reiterated their regaining flying speed, and then doing ing Committee and Loss of Control positions that the stall avoidance and a high-altitude, low-speed stall with Avoidance and Recovery Training, recovery aspect of UPRT is valid and the autopilot engaged, [reinforced] a committee of global civil aviation important for all airline pilots, regard- how much time it actually took once authorities; and co-chairman of the less of the protective automation of you dropped the nose. … The airplane International Committee for Aviation fly-by-wire airplanes. Such training is would break the stall, but your ten- Training in Extended Envelopes Train- necessary in part to prepare flight crews dency to recover way too early and get a ing Committee. for a lower level of protection — for secondary stall was extremely impres- example, changing from normal law to sive [in] that it took patience to get the Watershed Event alternate law2 on Airbus aircraft. airplane … roughly back to about 200 In February 2009, the Colgan Air Flight “We do the stall exercises up to the kt. Anything between the 130-kt to 3407 crash in the United States (ASW, point where it is valuable,” said Jacques 140-kt stall — and even [at] 170 kt — 3/10, p. 20, and 5/12, p. 33) began to Drappier, a captain and senior adviser you get back to a secondary stall. So the raise LOC–I to the highest tier of the training, Airbus. “We’re not at the point training was fantastic.” safety agenda of the Air Line Pilots As- that we go into a post-stall situation, sociation, International (ALPA), eclips- which was the case of the Air France Notes ing airline pilot selection, licensing and [Flight 447 LOC–I, ASW, 8/12, p. 14]. 1. The Airline Safety and FAA Extension mentoring, recalled Frank Cheeseman, There you are in a totally different Act of 2010 affected many aspects of human factors and training group regime. And I don’t think anybody airline pilot licensing and training in chairman for ALPA and an Airbus is ready to go into that regime at this the United States in the wake of the Colgan Air Flight 3407 crash near A320 captain for United Airlines. point in time. … I think the limitation Buffalo, New York. “We need to give pilots the tools to is ‘What are the capabilities of training?’ survive: low-altitude, medium-altitude not ‘What are the airplane capabilities?’” 2. The Airbus system logic callednormal law provides a number of automatic pro- and, in most of our operations, high- ALPA’s Cheeseman said, however, tections against exceeding flight envelope altitude [UPRT],” he said. “It’s a pass- “There are some airlines that are parameters. Manual selection or unex- fail exercise. It’s a train-to-proficiency engaging [in simulator] training in a pected system reversion to alternate law exercise. It’s a survival exercise.” flight-protected airplane in a full-stall logic requires different flight procedures.
38 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | AUGUST 2013 Save the Date Inaugural International Aviation Safety Management InfoShare August 29–30, 2013 Singapore
CAAS brandmark with descriptor lock-up Full Colour Positive
Approved by PANTONE COATED PANTONE COATED PANTONE COATED 540 C 2925 C 227 C PANTONE UNCOATED PANTONE UNCOATED PANTONE UNCOATED 541 U 2925 U 227 U CMYK CMYK CMYK Signature/Company Stamp C:100.0 M:80.0 C:85.0 M:25.0 C:0.0 M:100.0 27 May 2009 Y:20.0 K:30.0 Y:0.0 K:0.0 Y:10.0 K:20.0 HELICOPTERSAFETY
he pilot of a Eurocopter AS350 BA prob- helicopter to remain in the Poste Montagnais ably felt pressured by his employer, his area for three days for inspections and mainte- client and his passengers when he flew an nance of Hydro-Québec installations and to be overweight helicopter into an area of dete- flown back to Sept-Îles on Aug. 20. Triorating visibility in eastern Quebec, Canada, in Héli-Excel agreed to the charter request, August 2010, the Transportation Safety Board of although the specified load would have re- Canada (TSB) said. sulted in an overweight takeoff and the pilot The 235-hour pilot of the charter flight lost had less experience than required by Hydro- visual contact with the ground and then lost Québec’s criteria. control of the helicopter, which crashed 22 nm Because an AS350 B2 was not available, an (41 km) north of Sept-Îles. The pilot and his AS350 BA — with a maximum takeoff weight three passengers were killed in the crash, and 330 lb (150 kg) less than the AS350 B2 — was the helicopter was destroyed. selected instead, and plans were made to trans- “When inexperienced pilots face operational port some of the anticipated 300 lb (136 kg) of pressures alone, without support from the com- baggage by airplane. pany, they can be influenced to make decisions Nevertheless, the morning of the flight, the that place them and their passengers at risk,” the passengers, who presumably were unaware of the TSB said in its final report on the accident. weight limit or the agreement to divert some of On Aug. 13, 2010 — four days before the the baggage to the airplane, presented more than flight — Hydro-Québec, a generator and dis- twice the expected amount of baggage — 761 lb tributor of electricity, contacted Héli-Excel to (345 kg) — mostly consisting of work tools. arrange for an AS350 B2 for the Aug. 17 charter The flight was delayed more than 90 minutes flight from Sept-Îles to Poste Montagnais, because of instrument meteorological condi- 100 nm (185 km) north. Plans called for the tions (IMC), and departed from Sept-Îles at
BY LINDA WERFELMAN
A pilot’s decision to continue a charter flight into IMC led to a fatal crash on a cloud-covered plateau.
There were no indications of problems with the engine or flight controls of a Eurocopter AS350 BA, similar to this one, that crashed in low visibility
in eastern Quebec. Drouin/Airliners.net © Jean-Phillippe
40 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | AUGUST 2013 HELICOPTERSAFETY
1111 local time Aug. 17, 2010, carrying in early 2010, receiving the required Although the forecast for Poste three Hydro-Québec employees, 561 lb ground and flight training. He complet- Montagnais had called for a 900 ft AGL (254 kg) of baggage and 600 lb (272 kg) ed a pilot proficiency check and aircraft ceiling and visibility of 20 mi (32 km), of fuel — enough for two hours of fly- type rating in June 2010. helicopter pilots reported that ceilings ing, including the required 20-minute He lacked the minimum experi- in the Moisie and Nipissis river valleys reserve. ence required under Canadian Avia- were below the mountain peaks, with The pilot had reduced the fuel load tion Regulations (CARs) for flight in “adequate” VFR visibility. because of his concern about the weight reduced visibility and therefore was The accident flight was conducted the helicopter was carrying, the report permitted to fly only if visibility was at in uncontrolled airspace below 1,000 said, adding that it was “reasonable to least 1.0 mi (1.6 km). ft AGL and therefore subject to CARs conclude that the pilot was facing pres- The TSB report noted that he had requirements calling for visibility of at sure from the passengers, who wanted not been provided with training in least 1 mi and for the aircraft to remain to keep their tools.” several areas — including “the dangers clear of clouds. At 1115, the pilot told Hydro-Québec of VFR [visual flight rules] flight in … that he might return to Sept-Îles because IMC, flying in reduced visibility, the Fleet of 20 of the weather, but at 1121, as he flew dangers of loss of visual references, con- When the accident occurred, Héli- north over the Moisie River at 150 ft trolled flight into terrain, instrument Excel had a fleet of 20 helicopters, above ground level (AGL), he said he training and recovery from an unusual including Bell 206s, 206Ls and 214B-1s, expected to arrive at Poste Montagnais attitude without visual references” — in addition to AS350s and AS355s. at 1215. and that such training was not required The company is authorized un- Although he had planned to follow under the CARs. der the CARs for day VFR flight in the train tracks north to Poste Montag- The pilot had flown to Poste Mon- uncontrolled airspace with visibility of nais, he instead continued to follow the tagnais several times, and the route was less than 1 mi, provided its flights meet river at about 200 ft AGL, then changed not considered difficult. several conditions, including that the directions several times — presumably The accident report said investiga- pilot must have at least 500 flight hours because of poor visibility, the report tors found no indication that the pilot as a helicopter pilot-in-command. said — before striking the ground on a was tired the day of the accident flight. Transport Canada (TC) found “no plateau in a mountainous area. There also were no indications of non-compliance with any operational A Hydro-Québec flight follower problems with the helicopter’s engine control aspect” during its February noticed at 1205 that the helicopter’s or flight controls that would have pre- 2010 program validation inspection location on the satellite flight-following vented normal operations. of Héli-Excel, the report said, noting system had been unchanged for six that the inspections have become one minutes. Air traffic controllers had Low Clouds of TC’s “primary surveillance tools” for received no distress signal from the Weather conditions at Sept-Îles on the operators.1 helicopter’s electronic locator transmit- morning of the accident flight included Héli-Excel has implemented a ter, but the operations manager took low clouds at 300 ft and visibility of 1.0 safety management system (SMS), but off from the Sept-Îles base at 1328 and mi, with improvement forecast after because smaller operators are not yet located the wreckage 14 minutes later. 1000. The forecast for the area to the required to have the systems, TC has north, along the planned route of flight, not evaluated its effectiveness. The First Season included broken clouds at 3,000 ft AGL TSB said it has urged all air carriers The accident pilot had obtained his and visibility of 6.0 mi (9.7 km), with a to implement SMS and added in the commercial pilot license in November slight chance of reduced visibility of 5.0 report that it is “calling for TC to effec- 2007 and was hired by Héli-Excel in mi (8.0 km) and ceilings of 800 ft AGL. tively monitor the integration of SMS March 2008 as a “gopher” — who ran At the Sept-Îles Airport, 7 nm (13 km) practices into day-to-day operations.” errands and sometimes flew helicop- southeast of the Héli-Excel base, the Hydro-Québec’s Air Transport Unit ters on non-revenue flights. He began ceiling at 1100 was 300 ft and visibility is the helicopter services industry’s his first season as a commercial pilot was 8 mi (13 km). biggest customer in Quebec, averaging
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | AUGUST 2013 | 41 HELICOPTERSAFETY
15,000 hours of flight time a year. In 1992, in the company developed a technical assessment the aftermath of several accidents, the company program, which calls for an audit about every established a qualification and technical audit 18 months, followed by an assessment of the program to evaluate the operators it uses and operator’s performance and its compliance with the way their aircraft are maintained. In 2005, contract requirements. Héli-Excel was audited under the program in February 2010 and Flight Path received an R2 rating, placing it at the second- highest level. Hydro-Québec requires pilots to have at least 800 flight hours, including 100 hours on type; 250 hours total time is acceptable, however, “if the pilot has completed the training program offered by the Association Québécoise du Trans- port Aérien,” the report said, noting that the accident pilot had not completed the training.
VFR Flight in IMC The report cited several earlier safety studies that found that about 80 percent of accidents associated with VFR flight into IMC involved fatalities. In Canada, those VFR-into-IMC acci- dents account for 15 percent of total accidents.2,3 An earlier TSB safety recommendation called for requiring commercial helicopter pilots to demonstrate their proficiency in basic instru- ment flying skills during annual check flights — a recommendation that would require heli- copters to be equipped with an attitude indicator and a directional gyro. The accident helicopter lacked those instruments, and the CARs do not require them. “The risks associated with VFR flights in ad- verse weather conditions are still significant, and TC has not indicated that it plans to take steps to ensure commercial helicopter pilots who are not qualified in instrument flying … maintain their proficiency in this regard,” the report said.
‘Another Option’ At one point in the flight, 43 minutes after takeoff, as the helicopter flew south over the Moisie River and then veered east, the helicopter had 77 minutes of fuel remaining (Figure 1). If
Note: Blocked numbers indicate local time when the helicopter reached that point. the pilot had continued toward the junction of
Source: Transportation Safety Board of Canada the Nipissis River and then on to Poste Montag- nais, the helicopter’s low-fuel light would have Figure 1 illuminated at least seven minutes before arrival.
42 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | AUGUST 2013 HELICOPTERSAFETY
Company policy is to land immediately if the that caused him to make compromises that left light illuminates, and await a delivery of fuel by him with less leeway than he had planned,” the another helicopter. report added. “Because the aircraft was approximately 24 “Resources exist to reduce these operational nm [44 km] from the departure point, it was still pressures in the form of direct supervision with possible to return to the Sept-Îles base to refuel the use of risk assessment and decision-making and depart again,” the report said. “However, the tools before takeoff. … With little support from weather conditions had been marginal at take- the company, it seems that the safety of the off, and the pilot had been unsure that he would flight rested on the pilot’s own ability to resist make it to Poste Montagnais. … the operational pressures with which he was “A helicopter pilot always has another option confronted. … — namely, to set down in a safe place and wait “From an organizational perspective, it ‘It seems that the for the weather to improve. However, none of does not make sense to expend so much effort these three options would sit well with passen- to satisfy the CARs’ numerous operational safety of the flight gers, and the pilot would have had to admit to requirements, Hydro-Québec’s audits and rested on the pilot’s the passengers, his employer and Hydro-Québec contractual stipulations, and then rely on a that he was unable to complete the flight as- young, inexperienced pilot to ensure flight own ability to resist signed to him. As the flight was also monitored safety.” by Hydro-Québec, a delay would have raised In the aftermath of the accident, Héli-Excel the operational questions about the history of the flight, increas- has taken a number of steps toward remedial pressures with which ing the likelihood that Hydro-Québec would action, the report said, including installing realize that the pilot did not have the experi- more reliable digital flight instruments, adding he was confronted.’ ence for the flight required under the contract. managers to increase pilot supervision, creating Consequently, the pilot probably chose to take a a safety system manager’s position and upgrad- shortcut to the east in the hopes of reaching the ing pilot training. Nipissis River valley and reducing the flight time In addition, Hydro-Québec introduced an to Poste Montagnais.” air safety awareness program for its employees, Minutes later, he probably continued the increased surveillance of operators that pro- VFR flight into IMC because he considered it vide its helicopter services and strengthened “the best option,” the report said, adding that requirements for completion of weight and according to the theory of cognitive disso- balance forms. nance, “his subsequent decision to continue This article is based on TSB Aviation Investigation Report on in marginal conditions may have distorted A10Q0132, “Loss of Visual Reference With the Ground, how he weighed the choice between continuing Loss of Control, Collision With Terrain; Héli-Excel Inc., the flight and initiating a diversion. The more Eurocopter AS350-BA (Helicopter) C-GIYR; Sept-Îles, consideration a pilot gives to his decision to Quebec, 22 nm N; 17 August 2010. continue flying, the more likely it is to reinforce Notes his choice, further distorting the situation he 1. A program validation inspection is defined in the is in and increasing the odds that he will make report as “a process comprised of a documenta- risky decisions.” tion review and an on-site review of one or more Immediately before the crash, the pilot lost components of an SMS or other regulated areas of a visual reference and, because he was not quali- certificate holder.” fied for instrument flight and the helicopter did 2. ATSB. Aviation Research and Analysis Report not have the required instruments, he was un- B2007/0063, An Overview of Spatial Disorientation able to maintain aircraft control, the report said. as a Factor in Aviation Accidents and Incidents. 2007. The circumstances of the accident indicate 3. TSB. Aviation Investigation Reports. A08P0383, that the pilot “experienced operational pressures A09Q0111. A10A0056.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | AUGUST 2013 | 43 DATALINK
BY FRANK JACKMAN European Safety EASA states see a decline in fatal commercial air transport and general aviation accidents.
fter suffering an average of 3.4 commercial more than 2,250 kg (4,960 lb) maximum takeoff air transport fatal accidents per year from mass (MTOM), according to the recently released 2001 through 2010, member states of the EASA Annual Safety Review 2012 (Table 1). The European Aviation Safety Agency (EASA) total number of commercial air transport (CAT) Asaw just one fatal accident in each of the past two airplane accidents per year, however, increased years involving European-operated airplanes of from an average of 25.2 annually during the 2001–2010 period, to 30 accidents in 2011 and 34 Fatal Accident Rate, EASA Member States vs. in 2012, according to the report, which defines Third-Country Operators, 2003–2012 EASA member states (EASA MS) as the 27 European Union member states plus Lichtenstein, 8 7 Norway and Switzerland. 6 Onboard fatalities declined from an average 5 of 77.8 per year in 2001–2010 to six in 2011 and 4 EASA MS operators 3-year average Third-country operators 3-year average 3 none last year as 2012’s lone fatality occurred 2 when a ground operator got trapped between 1
Rate of fatal accidents an aircraft baggage door and a baggage loader 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 during the boarding of an Airbus A320 at Rome Year Fiumicino Airport, EASA said. There were no
EASA = European Aviation Safety Agency; MS = member state ground fatalities involving CAT airplanes in Note: The fatal accident rate is created by comparing the number of fatal accidents in 2011. The annual average for the 2001–2010 scheduled passenger operations with the number of flights carried out. period was 0.8, according to the report. Source: European Aviation Safety Agency Looking back over the past decade, 2003– Figure 1 2012, the most common type of accident among
Overview of Commercial Air Transport Accidents for EASA MS Aircraft Above 2,250 kg MTOM
Airplanes Helicopters Number of Fatal Fatalities Ground Number of Fatal Fatalities Ground Period Accidents Accidents on Board Fatalities Period Accidents Accidents on Board Fatalities 2001–2010 25.2 3.4 77.8 0.8 2001–2010 13.2 3.3 17.6 0.1 (average per year) (average per year) 2011 (total) 30 1 6 0 2011 (total) 9 3 19 0 2012 (total) 34 1 0 1 2012 (total) 11 2 8 0
EASA = European Aviation Safety Agency; MS = member state; MTOM = maximum takeoff mass; 2,250 kg = 4,960 lb
Source: European Aviation Safety Agency
Table 1
44 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | AUGUST 2013 DATALINK
CAT airplanes was what EASA called “abnormal Fatal Accidents, EASA Member States and runway contact,” which includes long, fast or Third-Country Operators, 2003–2012 hard landings and scraping of wing or tail dur- ing takeoff or landing. Fatal accidents EASA MS operators EASA MS operators 3-year average The fatal accident rate for EASA MS opera- Fatal accidents third-country operators Third-country operators 3-year average 60 57 tors has remained at the same level for the past 53 43 50 45 three years, and is below the rate for non-EASA 43 36 38 37 operators (Figure 1). The number of fatal ac- 40 37 28 cidents among EASA MS operators also has held 30 20 steady at a low rate (Figure 2). 10 3 1 3 3 4 1 1 The most common type of fatal accident Number of accidents 0 1 1 0 for EASA MS operators during the 2003–2012 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 period was loss of control–in flight (LOC–I), Year “which involves the momentary or total loss of EASA = European Aviation Safety Agency; MS = member state control of the aircraft by the flight crew. This Source: European Aviation Safety Agency might be the result of reduced aircraft perfor- Figure 2 mance or because the aircraft was flown outside its capabilities for control,” according to the accidents during EASA report. There were seven fatal LOC–I the period, and the Proportion of Injury Levels for Accidents in EASA MS–Operated CAT Helicopters, accidents involving EASA MS operators during smallest MTOM 2003–2012 the 2003–2012 period. During the same period, airplanes accounted there were three fatal accidents in each of the for 21 percent. Fatal following categories: system/component failure– Among EASA 25% non-powerplant (SCF–NP), system/component MS–operated CAT None failure–powerplant (SCF–PP), unknown, fire/ helicopters, there 44% smoke–post impact (F-POST) and controlled were two fatal ac- flight into terrain (CFIT). cidents in 2012, down Accident categories are assigned based from three in 2011, on the definitions of the Commercial Avia- and an average of tion Safety Team/International Civil Aviation 3.3 per year in the Serious 20% Organization Common Taxonomy Team, and 2001–2010 period an accident may have more than one category, (Table 1). The num- Minor “depending on the circumstances contributing ber of CAT helicopter 11% to the accident,” EASA said. accidents last year EASA = European Aviation Safety Agency; MS = member EASA also categorizes accidents based on increased to 11 from state; CAT = commercial air transport the MTOM of the aircraft. Most CAT turbine- nine the previous Note: Data are for all maximum takeoff mass categories. powered airplanes fall into the 27,001 kg to year. The 10-year Source: European Aviation Safety Agency 272,200 kg MTOM range, EASA said, while average was 13.2 per Figure 3 smaller jets and most turboprops are found year, according to in the 5,701 kg to 27,000 kg range, and light the report. Onboard fatalities in 2012 declined turboprops generally are found in the 2,251 more than 50 percent to eight, down from 19 kg to 5,700 kg range. CAT airplanes in the in 2011 and from an annual average of 17.6 in 5,701 kg to 27,000 kg range accounted for 42 2001–2010. percent of the 19 fatal accidents suffered by During the 2003–2012 period, there were EASA MS operators during the 2003–2012 20 fatal accidents involving EASA MS– period. The MTOM category for the largest operated helicopters with an MTOM of more airplanes accounted for 37 percent of the fatal than 2,250 kg. The worst year during the
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | AUGUST 2013 | 45 DATALINK
The most common type of CAT helicopter EASA MS–Operated CAT Helicopters By Operation Type, 2013 accident during 2003–2012 was LOC–I, fol- 50 lowed by SCF–NP, SCF–PP, and collision with 45 obstacles during takeoff and landing, which 40 35 includes all accidents during takeoff and landing 30 in which the main or tail rotor collided with ob- 25 jects on the ground. The highest number of fatal 20 15 accidents was attributed to LOC–I and CFIT, Number of Ac cidents 10 followed by low-altitude operations. 5 When looking at type of operation for 0 Conventional Emergency Air taxi Ferry/ Sightseeing Cargo Unknown EASA MS–operated CAT helicopters in all passenger medical service positioning mass categories for the 2003–2012 period, Operation Type conventional passenger operations had the EASA = European Aviation Safety Agency; MS = member state; CAT = commercial air transport most accidents, followed closely by helicop- Note: Data are for all maximum takeoff mass categories. ter emergency medical services. Other types Source: European Aviation Safety Agency of operations analyzed by EASA included air Figure 4 taxi, ferry/positioning, sightseeing, cargo and unknown (Figure 4). Helicopters often are flown in offshore Proportion of Fatal Accidents and Fatalities in EASA MS Offshore and Non-Offshore Operations, 2003–2012 operations. According to EASA figures, 10 percent of fatal accidents in 2003–2012 in all O shore MTOM categories occurred in offshore opera- 10% O shore tions, but 21 percent of all fatalities occurred in 21% those accidents (Figure 5). “In general, offshore operations are carried out with large helicop- ters, which, when an accident occurs, could give a larger number of casualties,” EASA said. Fatal accidents Fatalities The agency calculated that the ratio of fatalities to fatal accidents is higher for offshore opera- tions (8.67 fatalities per fatal accident) than for non-offshore operations (3.63 fatalities per fatal accident). Non-o shore Non-o shore There were 918 accidents involving EASA 90% 79% MS–operated general aviation light aircraft, EASA = European Aviation Safety Agency; MS = member state those below 2,250 kg MTOM, in 2012, which Source: European Aviation Safety Agency represents a decline of slightly more than 11 per- cent from the average total of 1,035.6 per year Figure 5 for the previous five-year period (2007–2011). period was 2006, when there were five fatal The number of fatal accidents last year declined accidents. Last year and in 2010, there were 7.5 percent to 133 from an average of 143.8 per none. Looking at all the MTOM categories, year during the previous five years. The number there were no injuries in 44 percent of the of fatalities on board declined to 226 in 2012 EASA MS–operated CAT helicopter accidents from an average of 239 per year in 2011. during the period (Figure 3, p. 45). Minor or Included in the general aviation category serious injuries occurred in 31 percent of the of aircraft are balloons, dirigibles, airplanes, accidents, and there was at least one fatality in gliders, gyroplanes, helicopters, microlights, 25 percent of the accidents, EASA said. motorgliders and other.
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A Year in Review The TSB’s annual report laments inaction on key safety recommendations.
BY LINDA WERFELMAN
REPORTS work in those transportation modes percent fewer than the 2007–2011 aver- from April 2012 through March 2013. age of 808. Annual Report to Parliament, 2012–13 The report includes annual safety During the 2012–2013 period cov- Transportation Safety Board of Canada (TSB). June 2013. data in each mode for 2012, noting that ered by the report, the TSB completed 46 pp. Appendixes, figures, tables. Available from TSB at
48 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | AUGUST 2013 INFOSCAN
of safety” (“Working Safely on an Operative report said, noting that North Texas and Hous- Runway,” p. 12). ton were to be added soon. Only one of eight aviation safety items on The report said the FAA envisions signifi- the TSB’s “watchlist” of critical recommenda- cant improvements in all phases of flight within tions — calling for installation of ground- the next decade. proximity warning systems in some classes of “Technologies such as ADS–B and data aircraft — has received a “fully satisfactory” re- communications, combined with performance- sponse, the report said, describing the response based navigation (PBN), will increase safety to other items as “troubling.” and capacity and save time and fuel, decrease aircraft emissions and improve our ability to ad- NextGen Implementation Plan dress noise,” the report said. “With NextGen, we U.S. Federal Aviation Administration (FAA) Office of NextGen. June continue to advance safety as we look to increase 2013. 98 pp. Appendixes, figures, tables. Available from the FAA at
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | AUGUST 2013 | 49 INFOSCAN
FAA. Of these, 97 percent involved birds. Most This AC cancels its predecessor, AC 150/ of the strikes associated with a loss of human 5200-32A, issued Dec. 22, 2004. life involved European starlings, but ducks, geese, gulls and raptors (primarily hawks DIGITAL MEDIA and vultures) were responsible for the International Civil Aviation Organization (ICAO) most damage to civil Safety Management Website
50 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | AUGUST 2013 ONRECORD Bird Scare Leads to Overrun Fearing an imminent collision, the pilot rejected the takeoff after the aircraft had accelerated through V1.
BY MARK LACAGNINA
The following information provides an awareness of problems that might be avoided in the future. The in- formation is based on final reports by official investigative authorities on aircraft accidents and incidents.
JETS
Mired in Mud During this time, the commander saw a Dassault Falcon 20E. Substantial damage. No injuries. large bird take flight from the runway and he flight crew was assigned to conduct an then fly toward the aircraft over the runway electronic-warfare training mission with centerline. “The commander believed the bird TRoyal Air Force pilots over the North Sea represented a significant threat to the aircraft,” the morning of Aug. 9, 2012. The weather at the report said. He later recalled that he an- the departure point, Durham (England) Tees nounced “bird, aborting” at the same time the
Valley Airport, was good, with light winds. copilot called out “V1.” The crew’s preflight calculations included However, investigators determined from
141 kt as V1, which is defined by British avia- limited recorded flight data (the operator tion authorities as the maximum speed at had received an exemption from the require- which the crew must decide to either reject or ments to equip the aircraft with a flight data continue a takeoff following an engine failure, recorder and a cockpit voice recorder) that according to the report by the U.K. Air Ac- the rejected takeoff (RTO) was begun 9 kt
cidents Investigation Branch (AAIB). Other above V1. European and U.S. civil aviation authorities, The commander reduced thrust to idle,
among others, define V1 as the speed at which applied full manual braking and deployed action must be taken to reject or continue a the airbrakes; the Falcon was not equipped takeoff, with the decision already made. with thrust reversers or a drag chute. As the The Falcon was specially equipped to support aircraft neared the end of the runway, the military training missions and was close to its ap- commander told the copilot to assist him on proved gross weight of 30,000 lb (13,608 kg) when the brakes. “The copilot did so, but with no the crew initiated the takeoff near the approach discernible effect on the aircraft’s decelera- threshold of the 2,291-m (7,516-ft), dry runway. tion,” the report said. “Takeoff was continued with the standard Deceleration was reduced when the Falcon calls being made between the two pilots,” the overran the runway at 75 kt and entered the report said. “These included calls on passing 80 119-m (390-ft) stopway and 60-m (197-ft) kt and 100 kt, with the commander expecting strip, which were covered by scattered loose
the next call to be on passing the calculated V1 gravel. The aircraft then came to a stop quickly of 141 kt.” when the landing gear sank into soft ground
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on contact with the runway end safety Shortly after the ERJ-145 reached down the right engine, following which area. The pilots and the electronic rotation speed, the captain, the pilot they carried out an uneventful single- warfare officer were not hurt, but the monitoring, saw the ERJ-135 and told engine diversion and landing at New- Falcon’s engines had ingested mud and the first officer to delay the rotation. castle Airport,” the report said. stones, and the landing gear and wheel At about the same time, the controller Examination of the Rolls-Royce brakes had minor damage. said, “Traffic alert, left to right … stay RB211-535E4 engine showed that fuel “The remains of a single carrion as low as you can.” The captain re- was leaking from a flange on a fuel crow, weighing approximately 1.0 lb sponded, “Yeah, we’re doing that.” tube that runs from the high-pressure [0.5 kg], were recovered from the run- Meanwhile, the controller han- fuel pump to the fuel-flow governor. way at a point approximately 1,400 m dling the ERJ-135 had told the crew The fuel tube had been replaced dur- (4,600 ft) from the start of the aircraft’s to go around. The NTSB said that the ing the C-check in compliance with a takeoff roll,” the report said. Investiga- airplane crossed Runway 32L about 125 service bulletin. tors believe that the bird had collided ft (38 m) above and 350 ft (107 m) in Investigators found that one of the with the Falcon’s landing gear. front of the ERJ-145. two bolts attaching the fuel tube flange The report said that performance to the high-pressure pump had dam- calculations showed that if the RTO Damaged Seal Causes Fuel Leak aged threads and was loose, and that had been initiated at 141 kt, the aircraft Boeing 757-200. Minor damage. No injuries. the internal O-ring seal was damaged, likely could have been stopped with 97 he 757 had undergone a C-check with a section missing. m (318 ft) of runway remaining. and two post-maintenance test “Examination of the damaged Tflights, and was scheduled for an thread forms showed that the bolt had Controller Overlooked Conflict “airtest” prior to its release to service not been cross-threaded, rather that the Embraer 135, 145. No damage. No injuries. the afternoon of Aug. 7, 2012. The flight start thread of the wire-thread insert controller’s “lack of monitoring crew and a maintenance engineer con- had ‘picked up’ during insertion of the and lack of awareness” led to a near ducted the airtest over the North Sea. bolt, causing a progressive rounding- Amidair collision between two Em- “Approximately three hours of the over of the bolt’s thread as the bolt was braer regional jets at Chicago (Illinois) airtest had elapsed when, during a rou- tightened,” the report said, noting that O’Hare International Airport the morn- tine fuel check, the crew noticed a lateral the O-ring had been displaced and ing of Aug. 8, 2011, said the U.S. National fuel discrepancy of approximately 600 kg damaged during this process. Transportation Safety Board (NTSB). [1,323 lb], with the right wing fuel tank The fuel tube had been replaced The incident occurred in visual quantity indicating less than the left wing while the engine was mounted in a meteorological conditions and involved fuel tank,” the AAIB report said. Shortly transport cradle during the C-check. an ERJ-135, with 39 people aboard, that thereafter, the imbalance reached 800 kg “The lower parts of the engine, includ- was on a visual approach to Runway 09R [1,764 lb], causing the engine indicating ing the area where the fuel tubes were and an ERJ-145, with 45 people aboard and crew alerting system to generate a to be replaced, were close to the ground and operated by a different airline, that “fuel configuration” warning. and partially obstructed by the cradle’s was departing from Runway 32L. While helping the pilots perform steel framework,” the report said. The approach threshold of Runway the applicable quick reference hand- “These restrictions made access signifi- 09R is east of Runway 32L; thus, the book checks, the engineer saw fuel cantly more difficult than if the engine ERJ-135 would pass over Runway 32L leaking from the right engine. The leak had been mounted on its pylon or in an on its way to land on Runway 09R. was confirmed by the first officer. The engine overhaul fixture.” The controller handling the ERJ-145 commander then declared an urgency told investigators that he was “distracted and requested and received clearance Smoke Traced to House Fire by coordination requirements affecting from air traffic control (ATC) to divert Bombardier CRJ700. No damage. One serious injury. two other airplanes” and had “over- the flight to Newcastle (Scotland) Air- he airplane had been dispatched looked the arriving airplane [the ERJ- port, about 85 nm (161 km) southwest. for a scheduled flight from Den- 135] during his scan” when he cleared “The flight crew then completed the Tver to Chicago the night of July the crew of the ERJ-145 for takeoff. ‘Engine Fuel Leak’ checklist by shutting 18, 2012, with only one of the two
52 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | AUGUST 2013 ONRECORD
air-conditioning packs of the environmental evacuation. One passenger suffered a broken control system operative, according to provi- ankle during the evacuation; the other 56 sions of the minimum equipment list. Due to people aboard the airplane escaped injury. adverse weather at Chicago O’Hare Interna- An examination of the CRJ revealed no tional Airport, the flight crew diverted to Peoria obvious source of the smoke. Investigators (Illinois, U.S.) International Airport. found, however, that the pack had failed on The crew detected smoke during the ap- approach, allowing ambient air to enter the proach to Peoria and ordered an emergency cockpit and cabin. The smoke likely was from evacuation after landing. The two overwing a large house fire that the airplane had flown exits and the main cabin door were used for the over on approach, the report said.
TURBOPROPS Improper Response to RA The King Air pilot attempted several times to Saab 340B, Beech King Air B200. No damage. No injuries. tell the Saab crew that he would maintain 14,000 ft he King Air was at 14,000 ft and inbound until passing the Saab, but there was no response on an emergency medical services (EMS) on the CTAF frequency. He then received a TCAS Tflight to Broken Hill, New South Wales, traffic advisory and initiated a left climbing turn. Australia, the morning of Aug. 26, 2011, when About the same time, the Saab was climb- the flight crew was advised by ATC that a Saab ing through 13,200 ft when its TCAS issued a 340B had departed from the Broken Hill air- resolution advisory (RA) to “adjust vertical speed, port and was climbing on an opposite-direction adjust,” which requires reduction of vertical speed heading to 17,000 ft. to the indicated value of 2,000, 1,000, 500 or 0 The King Air was about 50 nm (93 km) east fpm. The first officer, the pilot flying, believing of the airport, in uncontrolled airspace, when the erroneously that they were above the King Air, crew contacted the flight crew of the Saab on the disengaged the autopilot and initiated a climb common traffic advisory frequency (CTAF) and while the captain advised ATC that they had requested their current altitude. The Saab crew received and were responding to a TCAS RA. replied that they were climbing through 12,000 ft Lateral separation was 2.2 nm (4.1 km) and were 27 nm (50 km) east of the airport. when the aircraft passed each other at 14,200 “They further advised that [the King Air] ft. “About the same time, the captain of [the was observed on their aircraft’s traffic-alert and Saab] noted that the first officer’s actions were collision avoidance system (TCAS) about 20 nm contrary to the RA and that he had initiated a [37 km], in their 1 o’clock position,” said the re- climb instead of a descent,” the report said. “The port by the Australian Transport Safety Bureau. captain immediately advised the first officer, “The pilot of [the King Air] acknowledged the who then commenced a quicker-than-expected information and advised that he also had [the descent. The captain then assumed control of Saab] on his TCAS and that both aircraft were the aircraft and reduced the descent. Separation ‘well clear at the moment.’” between the aircraft began to increase, with [the The Saab crew then changed their no. 2 Saab] descending through [14,000 ft] and [the radio from the CTAF frequency to the guard King Air] climbing through [14,300 ft].” (emergency) frequency, leaving the no. 1 radio There was no damage to either aircraft and on the ATC frequency. “The pilot of [the King no injuries to the 33 people aboard the Saab or Air], however, expected the crew of [the Saab] to the four people aboard the King Air. Both aircraft remain on the CTAF and maintain [13,000 ft], completed their flights without further incident. delaying their climb until after passing [the King “This incident emphasises the benefit of TCAS Air],” the report said. in assisting pilots with their awareness of other
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traffic,” the report said. “It is critical that pilots areas to be aware of in the cockpit. He had been respond appropriately to a TCAS RA command.” adjusting himself in the seat just prior to the engine shutting down.” Inadvertent Fuel Shutoff De Havilland Turbo Beaver. Substantial damage. No injuries. Ditch Foils Off-Runway Landing he pilot was conducting an on-demand Cessna 208B Caravan. Substantial damage. No injuries. sightseeing flight near Cantwell, Alaska, U.S., he pilot said that he regularly landed the Tthe evening of July 7, 2012, when the engine Caravan on the grassy area adjacent to the abruptly lost power. “He attempted to restart the Tpaved runway at the airport in Raeford, engine but was unable to, and elected to make a North Carolina, U.S., to minimize wear on the forced landing in a bog,” said the NTSB report. main landing gear tires. However, before Aug. The airplane’s left wing and right elevator 18, 2012, all the landings had been conducted in struck trees during the landing, but the seven the same direction. passengers and the pilot were not hurt. Returning from a skydiving flight that day, “After the forced landing, the pilot noticed the pilot decided to land in the opposite direc- that the emergency fuel shutoff lever on the tion. The airplane struck a ditch about 200 ft right side of the center console had been moved (61 m) from the touchdown point on the grassy toward the shutoff position,” the report said. area, became airborne again and landed hard, “The passenger who was seated in the right seat collapsing the nose landing gear and causing of the cockpit stated that he was unaware of the substantial damage to the fuselage. The pilot and fuel shutoff lever and was not briefed on specific his passenger escaped injury.
PISTON AIRPLANES Control Lost After Power Loss quarter turn,” the report said. During tests, the Cessna 310Q. Substantial damage. One fatality. engine operated satisfactorily with the B-nut he airplane had just undergone an annual fully tightened but immediately lost power when maintenance inspection, during which the nut was loosened a quarter turn. Tthe fuel hose on the left engine had been NTSB concluded that the probable cause of removed and reinstalled to facilitate replace- the accident was “the pilot’s delayed reaction in ment of a cylinder. “A postmaintenance engine performing the engine failure procedures and ground run was performed, and no discrepan- his failure to maintain adequate airspeed, which cies were noted,” the NTSB report said. resulted in loss of control” and that a contrib- The owner picked up the airplane at Tupelo, uting factor was “maintenance personnel’s Mississippi, U.S., the morning of Aug. 17, improper torquing of the B-nut between the fuel 2011. Witnesses heard sounds similar to a loss supply hose and the manifold valve.” of power on takeoff and saw the 310 enter a descending left turn at about 500 ft. The landing Hard Impact Avoiding Geese gear separated when the airplane touched down Piper Navajo. Substantial damage. No injuries. on a road; the 310 then struck a vehicle and he pilots were taking off from Washington several trees before coming to a stop in front of County (Pennsylvania, U.S.) Airport with two a house. The owner/pilot was killed, but no one Tpassengers for an air taxi flight the morning on the ground was hurt. of Sept. 9, 2012, when they saw a flock of geese Investigators determined that the left engine approaching from the right. “The pilot-in-com- had lost power on takeoff. “The B-nut connect- mand believed that the birds would impact the ing the fuel supply hose to the manifold valve cockpit windows, so he pushed forward on the on top of the left engine had backed off about a control yoke to descend,” the NTSB report said.
54 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | AUGUST 2013 ONRECORD
The Navajo touched down hard on the gear was pushed up through the wing and the runway and bounced. The pilots continued nose gear collapsed,” the NTSB report said. “The the takeoff and returned to the airport for an airplane subsequently exited the runway before uneventful landing. “Postaccident examination coming to rest in an upright position.” The pilot revealed structural damage to the airframe,” the and his two passengers escaped injury. report said. “Also, bird remains were found on Examination of the airplane revealed that the fuselage.” the bolt attaching the rudder trim tab to the actuator connecting rod was missing. “The Rudder Trim Bolt Removed absence of this bolt would have allowed the trim Piper Aerostar 601P. Substantial damage. No injuries. tab to swing freely on its hinge,” the report said. hortly after taking off from Alpine, Texas, The pilot told investigators that during his U.S., the afternoon of Aug. 22, 2011, the preflight inspection of the airplane, he found Spilot felt a vibration in the Aerostar’s flight that the rudder trim system was inoperative. controls and decided to return to the airport for “Unable to center the rudder trim tab, the pilot a precautionary landing. elected to remove the bolt before takeoff,” the The Aerostar struck a fence on short final report said. “The pilot further reported that he approach and touched down hard on the was planning to have the trim system repaired runway. “During the landing, the main landing when he returned to his home base.”
HELICOPTERS Unlatched Cowling Opens Rotor Drag Damper Fails Eurocopter MBB-BK 117-C2. Substantial damage. No injuries. Schweizer 269C. Destroyed. Two fatalities.
he pilot was landing the EMS helicop- he pilot was repositioning the helicopter ter on a rooftop helipad at a downtown from Saint-Aignan to Breuil in France the THouston hospital on July 24, 2012, when Tmorning of July 25, 2010, in preparation he felt a brief shudder, similar to flying for initiation flights at an air show. About 10 through another helicopter’s rotor wash. minutes after takeoff, a main rotor blade drag “The pilot was unaware that any damage had damper failed. The pilot lost control of the occurred and landed uneventfully,” said the helicopter, which collided with treetops and NTSB report. descended to the ground. A third medical crewmember boarded, and “The helicopter was being operated in the the helicopter was flown to a suburban hos- context of an aerial work company without pital. After landing there, the crew found that an AOC [aircraft operating certificate],” said the cowling on the left side of the engine had the report by the French Bureau d’Enquêtes opened during the previous landing and had et d’Analyses. struck all four main rotor blades. The pilot, also a certified maintenance tech- “The pilot stated that he failed to com- nician, recently had performed a required 300- plete a thorough preflight inspection before hour inspection of all three drag dampers and the accident flight because the crew was had signed them off as meeting specifications. assigned a medical mission just after their However, he had failed to notice “degradation of shift started,” the report said. “The pilot who the elastomer on the drag dampers,” the report flew the helicopter the evening before the ac- said. “This maintenance operation on a critical cident stated that he had opened the cowling part performed by a lone mechanic and without to check the oil level and became distracted. approval by another person or an organisation He could not remember if he had secured the independent of the operator could have contrib- cowling latches.” uted to the accident.”
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Preliminary Reports, June 2013
Date Location Aircraft Type Aircraft Damage Injuries June 1 Simikot, Nepal Dornier 228-202K substantial 7 none After a go-around in fog, the Dornier landed hard, short of the runway. The left main landing gear separated, and the left wing broke in two. June 2 Davao City, Philippines Airbus A320-214 substantial 165 none The nose landing gear collapsed when the A320 veered off the runway on landing. June 4 Petersburg, Alaska, U.S. de Havilland Beaver substantial 1 fatal, 2 serious, 4 minor One passenger was killed when the single-engine floatplane crashed in a mountain pass during a commercial sightseeing flight. June 6 Manchester, Kentucky, U.S. Bell 206L-1 destroyed 3 fatal The pilot and two medical crewmembers were killed when the LongRanger crashed in a school parking lot during approach to its home helipad in night visual meteorological conditions (VMC). June 7 Shanghai, China Embraer 145L1 substantial 44 none Instrument meteorological conditions prevailed when the nose landing gear collapsed during a hard landing. June 7 Baton Rouge, Louisiana, U.S. Beech King Air B200GT destroyed 1 fatal No one on the ground was hurt when the King Air crashed in a residential area shortly after takeoff in VMC. June 10 N’Gaoundéré, Cameroon Cessna 208 destroyed 1 fatal, 1 serious, 3 minor The Caravan was en route to Douala when the flight crew reported an engine problem and that they were diverting to N’Gaoundéré. The captain was killed when the airplane stalled and crashed on approach. June 10 Saint-Mathieu-de-Beloeil, Beech King Air A100 destroyed 4 NA Quebec, Canada No fatalities were reported when the King Air crashed in an open field on approach. June 10 Kupang, Indonesia Xian MA60 destroyed 50 NA No fatalities were reported when the MA60 crashed short of the runway on landing. June 10 Kawthaung, Myanmar Xian MA60 substantial 64 none The aircraft veered off the runway on landing and came to a stop in bushes. June 11 Talihina, Oklahoma, U.S. Eurocopter AS350-B2 substantial 1 fatal, 1 serious, 2 minor The pilot said that he lost control of the helicopter when the rotor blades struck a light pole during takeoff from a road for an emergency medical services (EMS) flight. The passenger was killed, the flight nurse was seriously injured, and the flight paramedic and the pilot sustained minor injuries when the AStar struck terrain. June 13 Marsh Harbour, Bahamas Saab 340B destroyed 21 none Storms were reported in the area when the Saab bounced three times on landing and veered off the runway. June 13 Chino, California, U.S. Canadair Challenger 601 substantial none Maintenance technicians were performing an engine test when the Challenger jumped its chocks and struck a hangar. June 18 Cincinnati, Ohio, U.S. Israel Aircraft Industries 1124 substantial 3 none The Westwind was on an instructional flight when the left main landing gear collapsed during a touch-and-go landing. June 19 Jonesboro, Arkansas, U.S. Bell 206L-4 substantial 3 none The pilot conducted a forced landing after a partial loss of engine power occurred on final approach to a helipad during an EMS repositioning flight. June 20 McClellanville, South Carolina, U.S. Rockwell 690B destroyed 2 fatal The private pilot and flight instructor were killed when the Turbo Commander crashed out of control during a flight review. June 25 Casa Grande, Arizona, U.S. MD Helicopters 500E substantial 3 minor The helicopter touched down hard and rolled over during an autorotative landing following a loss of power during a postmaintenance test flight. June 25 Chicago, Illinois, U.S. Beech King Air 200 substantial 1 minor The King Air’s right wing struck a tree during a forced landing on a road in a residential area short of the runway at Chicago Executive Airport.
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.
56 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | AUGUST 2013 66th annual International Air Safety Summit IASS 2013 october 29–31, 2013
Omni Shoreham Hotel Washington, DC, USA
IASS 2013 The 66th Annual International Air Safety Summit (IASS) will be held October 29-31, 2013 at the Omni Shoreham Hotel in Washington, DC, USA. Please visit website below for hotel details and further details about the event as they become available.
flightsafety.org/IASS2013
@Flightsafety #IASS2013 ESCO-ZA ASW Ad Aug 2013 .pdf 1 7/11/2013 5:11:24 PM
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