43225®Fli ISSUE g ht 83

S a f e ON COMMERCIAL AVIATION SAFETY t y i ss 83

14/6/11 UK FLIGHTSAFETYCOMMITTEE h fiilpbiaino h ntdKndmFih aeyCmiteISSN1355-1523 The official publicationoftheUnited KingdomFlightSafety Committee

13 “Celebrating 50years!” : 01

P age 1961 –2011 1

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Contents

The Official Publication of THE UNITED KINGDOM FLIGHT SAFETY COMMITTEE ISSN: 1355-1523 SUMMER 2011

FOCUS is a quarterly subscription journal devoted Editorial 1 to the promotion of best practises in aviation safety. It includes articles, either original or reprinted from other sources, related to safety issues throughout all areas of air transport Chairman’s Column 2 operations. Besides providing information on safety related matters, FOCUS aims to promote debate and improve networking within the industry. It Emotionally Enabled 3 must be emphasised that FOCUS is not intended as a substitute for regulatory information or by Shari Frisinger company publications and procedures.

Editorial Office: European Aviation Safety Programme 7 The Graham Suite, Fairoaks Airport, Chobham, by Rodrigo Priego Woking, Surrey. GU24 8HU Tel: 01276 855193 Fax: 01276 855195 e-mail: [email protected] Web Site: www.ukfsc.co.uk Mode S Interrogation Pattern - Operators Fact Sheet 9 Office Hours: 0900 - 1630 Monday - Friday by Philip Worgan, NATS

Advertisement Sales Office: UKFSC The Graham Suite, Fairoaks Airport, Chobham, Aviation Safety’s Weakest Link 10 Woking, Surrey GU24 8HU Tel: 01276 855193 Fax: 01276 855195 email: [email protected] Web Site: www.ukfsc.co.uk Mixed Blessings 12 Office Hours: 0900 - 1630 Monday - Friday

Printed by: Hard Lessons on Windshear 14 Woking Print & Publicity Ltd The Print Works, St. Johns Lye, St. Johns, by David R. Carlisle Woking, Surrey GU21 1RS Tel: 01483 884884 Fax: 01483 884880 e-mail: [email protected] Losing it… 18 Web: www.wokingprint.com by Captain Gavin McKellar FOCUS is produced solely for the purpose of improving flight safety and, unless copyright is indicated, articles may be reproduced providing Airstair Vigilance 20 that the source of material is acknowledged. by Wayne Rosenkrans Opinions expressed by individual authors or in advertisements appearing in FOCUS are those of the author or advertiser and do not necessarily Scheduling To Manage Fatigue 22 reflect the views and endorsements of this journal, by George C. Larson the editor or the UK Flight Safety Committee.

While every effort is made to ensure the accuracy of the information contained herein, FOCUS Members List 24 accepts no responsibility for any errors or omissions in the information, or its consequences. Specialist advice should always be sought in relation to any particular circumstances. Front Cover Picture: Air Contractors A300 Freighter at night loading.

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EDITORIAL Fatigue and Sub Part Q - A Wake-Up Call for Europe?

by Rich Jones, Chief Executive UKFSC

xtensive scientific analysis of the on in leaps and bounds. The gradual the Consultation phase of rulemaking has Ephases of flight when accidents and development of fatigue rate management attracted a record number of comments high risk incidents occur in the commercial systems is an important output of such work, which has, in turn, gained the attention of the aviation sector has shown that approach since it is the insidious and cumulative effect of European Commission, to the point where and landing brings the greatest risk. It fatigue over time that must also be taken into they have appointed a team of three fatigue requires very little scientific or intellectual account alongside the short term daily impact. specialists to review the latest EASA proposal. stretch to conclude that this phase of flight will invariably take place when the Current UK CAA regulation on flight time To say that there are many competing and crew are at their most vulnerable to poor limitations, known as CAP 371, is the result of contrary pressures being exerted on EASA, decision making and low levels of initial work by Sir Douglas Bader in 1973 when it comes to producing flight time alertness generated by fatigue. which has been further modified by scientific limitations to meet the commercial and study and practical experience. Although to safety needs of the air transport sector, is In researching the background to our some extent prescriptive, with a requirement clearly an understatement; a balance, which is understanding of effects of fatigue, I was for approval of each operator’s schedule, this firmly and fairly applied across the entire amazed to learn that the logic behind the scheme allows for a degree of flexibility to European commercial aviation sector, is vital. total number of hours that a pilot can safely cater for the significant variations in routing, But it should be borne in mind that a more fly each year was first established in the US distance, roster and sector requirements scientific approach to flight time limitations way back in the Thirties. The 900 hours limit amongst UK AOC holders. Further afield and which effectively counters short and longer appears to have been set, not based on any more recently, the FAA is now responding to term fatigue now, would be more cost- scientific analysis, but on what it was fatigue and its effects on flight crews by effective for airline operators and much more considered to be physically possible to endure developing flight time limitation regulation acceptable to the European air traveller than whilst flying mail across the vast continent of based on scientific and safety analysis a European repeat of the US ‘Wake-up Call’ America in basic aircraft. expertise. Sadly, it took the Buffalo accident from Buffalo in 2009. to drive fatigue up, and onto the top of, the I was equally astonished to learn that science US safety agenda. once again failed to intervene in the logic of flight time limitations in the Forties, when the So where are we going in Europe? Although annual flying hours allowed was increased to the environment and operating conditions do 1000 hours. This revision was based on the vary between road and air, comparison of the notion that American aviators, with the US European Union rules are useful indicators of having joined in the Second World War, should the application of science and experience to demonstrate their commitment and support the man-machine interface and effects of to their country by increasing the hours they fatigue on performance. The rules for would be willing to fly. Once the war was commercial lorry and coach drivers are won, the limit reverted back to 900 hours and straightforward and are legally enforced there it has stayed for the past 65 years. through regular checks of their ubiquitous tachograph; 4 and half hours driving, 45 We are all aware that aviation safety has minutes rest, a further 4 and a half hours moved on significantly, in parallel with driving. An extension to 10 hours for 2 days commercial air transport manufacture and each week is allowed. And that’s it for the training since the Forties. Air accidents remainder of 24 hours. numbers have been reducing by roughly a half every decade up until the last one, when air Turning to the aviation regulator’s approach, a accidents appear to have reached an good start was made in 2008 when EASA undulating statistical plateau. No doubt, commissioned the Moebus Report, consisting increasingly more sophisticated flight time of a team of scientific and human factors limitations such as individual flight duty aviation fatigue experts, to assist in EASA’s periods, specific rest periods between duty and evaluation of the likely Sub Part Q regulation set hours for a set number of days have all on flight time limitations. Unfortunately, it made a contribution towards this reduction. appears that the recommendations of the Science and our understanding of human report were widely disregarded by EASA in the factors as they apply to fatigue have also come resulting draft EU Ops Sub Part Q. However,

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CHAIRMAN’S COLUMN

“Security And You”

by Capt. Tony Wride, Monarch Airlines

watched with interest the events that amazing to hear the complaints from crews A330 that crashed into the Atlantic. So much Ioccurred recently and were reported in about inconsistency in security screening not has been speculated about this aircraft loss the news. The first major event was because the screening is lax but because it is with lawyers going after Airbus, Air France, something that I fear could have serious too thorough! We had the benefit a while and Thales for compensation. Hopefully the repercussions on the Aviation Industry, back to have the person responsible for recorders will finally provide the answers as to perhaps more so than the tragedy that was setting DfT policy on screening give the what exactly happened and we can all learn 9/11 and ultimately led to what happened Committee a presentation which explained from it. If it's identified as an equipment recently. It could be argued that the Navy the rational behind what was happening. malfunction then that equipment can be Seals that finally found and killed Osama Personally I take the view that the Security modified. If it's identified as pilot error, Bin Laden concluded the long overdue staff have a task to perform to ensure our perhaps due to a training deficiency, then revenge (justice?) for the loss of lives at safety so if they need me to strip off, do a training can be modified. If however the cause the World Trade Centre and other terrorist handstand, and empty my case then that's is identified as the aircraft flying into severe attacks over the last decade. It could also what I will do! I may not enjoy doing it but if weather conditions and getting into an be argued that by killing Osama Bin Laden that's what's required to ensure nothing unrecoverable state what are we going to do, those Navy Seals had simply fuelled an dangerous gets onto my aircraft then it has to sue Mother Nature? Perhaps if the weather is already burning fire and giving the be done. But it's not just the Security staff identified as being the cause then it will serve terrorists even more justification for that are responsible for security it's all of us! as a timely reminder that the environment in carrying out their acts. Only time will tell which we work can be hostile at times and but I fear that the latter is what's going to Anybody planning an attack on an aircraft, seriously threaten safety. happen and as an Industry we will have to airport, or wherever, will carefully study the be even more vigilant with our security. target and identify the weak points that will As my 2 year term as Chairman ends, in enable them to achieve their aim. If they accordance with the UKFSC Constitution, I If you had to nominate “The Person Who Has identify that screening of airport staff and would like to thank all the membership for Had The Greatest Impact On Commercial access to the ramp area is not strictly your support, not just while I've been Aviation In The Last Decade” who would you controlled then that will be their way in to do Chairman, but also during the 8 years that I choose? You might nominate the inventor of their worst. If they know that screening of have been part of the Committee. I've the Southwest Airlines business model who pilots and crew is particularly lenient then certainly enjoyed being an active member of enabled the masses to fly for peanuts but who that's what they will use. Remember that just the Committee and I will miss seeing you at has forced many airlines to the very brink of because you have known somebody for a year the meetings. Your new Chairman will need survival. You might nominate the Boeing CEO or two doesn't mean you really know them. your support and I'm sure you will provide it. for the revolutionary B787 that at the time of Their family could be being held hostage and Keep Safe! writing, is years late and still grounded, leaving they could be forced into doing something companies still dreaming of their Dreamliner. they wouldn't normally do. Alternative they Or you could nominate Osama Bin Laden! No, could have long standing beliefs and have been I'm not joking! If you think about our industry waiting for the right opportunity to strike. before he came onto the scene and the 9/11 tragedy and compare it to now a lot has As the Summer flying ramp up starts a large changed because of what he instigated. number of new and inexperienced staff are recruited into our industry.They should all have Security was always something we had to been security screened and undergone security take seriously in our industry but before 9/11 training but they are an unknown commodity some parts of the world had become blasé and have a lot to learn. They will follow the about it, allowing curb side check-in and very example set by the experienced staff so if you lax screening of hand baggage and aren't vigilant then they won't be! passengers. In the UK we had lived under the terrorist threat from the IRA for decades so The message is simple. Be vigilant and always we did take security seriously. After 9/11 challenge if you are not sure about somebody aircraft had to be modified with secure flight or something, it just might save your life or deck doors, security screening had to be the lives of others. stepped up to a state now where as you pass through security they can almost tell you The other item in the news was the discovery what you ate for breakfast! I still find it of the flight recorders from the Air France

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Emotionally Enabled

by Shari Frisinger ‘Emotionally Intelligence’ means being aware of an entire crew’s mental state, not just your own.

e watched in astonishment when WChesley Sullenberger in early 2009 skillfully piloted US Airways Flight 1549 to a safe landing in the Hudson River, and listened in horror a month later when we heard of Colgan Air Flight 3407 crashing into a Buffalo, New York, U.S., suburb.

Among the factors that caused one perfectly good aircraft to fall out of the sky, killing 50 people, while another very crippled aircraft made a safe water landing that resulted in only a few minor injuries, technical flying skills obviously play a major role. However, success or failure to a large degree can be linked to the captain’s ability to control his own emotions in order to think clearly, while being aware of Many years ago, airlines implemented cockpit crew and passengers is the combination of the crew’s emotional and mental states. resource management (CRM) techniques to the leader’s objective thought process and his enhance crew coordination. This new concept or her emotional awareness. When the role pilots play in aircraft incidents was partially based on a U.S. National and accidents is considered, the initial focus of Aeronautics and Space Administration The word “emotion” may conjure up negative the U.S. National Transportation Safety Board investigation that discovered a common elements that tend to degrade safety: anger, (NTSB) and many analysts is on the technical theme in many accidents — failure of fear, crying, shouting and other unhelpful abilities of the pilots: When was their last leadership and ineffective crew interaction. behaviors, but everyone every day recurrent training? How many flight hours did experiences more subtle varieties of emotion.2 they have in the aircraft type? How many CRM focused on how the crew interacted in In the cockpit this might include satisfaction total hours of flight experience?1 But some the cockpit, not necessarily on acceptable or for having achieved a smooth landing, pride in time ago it was realized that technical skills appropriate cockpit behaviors. During the first maneuvering around turbulence, excitement are not the only desirable traits a captain decade of CRM use, it morphed into crew in getting desirable days off, irritation when should have. resource management, to include helping all plans don’t work out, and sometimes crewmembers work more effectively as a annoyance with others. team, improving situational awareness and providing techniques to break the error chain. Regardless of the situation, there always exists some degree of emotional response, and CRM has become a training mainstay.To date, emotions are simply another type of CRM has included only the technical skills and information that must be considered in making thinking abilities — analytical, conceptual and effective decisions, especially in a team problem solving. However, research beginning environment. A high degree of situational in the 1980s demonstrated that emotions awareness relies on a person being attentive to greatly influence a person’s cognitive abilities. the environment. Internal situational awareness A major factor in maintaining the safety of consists of understanding one’s own emotions the crew and passengers is the combination To be effective, the next level of CRM needs to and emotional triggers. External situational of the leader’s objective thought process include more of the “people” side — self- awareness involves insights into team members’ and his or her emotional awareness. confidence, teamwork, cooperation, empathy moods and unspoken communication, and and flexibility in thoughts and actions. A appropriately addressing them. major factor in maintaining the safety of the

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The cornerstones of emotional intelligence Today’s fears, threats and dangers are not uh, I spent the first three months in, uh, (EI) are consciousness of one’s thoughts and unlike those of prehistoric man. A flight Charleston,West Virginia and, uh, flew but I — moods, of how the behaviors resulting from department manager who needs to justify the first couple of times I saw the amount of ice those impact and influence others, and of the expenses of his department can experience that that Saab would pick up and keep on moods and behaviors of others.3 People with a the same “fight or flight” reaction that the truckin’… I’m a Florida man…”Then he added, high level of EI recognize and control their caveman did when faced with a saber-toothed “There wasn’t — we never had to make own emotional outbursts, step back from the tiger. A similar reaction occurs when people decisions that I wouldn’t have been able to heat of any situation, analyze it objectively feel their reputation or credibility is make but ... now I’m more comfortable.” The and take the appropriate action that produces threatened. Fear and stress envelop thinking captain was still unaware of what was rapidly the most desirable results. and people over-focus on a narrow selection of developing around him, chatting while the solutions, disregarding alternative approaches. aircraft’s airspeed rapidly decayed. His failure A person’s perception of reality shapes to quiet his instinctive emotions narrowed his emotions and feelings, and these drive When people allow their stressed brains to perception to the point that airspeed, one of thoughts and behaviors. Status quo is overtake thoughts, the perspective narrows the most basic elements of flying an airplane, maintained until new strong feelings are and the main focus becomes escaping from no longer had his attention. experienced. Simply being unhappy in a job is the situation. Unable to think of alternatives, usually not enough to warrant a change. they don’t see the “big picture” or question There were few instances when the captain Getting passed over for a promotion, assumptions. At this level of thought, referred to the first officer’s health. He did not accompanied by the belief that the decision perception of the complexity of the situation ask how she felt about her ability to perform was wrong, usually sparks anger and an active becomes paralyzing, and the focus is on her flight duties, even though she sneezed job pursuit. The amygdala is the part of the current limitations. twice and six minutes later, she mentioned brain that controls a person’s level of her ears. Basic understanding of CRM and emotional reactivity. It never matures, and, if Remember the last time you became angry crew performance should have tipped off the left unchecked, it can bring chaos to a life. To during an argument? It probably wasn’t until captain that the first officer was not feeling compound the problem, the human brain later, after you could see the situation well that day and her performance could be instinctively cannot distinguish between a without emotion, that you thought of several negatively impacted. A person with higher EI real threat and an imagined one. obvious points that could have helped your could have recognized that, and probably case. These become apparent because your would have been empathic to her condition Sitting in a theater, watching a panoramic or rational mind was back in control. Your and her inability to actively participate as a 3-D movie, the sudden loud sound of an primary focus, in the midst of that argument, viable crewmember. airplane approaching will make most people was to defend yourself. Success is more reflexively duck. Intellectually, they know the assured when this emotionally downward The captain told stories for most of the flight. airplane is not real, but the emotional brain spiraling thinking is halted and the problem is At one point, he rambled for over three hears the loud sound and tells the body it addressed more creatively. minutes while the first officer only said 34 needs to avoid getting hit. When a situation words, most of which were “yeah” and “uh- changes, the emotional brain determines if The next level of CRM needs to include more huh.” Research on how the mind processes the stimulus causing the change is a threat. If of the ‘people’ side — self-confidence, information has revealed that people can only a threat is sensed, awareness becomes teamwork, cooperation, empathy and consciously execute one task at a time, and heightened and physiological changes take flexibility. unconsciously perform one additional task. place to cope with this new danger. When driving in heavy traffic or merging onto Adrenaline is released to pump the heart The captain in the Colgan Air 3407 accident a freeway, are you able to continue your faster and prime the muscles for action. chose the “flight” reaction; he chose to avoid conversation? Your mind moves from the a developing situation.4 When the first officer conversation you were having to looking at If the situation is later deemed to not be a brought up the icing conditions — “I’ve never traffic, calculating vehicle speeds and analyzing threat, logic and objectivity take over again, seen icing conditions. I’ve never deiced. I’ve the best opportunity to speed up and merge. but it takes four hours for the adrenaline to never seen any, … I’ve never experienced any Your automatic mind does not have the ability dissipate from the body. of that” — the captain’s response was, “Yeah, to safely handle non-routine driving tasks.

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these ways, the captain would have reflected the emotional pressures he was experiencing, and, as a result, his crew would have had his pressures added to their own. Instead, he worked as part of the crew, alternating between giving direction and explaining his actions and taking input from anyone in the cockpit, including a training pilot. Emotions are contagious, and the strongest expressed emotion will be felt unconsciously by others and mimicked.

In this case, the captain’s calm demeanor was mirrored by the crew and they were able to contain their emotional reactivity.

Captains infected with ‘captainitis’ are so situational awareness of the Colgan and Aviation history is overflowing with accidents absorbed in their own world that they lose United crews to those of the captain of the due to pilot error. Many of them could have their situational awareness. US Airways A320 that landed in the Hudson been avoided if the crews were more aware of River. Sullenberger kept his emotions under their own emotional reactivity and those of the A classic example is United Airlines Flight 173, control and remained focused on doing his others. Captains infected with “captainitis” are a McDonnell Douglas DC-8, which in 1978 was job — to safely land the plane. so absorbed in their own world that they lose destroyed when it crashed during an approach their situational awareness. to Portland (Oregon, U.S.) International Airport.5 The captain’s words “my airplane” when he The captain’s intense preoccupation with took over the controls after the bird strike The captain in Colgan Air 3407 was self- arranging for a safe emergency landing could have been trigger words, words to focus absorbed, talking about himself for nearly 20 prohibited him from considering other on, snapping his rational brain into action and minutes of the last 40 minutes of the flight, anomalies. His concentration was so focused on putting him into a safety frame of mind. missing a number of clues that eventually led the emergency landing checklist that he did not to the crash; on the other hand, the captain of modify his plans when the first officer and flight He repeated the commands from the first US Airways 1549 maintained his composure engineer twice warned him about their officer, indicating that during those critical throughout his short flight and focused on airplane’s dwindling fuel supply. Ten people seconds there was no room for any every element of the emergency. were killed when the aircraft crashed into a misunderstanding.This flight crew’s emotional wooded area due to fuel exhaustion. intelligence was as good as it gets, which Why is EI relevant? The Center for Creative enabled their processing information quickly Leadership found that the leading causes of The NTSB said, “The probable cause of the and using every resource available to them at failure among business executives are accident was the failure of the captain to the time. inadequate abilities to work well with others, monitor properly the aircraft’s fuel state and to either in their direct reports or in a team properly respond to the low fuel state and the The captain of United Airlines Flight 232, environment. Another study of several hundred crewmembers’ advisories regarding fuel state. a McDonnell Douglas DC-10 that in 1989 executives revealed a direct correlation …His inattention resulted from preoccupation attempted to land in Sioux City, between superior performance and executives’ with a landing gear malfunction and Iowa, U.S., with catastrophic hydraulic and ability to accurately assess themselves. preparations for a possible landing emergency.” flight control systems failures, could have reacted to his challenges by becoming What actions demonstrate an increased This accident was one of the key events indecisive, shutting out the crew or dictating level of EI? driving the adoption of CRM in airline orders to them.6 If he had responded in any of training. Contrast the reactions and

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■ When crewmembers voice their concerns ■ Put yourself in the other person’s position. 6. Aviation Safety Network. . in a calm, firm manner, giving evidence to How would you react if you were on the back up those concerns; receiving end of your emotions? The other 7. Helmreich et al. person’s brain will send him through the ■ When leaders acknowledge the same fight/flight/freeze reaction that Reprinted with kind permission to Aerosafety atmosphere and question crewmembers yours is experiencing. World August 2010 in a non-defensive manner to determine the causes of the uneasiness; and, Imagine both people fighting for their pride or their reputation – chances are slim that the ■ In a crisis or stress situation, when leaders discussion will end well. maintain their composure and communicate more frequently and more Leaders need a considerable amount of calmly with the crew. cognition.7 The ability of the leader to broaden his or her focus from technical and task-related There are several techniques that can raise activities to include an awareness of the moods your level of EI: of the crew is critical to success. It would benefit all parties to know which skills in ■ Be aware of the thoughts going through specific circumstances are most appropriate. your mind. Are they stuck in the past and wallowing in problems, or are they A leader’s behaviors directly affect the team’s focused on the future and actively looking disposition, and the team’s disposition drives for solutions? Once we choose negative performance. When the leader can analyze thoughts, they can very easily spiral and manage his or her own emotional downward, the cycle descending into reactivity, the team members can more easily hopelessness. manage their own emotions. How well the leader performs this can have a direct effect ■ Acknowledge your emotions. Remember on the safety and morale of the crew. they are neither good nor bad, they are what they are. Next, identify these Shari Frisinger, president of CornerStone Strategies, , is an adjunct faculty member in emotions: Angry? Irritated? Defensive? the Mountain State University Aviation Department and Disappointed? Guilty? Frantic? Miserable? School of Leadership and Professional Development. Naming your emotions makes them less abstract and helps release their influence on you. It becomes easier to detach Notes yourself and think objectively. 1. Helmreich, R.L.; Merritt, A.C.; Wilhelm, J.A. “The Evolution of Crew Resource Management Training in Commercial ■ Look back over your previous reactions. Aviation.” The International Journal of Aviation Psychology. Jan. 1, 1999. How could you have made a better choice? What information and 2. Goleman, D. “What Makes a Leader?” Harvard Business Review. Jan. 1, 2005. alternatives are clear now that weren’t at that time? As we frantically search for 3. Mayer, J.D.; Salovey, P.; Caruso, D.R. “Emotional Intelligence: Theory, Findings, and Implications.” quick solutions to rectify the situation, we Psychological Inquiry. Jan. 1, 2004. automatically use the techniques that we 4. NTSB, Colgan Air 3407 cockpit voice recording. have used before, whether they are the . best choice or not. Our mind is not free to 5. Aviation Safety Network. .

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European Aviation Safety Programme, a pioneer approach for safety in Europe

By Rodrigo Priego, Safety Risks Expert - European Aviation Safety Agency

n order to further improve the already Europe is pioneer in this endeavour as no industry is still in its infancy. Indeed, ICAO has Ihigh level of safety obtained in the civil other region in the world has similar introduced a paradigm change which is being aviation industry, ICAO has promoted the documents that turn safety management into deployed at the moment. This change of principles of safety management1 action. Both elements have been warmly paradigm consists of two elements: SMS/SSP revolving around Safety Management endorsed by the Management Board of the and performance based regulation using a Systems (SMS) for industry organisations Agency in December 2010. total system approach. To take into account and State Safety Programmes (SSP) for this changing environment, this part of the contracting states.When developing these document proposes aspirations as well as principles, ICAO mandated that all The main elements existing processes. It constitutes EASAC’s contracting states have an SSP, but certain proposal for transitioning towards a safety political systems such as the one set up in The proposed approach for European aviation management approach which encompasses the European Union need further safety is based on three elements: this change in paradigm that is not consideration. implemented today in all cases. The proposal ■ A set of policies and objectives from places the collective management of safety at The sharing of roles between the European political authorities (the strategy). the core of the aviation system. Union and the Member States, as described in ■ the Basic Regulation makes it impossible for An integrated set of regulations and The EASP manual is an initial document. As the Member States to alone take full activities aimed at improving safety (the the implementation of the safety responsibility for an SSP. Many States do not programme). management principles develops, the system have such a programme today.There is a need will have to evolve. The institutional ■ for a European Aviation Safety Programme A high level safety issues assessment and framework adds an extra level of difficulty to (EASP) to complement what is done by the related action plan (the safety plan). an already complex exercise. That is why the Member States which encompasses the document must serve as a basis for a powers transferred to the Union. collaborative development of a more mature The Manual EASP in the future. Collaboration is the key to In view of this need and in order to streamline the successful implementation of safety the strategic approach, a European Aviation A manual describes the EASP and how it management. This is especially true in our Safety Advisory Committee (EASAC) was should function. It comprises a set of case and may well serve as a model for other established in October 2009 with processes and activities. regional cooperation approaches. representation from industry, some Member States, EUROCONTROL, the European It is divided in two parts. The first part The EASP also aims at providing assistance to Commission and the Agency. Its fruitful addresses the European aviation safety Member States in preparing their SSPs. It gives guidance and the collaboration mechanisms system created by the Basic Regulation, the so the European view of the different interfaces established have culminated in the called EASA system. It sets the scene. It and of the common issues to be addressed. development of two important elements of describes the different actors, their roles, their This European vision is fundamental to the the EASP: a manual and a safety plan. responsibilities and how they interact with collaborative approach and vice-versa. Indeed, each other. This is fundamental to a common understanding of how the EASA The last piece of the puzzle will be provided by understanding how the system can be used to system functions and of the roles and the European Commission in the form of a improve safety. The document also describes activities of all the actors is the basis of the suitable strategy for the future of European the external actors who influence the system. teamwork we will have to set up in order to aviation safety. This will be a high level They are quite varied and also have a succeed in this challenging endeavour. statement expressing where we wish to be in significant role on the functioning of the a few years; thus providing direction. With system. these three elements: a strategy, a The Safety Plan programme and periodic safety plans the The second part describes how the system picture is complete. should work to continuously improve safety. The management of safety has evolved over The introduction of formalised safety the years. The review of the rare accidents management in all sectors of the civil aviation that occur is not enough to achieve

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significant improvement; incidents and internal safety programme. It builds a network The ultimate value of this Plan resides in the occurrences must be analysed to understand for action. Coordination and close actions it contains and stakeholders’ the risks to aviation safety. Improving our collaboration are key to keeping it up to date commitment to implementation. It is safety records has become a challenging job and effective. a living document. that requires collective effort and prioritisation of scarce resources. The publication of a Safety Plan shows the Content of the first Safety Plan Notes European commitment to action. This first edition of the Plan encompasses 1. Requirements are now included in ICAO Standards: Annex 6, 8, 11, 13, 14 and parts of Annex 1. The intention behind such a document is to three broad areas: systemic, operational and close the safety management loop by emerging issues. The risks identified in these 2. ECAST is the European Commercial Aviation Safety Team, a component of the European Strategic Safety connecting the safety issues identified at areas are mitigated by safety actions that Initiative (ESSI). ESSI is an aviation safety partnership European level through the analysis of safety Member States, EUROCONTROL, the between EASA, other regulators and the industry. For more occurrences with the action plans and European Commission, the industry and the information visit http://www.easa.europa.eu/essi/ initiatives launched to mitigate the Agency will consider taking on board. All the underlying risks. It states the European will to partners work together, streamline their resolve the key issues that concern aviation activities and add their efforts to drive our safety. accident rates even further down.

The first edition has been developed following Among the systemic issues within the Plan is a bottom up approach. The initial priorities the implementation of Safety Management have been set up by aggregating the national principles in the States and across industry, priorities provided by the Member States. along with the enablers of such These priorities have been compared to implementation. These principles will have to priorities established by ECAST2, be embedded in a system that is becoming EUROCONTROL or the Agency. more and more complex.

This first version of the Plan allows starting a The operational issues cover the main risk areas process of fruitful exchanges between the that affect fixed wing commercial air transport various actors (EC, EASA, Member States, operations: runway excursions, mid-air collisions, EUROCONTROL, stakeholders and safety controlled flight into terrain, loss of control in initiatives) and will be a clear sign of Europe’s flight and ground collisions. Most safety determination to achieve high consistent outcomes fall under one of these broad families. levels of safety. Some of the operational issues affecting other types of operation like helicopters or general Future editions will follow a more robust aviation are also addressed. cooperative methodology as opposed to the one (bottom-up) used for this first version. Actions to address issues that are emerging, The principles for development of the next like the introduction of new systems and plans are described in the EASP manual. types of operations, new regulatory and oversight approaches, environmental factors The Safety Plan proposes a path for the next or the next generation of aviation 4 years that depicts a comprehensible picture professionals have been also identified of the safety work in Europe across all in the Plan. domains of aviation. It establishes the first layer of priorities which is further Human factors and human performance complemented at national level by safety affect all the above areas and are addressed in plans and SSPs and at Agency level by an a dedicated section.

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Mode S Interrogation Pattern – Operator’s Fact Sheet

by Philip Worgan, Systems Engineer, NATS

What is the current situation? What do these False Targets look like to controllers?

s part of the transition to Mode S, Figure 1 - Reflection of aircraft near Biggin Hill appears close to Luton Approach – this would not ANATS radars were configured such that appear had the radar be configured in the new Mode S pattern. Mode S equipped aircraft would respond with both a Mode S and a Mode A/C reply as a failsafe to protect against possible transponder anomalies.

Whilst using this mixed interrogation pattern Reflection of aircraft that in does provide a belt and braces approach to reality is near Biggin Hill detection it also has the following issues:

■ It places the radio spectrum under much greater strain increasing the risk of corruption or reduced detection.

■ It causes a number of false targets to be presented to controllers, including:

■ Reflections (where a radar detects a second copy of a real aircraft in a false position some way from the true aircraft) Figure 2 - Splits and Corruption in the Lamborne Stack. One aircraft is detected as two with the same identity (505) but corrupt and different heights this then leads to a false conflict alert with a ■ Splits (where the Mode A/C and Mode second non existent aircraft, that results from a subsequent corruption of identity (505->168) – S returns appear as two separate this would not have occurred in the Mode S pattern. aircraft side by side)

What is changing?

In response to The National IFF/SSR Committee (NISC) letter (Ref. 8AP/65/ 02/58_SS3/07/102) we have now started to reconfigure our radars so that Mode S equipped aircraft will only respond to Mode S interrogations.The requirement they have set, is to complete this by 31/12/2011. ■ ■ Mode A/C equipped aircraft are unaffected by A random fault which has occurred with a If you are a military operator and have the this change. particular installation (e.g. a loose ability to disable Mode S responses from connection, damaged feeder cable or within the cockpit please ensure that any When is the change being made? faulty weight on wheels switch) time you have Mode A/C enabled you also have Mode S enabled. ■ Five radar stations spread across the UK Controllers will inform the pilots of aircraft that they cannot see and amend their What Types are affected? have already been switched across - these clearance as appropriate – this may involve are being used to identify aircraft faults aircraft being refused access to controlled Many different types of aircraft are affected through analysis. airspace. Reports on these occurrences will be (Micro-lights to 747s), and a random fault may ■ raised in the normal way and the aircraft occur with any type of transponder. However NATS is planning to re-configure the operator informed. systematic design or implementation issues remaining radars to a Mode S interrogation account for a large proportion of faults pattern by the end of June 2011. NATS are working with other ANSPs and the observed, associated Air Worthiness Directives UK CAA through Eurocontrol to address the have been published on the following So what’s the catch? issue and are also engaged in offline analysis transponder types: to provide early notification to operators of A small number of Mode S transponders do not issues before an event occurs. ■ Rockwell Collins TDR-94 and TDR-94D reply correctly to Mode S interrogations and ■ Honeywell MST-67A these aircraft will therefore be undetected by a What should Operators do? ■ Funkwerks/Filser Avionics TRT-800 and Mode S interrogation pattern.This may happen TRT-600 for a number of reasons: ■ Respond as soon as possible to resolve any ■ Narco Avionics AT-150 issue with a particular airframe if it is reported ■ Terra TRT-250 ■ A design fault with a particular to you by CAA, NATS or another ANSP. transponder type For more information, search for “transponder” ■ Be proactive in looking at airworthiness at http://ad.easa.europa.eu/ ■ A systematic fault with the way an directives and manufacturers service aircraft manufacturer fitted a transponder bulletins to identify and fix issues which to an aircraft type (e.g. crossed wires) may exist within your fleet.

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Aviation Safety’s Weakest Link Can Also Improve It

The majority of aviation accidents today are related to human error, but the human element is also that which can lead to greater aviation safety. Chuck Weirauch gives an update on human factors training.

n April 26, 2010, the FAA released OInformation for Operators (InFO) 10003 on Cockpit Distractions, which addressed “the safety risks of personal electronic devices in the cockpit.” Presumably this document was in response to the incident when the flight crew of Northwest Airlines Flight 188 overflew the Minneapolis-St. Paul International Airport last year when they reportedly became distracted while using their laptop computers in the cockpit. However, ultimately it is just another example of the increasing focus on human factors on the flight deck by the agency, other regulators and the airline rollout to takeoff because of distractions. And Technical Advisor for Flight Deck Human industry throughout the world. of course, distractions that implied a violation Factors. “It’s not just the individuals that are of the sterile cockpit rule, along with crew out there flying the airplane or maintaining Since the InFO also called for training directors fatigue, were considered by the NTSB as them or controlling them that have a role in to “review and reinforce crew training on this factors that led to the crash of Colgan Air these safety events, it’s the environment in subject” as a Recommended Action, it was also Flight 3407 in February 2009. which they operate as well. So I think that another reminder of the correlation to and much of the intent of things like safety importance of human factors in aviation According to various aviation sources, such management systems are intended to address training. Human factors elements have long human error has been identified as a causal some of these factors.” been considered a part of crew resource factor in 60 to 80 percent of aviation incidents management (CRM) training from a crew and accidents. An Airbus Flight Operations Rather than citing a list of the key human communications and human performance Briefing Note goes further than that, stating factors most often implicated in incidents and aspect, and are increasingly becoming a part of that “ultimately, human factors are involved in accidents, such as fatigue, the FAA is taking a threat and error management (TEM) training, all incidents and accidents.” Since aircraft global approach to human interaction with as well as safety management systems (SMS). technology has advanced to the point where aircraft operations. According to John Duncan, equipment and mechanical failures have been Manager of the FAA’s Flight Standards Air greatly reduced, the effort to further improve Transportation Division, the agency is looking aviation safety has focused on the reduction at all aspects of air carrier operations that of human error. impact human factors within an organization. Some specific areas on the flight deck include Distractions and fatigue are just two human not only the direct interfaces between factors that have been implicated in aviation automation and the crew, but the design of incidents and accidents. Others include lack of the tasks and procedures involved with communication, complacency, lack of automation and how they might “load up” the knowledge, lack of teamwork, lack of resources, crew, he explained. pressure, stress, lack of awareness and traditional “norms”, or the “that’s the way we Many aviation safety experts and others in the Above John Cox and. Kathy Abbott provided a have always done it” attitude. While in the US international aviation industry agree that joint human factors presentation at WATS. most of the recent human factors awareness human factors must be considered in all Image credit: David Malley/Halldale Media. efforts have been directed at maintenance aspects of organizations and systems, including personnel and for flight crews through CRM, it John Cox, President and CEO of Safety Human Factors Impact is also becoming understood that human Operating Systems. He and Abbott provided a factors awareness and training is vital for the joint presentation on aviation safety and The Flight 188 debacle is just one example of whole of aviation systems and organizations as training at the 2010 World Aviation Training how a distracted flight crew could lead to an well. That is because the responsibility for Symposium and Tradeshow (WATS) in April. incident or accident. During the ongoing incidents and accidents can no longer rest solely National Transportation Safety Board (NTSB) on the shoulders of the flight crew members “Human factors needs to be included in the public hearings that were being conducted in and maintenance personnel involved in very first step of any aviation endeavor, be it May in relation to H.R 3371, the Airline Safety incidents and accidents. design, certification, training or operation,” Cox and Pilot Training Improvement Act, it was said. “Human factors needs to be a seamless reported that the flight deck crew on two “We have to consider that organizational integration throughout the entire industry regional airliners in two separate incidents factors can play a role in accidents,” said Dr. because we have been and will be dependent “forgot” to start the second engine before the Kathy Abbott, the FAA’s Chief Scientific and on humans to sort things out. Automation is

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great and has helped reduce the accident rate, because we are finding that there is inadequate approach procedures design and the way new so now we need to focus on such human knowledge by too many pilots on basic technologies are used on the flight deck is elements as loss of control as the key to aerodynamics and stall recovery procedures. something we have studied from the further reducing the accident rate.” From an academic standpoint, we have to beginning to ensure that they are optimized demonstrate proper procedures in flight for what the pilot is going to use them for.We Human Factors and Training simulation and even the use of actual inflight have made changes to improve human training. All of these will bring together a pilot performance in the area of RNAV instrument During the WATS presentation,Abbott and Cox group that is more capable of dealing with a procedure design, for example.” cited a number of human factors-related loss of control event.” elements involved in a recent analysis of Another recent effort is the development of airliner accidents. Of those accidents studied, Flight Deck Automation new regulations on the aircraft certification inadequate knowledge was considered to be a side to help address design related pilot error, causal factor in slightly over 40 percent of the While automation on the flight deck has Abbott pointed out. This is to ensure that accidents.While this area “is a critical piece for helped reduce accidents, it has also increased newer aircraft have equipment with design training,” it can’t be considered just as what in complexity as more advanced flight systems characteristics that are known to reduce such the flight crews knew, Abbott pointed out. are integrated into the aircraft. The foremost error, she explained. thing to recognize is that as aviation has Other causal factors involved could also be moved into the increasing use of automation, “We certainly have been seeing that there are flight deck instrument and equipment design, the criticality of human factors in the malfunctions that are occurring for which as well as documentation available on the relationship to automation has grown, Cox there are not specific checklists, such as the flight deck, she explained. In 50 percent of the pointed out. On few rare occasions, there has Malaysia Airlines 777 that had a software accidents studied, communication errors been a breakdown between the automation issue,” Abbott said. “As the flight systems are between flight crew members were considered and the flight crew, and that is what can be getting more complicated, we are realizing to be causal factors, Abbott and Cox stated, improved, he pointed out. that there are different interactions that can while aircraft handling input errors were occur that we didn’t fully anticipate. So that’s implicated in 60 percent of the accidents. “What we are really focusing on is looking at an area that we are looking at very closely, management of the flight path of the aircraft,” because this is an area that might prove to be Based on the analysis of the accident data. Abbott said. “So rather than focusing very important. This area has some Abbott and Cox cited several areas for exclusively on automation, we talk about it in implications for training and procedures improved pilot training. They include: terms of flight path management, and certainly, or else equipment design and how automation systems like the autopilot and the we do regulation during the aircraft ■ Manual handling of the aircraft auto throttle are some of the many tools that certification process.” the pilots on the flight deck use to help ■ Flight plan management systems, manage the flight path of the airplane. Humans Can Improve Safety including automation management Automation is part of the picture, not the whole focus of the picture. The focus of the Despite the fact that humans are the most ■ Unusual attitude recognition and recovery picture is flying the airplane. So that is what unreliable component of the aviation system (loss of control) we are trying to emphasize in what is coming because most aviation accidents today are out of our research.” related to human error, the human element is ■ Managing malfunctions, including those also that which can lead to greater aviation for which the flight crew has no checklists Abbott is involved with a govemment- safety, Abbott and Cox stressed at WATS. industry Flight Deck Working Group that is ■ Managing distractions from other sources, studying all aspects of human factors on the “We have to think about how humans can including distractions from other systems flight deck, including the man-machine contribute to safety through such efforts as that are distracting the crew from the interface aspect of automation. The group risk mitigation and equipment design,” Abbott flight path management system anticipates releasing its findings sometime this emphasized.“We have to unleash and leverage fall, she said. human performance to improve aviation ■ Crew coordination and communications safety, and we need to recognize the “One thing that I would like to emphasize significant contributions humans can make in “Loss of control in flight is the largest accident about this is that it is not just about improving the areas of task management, flying the type that we are seeing in airliner and business man-machine interfaces,” said Terri airplane and automation - and think beyond aviation today,” Cox emphasized. “There is Stubblefield of the FAA Flight Technologies human pilot error.” nothing else near it. As far as the rate of and Procedures Division. “This is also about accidents caused by specific action or inaction how the operating environment, including Reprinted with kind permission of CAT by the crew, it stands alone.We have to look at existing and new operational concepts affect Issue 3/10 it from a multifaceted approach with multiple how the equipment is being used. From our layers of mitigation. I think that we have to train perspective, improving where man-machine better, and that means academic training.That’s and other interfaces, such as instrument

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Mixed Blessings

The global positioning system (GPS) is a precious gift to aviation. But several new studies have found there are real issues about how pilots use the system, and these issues apply to both private and commercial licence-holders.

n a good day, GPS easily fulfills twin who had flown there from the east coast deadreckoning mode, rather than by reference Oscience fiction writer Arthur C. with no charts, relying instead on a GPS to satellites overhead. Clarke’s dictum that ‘Any sufficiently receiver. ‘He was only a battery failure away advanced technology is indistinguishable from being totally lost,’ the appalled ‘Planning is important because it constructs a from magic’. instructor said. four-dimensional picture of the flight in your mind. The benefit of planning is not that you When the system is working perfectly it can CASA’s Flight Planning Guide for VFR pilots, have a schedule you can follow at all costs, but locate an aircraft to within a wingspan (or a rotor due for release in March 2011, highlights the that the act of planning builds this picture of diameter) and guide it with similar accuracy. role of GPS in flight: Planning is important your flight in your head. You build the because it constructs a four-dimensional foundation of your situational awareness. GPS is the US military navigation system that picture of the flight in your mind. was made available for full-performance In dead-reckoning mode, when satellites are civilian use in 2000. It is one of several global The benefit of planning is not that you have a unavailable, the Cheyenne’s GPS was navigation satellite systems (GNSS), along schedule you can follow at all costs, but that designed to operate as a human navigator with the Russian GLONASS, European civilian the act of planning builds this picture of your would and calculate probable position based Galileo systems, and the Chinese Beidou-2 flight in your head. You build the foundation on time, heading and speed. system known as Compass. GPS is the only of your situational awareness. one of these systems in widespread civilian The ATSB investigation found that use in Australia. ‘To follow GPS prompts is to do exactly the deadreckoning navigation could not be opposite’ the guide says. ‘Now situational positively established. Inconsistencies between Alas, GPS is not magic, but technology, and a awareness resides in a machine, and you deadreckoning principles and the recorded fallible one at that. The results when it goes merely follow its directions. Your ignorance radar data made it seem unlikely, as did the wrong or is used wrongly can range from will become a problem if the machine stops.’ alerts and warnings the GPS receiver and hairraising to deadly. Under GPS guidance, instrument indications would have provided. aircraft have crossed restricted areas, taken The guide reminds pilots that errors can occur detours to waypoints that were not on the from outdated databases, or from the Regardless, the ATSB issued a safety advisory flight plan and flown their own version of the inaccurate press of a finger entering flight notice alerting users of GPS navigation flight plan based on out-of-date data. data into a system. receivers to take appropriate action to ensure familiarity with dead-reckoning General aviation pilots using, or attempting to It also argues pilots should only use GPS if they operation and any associated receiver- use, GPS have had collisions and near-collisions have a functional understanding of how the generated warning messages. with other aircraft, and have crashed into the system works, and all the current information ground when distracted by the sometimes- and charts–VTC, weather and NOTAM. ‘The investigation found that there was little, cryptic interface of many GPS receivers. if any, information about the in-flight DR Private flying is not the only area of [dead reckoning] operation of GPS receivers in GPS has been embraced by Australian aviation. aviation where the down side of GPS is any of the operating manuals published by GPS receivers can be found on 85 per cent of causing unease. manufacturers of GPS navigation receivers,’ Australian aircraft, and why wouldn’t they be, the ATSB said. when prices for aviation-specific receivers start A GPS failure was implicated, although not at under $500? But there’s growing disquiet conclusively established as having been ‘Some users of these navigation receivers may about how misuse and occasional failure can involved, in the crash of a Piper PA-31T not have been aware that the GPS receiver turn it from an acknowledged safety aid into an Cheyenne that killed a 14,000 hour display unit would provide tracking guidance, unrecognised risk factor. commercial pilot and five passengers, including the legs of a GPS instrument including a Qantas jet captain and a military approach, during DR navigation. This is a There is a strong perception among general helicopter pilot. safety issue.’ aviation trainers that some private and commercial pilots are letting GPS do what The crash near Benalla, Victoria, in July 2004, The ATSB’s second look at the Benalla crash they should be doing - or should at least be happened after the aircraft diverged left of its highlighted some other incidents with the aware of - themselves. westerly track.The pilot reported commencing technology. Errors have been reported that a GPS non-precision approach to Benalla can’t be explained or reproduced. ‘If there is a crisis in flight planning, then it’s aerodrome, but the aircraft flew into high ‘On 9 February 2003, a Bombardier Dash 8 GPS that’s the culprit,’ a chief flying instructor ground 34km southeast of the airfield. was observed on radar to diverge 9nm left of (CFI) with a university-linked flying training track during a flight from Emerald to Brisbane. organisation says. In 2008, the Australian Transport Safety Bureau (ATSB) reopened its investigation into The aircraft’s crew reported that the aircraft Another CFI mentioned being in outback the crash to examine the possibility the GPS was navigated by GPS and that the autopilot Queensland, and talking to the pilot of a light unit might have been operating in was engaged. No GPS warnings or error

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indications were observed and it was not FMS operations and the method of making ‘In the interviews and exercises it was determined if the receiver was navigating by selections is a human factors problem apparent that crews treated the FMS as a dead reckoning. When the controller informed that needs to be addressed with the primary navigation source and were failing to the crew of the track divergence, they reverted manufacturers.’ monitor the secondary system. The analysis to ground-based navigation aids and continued work showed that the redundant systems are to Brisbane. After landing, the GPS indicated a Its position on the flight deck was another not actually redundant, because there is a low position 59nm to the north of Brisbane.’ problem. probability that the crew will detect a failure in the primary navigation system. The operator advised the ATSB that crews had ‘To access the FMS control display unit (CDU), reported numerous other GPS anomalies the large angles involved make operating the Whether in the cockpit of a sport aircraft involving the Dash 8. system difficult through parallax, dexterity flown by a 100-hour pilot, or the FMS of an and the angle of force transfer to the keypad. airliner with thousands of hours experience ‘Between February and September 2003, This out of normal reach installation makes residing in its two flight deck seats, GPS there were three occasions when the aircraft operating errors more likely.A further problem presents the same issues. Arthur C. Clarke turned and tracked well left of the intended is the likelihood of unintentional operation of summed up not only the potential, but also flight path while being navigated by GPS. the power levers.’ the problem.

In two of those occurrences, the cabin crew Reading the FMS display could be very We must fly by knowledge, not faith, and detected passengers using laptop computers difficult, particularly in bright sunlight, the never confuse technology with magic. and compact disc players. Following each of study found.‘In bright sunlight the display was those events a functional test of the receiver often unreadable.’ Reprinted with kind permission of Flight was unable to detect any faults.’ Safety Australia, Issue 78 – Jan/Feb 2011 ‘The location of the control display unit The results of a recent study by Cranfield discouraged first officers from using the University in Britain into the use of GPS for system since it was not located in their area navigation (RNAV) in airline operations personal space, resulting in a lack of practice.’ were considered alarming enough for the International Civil Aviation Organization ‘The human factors associated with control (ICAO) to recommend its results be widely design and how they are actually used by publicised. pilots is an important consideration-putting a button in and expecting a pilot to use it is not The study focused on human factors in RNAV always the answer.’ operations. The study found pilots using the FMS made a One of its first findings was a severe criticism significant number of errors. of the location of the GPS-linked flight management system (FMS) on the aircraft During the sector with the induced GPS used in the study (a working regional airliner). integrity fault, approximately 75 per cent of crews made significant errors. About 25 per ‘The architecture of the system means that cent of crews flew the procedure with the errors are likely to be made,’ the study found. integrity light on.This highlighted considerable misunderstanding of the meaning of the light ‘The human factors associated with control and the actions needing to be taken. In one design and how they are actually used by pilots case, the crew attempted to fly the RNAV is an important consideration-putting a button missed approach procedure using the VOR. in and expecting a pilot to use it is not always the answer.’ Discussion with pilots revealed a disquieting level of faith in the GPS-linked FMS and lack ‘A point is made about the method of of knowledge of its limitations. selecting an arrival runway where the crew have to enter a number to make the selection ‘Many of the pilots had come through general rather than selecting the required runway aviation where flight management systems with a line select key. Entering codes to make are rare; they appeared to be impressed by it selection requires the crew to verbalise the and not understand its weaknesses. Many code to transfer it to the keypad. This creates confused the multiple inputs and system a high risk that an error will be made because accuracy with reliability.’ of other cockpit activity.

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Hard Lessons on Wind Shear

Planning and caution can minimize the danger of the low-level phenomenon. By David R. Carlisle

In the case of near-surface winds, the stronger the winds, the greater the turbulence will be in the boundary layer, as the strong winds interact with the frictional effects of the ground.

“In the Narita event this turbulence was no doubt enhanced with cooler air rapidly moving in behind the cold front and being heated by the sun, making the boundary layer more unstable and therefore more turbulent,” he said. “Finally, in this region of strong cold air advection, the wind direction was no doubt backing with height. Combined with strong solar heating, this can be expected to create horizontally oriented convective rolls, which are usually expressed as low-level ‘cloud streets’ if the air is sufficiently humid. but will be invisible if the air is dry.All of these effects can combine to cause rapid changes in wind speed and direction as an aircraft attempts to land.”

The hourly Narita wind reports suggested little crosswind, with Runway 34R by the Japan Transportation Safety Board, we y definition, low-level wind shear is a experiencing winds from 310 degrees or 320 do know from the Japan Meteorological localized meteorological event degrees. But significant and rapid changes in B Agency (JMA) that wind gusts up to 47 mph occurring below 2,000 feet of altitude the headwind could be expected, with were blowing through Narita City around the when an aircraft encounters rapidly corresponding changes in lift as the aircraft time of the crash. changing wind speed or direction over a was about to touch down. particular distance or time. When the According to Roy W. Spencer, principal encounter occurs at very low altitude - If pilot attempts at correcting for these research scientist at the University of say, at takeoff or landing - there's a very changes in lift happen to coincide with rapid Alabama in Huntsville, and former senior real possibility of the pilot losing control. lift changes in the opposite direction, a series scientist for Climate Studies at NASA's of unstable runway bounces could result, as Marshall Space Flight Center, “The strong, It is well known to flight crews that did occur with the FedEx MD-11. convective weather produces severe storms straight-line winds were associated with a low-pressure center of 992 mb moving that can include tornadoes, gust fronts and Airport officials told us it was premature to northeast and away from Narita, behind downbursts. Low-level wind shear often attribute the crash to strong winds, but a which high pressure was rapidly building in presents itself in those situations and can be Japan Airlines (JAL) captain who landed over the airport.” difficult to forecast due to its local nature. safely 10 minutes before the accident said the tower had issued a wind-shear advisory “The general region of highest winds can be Less well known is the fact that low-level to the FedEx pilots. wind shear can occur in the narrow pressure inferred from the anticyclonically curved isobars on the 2218 and 2300 UTC weather fields (frontal zones) of weather systems Little Rock Overrun between air masses having dissimilar thermal maps seen to the west and southwest of the 992 mb low,” he continued.“It is unusual to see and moisture properties. Surprisingly, it is not An example of the dangers posed by a squall isobars with that much anticyclonic curvature difficult to forecast this type of wind shear. line storm system and its powerful large- that closely spaced together, and such a scale, straight-line wind outflow occurred just condition always causes high wind speeds.” FedEx at Narita before midnight on June 1, 1999, when the weary pilots of an American Airlines MD-82 “It is also a reminder that isobar spacing on a An example of the dangers posed by a rapidly overran Runway 4R at Little Rock and crashed. developing low-pressure area and its associated weather map is only half the story when getting a feel for surface wind speeds. For the low-level wind shear occurred at 0649 on As the narrowbody jetliner approached the same isobar spacing, cyclonic curvature causes March 23, 2009, when a FedEx Boeing MD-11 runway from the southwest, strong low-level lower wind speeds, while anticyclonic curvature crashed into a runway and burst into flames crosswinds created by a “bow echo” squall line produces higher wind speeds. This is true while landing at Narita International Airport approached the airport from the northwest. outside Tokyo. The pilot and copilot - the only whether the low- and high-pressure centers are strengthening or not,” Dr. Spencer said. people onboard - were killed in the crash. According to the NTSB accident report, the While the accident is still under investigation flight crew learned that the winds were

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changing direction and that a wind-shear continuation of the approach to a landing The copilot tried to avoid a stall by pushing alert had sounded on the airport due to a when the company’s maximum crosswind the nose down, but the aircraft’s vertical thunderstorm nearby. component was exceeded and (3) use of speed increased to 1,700 fpm and the aircraft reverse thrust greater than 1.3 engine contacted the ground on a field about 6,300 ATC originally told the pilots to expect pressure ratio after landing. feet north of the approach end of Runway Runway 22L for landing, but after the wind 17L. It then bounced back into the air and rapidly changed direction, the captain Takeoff at DFW came down again, with the engine striking a requested landing on Runway 4R. car, killing the lone occupant. Delta Air Lines Flight 191, a Lockheed L-1011, As the aircraft approached the new runway, a crashed Aug. 2, 1985, while on approach to The aircraft skidded onto the airfield at a speed severe thunderstorm arrived over the airport. the Dallas-Fort Worth International Airport. of 220 knots, collided with a pair of four-million The controller's last report, prior to the Of the 152 persons onboard, 134 passengers gallon water tanks and burst into flames. landing, stated that the winds were 330 and crewmembers died as did one person on degrees at 28 knots. Those winds exceeded the ground. The NTSB attributed the crash to pilot error, the MD-82's crosswind limit for landing in combined with extreme weather phenomena reduced visibility on a wet runway. This accident is one of the first commercial associated with microburst-induced wind shear. air crashes in which a microburst-induced Despite that information, plus two wind- wind shear was a direct contributing factor. The Safety Board also attributed the accident shear reports, the captain elected to continue to lack of the ability to detect microbursts his approach. since the airbourne radar equipment at the time was unable to detect wind changes. During their rush to land, the pilots failed to Subsequently, that capability was developed arm either the automatic ground spoiler and and the FAA mandated onboard wind-shear the auto-braking systems, both of which are detection systems for commercial aircraft. essential to ensuring the airplane's ability to stop within the confines of a wet runway, Best Practices especially one that is being subjected to strong and gusting winds. Regardless of its cause, low-level wind shear continues to pose a threat to aircraft safety, After landing, the first officer stated, “We’re but its danger can be reduced with planning down. We’re sliding.” Neither pilot observed and vigilance – and cautionary operating that the spoilers did not deploy, so there was practices, such as: no attempt to activate them manually. This The DFW weather was poor and an isolated resulted in minimal braking because the wings thunderstorm was developing nearby. The ■ Delay departure or arrival if winds exceed were still “flying.” The captain then applied flight crew noticed the isolated storm, but your airplane operations manual too much reverse thrust, in contradiction to decided to proceed through it anyway, which limitation. the limits stated in the flight manual and resulted in the aircraft getting caught in a directional control was lost. The aircraft microburst. ■ Never attempt to take off or land if a skidded off the far end of the runway at high thunderstorm or heavy rain is located speed, struck the ILS array, crashed through a At about 1,500 feet above the ground, the within five miles of your flight path. chain-link fence, went down an embankment first officer, who was flying the aircraft, and collided with the approach light structure approached the runway in heavy rain. He ■ Be prepared to divert or hold when heavy before coming to a stop on the banks of the reported seeing lightning in one of the clouds rain is located on the approach, departure Arkansas River. The captain and 10 of the 139 ahead. At 800 feet above the ground, the corridor or within the airport boundary. passengers were killed. aircraft accelerated without crew intervention. ■ Abandon your approach if your SOPS for According to the NTSB, the accident probably a stabilized approach cannot be met. resulted from “the flight crew’s failure to The aircraft landing speed was bugged at 149 discontinue the approach when severe knots, but it accelerated to 173 knots IAS. The ■ Inform ATC of your decision to hold or thunderstorms and their associated hazards first officer tried to stabilize the aircraft's speed, divert to your alternate until the surface to flight operations had moved into the but the captain had recognized the aircraft’s winds subside. airport area and the crew's failure to ensure speed increase as a sign of wind shear, and he that the spoilers had extended after warned the first officer to watch the speed. ■ And by all means, if you are on final touchdown.” It said contributing to the Suddenly, the airspeed dropped from 173 knots approach and ATC issues a “microburst accident were the flight crew’s (1) impaired to 133 knots, and the first officer pushed the alert” for your runway of intended performance resulting from fatigue and the throttles forward, providing temporary lift. The landing, immediately execute a go- situational stress associated with the intent airspeed then dropped to 119 knots. around and, if necessary, execute your to land under the circumstances, (2) wind-shear recovery technique.

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■ Reject recklessness, especially if you fall they cross the isobars, moving from higher decreasing path. How rapidly the event is behind schedule, when landing at night, or to lower pressure. The angle at which the traversed determines the net loss. if aircraft in front of you have landed in wind crosses the isobars varies, but averages bad weather. Do not allow “get there-itis” about 30 degrees. The reason for this If you fly through a microburst from one side to take hold, especially at the end of a behaviour is friction. to the other, you will encounter the classic long duty day. headwind increase, which is performance Surface winds in the northern hemisphere enhancing.As the headwind decreases toward ■ Never let anyone pressure you into cross the isobars at about a 30-degree angle the center of the outflow, you will enter an making a poor decision, and never forsake away from the center of a high-pressure area area of downdraft.As you continue to traverse your good judgment just to get your and flow at a 30-degree angle toward the the divergent flow you will encounter an aircraft off or on the ground. center of a lower pressure area. increase in tailwind.

Finally, be alert for low-level wind shear from When you examine the surface analysis chart Penetrating the heavy rain outflow of a takeoff and all the way through to touchdown and see isobars that are closely spaced thunderstorm during approach and takeoff and roll-out. You and your passengers will be together and with anticyclonic curvature, 'represents the highest potential for a glad you did. remember that they will always cause high microburst encounter. wind speeds. THE THREATS Keep in mind that the net effect of a ■ Microbursts According to ICAO statistics, microburst and its associated wind shear in the ■ Surface Wind and Pressure In light of the between 1970 and 1985, there were 28 terminal area can cause a severe reduction in recent FedEx MD-11 crash in Narita, a review aviation accidents caused by low-level wind your aircraft performance. This is exemplified of pressure fields and isobars on the surface shear, resulting in 700 deaths. by the 1985 DFW accident, which followed analysis chart is in order. It's worth the effort downdrafts that exceeded 3,000 fpm. Because to study and interpret these charts before your A microburst can occur when convective the surface winds associated with a microburst departure, or en route if you have the activity is present. It is defined as a small can be so variable, real-time reports from capability to download weather maps in flight. concentrated pulse, or downburst, that preceding aircraft must be considered with produces an outward burst of damaging considerable caution. Do not take the absence Pressure fields are represented on weather winds on the surface. of a PIREP or the report of a smooth ride as “an charts by sets of isobars (lines or contours all clear signal” to continue the approach. along which the pressure is equal to a There are two kinds of microbursts: wet and constant value) on a horizontal surface, such dry. The former is accompanied by heavy ■ Gust Fronts A gust front is the leading as sea level. Isobars are usually plotted at precipitation at the surface, while the latter is edge of sinking, thunderstorm-cooled air that uniform increments, for example, every 4 hPa common in high plains and the intermountain displaces the warmer air as it spreads out at on a sea-level pressure chart e.g., 996, 1000, west, where little or no precipitation reaches the surface. The advance of the downdraft air 1004 ...hPa.Local maxima in the pressure the ground. Dry microbursts can exhibit virga tends to be concentrated in the gust front on field are referred to as high-pressure centers and generate rings of dust on the surface. the forward side of the storm relative to the and minima as lows. The horizontal pressure direction of propagation. gradient is oriented perpendicular to the Microbursts are usually a mile in diameter isobars and is directed from lower to higher above the ground, spreading out to A gust front is an example of a fluid flow pressure. The strength of this horizontal approximately 2.5 miles on the surface referred to as a density current, which has pressure gradient is inversely proportional to outward from the center. Microbursts are been extensively investigated in laboratories the horizontal spacing between the isobars in short-lived, lasting 10 minutes or less, and can and modeling simulations. the vicinity of that point. pack violent descending vertical columns of air that can exceed 3,000 fpm downward and A distinct feature of the gust front is the For the most part, the winds in the Earth's horizontal winds on the surface that can reach bulbous head, with its overturning circulation atmosphere parallel the isobars. In the 100 to 150 mph.The winds across the surface in which surface wind speeds exceed the rate northern hemisphere, lower pressure lies to can be quite variable. The downdrafts tend to of advance of the front itself. the left of the wind (looking downstream) and be the strongest at about 1,000 to 3,000 feet the higher pressure is to the right. Air then agl over a wide area, but there can be isolated Gust fronts are characterized by a wind shift, circulates counterclockwise around lows and areas of intense downdrafts within 300 feet temperature drop and powerful straight-line clockwise around highs. In the southern of the surface. wind outflows.The leading edge of severe gust hemisphere, the relationships are opposite. fronts can be accompanied by intense The circulation around a low-pressure center Be advised that multiple microburst activity turbulence, reduced visibility and hail. is cyclonic, while the circulation around a in the same area is common and should be high-pressure area is known as anticyclonic. anticipated. Following the crash of the American Airlines MD-82 in Little Rock, NASA Langley researcher Winds on a surface weather map do not From an aircraft standpoint, the excursion Fred H. Proctor, Ph.D., determined that the blow exactly parallel to the isobars; instead, through a microburst is a performance storm confronting the accident crew was a

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“bow echo” squall line pattern system that The head is not stable as the area constantly midpoint, thus forming a bulge in the radar approached the airport from the northwest. collapses on itself as the denser flow moves signature. Damaging straight-line winds often The storm system produced powerful large- forward, creating turbulence. Even though occur near the “crest” or center of the bow scale straight-line wind outflows. traversing the gust front is a performance- echo. Bow echoes can be over 300 km in enhancing path, that increase in itself is length, last for several hours, and produce The bow echo was located at the northwest usually enough to destroy a stabilized extensive wind damage on the ground. end of a squall line that stretched toward the approach.The turbulence simply makes things southwest. The echo moved toward the east- worse. Rain is not a good indication of the ■ Turbulence Threat Definition: Encounter southeast encroaching on the airport at 32 gust front's edge as sometimes rain is right at with manmade or atmospheric scales of knots and developed a deep bulge toward the the leading edge of the flow and sometimes it motion that produce intense, short-lived southeast as the apex of the system moved to is well behind it. random accelerations on the aircraft. the north and east of the airport. Hazard: (1) passengers and crew subject to Occasionally when the winds change direction unexpected and violent aircraft accelerations A large area of strong wind speeds in excess of rapidly with height, the air rising over the gust that cause injury or death. 36 knots was associated with the low-level front may form a long, horizontal vortex, which (2) Loss of control and possible aircraft upset, outflow from the bow echo. Radar reflectivity can sometimes be seen as a tube-shaped roll resulting in uncontrolled flight into terrain. exceeded 45 dBZ over a broad area, with cloud resembling a rolling pin. The roll cloud (3) Lack of control authority on touchdown embedded cells exceeding 60 dBZ. has a horizontal rolling motion to it and is resulting in damage to aircraft. Precipitation and strong wind gusts indicative of strong vertical wind shear, and (4) Airborne damage to aircraft. associated with the southwestern edge of the often-hazardous turbulence. Phase of flight: Can occur at any altitude, bow echo reached the airport 20 minutes and during all phases of flight. prior to the accident. The southwestern edge Old gust fronts can be found in clear air more remained near the airport as system than 20 miles away from the generating ■ Wind-Shear Threat Definition: Encounter advanced toward the east-southeast. thunderstorm(s). These gust fronts can still with atmospheric events that cause critical produce a strong shear zone and cause the reduction in airspeed or altitude, such as to An intense “bookend” cell located at the surface wind to change rapidly. Gust fronts threaten the ability of an aircraft to remain southwestern end of the bow echo passed that migrate over dry terrain are often made airborne. over the airport just following the time of the visible by thick blowing dust. Gust fronts can Hazard: Flight into terrain. accident. The cell registered greater than 65 initially affect an approach corridor or runway Phase of flight: Low altitude, during dBZ and was associated with strong wind, without affecting other areas of the airport. approach and departures. hail, frequent lightning and high rainfall rates. Thus, tower reported winds, altimeter settings During this time the strongest measured gust and PIREPs can often be misleading. ■ Crosswind Threat Definition: Strong was 76 knots. crosswinds that may endanger the control Regions of hazardous crosswinds may not and course of the aircraft during takeoff and The gust front can act like a golf pitching coincide with regions of hazardous wind shear. landing. Hazard: Collision with obstacles, lack wedge as the ambient air is undercut and Some meteorological conditions may produce of control authority on touchdown resulting wedged upward by an advancing gust front. either, but rarely in the same location. in damage to aircraft and injury to passengers, This can create a shelf cloud that rides the impaired directional control on the runway. leading edge of the gust front.This shelf cloud At low altitudes during approach and Phase of flight: On runway, low altitude marks the interface between cold air at the departure and while on the runway, the during approaches and departures. back or west side and warm air on the east hazards from strong crosswinds are a lack of side, and also between the stronger gusty cold control authority, impaired directional ■ Phase of Flight Threat Since 1975, every outflow and the prevailing surface winds. control, possible damage to aircraft and injury fatal U.S. commercial wind-shear accident has to passengers. involved an aircraft attempting to take off or A characteristic of severe gust fronts is that land in a heavy rain outflow from a the leading edge or head can be quite ■ Little Rock Bow Echo System The late Dr. thunderstorm. turbulent. If you examine a cross section of Tetsuya “Ted” Fujita’s career in meteorology the event you will see that denser mass is spanned over 50 years. The former University Reprinted with kind permission of Business always being pumped into the flow and works of Chicago meteorologist was best known for & Commercial Aviation November 2009 its way forward. Due to frictional effects of his discovery of the microburst after the crash shearing between the fluid and surface, it then of Eastern Air Lines Flight 66 in 1975. He also gets rolled under, as the gust front propagates. completed extensive tornado research and devised the Fujita or “F-scale,” which Because of this friction, a vortex can be categorizes the tornadoes' wind speed and created at the head. If you were up in a tower damage Potential. and a gust front flowed past, .you would find the gust front would first traverse that tower Dr. Fujita coined the term “bow echo” in somewhere above the ground, and then at reference to radar echoes that appear to ground level a short time later. undergo a forward acceleration at their

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Losing it...

Captain Gavin McKellar, Chairman of the IFALPA Accident Analysis and Prevention Committee, explains why maintaining control in all situations must remain at the top of our risk management agenda. It is an obvious imperative that EGPWS is fitted in all air transport aircraft. Additionally, we can further reduce the risk by adopting the minute-to-impact philosophy. This idea says that you should never have a rate of descent (ROD) greater than that which would have you in contact with terrain in less than a minute. In other words, at 3,000 feet above ground level (AGL), the ROD should be less than 3,000 feet per minute; at 2,000ft AGL, ROD is back to 2,000 feet per minute, and so on. Of course, by1,000ft AGL we should be in a stable approach.

To me, the implication is obvious: without EGPWS, the CFIT risk is just as bad as it ever was.

Losing it, LOC style y guess is that we have all 'lost it ' to until it was too late to do anything about it. In the majority of CFIT accidents, the point of Since the introduction of EGPWS and the Msome extent at some point in our dramatic fall in CFIT accident rates, loss of lives.You may have felt you have lost it after first impact is within 100 feet of the summit of the terrain. control (LOC) has taken over as the number being hijacked by your emotions. Suddenly, one category of accident - notice I said you find yourself in a place you never Perhaps you can recall the loss of a Flying ‘accident category’ rather than ‘accident intended to be.Acknowledging that this is a cause’. An accident can have a variety of possibility for any of us presents the Tigers aircraft in Malaysia, which continued on its fatal path despite the numerous 'pull up' causes - or, more accurately, factors - and it is opportunity to assign it a probability and never wise to focus on just one element. define how grave a risk 'losing it’ will be. warnings? I'm sure that you will remember the Korean Air 747 that crashed on approach to Guam, the image of that aircraft's The factors leading to a LOC accident can be In most of the world's developed countries, weather-related, as in the case of the ATR72 road accidents are a major cause of death - wreckage scattered on the hillside five miles from centreline is still imprinted on my mind. crash at Roselawn. In its first report into the loss certainly this is the case in my country. I would of United 585, while reaching no firm argue that most of these accidents are the In South Africa we also had the 2002 loss of an HS748 due to CFIT, which killed the conclusion, the NTSB thought that “an result of somebody ‘losing it’. Whether it's encounter with an unusually severe atmospheric driving into something (a bit like controlled disgraced former captain of the national cricket team, Hansie Cronje. disturbance” would be a likely cause. Later, flight into terrain - CFIT), rolling your car (let’s following another fatal loss and further call this a loss of control - LOC), or skidding off Of course, since the development of incidents, a flaw in the design of the rudder the road (excursion), in some way somebody actuator was revealed as the actual problem. has lost it - of course, it might that be the enhanced ground proximity warning system (EGPWS) and the advances in terrain person who lost it could have been the The crews had become fixated on diagnosing a designer of the car’s throttle or braking system. mapping, things have dramatically improved. Since the installation of this fancy kit not one fault, to the extent that far more serious problems developed. The point is, whatever the reason for losing it, aircraft fitted with it has been involved in a CFIT accident. taking back control must aIways remain at The same phenomenon was flagged up by the the top of our risk management agenda. Of course, there are still CFIT accidents. They investigation into the loss of an Adam Air 737-400 in Indonesia. However, unlike other Taking back control must remain at the top of happen every year, it's just now they happen to the five per cent of the world's airliner fleet events, this departure from controlled flight our risk management agenda - whatever the happened during the cruise phase rather than reason for losing it. not fitted with EGPWS.To me, the implication is obvious: without EGPWS the CFIT risk is on approach or immediately after an airflow just as bad as it ever was. disturbance. Further investigations revealed Losing it, CFIT style crew disorientation leading to the design This in turn raises a question: have those with limits being exceeded as the most likely In aviation, for many years the top threat was cause. It seems that in this case the crew from controlled flight into terrain (CFIT). By regulatory oversight ‘lost it’? What about the CEOs of airlines who have not fitted EGPWS, focused on a failure in the aircraft's inertial and large, CFIT accidents came as a result of reference system (IRS) and did not notice the the crews involved collectively losing it in the have they not ‘lost it’ too? I think it is clear that they have lost sight of the risk presented departure from controlled flight until it was form of degraded situational awareness and too late to recover the aircraft. continuing on a course of action despite a by CFIT and, as a result, taken the appropriate number of cues that something was not right, steps to reduce the risk.

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graphically illustrated in recent weeks. Where diagnostics separation’ - and it is also clear that there was an adequate runway end safety the pilot ‘flying’ must remain focused on that area (RESA) or an arrester bed, the outcome activity no matter how high the level of was far better with few, if any, injuries to sophistication of the automatics employed. We passengers and crews and little damage to the must make sure that the aircraft is doing what aircraft. It's not just for fun that we at IFALPA we want, and expect it to be doing what it is support the fitment of engineered materials actually doing, and this activity must take arrestor systems and require proper RESA at precedence over everything else. The pilot flying the end of runways we use. Who can forget must ‘aviate’, while the pilot not flying is tasked the Airbus overrun at Warsaw, in which the with the ‘navigate and communicate’, as well as captain lost his life due to the mound of sand troubleshoot. in the overrun area? It still happens. Let's get back to basics and apply situational What lessons can be learnt? control to every landing. Let's get the aircraft stable by 1,000 feet AGL and touch down in We see how the risk can be mitigated, but how the zone. Focus on using the correct This has echoes of other accidents, one can we reduce the risk? I argue that most techniques for the aircraft, with prompt use of involving an L-1011 and another a DC-8. In excursions are the result of losing it in just the braking, spoilers and reversers, and if the both accidents the crews became fixated on same way as a CFIT or LOG accident. If we land approach doesn't look good or you are floating diagnosing a fault, to the extent that far more long and fast on a slippery runway and continue in the flare, then go-around.We need to match serious problems developed. In the first case, a in the normal way, hoping that we will stop on policies with practice: even though your flight change in autopilot mode which allowed the the available pavement, doesn't that indicate operations manual (FOM) says that if you are aircraft to begin a gentle descent went that we are not really aware of the situation? not going to touch down in the zone you must undetected; a descent which continued until go-around, we don't practise the manoeuvre in impact with the swamps of the Florida Where there was an adequate runway safety the simulator. Maybe we should. Everglades. In the latter, the aircraft ran out of end area or an arrester bed, there were few, if fuel while the crew attempted to troubleshoot any, injuries. Stay 'legal' - within the regulations, standard a fault in the right main landing gear. operating systems and training you have But what do the lessons of completed received. There have been more recent, and as yet investigations teach us? Reports by investigating unexplained, control loss events. Why did a authorities of LOC and CFIT accidents often have Legally does it nearly new Kenya Airways 737 end up a loss of cockpit resource management (CRM) or destroyed in a mangrove swamp shortly after a loss of situational awareness in the list of In all the examples I have given, another takeoff? More recently, the LOC events in the accident causes. That's pretty obvious, really - if valuable lesson to learn is to stay 'legal' - stay Middle East and Central Asia and the United they had known where they were they wouldn't within the regulations, standard operating States are causes for concern. Not to mention have flown into the mountain - right? To me, this procedures and training you have received. the pending investigations into the losses is a baseline problem. I don't think that I've racked my brains and I cannot think of a suffered by Air France, Ethiopian and Turkish in statements about loss of CRM or situational single instance where being 'legal' has been the last year. awareness belong in the causal summary. unsafe. Remember, the more we rationalise, the greater the potential to accept risk and by Losing it, runway excursion style I think they would be better placed in the extension, the risk increases. findings, in the list of safety factors involved. Runway excursions and their causes are After all, what we really want to know is why Pilots tend to be mission-oriented people and receiving a good deal of attention and rightly there was a loss of situational awareness or the temptation to ‘press on’ is an alluring one. so, since around 30 per cent of all accidents poor CRM, since this is the only way we can We see what we want to see, hear what will fall into this category. Although, happily, they formulate strategies to rectify the problem confirm the decision and act as our own ‘sirens do not have the injury or body count of CFIT and reduce the risk. on the rocks of risk’. Being compliant and legal or LOC accidents, they do occur with means managing the risk and being safe. unacceptable frequency. We must take into our equation the effects of disorientation, stress and fatigue. By their In recent years there have been a number of nature they are more difficult to address and high-profile excursions, at Little Rock, Toronto harder to prevent, so we must have robust and Chicago to name but three examples. In systems that are error-tolerant. Good each of these cases adverse weather and monitoring can help trap errors, checklists fatigue played an important part in the way can identify items missed, and redundancy the sequence of events developed. can help mitigate the effects of errors. Reprinted with kind permission of LOG Much can be done to mitigate the effect of an The division of labour on the flight deck should August/September 2010 excursion and we have seen this very be maintained-the so-called ‘I’ll fly, you run the

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Airstair Vigilance

by Wayne Rosenkrans A small child's fall reminds adults of the need for close supervision and reveals inadequate updates to operators.

attendant manual for the 737 series of aircraft, to include a warning regarding the need for operators to pay particular attention to passengers boarding [or deplaning] with small children or [passengers] with special needs.” The AAIB report cited a paragraph from this template for operators, which says, in part, "Small children on airstairs should be attended by an adult or responsible person.4”

Investigation of the 2009 incident, however, found no process in place for operators to receive amendments to these type-specific cabin safety recommendations. “The flight attendant manual received by the operator with its first Boeing 737-800 was issued on 28 September 1998,” the report said.

Investigators noted that, at the time of the incident, implementation of the most current 3-year-old girl's fall from the forward on either side,” the report said. “These airstair safety improvements recommended integral airstair of a Ryanair Boeing [handrails] rise into position during A by Boeing and the airstair manufacturer was 737-800 - an approximate height of 8.5 to deployment of the stairs, but due to the incomplete. “The airstair . . . had the warning 9.0 ft (2.6 to 2.7 m) - has prompted the geometric restrictions imposed by the placards on the risers and anti-slip material U.K. Air Accidents Investigation Branch retraction mechanism design, they do not installed in accordance with [the] Monogram (AAIB) to issue several safety extend to the fuselage side. Systems [service bulletin], but the door recommendations, including one for aperture placards, detailed in [the] Boeing airstair modification. She was released “In order to bridge the gap between the top of [service bulletin], had not yet been applied”, from a hospital after a 24-hour assessment the handrails and the fuselage, a manually the report said. and treatment of minor injuries. extendable handrail is fitted to each of the integral rails. After deployment of the airstair, Small children require close supervision The child had climbed the airstair to the upper these are extended and secured to points in because of limitations of the geometry of the platform followed by her mother, who was the entry door frame. Each extendable rail is rails. “When deployed, the left and right carrying a younger sibling and a carry-on bag. supported by a strut extending from the side extendable handrails are intended to provide “Due to her mother's lack of a free hand, the rail of the airstair.” protection against people falling sideways off child climbed the airstair unassisted, but she the upper section of the airstair,” the report held onto the lower handrail,” the report said. Previous Child Falls said. “While these handrails appear to provide “When [the girl] reached the top of the stairs, adequate protection for adults, a gap exists she turned towards her mother, leaned Four similar incidents involving small between the handrail and the airstair platform backwards and fell through the gap between children had prompted the U.S. Federal which is large enough to allow a small child to the extendable handrail and the top of the Aviation Administration (FAA) in September pass through it and fall onto the [ramp airstair, onto the hardstanding [ramp 2007 to issue advisory information to all pavement] below.” pavement] below.” Other passengers also current owners and operators of 737s. This were on the airstair at the time. comprised a special airworthiness information bulletin1, calling for the According to procedures in Ryanair's safety equipment and procedures manual (SEP), The incident occurred at 1225 local time on incorporation of the latest safety advice and three of four flight attendants are assigned to July 17, 2009, at London Stansted Airport, the advances from a service bulletin developed 2 maintain positions by the forward and rear AAIB report said. The airplane was by Boeing Commercial Airplanes , and doors, and near overwing exits for the manufactured in 2005 and certificated to another developed by Monogram Systems, 3 duration of boarding. “However, during applicable European standards. the manufacturer of the airstair. boarding, the ability of the cabin crewmember at the forward doors to identify This integral airstair (Figure 1) primarily was “These bulletins required warning placards to those passengers requiring assistance, while used to facilitate routine boarding and be added to the risers of the airstair steps and they are ascending or descending the airstair, disembarkation in place of portable ground- the aircraft door apertures, together with the is limited,” the report noted, citing a provision based steps or an airbridge, and safe operation addition of anti-skid material to the top from the SEP, which says, “Passengers depended on a combination of barriers, platform and the side rails,” the report said. accompanying young children should be procedures and warnings on placards. These “The [Boeing bulletin] also highlighted the instructed to hold their hands when airstairs include an integral two-rung handrail fact that Boeing had revised the flight

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descending the stairs and on the ramp.”5 The Figure 1 report did not mention the positioning of the Forward Integral Airstair on Boeing 737s flight attendants in the 2009 incident.

Other Airlines

AAIB observers also looked beyond the airline involved to assess supervision of small children on the 737 forward integral airstair. “In 95 percent of cases, during disembarkation, passengers traveling with several small children and hand baggage received no assistance from either cabin crew or ground staff,” the report said. "However, ground [staff] and cabin crew provided assistance in 78 percent of cases when single passengers accompanied by small children were allowed to pre-board the aircraft." The 2009 pre-boarding incident was an exception: Neither the cabin crew nor the ground staff provided assistance, according to the AAIB.

“When portable ground-based steps or the aircraft's integral airstair were used, an adult boarding or disembarking with ‘carry-on’ baggage, which could not easily be placed FAA = U.S. Federal Aviation Administration Notes: The upper handrail extensions, when secured to the inside of the door opening, are over the shoulder, and a small child, found designed to provide a continuous support from the ground to the airplane cabin. However, an themselves, in certain situations, in a position FAA special airworthiness information bulletin (SAIB NM-07-47) in September 2006 advised where neither hand was available to provide 737-series owners and operators of four occurrences in which, during the process of support during the ascent or descent. disembarking or entering the airplane, unattended small children fell through or over the handrails or lost their balance and fell from the airstair. This situation was further complicated when Source U.K. Air Accidents Investigation Branch; FAA an adult was accompanied by more than one ■ small child and ‘carry-on’ baggage, as some of “Boeing review the design of the Boeing falling through the gap. The modification the children had to negotiate the steps with 737 forward airstair with the intention of proposed by the operator provides a significant little assistance from the adult.” adding a removable barrier to minimize visual cue to the lack of a rigid barrier in this the possibility of a child falling through the area, but provides only a limited physical protection against falling.” Mitigation Measures gap between the extendable handrail and its upper platform.” The AAIB said that Ryanair also analyzed this This article is based on AAIB Bulletin 8/2010, incident and instituted measures to reduce The report explained the analytical basis of EIDLJ,EW/C2009/07/08, published in August 2010. the risk. “As a result, the operator raised a each safety recommendation. “The lack of an modification which introduces a roller- amendment service for the Boeing 737 flight Notes tensioned, high visibility tape between the attendant manual . . . applies to all of the door aperture and the extendable handrail Boeing commercial aircraft product line,” the 1. FAA. Special Airworthiness Information Bulletin NM-07-47. September 2007. strut,” the report said. “After approval by the AAIB noted.“In this case . . . the operator would have been aware that some changes had been 2. Boeing. Service Bulletin 737-52- 1157. relevant airworthiness authorities, this 3. Monogram Systems. Service Bulletin 870700-52-2130. modification will be embodied on the made to the manual upon receipt of [the FAA 4. Boeing Commercial Airplanes. Boeing Flight operator's fleet as a matter of priority.” special airworthiness information bulletin].” Attendant Manual, page 7.10.34.October 29,2008. 5. Ryanair. SEP Manual, Section 2.4.13.5. The AAIB recommended that: Investigators concluded that the absence of a Reprinted with kind permission of ■ “Boeing establish a process to inform the barrier that specifically protects small children Aerosafety World September 2010 operators of all Boeing commercial aircraft also should be addressed. “The gap between of changes to the relevant flight attendant the extendable handrail and the upper manual;” platform of the Boeing 737 airstair represents a hazard to small children boarding or ■ “Ryanair review their current passenger disembarking the aircraft,” the report said. boarding and disembarking procedures so “Four previous events resulted in [amended that assistance is made available to guidance or safety bulletins that] do not passengers accompanied by children, and provide physical protection against a child those with special needs; [and,]

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Scheduling to Manage Fatigue

Are you scheduling your aircrews with fatigue factors in mind? By George C. Larson ([email protected])

chedulers and dispatchers who operate As just one example, it used to be thought that Accident investigators and sleep researchers Sin the real world know that it's if the Earth didn't rotate, human biology would had long suspected that fatigue was a factor in unrealistic to expect a nine-to-five operate on a “natural” sleep-wake cycle of a majority of aircraft accidents but could never operating schedule in a typical flight about 25 hours, not 24, and NASA scheduled prove it. All that changed, though, on Aug. 18, department. Your department manager or International Space Station personnel 1993, when a McDonnell Douglas DC-8 chief pilot has been selling the executives accordingly. Today nobody seems to know registered to American International Airways downtown on how they can do three where that figure came from. Current science and flying on a military contract as AIA Flight meetings in a single day and, assuming the says the natural number is probably closer to 808 crashed on approach to Guantanamo Bay aircraft can go the distance, on different 24.2 hours. But what's more important is that Naval Air Station. The aircraft was written off continents. It can be an intimidating the natural cycle is longer than a normal day, and the crew of three survived with serious environment in which the cultural which may explain why it's easier to travel injuries. For the first time in history, fatigue differences within an organization westbound than eastbound; a longer day feels was cited in the final NTSB accident report as combine to possibly erode the safety of slightly more normal. But one of the most the probable cause. Now fatigue has moved to your operations. Preaching fatigue important questions science has answered is the forefront in safety management as well as management may only earn you some what not to expect of yourselves as you accident investigations. unwanted pushback. manage fatigue issues in your daily scheduling and communication with flight crews. Two seminal publications on fatigue are available to aviation staff via the Internet, one Science says you cannot tell if people are tired at NASA Ames (http://human-factors. simply by looking at them or talking to them arc.nasa.gov/zteam/) and another at the Flight on the phone. Humans generally are unable to Safety Foundation (search Archives for detect early symptoms of fatigue in Principles and Guidelines for Duty and Rest themselves, and therefore are almost Scheduling in Corporate and Business Aviation). universally inclined to deny being tired when The NASA “Z” Team document that emerged asked. Nor is fatigue visible in others in any from the Fatigue Countermeasures Group way - unless they're actually nodding off. served as the basis for the FSF publication, so Whenever the question arose as to whether a the latter comes highly recommended. flight crew member or an aircraft technician Neither one is likely to help a scheduler or had been fatigued prior to a mishap, a dispatcher who is trying to proactively effect scheduler or dispatcher might find themselves an enlightened flight department policy being put on the spot: “Did they look tired?” because the charts and arrows and numbers But you won't get any from Deborah Hersman, Well, science has settled that one, and you're make the subject look too complex and currently chairman of the NTSB. She delivered off the hook. expensive. Accordingly, we've simplied it all so an address on the subject of fatigue and-its that nobody falls asleep. adverse effect on safety in early March before a Of course, regulations are also on your side, gathering of the National Sleep Foundation, but regulations don't have the power to The basics are easier to teach and remember, telling them, "Identifying fatigue and reducing prevent people from doing the wrong thing. as there are just four primary factors in coming risks for fatigue in accidents is included on our The FAA can publish duty time limits and to grips with fatigue: sleep loss, continuous Most Wanted List." She cited the role of science authorities like the NTSB can write speeches hours awake, circadian cycles (or time of day) in developing new sets of guidelines for duty about fatigue, but if a member of a flight crew and sleep disorders such as sleep apnea, which hours among transportation workers, and fails to heed the rules and flies anyway, he or is an interruption of normal breathing, which, added, "In recent years, our understanding of she is placing passengers at risk. So any safety in turn, interrupts normal sleep. the factors that lead to fatigue has broadened, management system that does not address as have our recommendations." When the complex issues of fatigue is sorely lacking. Sleep loss comprises a daily component, schedulers and dispatchers confront fatigue The science, being new, has not yet fully meaning how much of an eight-hour sleep issues with your flight departments. you now migrated into the regulations or into was lost within a given 24 hours, and sleep have a powerful force to wield: Science is on operations, so the policy you set within your debt, which is a cumulative loss over a period your side in this. Real scientific research done by own department should be thought through of several days. real scientists using humans wired to machines based upon our own study of the science.And at NASA Ames, among other places, has led to only by getting total buy-in can your flight Continuous hours awake links to performance easily followed guidelines that replace the gut department succeed. loss and is now equated with the use of instinct we as a community used to rely on. alcohol. That's interesting, because professional flight crews would never violate

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alcohol rules, and everyone knows them and deeper sleep from which it may take 15 fatigue." He says he got interested in the issue embraces them. And here's where science minutes to recover full alertness.To nap or not in the course of running a flight department steps in to provide a clear understanding of to nap is more of a policy matter for a and sat down with all his pilots. "I said to performance. It says that being awake for 17 department manager than a scheduler or them 'Here's the science from 10 years [of continuous hours is the equivalent of a dispatcher issue but it’s interesting that the research at NASA Ames].We can wing it or we can take these data and figure out a way to Breathalyzer reading of 0.05. Keep going for wind is shifting’. incorporate them into our daily operations so 22 hours and you blow a 0.08, but go for the we're within the criteria.' To me it was a whole enchilada at 24 hours and you will be There are some simple steps schedulers and mandate." It's time flight departments large the rough equivalent of a drunk at 0.10. dispatchers can take to provide some and small think of fatigue management the measure of intervention to prevent fatigue. same way, and schedulers and dispatchers The circadian factor has a biological basis and The first is to study the science - not to should lead the effort. is one fatigue factor that's been widely become an expert but to be able to state your understood and embraced, although case with assurance when you need to. Reprinted with kind permission of Business regulations and your own operations manual Another important measure is to & Commercial Aviation April 2010 may be subject to change as new information communicate with and educate your emerges. Unless you're an arctic reindeer, colleagues in the flight department and your which can alter its circadian rhythm, you have customers at headquarters. Says Ken Law, a sleep-wake cycle within 24 hours that chief pilot for an S&P 500 firm, “We in the affects your body's biochemistry and, more aviation department must communicate with important, your performance. The science the company on fatigue issues. . . . The says there are two "lows" when performance company must have a policy that encourages hits a wall, and both occur between three and people to report themselves fatigued and to five o'clock, one in the pre-dawn morning and take themselves off duty.” At the NASA Ames the other in the afternoon. (Now you begin to Web site for Team “Z” there are education see the wisdom behind taking a siesta.) A modules for downloading if you need help. second component of the circadian factor is But keep it short, keep it simple and refresh any irregular scheduling, whether due to time everyone’s memory from time to time. zone change, a shift to night work or flipping Finally, when you work with anyone involved back and forth. Sleep apnea is treatable, but in the safety of flight or even simply talk with most people affected by it are unaware they them on the phone, you, as a scheduler or have it. It's associated with snoring, and a dispatcher, have an opportunity to perform a person is as likely to be aware they have quick fatigue “checklist” based on Sleep, apnea as they are to be aware they snore. On Awake, Clock: one recent flight during which a crew over- flew the destination and both airmen were ■ Slept less than eight hours in the last 24? determined during an ensuing investigation to ■ have been asleep, the captain was later Awake more than 17 hours? diagnosed with sleep apnea. He'd had no idea. ■ Any major schedule shifts? Visit the National Sleep Foundation Web site (www.sleepfoundation.org) and click on "Find Durwood Heinrich presented a class on a Sleep Professional" for medical sleep centers fatigue management to a standing room- nearby. As awareness of fatigue as a public only audience at the recent NBAA Schedulers health issue has risen, so have the number of & Dispatchers Convention in San Antonio. medical personnel trained and equipped to Those who attended received a slide rule-like treat the problem. tool he designed that makes it easy to establish duty time and required rest. Heinrich Napping during the en route segment is has a Ph.D. in Industrial Organizational finding increasing acceptance among fatigue Psychology in addition to a B.S. in Aerospace experts who are familiar with flight Engineering. The former chief pilot for Texas Instruments and PetSmart says, 'We as operations. The only caution is to limit the humans are terrible judges of our own fatigue. sleep to about 45 minutes, no longer. Sleeping On average, we're getting two hours less sleep for more than 45 minutes risks slipping into a than we should be. There's no blood test for

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Members List

Members of The United Kingdom Flight Safety Committee

FULL MEMBERS AVISA Cyprus Airways Ian Chapman Andreas Georgiou Chairman Monarch Airlines BA Cityflyer DHL Air Capt. Tony Wride Alan Taylor Shayne Broad

Vice-Chairman BAA Ltd Eastern Airways UK Ltd RTI Tim Hardy Capt. Jacqueline Mills Steve Hull BAE SYSTEMS Reg. A/C easyJet Treasurer Alistair Scott Capt. Chris Brady Air Contractors Capt. Anthony Barrett-Jolley Baines Simmons Flight Data Services Ltd Bob Simmons Capt. Simon Searle Executive Board CAA Rep CAA BALPA flybe. Mark Chesney Carolyn Evans Neil Woollacott

Non Executive Board Member Belfast Intl. Airport Gael Ltd CTC Aviation Services Ltd Alan Whiteside Craig Baker Robin Berry Blink GAMA Aviation Acropolis Aviation Guy Sayer Nick Mirehouse Phil Breeze-Lamb bmi regional GAPAN A|D|S Alistair Stenton Capt. Alex Fisher Mel James British International GATCO Aegean Airlines Phil Keightley Shaneen Benson Capt. Vassilis Anadiotis CargoLux Airlines GE Aviation Aer Arann Mattias Pak Mike Rimmer Stuart Dobbyn Cathay Pacific Airways Global Supply Systems Aer Lingus Rick Howell John Badley Capt. Conor Nolan Cello Aviation Goodrich Actuation Systems Ltd Airbus S.A.S Stephen Morris Gary Clinton Christopher Courtenay Charles Taylor aviation Gulf Air Co Airclaims David Harvey Capt. Khalil Radhi John Bayley Chartis Ins. UK Ltd Independent Pilots Association Air Contractors Jonathan Woodrow Rod Bruce Capt. Anthony Barrett-Jolley CHC Scotia Irish Aviation Authority Air Mauritius Mark Brosnan Capt. Harry McCrink Capt. Francois Marion CityJet Jet2.com Air Seychelles John Kirke David Thombs Annie Paul City University London JRA Aerospace Air Tanker Services Ltd Cenqiz Turkoglu Andy Evans TBN Cobham Aviation Services Loganair ALAE Capt. Gary Wakefield Robin Freeman Ian Tovey Cranfield Safety & London City Airport Astraeus Ltd Accident Investigation Centre Sharon Preston Chris Barratt Dr. Simon Place Lufthansa Consulting GmbH Atlantic Airlines CTC Aviation Services Ltd Ingo Luschen Alex Wood Robin Berry

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Malaysia Airlines Thomas Cook Airlines QinetiQ Ooi Teong Siew Terry Spandley Flt. Lt. Bryan Tennant

Manchester Airport plc Thomson Airways QinetiQ Eng. Simon Butterworth Martin Ring Phil Bevan

Monarch Airlines Titan Airways RAeS Usman Hussain Pavan Johal Peter Richards

Navtech (EAG) Virgin Atlantic Airways RAeS Eng. Max Harris Rob Holliday Jim Rainbow

Panasonic Avionics Vistair TAM Brazilian Airlines Bob Jeffrey Stuart Mckie-Smith Capt. Geraldo Costa de Meneses

PrivatAir TAM Executiva Tom De Neve GROUP MEMBERS Capt. Castro

Pen Avia bmi Brad Preston Jeffery Thomas CO-OPTED ADVISERS

QBE Aviation bmi Eng. AAIB Capt. Margaret Dean Jerry Flaxman Ian Johnston CAA RTI bmi baby Steve Hull Sean Parker - Grp. Safety Services Nicole Stewart Graham Rourke - Airworthiness Rolls-Royce Plc Simon Williams - Flight Operations Policy Bond Offshore Helicopters Phillip O’Dell Garth Gray – Flight Operations Tony Duff Ryanair CHIRP Capt. George Davis Bond Offshore Helicopters (Maint) Peter Tait John Crowther ScotAirways GASCo Nigel McClure Bristow Helicopters Mike Jackson Capt. Derek Whatling Shell Aircraft Intl. Legal Advisor Tony Cramp Bristow Helicopters Eng. Edward Spencer Brian Bolda Barlow Lyde & Gilbert Superstructure Group NATS Eddie Rogan MOD Representatives Karen Bolton Capt Al Clark (RN) - MAA Deputy Head Ops TAG Aviation (UK) Ltd Group, Flt Ops Division Malcolm Rusby Royal Met. Society Wg Cdr Andrew Tait - MAA Flt Ops Div Rob Seaman Cdr Mark Leaning - Royal Navy Teledyne Controls Lt Col Chris Hyslop - Army UK Airprox Board Mark Collishaw Gp Capt. Simon Brailsford - RAF Air Cdre. Ian Dugmore

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