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CONTROL ISSUES On-airplane UPRT training UNRECOGNIZED Crew misses go-around cues MEETING EXPECTATIONS MPL grads gain acceptance
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Aviation Publication.indd 1 4/12/2014 11:52:14 AM PRESIDENT’SMESSAGE
THOUGHTFUL RESPONSE VS. Speculation
nce again, we have been reminded of the accident and, hopefully, bring comfort to the the significance of our aviation system victims’ families. safety work, including the intense news There also is a deep connection with our media scrutiny that a single aviation event strategic priorities, previously introduced in this Ocan generate. The tragic situation involving Malay- column, to better utilize data to improve investiga- sia Airlines Flight 370 (MH370), which had lasted tions and safety. The aviation system is astound- 31 days as I wrote this, has brought our industry ingly safe, but we cannot pass on opportunities to role into sharp focus. make it ever safer. The Foundation is pleased to You may have noticed, and perhaps wondered, be working with our safety partners around the why Flight Safety Foundation was not front-and- world in a leadership role to bring forward the dia- center in the media speculation on the root cause logue, and ultimately to take action, to continually of this event. The answer lies in the word specula- improve aircraft tracking, operations and safety. tion. Quite simply, we refused to add to the mass Leading this charge for the Foundation will of speculation already being disseminated. be our newly appointed president and CEO. After The Foundation prides itself, and our mem- an exhaustive search, the Board of Governors is bers demand, that we be a voice of reason and pleased to announce that Jon L. Beatty will assume calm in situations like this. That is why, after most leadership in late April. Jon brings a strong, senior of the wild speculation passed, we chose to call for aviation management background to the post. The a detailed review of technology and processes to Board is thrilled to have a person with his business improve aircraft location-tracking in a practical and technical credentials coming aboard to guide and prudent manner. We believe that this is the us forward. We are confident that he will bring fresh seminal issue that needs to be addressed. ideas and vision to all aspects of the Foundation. We recognize that aircraft location-tracking is not a primary flight safety issue, such as training, reliability or compliance. But in this day and age, not being able to locate, in a timely manner, a large commercial airliner is unacceptable. More expeditious discovery of a missing airplane would Kenneth J. Hylander not only aid in search and rescue but also allow President and CEO (Acting) faster understanding of the issues that caused Flight Safety Foundation
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MAY 2014 | 1 AeroSafetyWORLD
contents May 2014 Vol 9 Issue 4 features
12 CoverStory | Glider-Rated Airline Pilots
17 CoverStory | On-Airplane UPRT Advantages
23 CausalFactors | Brit Air Excursion
28 FlightOps | BEA Go-Around Report
12 33 AviationMedicine | Assessing Color Vision
38 FlightTraining | ICAO MPL Update
departments
1 President’sMessage | Thoughtful Response vs. Speculation
6 SafetyCalendar | Industry Events
8 InBrief | Safety News 17
2 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MAY 2014 23 28 33
44 DataLink | Commercial Aviation Fatalities Down
47 InfoScan | Risk Roundup
51 OnRecord | ‘Conflict of Plans’ 38 AeroSafetyWORLD telephone: +1 703.739.6700
About the Cover The pilot’s view inside a Schempp- Frank Jackman, editor-in-chief, Hirth Duo Discus glider flying FSF director of publications above the Pyrenees in Spain. [email protected], ext. 116 Unusual attitudes are anything but unusual for glider pilots, says a British airline captain. Wayne Rosenkrans, senior editor [email protected], ext. 115 © Neil Stuart Lawson/whiteplanes.com Linda Werfelman, senior editor [email protected], ext. 122
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OFFICERS AND STAFF ince 1947, Flight Safety Foundation has helped save lives around the world. The Chairman Foundation is an international non-profit organization whose sole purpose is to Board of Governors David McMillan provide impartial, independent, expert safety guidance and resources for the President and CEO Jon L. Beatty S aviation and aerospace industry. The Foundation is in a unique position to identify General Counsel and Secretary Kenneth P. Quinn, Esq. global safety issues, set priorities and serve as a catalyst to address the issues through data collection and information sharing, education, advocacy and communications. The Treasurer David J. Barger Foundation’s effectiveness in bridging cultural and political differences in the common cause of safety has earned worldwide respect. Today, membership includes more than FINANCIAL 1,000 organizations and individuals in 150 countries. Financial Operations Manager Jaime Northington
MEMBERSHIP AND BUSINESS DEVELOPMENT MemberGuide Flight Safety Foundation Senior Director of 801 N. Fairfax St., Suite 400, Alexandria VA 22314-1774 USA Membership and Business Development Susan M. Lausch tel +1 703.739.6700 fax +1 703.739.6708 flightsafety.org Member enrollment ext. 102 Director of Events Ahlam Wahdan, membership services coordinator [email protected] and Seminars Kelcey Mitchell Seminar registration ext. 101 Manager, Conferences Namratha Apparao, manager, conferences and exhibits [email protected] and Exhibits Namratha Apparao Seminar sponsorships/Exhibitor opportunities ext. 105 Membership Kelcey Mitchell, director of events and seminars [email protected] Services Coordinator Ahlam Wahdan Donations/Endowments ext. 112 Consultant, Student Susan M. Lausch, senior director of membership and development [email protected] Chapters and Projects Caren Waddell FSF awards programs ext. 105 Kelcey Mitchell, director of events and seminars [email protected] COMMUNICATIONS Technical product orders ext. 101 Director of Namratha Apparao, manager, conferences and exhibits [email protected] Communications Emily McGee Seminar proceedings ext. 101 Namratha Apparao, manager, conferences and exhibits [email protected] Website ext. 126 GLOBAL PROGRAMS Emily McGee, director of communications [email protected] Director of Basic Aviation Risk Standard Global Programs Rudy Quevedo Greg Marshall, BARS managing director [email protected] Foundation Fellow James M. Burin BARS Program Office: Level 6, 278 Collins Street, Melbourne, Victoria 3000 Australia tel +61 1300.557.162 fax +61 1300.557.182 [email protected]
BASIC AVIATION RISK STANDARD BARS Managing Director Greg Marshall
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FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MAY 2014 | 5 ➤ SAFETYCALENDAR
MAY 1 ➤ ISASI Mid-Atlantic Regional MAY 20–22 ➤ European Business Aviation JULY 14–20 ➤ 49th Farnborough International Chapter Spring 2014 Dinner/Meeting. Convention and Exhibition (EBACE2014). Airshow. Farnborough Airport. Farnborough, International Society of Air Safety Investigators National Business Aviation Association. Geneva. Hampshire, England.
MAY 18–21 ➤ 86th annual AAAE Conference JUNE 30–JULY 2 ➤ Safe-Runway Operations If you have a safety-related conference, and Exhibition. American Association of Airport Training Course. JAA Training Organisation. Abu seminar or meeting, we’ll list it. Get the Executives. San Antonio, Texas, U.S. Dhabi, United Arab Emirates.
6 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MAY 2014
INBRIEF Safety News Global Flight Tracking
purred by the disappearance of a Malaysia Airlines Boeing 777, government and aviation industry Sexperts are scheduled to meet this month to discuss how to implement worldwide flight tracking. The planned meeting, to be convened by the Interna- tional Civil Aviation Organization (ICAO), will examine “specific aircraft- and satellite-based capabilities” that would permit flight tracking on a global basis (ASW, 8/09, p. 24). Malaysia Airlines Flight 370 disappeared March 8 dur- ing a flight from Kuala Lumpur to Beijing with 239 people aboard. At press time, searchers were trying to locate the source of acoustic signals that matched those emitted by flight recorders, coming from deep in the Indian Ocean. ICAO said that its Flight Recorder Panel is reviewing suggested methods of speeding up the location of accident sites, “including deployable flight recorders and the trig- gered transmission of flight data.” Olumuyiwa Bernard Aliu, Council president of ICAO, © Boeing added, “No matter how safe or secure we make the air transport network, these types of events remind our entire 787 Review sector that no effort is ever enough, no solution ever a reason to stop seeking further improvement.” report on the review of the design, manufacture and Announcement of the May 12–13 special meeting assembly processes for the Boeing 787 has made seven followed calls from several international aviation organiza- Arecommendations for improvements in Boeing’s pro- tions, including Flight Safety Foundation, for such a cesses and the U.S. Federal Aviation Administration’s (FAA’s) gathering. oversight. “Emerging technology exists to provide much more The FAA said that its review team concluded that the real-time data about aircraft operations and engine perfor- airplane was “soundly designed, met its intended safety level mance,” said David McMillan, chairman of the Founda- and that the manufacturer and the FAA had effective processes tion’s Board of Governors. “That data can help us unlock in place to identify and correct issues that emerged before and mysteries, leading to timely safety improvements and after certification.” more focused search and rescue missions, while avoiding Nevertheless, the panel issued recommendations that some of the pain and anguish felt by victims’ loved ones in included calls for Boeing to address manufacturing and “supplier- the wake of a tragedy.” quality” issues and for the FAA to institute “improved, risk- based … oversight to account for new business models.” The team — made up of Boeing technical experts and FAA engineers and specialists who had not been closely involved in the 787 certification process — was appointed in January 2013, in the aftermath of a fire in a Japan Airlines 787 while it was parked at a gate at Boston Logan International Airport. One firefighter was injured fighting the blaze. A preliminary report from the U.S. National Transporta- tion Safety Board traced the origin of the fire to the lithium-ion battery in the auxiliary power unit. The FAA said that the review team also examined service- reliability data for the 787 and found that its “reliability per- formance in the first 16 months of service was comparable to the reliability of other new Boeing models over the same time period.” Jennifer Moore
8 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MAY 2014 INBRIEF
New Moves to Regulate UAS
he European Commission (EC) and the European Aviation Safety Agency are preparing to develop a Tpolicy framework for integrating unmanned aircraft systems (UAS) — also being called remotely piloted avia- tion systems or drones — into European airspace. “Drones are already beginning to appear in our skies, but there are no clear general rules, at a national or at European level, which put in place the necessary safeguards [to] protect the safety, security and privacy of people,” said Siim Kallas, EC vice president responsible for transport. Frankhöffner/WikiMedia EC plans call for the integration of UAS into civil airspace “based on the principle that all operations will have an equivalent level of safety in comparison to regular manned aviation.” The European Council has said that rules should be developed for integrating UAS into civil airspace beginning in 2016. In related action, in the United States, the Aerospace Industries Association (AIA) has urged the U.S. Federal Aviation Adminis- tration (FAA) to expedite its consideration and approval of the notice of proposed rulemaking concerning the safe use of small UAS — those with vehicles weighing less than 55 lb (25 kg). “Only after issuance of the proposed rule can we begin a transparent dialogue between government, industry, users and other interested parties to allow the safe use of these systems by American businesses,” said a letter signed by AIA President Marion Blakey and Gary Shapiro, president of the Consumer Electronics Association. The FAA is required by law to issue a final rule on the matter by August.
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FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MAY 2014 | 9 INBRIEF
MD-11 Hard Landings ‘Extra Vigilance’
iting 13 hard-landing accidents over the last two decades involving the he U.S. National Transportation global fleet of McDonnell Douglas MD-11s, the U.S. National Transporta- Safety Board (NTSB), distressed by Ction Safety Board (NTSB) is calling for action to review the effectiveness Ttwo recent incidents in which the of flare-cueing systems to determine whether they could provide useful infor- crews of air carrier aircraft landed at the mation for MD-11 flight crews. wrong airport, has issued a safety alert The U.S. Federal Aviation Administration (FAA) and Boeing should work urging pilots to always verify that they are together on the review and produce a formal report on their findings, the landing at the correct airport. NTSB recommended. If they determine that the systems would “assist pilots “The consequences for pilots mistak- in making timely and appropriate inputs during the landing flare,” they should ing a nearby airport for the intended one, distribute copies of the report to U.S. operators of MD-11s and encourage the or landing on the wrong runway or a taxi- operators to install flare-cueing systems on these airplanes, the NTSB said. way, can have catastrophic consequences,” Accompanying recommendations call for the FAA and Boeing to conduct NTSB Chairman Deborah Hersman said. a similar assessment of methods of providing “weight-on-wheels cueing” to The safety alert directed flight crews enhance awareness of bounced landings and effective responses, with reports to comply with standard operating to operators if they determine such cueing would be useful; and to “evaluate procedures, verify the airplane’s position the effect of brief power increases on simulated MD-11 landing distances,” with relative to the airport, and “use available adjusted landing distance tables, if necessary. cockpit instrumentation to verify that you Another recommendation said that the FAA should reconvene the MD-10/ are landing at the correct airport.” The MD-11 flight standardization board to determine whether currency require- document urged “extra vigilance when ments should be strengthened for MD-11 pilots. identifying the destination airport at night “MD-11 hard landing accidents have frequently involved a pilot’s late or and when landing at an airport with oth- ineffective flare and/or mismanagement of bounced landings, which can cause ers in close proximity.” the airplane to porpoise,” the NTSB said. “This sequence of events could be Other recommended precautions particularly hazardous in the MD-11 because overloading of the main landing are to be familiar with the destination gear in the vertical direction could cause the main wing spar to fracture and the airport’s layout, use the most precise navi- airplane to subsequently roll over.” gational aids in conjunction with a visual The NTSB said that a review of data showed that the MD-11 had the high- approach and “confirm that you have est rate of hard-landing events of 27 large Western-built transport category correctly identified the destination airport airplanes — 5.63 per 1 million flight cycles. before reporting the airport or runway is Factors that might have contributed to the problem include the MD-11’s in sight,” the NTSB said. high landing speed, which “increases the difficulty of a properly timed and ex- The two incidents cited by the NTSB ecuted flare because it must be initiated within a narrow timeframe,” the NTSB were: said. Other factors include the location of the cockpit ahead of the center of • The Jan. 12 landing of a Southwest gravity and the main landing gear, the automatic reduction of thrust during the Airlines Boeing 737 on a 3,738-ft landing flare and the MD-11’s extensive use in long-range cargo flights, which (1,140-m) runway at M. Graham offer pilots relatively few opportunities to maintain landing proficiency. Clark Downtown Airport in Branson, Missouri, instead of on the 7,140-ft (2,178-m) runway at Branson Airport, as planned; and, • The Nov. 21, 2013, landing of a Dreamlifter 747 on a 6,100-ft (1,860-m) runway at Colonel James Jabara Airport in Wichita, Kansas, instead of the planned destination 12 nm (22 km) away — a 12,000-ft (3,660-m) runway at McConnell Air Force Base. Both landings were made in night visual meteorological conditions and both ended without further incident.
Faisal Akram/WikiMedia
10 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MAY 2014 INBRIEF
New FSF President and CEO David McMillan, chairman of the FSF Board of Governors, said Beatty on L. Beatty, a former top executive at International Aero “brings an international executive Engines, is the new president and CEO of Flight Safety perspective that will be instrumental JFoundation. in moving the Foundation into its next He officially took over at the Foundation on April 21, suc- chapter as the leading voice of aviation ceeding Kevin L. Hiatt, now senior vice president of safety and safety around the world.” flight operations at the International Air Transport Association. During a two-month transition pe- Beatty was president and CEO of International Aero riod after Hiatt’s departure in February, Beatty Engines from 2007 through 2009 and from 2012 until his retire- Kenneth J. Hylander was the Founda- ment earlier this year. He also held several executive positions at tion’s acting president and CEO, and William G. Bozin was Pratt & Whitney, BF Goodrich and AlliedSignal Aerospace. acting chief operating officer.
In Other News …
The Transportation Safety Board of Canada has updated regulations governing the reporting and investigation of aviation ac- cidents and incidents — as well as occurrences in other modes of transportation — to take full advantage of electronic information sharing and to harmonize definitions with international standards. … The U.K. Civil Aviation Authority has won a conviction in its first prosecution of an unmanned aircraft pilot for “dangerous and illegal flying.” The man was found guilty in early April of flying the unmanned aircraft system vehicle in restricted airspace above a nuclear submarine facility. … The Australian Civil Aviation Safety Authority says it is developing a package of improvements in airport safety standards to clarify the intent of some rules and limit the need for exemptions. Changes will be focused on specific areas, including apron parking clearances and lighting levels, approach slope guidance for large aircraft, wind direction indicators and movement-area guidance signs.
Compiled and edited by Linda Werfelman.
www.skybrary.aero/index.php/Portal:Airborne_Conflict
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MAY 2014 | 11 COVERSTORY
As airline pilots pursue manual-handling practice and startle resilience, a British captain suggests glider flying. © Neil Stuart Lawson/whiteplanes.com
High-AlphaBY WAYNE ROSENKRANS Culture
12 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MAY 2014 COVERSTORY
pset prevention and recovery training upset incidents, but those who pursue the sport (UPRT) at the commercial and multi- are given a deep grounding in hand-flying skills, crew pilot licensing (MPL) levels — not situational awareness and risk management — to mention initial and recurrent training all of great use to a modern airline pilot — and ofU airline pilots — has reemphasized hand- the training should be taken seriously by com- flying proficiency, recognition of potential upset mercial training organizations and operators,” situations and immediate recovery from stall in- Kelman told ASW after the conference. dications, among other skills. A recent analysis of automation and flight path management vul- Unusual Attitudes nerabilities also reinforces these themes (ASW, The types of flights conducted in gliders may 2/14, p. 12). One unsettled question, however, is surprise airline pilots unfamiliar with this whether the airline pilots who complete UPRT segment of flying. “The main feedback on the might gain an additional advantage from rou- conference day was along the lines of ‘I had no tinely hand-flying some type of general aviation idea you do those sorts of things in gliders!’” aircraft on their own time. she said, citing as an example one friend’s recent A British airline captain favors this practice, 750-km (405-nm) flight in southeast England drawing from her aeronautical engineering and in a sailplane without an engine. The pilot flew, safety background, involvement in implement- primarily in thermals, at altitudes between ap- ing UPRT, and experience during more than proximately 1,000 ft and 5,000 ft. Thermals are 20 years as a glider instructor and an interna- bubbles or columns of warm rising air. tional competitor in racing sailplanes.1,2 Last Another friend, flying in mountain waves in December, Sarah Kelman, who flies the Airbus Scotland and limiting his climbs to maximum A320 for easyJet, explained the perspective she altitudes of about 9,000 ft, recently flew 1,000 and fellow airline-pilot members of the British km (540 nm) as a double out-and-return flight. Gliding Association
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MAY 2014 | 13 COVERSTORY
The British Gliding Association’s the horizontal — to regain the speed. angle-of-attack] to make the radius of leaders and safety specialists assume If that happens low down — below the turn as small as it can be,” Kelman that glider pilots have a high degree of 200 ft — then they’re faced with the said. “Stall and spin awareness is para- exposure to unusual attitudes that, in ground rush.” mount. We’re flying right on the edges the United Kingdom, typically begins The possibility of such a winch-cable of the envelope.” One of her video with the winch launch. During the break, which creates a circuit (i.e., examples showed a pilot maintaining launch, the glider accelerates from 0 landing-pattern) emergency situation, the desired relative position with a to 60 kt in two to three seconds. “The underscores the importance — also 70-degree bank angle in a typical gusty glider is then climbing at around 40 at the pre-solo training phase — of thermal, then demonstrating a calm, degrees to the horizontal,” she said. continual contingency planning to be swift and correct recovery from an “That’s combined with the glider seat- ready for sudden, unexpected, rapidly intentional stall and spin. ing position of around 45 degrees re- changing and dynamic situations. “There was no startle effect there clined, which means that the sensation “The pilots have to decide after a cable at all,” she noted in describing the is of a near-vertical climb. The horizon break whether they have the energy to maneuver. “The recovery is so famil- is out of sight of the pilot. land ahead or whether they have to go iar that he just continues to fly in the “The pilot-performance margins into some sort of low-level emergency thermal. And that’s where we want our are quite small on a winch launch. circuit,” Kelman said. “Dealing rapidly trainees to be — to be able to deal with You often have a 10-kt speed window with contingency is the essence. The these situations safely and habitually.” between overspeeding the glider and a glider pilots must aviate, aviate and This situational awareness also high-speed stall that occurs due to the aviate to fly by attitudes and with air- comes into play in hand-flying preci- loading on the wing. Our trainees are speed cues, and to overcome somato- sion and understanding of aerodynam- taught that they have to fly within 2-kt gravic effect. In case of lack of a real ics governing the limits of high-speed to 3-kt accuracy all the way up there, horizon, the attitude indicator is the flight for the specific glider. “Our pilots even though they can’t see the ground. only safe alternative.” have to be very aware of the limits We mention about putting the pitch at- As in commercial airlines, glider pi- of high-speed flight, the relevance titude in the correct place even if there lots at times have failed to overcome the of maneuvering speed, the limits of is a 1-degree diversion [deviation].” somatogravic effect. “People have come never-exceed speed and also the ap- Even at this early stage of glider off the top of a failed winch launch, propriate control inputs at high speed, training, Kelman finds parallels to pushed the nose forward to recover the as opposed to the low-speed ends of the UPRT. “That initial acceleration is very speed, and inappropriately interpreted envelope,” Kelman said. abrupt — not dissimilar to the sort of the reduced g [standard gravitational thing we’re seeing in extreme upsets in acceleration] as a stall and continued Airline Relevance the airline industry,” she said. “We have to nose the glider down into an impact The systems-monitoring demands of to teach them to overcome the somato- with the ground,” she added. a flight crew’s duties during airline gravic effect.4 At the top of a normal operations these days translate into winch launch, the glider pilot needs to High-Alpha Culture less hand-flying, despite the consen- lower the nose to regain the speed.” Operating close to the limits of the sus that this is a highly degradable Another parallel is the necessity normal flight region of the aircraft’s skill. Some airlines have seen evidence of pilots overcoming any instinc- aerodynamic envelope is the key of this trend, Kelman said, based on tive reluctance or hesitation to lower to glider pilots’ capability to fly in analyses from flight data monitoring the nose to recover from a stall near thermals for extended periods and, programs and the performance of some the ground. “It’s something that we in turn, makes possible cross-country MPL-trained pilots. Manual-handling endeavor to train out of them before flights in sailplanes. “The thermal cores deficiencies may show up as unstable they are even permitted to go on their are quite small, and so, to maximize approaches, exceedances of flight pa- first solo in a glider,” she said. “If the the strong lift in the center, the glider rameters, landings without flare, land- cable breaks, the pilot needs to lower needs to fly typically at a very high ings outside the touchdown zone and the nose — often to 30 degrees below angle of bank and a low speed [i.e., high go-arounds conducted solely because of
14 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MAY 2014 COVERSTORY
Characteristics of Airliner Piloting and Glider Piloting
Airline Pilot Glider Pilot Normal Operations Abnormal Operations All Operations High reliance on automation Degradation or loss of automation No automation Mostly monitoring of autopilot Hand flying with degraded All hand flying protections Instrument approaches Nonprecision or visual approach Visual approaches Long periods of inactivity/boredom High arousal Long periods of concentration — up to 10 in cruise hours but flight durations vary widely Mainly straight and level flight Degraded protections and flight Always maneuvering; steep turns closer to limits of envelope Fly conservatively to maximize Fly to edges of envelope to maximize performance performance
Note: A British airline captain referred to this table while outlining how glider rating–specific knowledge and skills may positively influence what airline pilots bring to their normal and abnormal operation of large commercial jets.
Source: Sarah Kelman
Table 1
flight crew reluctance to disconnect the automa- noted, “As a colleague of mine said, ‘When you tion and hand-fly as expected in the situation. disconnect the autopilot, it’s where technology If workload becomes unacceptably high becomes art.’” when pilots feel “forced” to hand-fly the airplane, Safely interpreting energy state and maneu- situational awareness and task-completion vering visually at low altitude after breaking out ability can be affected. “The lack of manual from clouds, for example, also sometimes reveal flying–basis [proficiency] also leads to a lack of airline pilots’ actual confidence in their level recognition of excursions toward the end of the of proficiency, in their ability to complete this flight envelope, i.e., the approaching stall; an maneuver according to company policy for sta- overreliance on automation; and also a reliance bilized approach and in their judgment of when on the flight management system for flight guid- a diversion is necessary. ance rather than checking for gross errors,” she She offered, as another example, a situation said. “Skills practice in general aviation aircraft in which flying time could be reduced by at least — particularly in gliders — can really help to 10 minutes “if pilots are competent and confi- address these issues. Hand-flying skills do offer dent enough in their handling skills” to request airline pilots resilience so that when things do and fly a visual approach rather than the longer go wrong, we have got the capacity to deal with instrument approach when conditions are suit- them, to fly the aircraft and still have enough able. “As a glider pilot, this is the sort of decision mental capacity left to deal with the abnormal we’re trained to do, managing the energy all the situation.” Table 1 summarizes several key dif- way in,” Kelman added. ferences in the perspectives of airline pilots and A number of airlines already encourage glider pilots. pilots to do as much hand-flying on the line The level of hand-flying proficiency also can as safely feasible according to policy, such as be a factor in decisions about serving new desti- electing visual approaches and conducting them nations where the approaches are not conducive with autopilot, flight director and autothrust to typical flight automation for reasons such as disengaged to keep skills current, she said. In infrastructure or terrain issues, she said. Kelman some companies, hand-flying during simulator
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MAY 2014 | 15 COVERSTORY
sessions is required but hand-flying the airliner at home base; Surprising Handling-Quality Parallels airplane is not required. there is really a lot of similarity.” 28.9 m Qualities of Scale She also cited (94.9 ft) Also surprising to many airline pilots one relevant study are the handling-quality parallels of outcomes from a between gliders and airliners. “When training exercise in we’re looking at the roll and yaw which flight crews handling, the principal scaling factor responded to a triple– is the wingspan,” she said. “Inertia in inertial reference Older-generation roll is proportional to the mass but also system failure. The Boeing 737 to the fifth power of the wingspan. If participants who were (example) we look at a typical 150-seat airliner, a currently involved Boeing 737 earlier-generation is typi- in a large amount of cally around 29 m [95 ft; Figure 1]; an general aviation flying Airbus A320 up to around 34 m [112 ft]. — whether in gliders A high-performance, two-seater glider or airplanes — essen- wingspan is around 25 m [82 ft]. The tially flew the exercise Two-seater glider (example, unspeci ed type) largest-span glider flying at the moment much more smoothly is 33 m [108 ft]. Typical training gliders and accurately than 26.0 m (85.3 ft) are around 18–19 m [59–62 ft]. And colleagues who only that means that their handling is sur- flew for their airline, Notes: In aerodynamic terms, effects of inertia on the roll rate of an aircraft prisingly ponderous and the roll rates Kelman said. depend on aircraft mass and wingspan, providing a handling experience in gliders similar to that of flying a 150-seat airliner in manual mode with quite similar to the handling of our The final ben- protections disengaged. 150-seat airliner in manual mode with efit to airline flight Source: Sarah Kelman the protections disengaged. crews, in her experi- “However, unlike the airliner, the ence, can emerge Figure 1 glider handling can be demonstrated in from a glider-flying unusual attitudes to the extremes of the airline pilot’s experience in assessing stable parameters. So it may be appropri- envelope. All gliders are utility category dynamic weather phenomena near land- ate then to use a slightly increased-drag and at least semi-aerobatic. Gliders are ing sites while flying gliders. “If adverse approach even though it looks like a very well suited to demonstrate loss conditions are approaching an airfield, light-wind, very pleasant day.” of control to airline pilots because we and I’m in my Airbus looking to make can demonstrate the full range of the an approach, then I can bring all that Notes dynamic effects and the accelerations — gliding perspective into my threat-and- 1. Imperial College London. “High Flying.” and what it actually feels like to have the error management straightaway,” she Focus on Alumni. Imperial Matters. Issue nose pointing at the sky.” said. “I know where the lift’s going to 30 (Summer 2007). Digital avionics, including moving- be, I know where the sink is going to be, 2. Although many people use the words map displays, in the most advanced glider and I know how the airplane is going to glider and sailplane interchangeably, some cockpits also have many characteristics of respond and whether it is safe to make consider sailplanes to be gliders capable of commercial jet simulators for purposes of an approach or whether to hold off for a higher performance. manual flying practice. “The glass cockpit later time. If you’ve got a light-wind day 3. High-alpha culture refers to glider pilots’ that I have in my glider, including the and strong thermal activity, low-drag, skill and comfort level using high angles- artificial horizon, is fully configurable reduced-flap approaches to save fuel of-attack in normal operations. on a laptop computer,” she said. “You may not be appropriate because a strong 4. Somatogravic illusion describes a pilot’s can set it up so it looks exactly like the thermal on short final may give the air- acceleration-induced false perception that PFD [primary flight display] on your craft enough energy to take it outside its the aircraft is pitching nose-up.
16 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MAY 2014 COVERSTORY
Whenever possible, UPRT by specially qualified instructors in all-attitude, all-envelope aircraft adds unique advantages.
BY RICK DARBY
educing the risk of loss of control–in Previous ASW articles have reported on flight (LOC-I) accidents, the leading ICAO’s mid-2013 decision to update its existing cause of fatalities in commercial aviation standard to require prevention as well as recovery between 2001 and 2011,1 remains a prior- elements when UPRT is delivered for the multi- ityR of the International Civil Aviation Organiza- crew pilot license (MPL) and to make on-aircraft tion (ICAO) and the entire aviation community. training of pilots at the commercial pilot licensing As one of several steps to standardize and har- level (ASW, 7/13, p. 27) a recommended practice monize upset prevention and recovery training rather than a standard. (UPRT), ICAO most recently has published Doc For multi-crew aircraft in air transport, 10011, Manual on Aeroplane Upset Prevention however, the latest standard requires that the © Aviation Performance Solutions Performance LLC © Aviation and Recovery Training.2 “applicant shall have, for the issue of an airplane
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category type rating, received upset pre- flight. Such extreme bank angles and paper says. Increased physical energy per vention and recovery training.” A recent angles-of-attack are limited to specific se is irrelevant to responding correctly to ASW article also detailed the role that airplane categories, to be discussed later. conditions where LOC-I is a real threat, near-term advances in flight simulation Prevention of negative transfer of but they cite scientific evidence that an are expected to have in UPRT (ASW, training to transport airplane operation “adrenalized experience” or “adrenal- 3/14, p. 28). requires that recovery be taught and ized training” has a tendency to enhance To re-emphasize the on-aircraft supervised by specially qualified UPRT learning and retention.7,8 element of UPRT last covered in ASW instructors, not typical certificated flight The retention aspect is important. three years ago, representatives of the instructors and maybe not even tradi- “Experiences acquired during the early Upset Prevention & Recovery Training tional aerobatic instructors, because most stages of a pilot’s development shape that Association (UPRTA),3 which contrib- lack the essential background in demon- pilot’s approach to operating airplanes, and uted expertise during development of stration and recovery from severe upsets. equally important, … the lessons learned the Manual, provided ASW with a new To put their perspective in context, it are perishable,” the paper says. “The ap- report that explains and encourages helps to zoom out to view the whole scope plication of upset prevention and recovery voluntary adoption of the on-aircraft of UPRT. “UPRT resources are divided skill sets, therefore, not only needs to be element of UPRT whenever possible in into two training tracks: academic and reinforced continually throughout a pilot’s light of ICAO’s recommended practice. practical,” Brooks, Ransbury and Stowell career, but also needs to be framed con- In this paper, titled “Addressing On- say. “Practical training is further subdi- tinually within the proper context.” Airplane Upset Prevention & Recovery vided into two parts: on-airplane and flight Given the strong influence of adre- Training: Primary Considerations for the simulation training device (FSTD). … nalized learning on the UPRT experi- Safe and Effective Delivery of UPRT,”4,5 “The framework of academics, ences of pilots that the authors have authors Randy Brooks, Paul “BJ” Rans- on-airplane and FSTDs, coupled with observed — and potentially on the pre- bury and Rich Stowell6 assert that, ideally, consistency of language, concepts, tech- vention of LOC-I accidents — the paper UPRT must culminate in “a structured niques and application across all stages, describes three core issues concerning experience throughout the flight envelope will provide pilots with the strongest the value of the on-airplane phase: and stall/spin upset red zones.” and most enduring learning experi- • “On-airplane training considerations; They note that the Manual defines ence possible. Cementing the training an airplane upset as “an in-flight condi- to maximize the stated goals of UPRT, • “Airplane and equipment consid- tion by which an airplane unintention- however, will require pilots to have an erations; and, ally exceeds the parameters normally adrenalized, on-airplane experience. • “Instructor considerations.” experienced in normal line operations or “It is the on-airplane experience where training. An upset is generally recog- academics become reality; where tech- Mind the Gaps nized as a condition of flight during niques practiced in FSTDs can be applied One ICAO document they cited states which the pitch of the airplane uninten- under real-time constraints and with that “current FSTDs have limitations tionally exceeds either 25 degrees nose more accurate aerodynamic behavior; and that render them incapable of provid- up or 10 degrees nose down; or a bank where pilot stress levels can be manipulat- ing the complete exposure to condi- angle exceeding 45 degrees; or flight ed to levels comparable to those of real-life tions synonymous with preventing or within the aforementioned parameters upsets, but in a controlled environment recovering from [an] LOC-I event…. but at inappropriate airspeeds.” where skill sets can be perfected, bonds to These areas of missing experience The paper stresses that there is no mental models for recovery strengthened provide gaps in pilots’ understanding substitute for actual airplane handling and confidence gained.” and proficiency when confronted with experience during training involving Adrenaline is a hormone secreted by an actual upset.” bank angles beyond 45 degrees, conduct- the adrenal glands under conditions of The authors say that, “consequently, ed in gradual stages increasing to 180 high stress or excitement. It boosts the on-airplane UPRT is seen as necessary degrees, as well as high angles-of-attack, body’s energy level so it can act quickly to fill the gaps. ICAO further acknowl- that will lead to a full aerodynamic and decisively, increasing blood flow to edges that on-airplane training pro- stall-and-spin departure from controlled the muscles and oxygen to the lungs, the vides experience and confidence in the
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psychophysiological domain of upsets Operational and Training Flight Envelopes that cannot be fully realized in FSTDs a l on e .” Pitch up +90° On-airplane UPRT pushes pilots be- yond their comfort zone, they say. Human +60° factors in a developing or actual upset can +30° include startle factor, disorientation, over- Roll +10° Roll reaction, fixation and cognitive bias. left 180° 90° 45° -10° 45° 90° 180° right Maximizing the positive effects of -30° adrenalized learning can be realized -60° under five conditions, they say: -90° • “Training is delivered in a con- Pitch down
sistent and regimented manner Normal ight Commercial licensing training Upset prevention and recovery training Per upset de nition Maximum limits Potential ight envelope red zone across all stages; (45° AOB, pitch +25° to -10°) (60° AOB, pitch +30° to -30°) (180° AOB, pitch +90° to -90°) 5% of potential flight envelope 11% of potential flight envelope 100% of potential flight envelope • “Trainees are exposed to the full range of roll and angle-of-attack AOB = angle of bank; ICAO = International Civil Aviation Organization envelopes; Source: ICAO Manual on Aeroplane Upset and Recovery Training • “Trainees are confident they can learn UPRT skills quickly; Figure 1 • “Trainees see that UPRT tech- should he or she ever have to recover • “Instilling the notion that inter- niques work, and experience from a severe upset, Brooks, Rans- vention [action] must be taken re- them personally; and, bury and Stowell say. “This does not gardless of the upset bank angle, at all suggest that pilots must only be rather than at some artificially • “Trainees have a positive training exposed to 180 degrees of bank; esca- set point on the escalation path.” experience.” lation and recovery from the UPRT Mitigation bridges are specific Pitch and Bank Envelopes red zone can — and indeed should be techniques appropriate to par- Per the Manual, specific pitch and — progressive,” they say. “For instance, ticular situations, the paper says. bank parameters define an airplane trainees might be exposed to escalat- They help establish a mindset in upset (Figure 1). In Figure 1, the green ing bank angles with roll recovery which a pilot does not wait [for] a rectangle represents the normal flight techniques applied at the following particular critical condition before envelope in which airline pilots operate. increments: 60 degrees, 90 degrees, beginning a recovery procedure, The yellow rectangle represents limits 135 degrees, and ultimately, 180 de- but instead reacts as soon as pos- that, when exceeded, pilots are meant grees. This approach offers several key sible (Figure 2, p. 21). to cope with as part of commercial benefits, including: pilot training. The much larger red area The paper provides an example of how a • “Experiencing red-zone excur- shows the full dimensions of the UPRT mitigation bridge works: “As it pertains sions coupled with appropriate envelope, which can involve essentially to recoveries from upset bank angles, mitigation strategies, initially any combination of pitch and bank. ‘push-then-roll’ is an important UPRT while at lower angles of bank and Ideally, an airplane should never enter technique … not only in terms of the reduced levels of stress; the red zone, and UPRT training is sequence of the inputs, but also in terms designed to prevent that from happen- • “Reinforcing the concept of preven- of their magnitudes. ‘Push’ beneficially ing or, if it does, to prepare the pilot to tion and the critical importance of reduces angle-of-attack and g-load [a immediately recognize the excursion bridging the gap between escalation positive/negative multiple of the stan- and to regain control without delay. and recovery paths with prompt, dard acceleration of gravity, experienced Incomplete exposure to the red effective action (i.e., roll recovery as weight], de-escalating from aerody- zone leaves a pilot at a disadvantage techniques in this case); [and,] namic red zones and nominally reducing
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stress on the pilot. This precursor action authors say. “The aggravating effects of The authors note, “Operating also results in an improved ‘roll’ re- instinctive reactions by the pilot are re- limitations prohibit intentional sponse. The magnitude of the ‘push’ on vealed only as control effectiveness decays maneuvers that exceed 90 degrees the elevator control, however, is gener- at high angle-of-attack and the airplane of bank. Intentional maneuvers ally notably smaller compared to the begins to exhibit post-stall behavior. with bank angles in excess of 60 aileron input applied during the ‘roll.’” Red-zone angles-of-attack must therefore degrees, however, will require Common errors — such as revers- be experienced not only to mitigate the approved parachutes to be worn ing the order of the ‘push-then-roll’ se- potential merging of unfavorable aerody- by the trainee and the instructor. quence — can occur under the pressure namic and psycho-physiological factors, Whether or not intentional spins of a roll upset, they noted. but also to maximize the beneficial effects are approved in the utility category “Many … correctable pilot errors do of adrenalized learning.” depends on the particular aircraft.” not manifest until beyond 90 degrees of As during excursions from the • The acrobatic category carries bank and will exacerbate as bank angle normal flight envelope, the internalized no restrictions other than those approaches 180 degrees,” according to mitigation bridge enables rapid recovery. shown to be necessary in flight the paper. “Consequently, progressively This training method also reinforces tests. The authors say, “Inten- escalating into the red zone will allow that recovery techniques should begin tional maneuvers with bank the pilot to practice the ‘push-then- at the first sign of a dangerous angle-of- angles in excess of 60 degrees, roll’ technique at lower bank angles attack or yaw, not waiting for a specific however, will still require ap- and reduced stress levels. Training can upset parameter (Figure 3, p. 21). proved parachutes to be worn by then proceed beyond 90 degrees, where the trainee and the instructor. Inclined Planes potentially debilitating effects such as Intentional spins are approved in startle can be worked through while “Regardless of the airplane being used, the acrobatic category (notwith- simultaneously executing ‘push-then- the safe and legal delivery of UPRT standing airworthiness directives roll’ actions. Thus, on-airplane explora- requires due consideration of the or supplemental type certifi- tion of bank angles from 90 degrees up training airplane’s approved operating cates that may affect the spins- to 180 degrees (the worst-case scenario) limitations, design limits, and avail- approved status). An accidental will be critical to the success of recover- able margins of safety,” the paper says. spin in the acrobatic category ing from real-world upsets.” “The success of UPRT will also depend could have up to a six-turn mar- on buy-in from both aircraft manufac- gin of safety wherein recovery Angle-of-Attack Threats turers and insurance underwriters — can be assured, provided proper Another class of upsets can arise from without their support, efforts to deliver spin-recovery actions are imple- mismanagement of angle-of-attack, when practical UPRT will be stymied.” mented and sufficient altitude the coefficient of lift decays in connec- In the United States, for example, remains in which to recover.” tion with airspeed. Unless corrected, a approved maneuvers for different cat- stall can result. Similarly to training for egories of airplanes are described in U.S. Considerations besides airplane recovery from the flight envelope red Federal Aviation Regulations (FARs) category apply, however. Structural zone, UPRT gives pilots the experience Part 23.3: design limits also depend on flaps of dealing with high angle-of-attack situ- configuration (deployed or not) and • The normal category is intended ations. Again, the inappropriate angle- how g-load is applied (symmetrically or for nonacrobatic operations. The of-attack is progressively increased so asymmetrically). authors noted, “Thus, in the nor- that the trainee gradually gets used to the “In the acrobatic category, design mal category, operating limitations phenomenon and its proper response, limits with flaps up and symmetrical prohibit intentional maneuvers that while developing confidence. g-load are positive 6.0 g and negative exceed 60 degrees of bank. Inten- “Undesirable changes in flight char- 3.0 g,” the paper says. “The design limit tional spins are prohibited as well.” acteristics and their ramifications [for] when simultaneously rolling and pull- controlled flight only reveal themselves • The utility category may be used in ing, however, drops to positive 4.0 g. during high angle-of-attack flight,” the limited acrobatic operations. Thus the structural margin of safety
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associated with design limits, struc- Concept of Mitigation Bridges in Recovery: Excessive Bank Angle tural fatigue definitely impacts the 0° 45° 60° 90° 135° 180° cost of, and comfort with, the delivery bank bank bank bank bank bank of UPRT. Higher g-loads can lead to increased aircraft maintenance and downtime — translating into increased Escalation path [training] delivery costs — as well as increased risk to pilots flying the sub-
Mitigation bridges ject airplanes.” Specialized Equipment Recovery path For airplanes regularly engaged in UPRT, extra equipment is either required by regulations or installed for Angle of bank optimal pilot safety. The authors say that among these items typically are: ICAO = International Civil Aviation Organization Source: ICAO Manual on Aeroplane Upset and Recovery Training • Parachutes — “With the excep- tion of spin training, [FARs Part] Figure 2 91.307 stipulates that no pilot Stall/Spin Escalation and Recovery Paths of a civil airplane carrying any person (other than a required Cruise Stall Stall Developed airspeed warning break spin crewmember) may execute an in- Airspeed/AOA Pre-stall Coordinated and uncoordinated tentional maneuver that exceeds decay region region stall/incipient spin region 60 degrees of bank or 30 degrees of pitch relative to the horizon, Escalation path unless each occupant is wear- ing an approved parachute that Mitigation bridges has been repacked at specified intervals.”
Recovery path • G-meters — “Airplanes approved for use in the acrobatic category are typically equipped with g-meters. Angle-of-attack trend This instrument not only allows the monitoring of the stresses imposed AOA = angle-of-attack; ICAO = International Civil Aviation Organization on training airplanes, but it also Source: ICAO Manual on Aeroplane Upset and Recovery Training provides important context dur- Figure 3 ing UPRT to calibrate trainees to acceptable load factors [in relation in the acrobatic category during an of wing structures, engine mounts, to] design structural limitations.” inadvertent rolling pullout would be seat frames, windows and other positive 4.0 g, provided the flaps were major components. … [R]elatively • Emergency egress — “Airplanes retracted.” small increases in g-load can result in approved for use in the acrobatic The possibility of airplane struc- dramatically reduced life cycles,” the category are typically equipped tural fatigue must also be monitored. authors say. with doors, canopies and windows “There is an exponential relationship “While perhaps not the deforma- that are capable of being jettisoned between g-load and the fatigue life tion or catastrophic failure concern for in-flight emergency egress.”
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• Seat belts — “Airplanes approved a core competency for all professional used the spelling aeroplane. In this article, for use in the acrobatic category pilots,” their paper says. “The specific airplane has been substituted. are typically equipped with dual competencies demanded of UPRT 5. The term UPRT was adopted by both lap-belt systems. This redun- instructors do not exist in current ICAO and the U.S. Federal Aviation dancy provides a greater margin instructor training and certification re- Administration to resolve earlier varia- of safety should a lap belt attach quirements. Even current stall and spin tions in terminology, including emergency maneuver training, advanced maneuver point fail or a pilot inadvertently awareness training mandates for flight training and upset recovery training. unlatch a lap belt during UPRT.” instructor applicants have proven in- adequate, resulting in demonstrable — 6. Randy Brooks is a master instructor, member of the Society of Aviation and To Instruct and Serve and almost universal — deficiencies in Flight Educators (SAFE), UPRT instructor Another critical element in on-airplane both instructor understanding of high and vice president of training for Aviation UPRT, besides the adrenalized learn- angle-of-attack dynamics and instruc- Performance Solutions with a background ing and the aircraft and equipment tor competency relative to providing in many facets of business aviation. His considerations, is the flight instructor’s adequate stall and spin instruction.9 air show acrobatic experience includes for- qualifications. “The on-airplane UPRT environ- mation team demonstrations, jet aircraft and sailplanes. He has delivered more than “A qualified instructor is arguably ment necessitates high levels of instructor 3,000 hours of flight instruction and is the single greatest asset to UPRT, not competency in, and comfort with, the president of UPRTA. just for the delivery of the requisite aca- flight regimes well beyond normal opera- Paul “BJ” Ransbury is the president of demic and practical training, but also tions, the performance and operating Aviation Performance Solutions, a multi- for the mitigation of risks associated limitations of different training aircraft national flight school that trains more than with the training itself,” the paper says. and the ability to respond appropriately 1,000 professional jet pilots annually in “Conversely, an unqualified instructor to inadvertent upsets encountered in the integrated UPRT. He is a four-time master will quickly become the greatest liabil- training environment. A failure to ad- instructor, SAFE member, former airline ity to the success of the UPRT initiative. equately qualify UPRT instructors from pilot and military fighter pilot. The qualifications of on-airplane in- the outset could have dire consequences Rich Stowell is an eight-time master in- structors, in particular, require special on safety and thus on broad acceptance of structor, SAFE member, the 2014 National consideration if the benefits envisioned the UPRT philosophy.” FAA Safety Team Rep of the Year and the 2006 National Flight Instructor of the Year. from UPRT are to be realized.” Notes He has been a full-time instructor special- The certified flight instructor grant- izing in spin and emergency maneuver ed privileges by the regulator for typical 1. Boeing Commercial Airplanes. Statistical training since 1987, and is the author of flight instruction, who has not com- Summary of Commercial Jet Airplane Accidents, three aviation textbooks. pleted UPRT-instructor training, lacks Worldwide Operations, 1959–2012.
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WORLD AEROSAFETY O by Bureau the d’Enquêtes etd’Analyses (BEA) of France. | MAY 2014 the regionalthe was hurt, jet but aircraft damage as severe was assessed at an on airport coast the of Brittany. None of 57people the aboard of acontaminated runway after touching down long with atailwind nightn the 16,2012,aBombardier of Oct. CRJ700ran offend the A tired CRJcrew didnotrecognize thatago-around was in order afterlandinglongonacontaminatedrunway. BY MARKLACAGNINA CAUSALFACTORS |
23 CAUSALFACTORS
“The investigation showed that the ac- certificate in 1999. He earned a CRJ700 type cident was due to the crew’s failure to decide rating in 2001 and had been flying as a captain to carry out a missed approach [and their lack since 2007. During the three months preced- of awareness] of the degree to which runway ing the accident, he had conducted 10 landings conditions were contaminated or of the re- at the Lorient Lann Bihoué airport — seven at maining length of runway available,” said the night and three during the day. BEA’s final report. The copilot, 45, had 5,244 flight hours, The controller Moreover, the report concluded that the including 3,014 hours in type, and had joined pilots’ situational awareness and decision mak- the airline in 2004. He held an ATP certificate advised the crew ing had been numbed by fatigue and routine, and type ratings in the CRJ700 and CRJ1000. He as well as the absence of clear communication had conducted eight night landings and two day that there was a ‘big about the condition of the runway. Investiga- landings at the airport during the previous three squall on the field’ tors also found that an opportunity had been months. missed for the flight crew to review recent les- Lorient Lann Bihoué Naval Air Base is a and that visibility sons learned and best practices for landing in joint-use facility on the southern coast of Brit- adverse weather conditions. tany that is operated by the French navy. had decreased The report said that the operator, Brit Air, Around the time of the accident, showers to 2,000 m in “did not have a true picture of the safety perfor- and frequent thunderstorms had been forecast mance of its operations.” For example, the re- throughout Brittany. Before beginning the heavy rain. gional airline was not aware of data showing that descent to the airport, the crew reviewed one-third of the landings made by its CRJ700s the current automatic terminal information on Runway 25 at the Lorient Lann Bihoué Naval system (ATIS) broadcast, which indicated that Air Base, where the accident occurred, were surface winds were from 170 degrees at 18 “overshoots,” or landings beyond the runway’s kt, visibility was 10 km (6 mi) and there were touchdown zone. broken ceilings at 1,000 ft and 1,500 ft. The The report also said that the operator’s ATIS also said that the runway was “wet with fatigue risk management system did not account water puddles” and that the precision ap- for the effects of flying trip sequences that incor- proach radar (PAR) procedure to Runway 07 porated multiple legs. was being used. A few minutes later, however, the approach Fifth and Last Leg controller told the crew that the surface winds The flight crew had completed four flight seg- were from 160 degrees at 17 kt, gusting to 26 ments before departing from Paris at 2030 local kt, and that visibility was 3,000 m (about 2 mi). time for the last leg to Lorient. Both pilots told The flight crew requested and received vec- investigators that they felt tired before beginning tors for the instrument landing system (ILS) the flight. The captain noted that this was typi- approach to Runway 25, which had a longer cal for the fifth leg of a trip sequence, especially available landing distance than Runway 07. at night. “In general, five-leg flights are tiring,” the ‘Fatigue and Weariness’ report said. “This is felt by a majority of pilots, The cockpit voice recording showed that both but few pilots, including [the captain], inform pilots expressed their “fatigue and weariness” the airline of this.” several times during the flight, the report said. The captain, 42, was the pilot flying. He had The effects of fatigue were manifested, in part, 6,910 flight hours, including 4,025 hours in type. in the crew’s conduct of the “Descent” checklist. He was hired by Brit Air as a cabin attendant in The copilot called out completion of items on 1992 and was promoted as a flight crewmember the checklist without waiting for confirmation after earning his airline transport pilot (ATP) from the captain; he also forgot certain callouts.
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At about 2106, the controller advised the crew that there was a “big squall on the field at Bombardier CRJ700 the moment” and that visibility had decreased to 2,000 m (1 1/4 mi) in heavy rain. The control- ler reiterated that the runway was “wet with some puddles” and advised that the crew of the preceding aircraft had encountered “difficulties during landing due to aquaplaning.” (The crew of that aircraft, an Embraer 145, later reported that they had temporarily lost control after touching down on the slippery runway.)
“This information did not trigger any 3.0 © Bene Riobó|Wikimedia CC-BY-SA particular reaction by the crew or an additional briefing taking into account the potential threats ombardier’s Canadair Group began design studies in 1987 for a medium-haul regional jet based on the Challenger 600 business associated with it,” the report said. jet, which had entered service seven years earlier. Sharing the The pilots were conducting the “Approach” B Challenger’s engineering designation CL600-2B19, the 50-seat CRJ100 checklist when the controller issued a new sur- entered service in 1992. The CRJ200 followed three years later with face wind report —150 degrees at 17 kt, gusting more powerful General Electric CF34 engines. to 25 kt — and cleared the crew to conduct the The CRJ700 model entered service in 2001 with a stretched cabin ILS approach to Runway 25. that seats 66 to 78 passengers and a new wing with leading-edge slats. The airplane’s CF34-8C1 engines each produce 12,670 lb (56.3 The crew told investigators that, due to the kN) thrust. Maximum weights are 72,750 lb (32,999 kg) for takeoff and risk of wind shear, they decided to conduct the 67,000 lb (30,391 kg) for landing. Maximum cruise speed is 0.85 Mach, approach with the flaps extended 30 degrees and and normal cruise speed is 0.78 Mach at the 41,000-ft service ceiling. at 140 kt, a landing reference speed (VREF) that Maximum range is 1,218 nm (2,256 km). was appropriate for the airplane’s gross weight The accident airplane, F-GRZE, entered service in 2002. To date, and the selected flap configuration. more than 1,600 CRJs have been delivered worldwide. Currently in production are the CRJ700, 900 and 1000 “NextGen” models. No Change of Plan Sources: BEA, Bombardier Aerospace, Jane’s All the World’s Aircraft and The Encyclopedia of Civil Aircraft At about 2124, “the controller again indicated the presence of heavy rain, the condition of the at the time, the BEA determined that the runway runway, the aquaplaning and the difficulties of was indeed contaminated by standing water. the preceding aeroplane,” the report said. “This However, the repeated reports that the information did not alert the crew and did not runway was “wet with water puddles” — phrase- change their plan of action [i.e., to land with a ology that was not proper for pilot-controller flaps 30 configuration].” communications — had led the crew to believe The crew’s selection of flaps 30 complied that the runway was wet, rather than contami- with the operator’s existing instructions for an nated with standing water, which reduces brak- approach and landing with known or suspected ing performance and typically results in a longer wind shear. According to the report, however, landing distance. the crew was not aware of another critical factor: The report indicated that a flaps 45 configu- that the runway was contaminated with stand- ration would have been more appropriate for the ing water. conditions because it would have provided for a The report said that a runway is considered shorter landing distance. contaminated, in part, “if more than 25 percent of Runway 25 was 2,230 m (7,316 ft) long and its surface area is covered by a film of water more surfaced with ungrooved concrete. The runway than 3 mm [0.125 in] deep.” Although no mea- was known to have water-retention problems. surements had been taken by airport personnel Following two landing excursions by military
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CRJ700 Flight Path
Thrust levers in IDLE position Not to scale radio altitude Runway 02/20 (RA) = 17 ft
Touchdown ground speed = 140 kt
Runway 25 RA = 65 ft Runway 07/25 indicated airspeed = 153 kt ground speed = 157 kt Aircraft nal stop Spoilers and reverse deployed Runway excursion ground speed = 66 kt Susan Reed; Source: Bureau d’Enquêtes et d’Analyses Bureau Susan Reed; Source: aircraft, the navy in 2010 had approved a recom- report said. “The aeroplane went through 500 ft mendation for runway reconditioning, including radio altimeter height at a speed of 154 kt.” grooving the concrete to improve water drain- Numerous roll-control inputs were recorded age. However, “as of the date of the accident, no before the CRJ crossed the runway threshold at reconditioning had yet been undertaken,” the 56 ft. Indicated airspeed was 153 kt (13 kt higher
report said. than VREF), and, due to the tailwind, groundspeed Investigators calculated that the CRJ’s land- was about 157 kt. The faster speed and the tail- ing distance on the contaminated runway was wind increased the calculated landing distance on 2,117 m (6,946 ft). It is important to note that the contaminated runway from 2,117 m to about this calculation assumed that the aircraft would 2,500 m (8,202 ft), according to the report. pass 50 ft over the approach threshold at the Just before touchdown, the copilot remarked reference landing speed. that visibility was “bad” and told the captain that the aircraft was left of the runway centerline. The ‘Stable, Continue Approach’ captain later told investigators that he had dif- As the aircraft descended through a radar ficulty estimating height and aligning the CRJ with height of 1,000 ft, the captain called out “stable, the centerline due to the aircraft’s inefficient land- continue approach.” Recorded flight data con- ing lights and the deficient runway marking and firmed that the approach was stabilized at that lighting. The runway did not have centerline lights. point but also that the latter portion of the ap- proach was conducted with increasing airspeed Long Landing and with a tailwind component of about 4 kt. The captain told investigators that he perceived The crew saw the runway approach lights at that the flare was initiated too high and that the about 800 ft. The captain disengaged the auto- aircraft floated, but he did not know how far pilot and told the copilot to set the windshield from the approach threshold the aircraft actually wipers at maximum speed. Both pilots recalled touched down. that it was raining heavily. The report said that groundspeed was 140 “For about 10 seconds, the airspeed increased kt when the CRJ touched down about 1,130 m above 150 kt, with a maximum of 155 kt,” the (3,707 ft) from the approach end of the runway
26 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MAY 2014 CAUSALFACTORS
at 2122. “The crew did not realise that the run- in adverse weather conditions that had been way was contaminated and that the landing was covered in a symposium hosted in 2010 by the long. At no time did they envisage a go-around.” Direction Générale de l’Aviation Civile (DGAC), The touchdown occurred with 1,100 m the civil aviation authority in France. “This sym- (3,609 ft) of runway remaining. “This length was posium specifically addressed the risk of runway sufficient for a complete stop of the aeroplane excursions,” the report said. on a dry or wet runway,” the report said. “It was Investigators also found discrepancies in inadequate on a contaminated runway.” the information provided by the airline and The spoilers extended after touchdown, by the aircraft manufacturer regarding flap and the crew deployed the thrust reversers and selection. Bombardier had recommended using applied maximum reverse thrust and wheel the minimum flap setting appropriate for the braking. A few seconds after touchdown, the available runway length when landing with captain told the copilot that he could not brake suspected or confirmed wind shear. Based on the aircraft. The report said that white tire tracks this information, Brit Air’s operations manual found on the runway after the accident indicat- specified a flaps 30 configuration in this situ- ed that aquaplaning likely had occurred. ation. However, the operations manual was The aircraft turned right just before it over- not revised after the manufacturer in 2010 ran the runway at 66 kt. The CRJ came to a removed the instruction to use the minimum stop in a grassy area about 200 m (656 ft) from flap setting in wind shear. the end of the runway after the left wing struck “Bombardier stated to the BEA that this localizer antennas. instruction had been removed because [the The captain ordered an emergency evacuation, CRJ700 was] certified only for the standard and the 53 passengers exited through the left front flaps 45 configuration,” the report said, noting door and the overwing exits. The report said that that among several changes made by Brit Air ‘The crew did the CRJ incurred major structural damage; the after the accident was an instruction to use a landing gear required replacement and the engines flaps 45 configuration for all landings. not realise that had to be removed for repair. The BEA issued several recommenda- the runway was tions based on the findings of the accident Unrecognized Threats investigation. The recommendations included contaminated and The report said that the pilots had accounted improvement of drainage and elimination for the possibility of wind shear and a wet of known areas of water retention on Lori- that the landing runway in their planning, but they had not ent’s Runway 07/25; extension of civil airport was long.’ identified the threats of a contaminated certification and safety management require- runway and an overshoot, even after receiving ments to all military airports where civil information about the previous crew’s dif- aircraft operations also take place; integration ficulties in landing. of TEM in recurrent training and checks by The airline recently had incorporated prin- commercial aircraft operators; and implemen- ciples of threat and error management (TEM) tation of effective and thorough fatigue risk in recurrent ground school sessions. However, management systems. The BEA also called on “this was not put into effect during simulator the DGAC to ensure improvement by Brit Air sessions,” the report said. “In addition, by the of its processes for checking and updating its date of the accident, only the captain had been documentation. given awareness training. The crew therefore This article is based on the English translation of the BEA was not predisposed to apply it.” report “Accident on 16 October 2012 at Lorient Lann Moreover, the report noted that the air- Bihoué (56) Aerodrome to the Bombardier CRJ-700 line’s training had not incorporated the “les- Registered FGRZE, Operated by Brit Air.” The report is sons learned and best practices” for landing available at
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MAY 2014 | 27 FLIGHTOPS
ost air transport pilots lack the study, begun after fatal accidents absence of a realistic ATC [air traffic adequate training in how in 2009 and 2010 that were associated control] environment.” to perform the most com- with “aeroplane state awareness dur- The study’s findings indicated that mon go-arounds — those ing go-around (ASAGA),” which the pilot training typically does not take Mwith both engines operating in the agency characterized as “loss of control into account actual go-around ac- high-pressure environment of a of the flight path during or at the end of cidents and incidents. Accompanying missed approach, according to a study a go-around maneuver.”1 recommendations to the International by the French Bureau d’Enquêtes et The Study on Aeroplane State Civil Aviation Organization (ICAO) d’Analyses (BEA). Awareness During Go-Around added, and the European Aviation Safety Although a go-around is considered “A go-around does not often occur Agency (EASA) included several calling a normal procedure, it nevertheless is during operations … and is one of the for the development of more realistic challenging because of its “rarity … and manoeuvres … poorly represented by training scenarios involving go-arounds complexity in terms of workload,” said simulators, in particular due to the with all engines operating. Goes A t ro ha u W n d
Study urges improved training to help flight crews to better cope with go-arounds.
BY LINDA WERFELMAN
28 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MAY 2014 © Sergei Karpukhin|Reuters approach. nighttime missed occurred duringa in thecrash,which airplane were killed 113 peopleinthe in Sochi,Russia.All after a2006crash is liftedbyacrane Armavia AirbusA320 as thetailofan personnel watch Emergency response
Susan Reed ; Source: Bahrain Accident Investigation Board flying (PF)]flying may have due to been somatogravic nose-downthe inputs [by captain, the pilot the “suggests that it is possible to hypothesize that sian Air Accident Investigation Commission 10/07, p. 44). gers and crew, and destroyed airplane the (ASW minimums.- 113passen The accident all killed VMC, were only slightly better than airport’s the at night with weather conditions that, while approachmissed (Russia) to Sochi the airport crash of an Armavia Airlines A320during a ground proximity warnings. overload,” and “non-effective their response” to crew’s “spatial disorientation and information tions from standard parameters, flight flight the draw captain’s the attention to aircraft- devia operating procedures, first officer’s the failure to ing captain’s the nonadherence to standard cited contributingBoard several factors, includ- Accident 2002).The Bahrain ber Investigation people aboard (Accident Prevention crash destroyed airplane 143 the all and killed conditionslogical (VMC) on Aug. 23,2000.The attempted go-around innight meteoro visual - Airbus A320into Arabian the Gulf during an discussionther (Table 1,p. 30). 954 deaths, and singling out 10events for fur FLIGHTSAFETY.ORG FLIGHTSAFETY.ORG The BEA study said report the by Rus the - Another example cited was May the 3,2006, Among was crash them the of aGulf Air |
AEROSAFETY WORLD were responsible for fatal accidents that events, including 15 identifying 25such incidents, ultimately accidents and serious for “ASAGA-type” and BEA databases searched ICAO the at events. selected and an in-depth look and serious incidents, of go-around accidents statistical examination study began with a | MAY 2014 MAY Researchers The multi-phase - , Decem - 2 ,
others, there and was no effect; inone event, the tions helped regain control of airplane; the insix and flaps.In four of 11events, ac- these these go-around, such as retracting landing the gear for a beginning tasks specified the performed nine events, report the said. probably aggravated situation,” the prevailed in instrument meteorological conditions, “which Visibility inone was not event, specified and ditions with no apparent visibility problems. events, report the said. came to as asurprise crew. the hazardous maneuvers.” The disruptions often was orderedthrust and generated potentially “a disruption after …soon level ahigher of reportthe said. In addition, events all involved result, “excursions inclimb and altitude,” speed and pitchspeed attitude excursions” and, as a of events, the engines were all operative. involving afour–engine airplane. In but all one tion to twin-engine theme the was one event required for ago-around maneuver. The excep - end of with more aflight, available thrust than is a twin-engine airplane —relatively light at the For example, of all events the but one involved The study anumber identified of shared themes. ThemesShared illusions and/or approaching speed …the V warning system] warning.” crew flight tothe GPWS the [ground-proximity lighted lack the of an appropriate reaction from his monitoring role adequately. It- high also sponses to requests, copilot the didnot perform situation and that, with exception the of his re- captain had engaged aircraft the inan abnormal BEAthe study said. “It concluded also that the go-around phase and until end the of flight,” the CRM [crew resource management] during the roll, and inadequate —or even non-existent — pilots’ loss of situational awareness inpitch and [maximum with flaps extended].” speed In 11events, pilot the monitoring (PM) Six events during day occurred the incon- CRM failures “were mentioned” of inall the butAll two events involved “significant The Russian “referred report also to the FLIGHTOPS FE
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Their answers Go-Around Events Described in Study indicated that the Date Location Aircraft Type Injuries Aircraft Damage go-arounds were Nov. 12, 1998 Surat-Thani, Thailand Airbus A310 101 fatal destroyed performed for three Aug. 23, 2000 Bahrain Airbus A320 143 fatal destroyed primary reasons: May 3, 2006 Sochi, Russia Airbus A320 113 fatal destroyed meteorological condi- September 20061 Naples, Italy Airbus A320 NA serious incident tions, an unstabilized 1 March 30, 2007 Abidjan, Ivory Coast Airbus A330 NA serious incident approach or “ATC July 21, 2007 Melbourne, Australia Airbus A320 NA serious incident involvement.” In ad- Sept. 23, 2007 Bournemouth, England Boeing 737 NA serious incident dition, 30 percent of Nov. 27, 2008 Perpignan, France Airbus A320 7 fatal destroyed pilots said they had Sept. 23, 2009 Roissy, France Airbus A319 NA serious incident performed at least one Oct. 11, 20102 New York Airbus A380 NA incident go-around while fly- NA = not applicable ing below minimums. Notes: 1. Information about this event was obtained by BEA from internal airline documents. Sixty percent in- 2. Information about this event was obtained by BEA during the course of the study. dicated that they had
Source: French Bureau d’Enquêtes et d’Analyses (BEA), Aviation Safety Network go-around “difficul- ties” — most often in- Table 1 volving vertical flight actions had a negative effect. After these initial path management (capturing the go-around actions, insufficient monitoring by the PM was altitude) or autoflight system management. Of mentioned in reports on nine of the events, the that 60 percent, half said that they also had dif- BEA report said. ficulties during go-around simulator sessions. In 10 events, the airplane’s “strong and quick- When instructors provided responses to the acting nose-up pitching moment generated by survey, they said those areas were not the only the engines at low speed placed the pilot in a situ- go-around–related problems observed during ation that necessitated a high level of vigilance,” simulator sessions; in addition, they cited “get- the report said, adding that although causes of the ting and maintaining pitch angle,” “visual scan disruptions were “extremely diverse,” they often management” and decision making. were made worse by automatic systems. “The pilots surveyed indicated that, overall, The most frequently cited “aggravating fac- they were sufficiently well trained in [go- tor” was the “unexpected or overlooked opera- arounds] with one engine out (85 percent of the tion” of the autopilot or the automatic horizontal pilots),” the study said. “However, almost half of stabilizer trim or both, the report said. Somato- the pilots indicated that they were not sufficient- gravic illusions were cited as aggravating factors ly well trained in [go-arounds] with all engines four times and suspected in two additional in operation. This figure was even higher for the events, the report said. pilots who indicated that they had encountered The “intervention of ATC” was cited in six difficulties in flight.” events, and related changes were mentioned in two others. Stress and Startle The study’s human factors analysis of pilot Pilot Survey behavior during a go-around concluded that the The study’s analysis of 831 survey responses go-around “introduces a discontinuity in the from pilots with 11 French and British airlines tasks to be performed and a disruption to their showed that 54 percent had performed fewer rhythm of execution. than nine actual go-arounds at that point in “The diverse nature of the tasks and the speed their airline flying careers. at which they must be performed generate stress,
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notably when the startle effect is also and climb steadily.” Procedures also “this would appear to be inappropriate included. … Since stress reduces our should describe the method of check- for this flight phase,” the study said. ability to cope with complex actions, ing automatic systems, clearly state performance levels drop during go- when landing gear and flaps should be Causal Factors arounds. The sudden onset of new tasks, retracted and describe the flight path ASAGA events have always occurred the need to perform vital, rapid and var- for returning to land, pilots said. with all engines operating, the study ied manoeuvres and the rapid changes in said, noting that, in a typical ASAGA the numerous parameters to be man- Simulator Sessions event, the crew begins a go-around with aged (controlled) in a limited period of In 11 simulator sessions (six in an A330 nose-up pitch and the application of time combine to make it difficult for a simulator and five in a Boeing 777 full thrust. crew to perform a go-around that is not simulator) designed to bolster other “The acceleration due to this rapid controlled right from the start.” study data, 11 flight crews each flew and significant increase in thrust can The human factors analysis said three go-arounds and participated in create the feeling of a too-high nose-up that the first challenges associated with post-session interviews. Although all pitch,” the study said. “In the absence a go-around are adapting to a new 33 go-arounds were studied, one subset of external visual references and visual situation, controlling related stress and of 11 was the subject of an in-depth monitoring of instruments, a somato- managing layers of tasks. The PM is analysis that found that at least one gravic illusion can cause the PF to forced to cope with an overload, which pilot in 10 of the 11 participating flight reduce the aeroplane pitch towards often prevents him or her from moni- crews reported having difficulty with inappropriate values. In practice, these toring the PF, the analysis said. the go-around session. somatogravic illusions are little known Typically, that crewmember was the to crews, and existing simulators do not Suggested Improvements PM, the study said, noting that within make it possible to recreate them so as The study said that the pilots partici- seconds of the start of the go-around, to train pilots to recognize them.” pating in the survey suggested several PMs were forced to deal with “multiple Automatic systems add to the ways of improving go-around training, and diverse” tasks involving callouts, problems because their “initial engage- including changes in ATC procedures, readbacks of ATC instructions, verifica- ment modes [are] different from those such as increasing the initial go-around tion of the pitch attitude, monitoring expected for the go-around … [and] altitudes, which sometimes are too low; the PF’s flight control and verification of when they are neither called out nor limiting pilot-controller communica- flight mode annunciator (FMA) modes. checked, [this] leads the aeroplane tion during portions of a go-around “The crews that experienced to follow an unwanted flight path,” that require crew concentration; and difficulties made adaptations to the the study said. “Thus, in addition to simplifying flight paths. procedure,” the study said. “Some ad- reading the FMA, the monitoring of One pilot elaborated, “Ideally, if aptations had positive effects (approach primary parameters — pitch and thrust there is no terrain restriction, the to interception altitude); others led to — is a guarantee for the crew to ensure flight path should go straight ahead deviations from the expected result that the automatic systems put the aero- in line with the runway and climb- (flight path, for example).” plane on a climbing flight path during ing to a height of more than 3,000 The researchers accompanied their the go-around.” ft. The flight paths are all too often evaluation of the simulator sessions The study emphasized that ASAGA complicated, with banks early on in with a discussion of simulator fidelity events result in a “sudden, high work- the manoeuvre, and altitudes that are issues, including the inability of a typi- load” for the PM, “higher than that of too low.” cal full flight simulator to accurately PF,” with tasks that are difficult to man- Other suggestions called for simpli- represent a somatogravic illusion — the age. Deficiencies in the performance fying operators’ go-around procedures “powerful perceptual illusion of a nose- of the PM’s monitoring tasks “can have to “indicate the pitch attitude to avoid up attitude” — that typically occurs catastrophic results,” the study added. a CFIT [controlled flight into terrain during an actual go-around. Although The document also noted that acci- accident]” and “indicate the thrust some airlines have suggested training dent reports often mention the absence needed to move away from the ground pilots only on fixed-base simulators, of CRM while crews cope with an
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MAY 2014 | 31 FLIGHTOPS
ASAGA event. Nevertheless, the study manufacturers should install devices to go-around simulator sessions, the BEA found that CRM often is in place before limit thrust during a go-around and “re- recommended that ICAO require image the event and again after the crew has evaluate the possibilities of errors linked recorders in all full-flight simulators regained control of the flight path. to the engagement of go-around modes.” used in training public transport pilots. “This ‘lack of CRM’ now seems to Other recommendations included “During the study, the use of video be a normal consequence where there calls for: was essential to carry out a proper analy- is a situation involving startle effect, • Manufacturers and operators sis of simulator sessions,” the study said. cognitive overload, time pressure and to study pilots’ visual scans as a “The video recordings made it possible high stress,” the report said. prelude to improving procedures, to have access to all the information The primary challenges in conduct- especially for go-arounds; presented to the crew. … Installed in a ing a successful go-around are identify- simulator, it [a video recording system] • National civil aviation authorities, ing “ways of giving the crew time to would be a source of additional informa- manufacturers and operators to carry it out and also to simplify their tion of use during crew debriefing.” identify methods of countering the actions,” the study said. “channelized attention phenom- This article is based on the BEA’s “Study on Aeroplane State Awareness During Go-Around,” ena” in which pilots become so fo- Recommendations originally published in French in August 2013 and cused on some of their go-around The BEA focused its nearly three dozen subsequently translated into English. The report is tasks that they neglect others; safety recommendations on flight available in both languages at
32 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MAY 2014 Photo Illustration: Jennifer Moore Face: © sskfoto/istockphoto; Globe: © alessandroiryna/istockphoto Color Vision a new study.a new cies and issue according certificates, medical to most likely- deficien to accept particular their outseeking aeromedical examiners incountries Watson, of principal officer New the medical A FLIGHTSAFETY.ORG BY LINDAWERFELMAN The study was conducted by Dougal B. aging “aeromedical tourism,” with pilots color (CVD)is encour vision deficiency lack of uniformity inassessing pilots with 1 |
WORLD AEROSAFETY | MAY 2014 - ment outcomes.” countries toward consistent assess- medical uniformity have inadequate been to encourage consistently across world. the Factors that favor assessment of CVDapplicants is not performed cine. The report concluded that “the medical sue of Aviation, Space, and Environmental Medi- on its findings was published February is inthe - Aviation Civil Zealand Authority, and areport threshold forpilots’colorvisiontests. criteria insettingthepass-fail Different countriesusevastlydifferent
GAP AVIATIONMEDICINE |
33 AVIATIONMEDICINE
This inconsistency does not con- landing grounds,” the report said, quoting accommodating medical assessment form to “the highest practicable degree from a history of aviation medicine in the from a different regulatory authority.” of uniformity in medical assessment Royal Air Force.2 The study examined information outcomes,” the report said. about 78 countries — all but one of Similar Requirements them ICAO member states — repre- Setting Standards Today, color vision standards set by the senting 92 percent of world aviation CVD is an inability to see some shades International Civil Aviation Organiza- activity and found that their national of color — or, in some severe cases, an tion (ICAO) specify that pilots must medical standards contained similar inability to see colors at all — that are have “the ability to perceive readily those color vision requirements. seen by people with normal color vision colors the perception of which is neces- For example, in Canada, India, (see “Explaining Color Vision Defi- sary for the safe performance of duties.”3 Pakistan, Singapore and South Africa, ciency,” p. 36). Noting that, in aviation, However, the report said that the the requirement is for professional pilots color has an important role in cockpit wording of the ICAO standard, as well to “perceive readily those colors the per- instruments and displays, on charts as the flexibility given to ICAO mem- ception of which is necessary for the safe “and throughout the external airborne ber states in determining exactly how performance of duties,” while in New and terrestrial environment,” the report they will evaluate pilots’ color vision Zealand, pilots must “have no deficit of added, “The ubiquity of color-coded and how they will interpret the results, colour vision to an extent that is of aero- information … has [led] to the impor- leads to “wide scope for variation in medical significance.” European Joint tance of pilots and air traffic controllers the examination and the assessment of Aviation Requirements call for pilots to being able to rapidly and accurately applicants’ [color vision].” “have normal perception of colours or differentiate and identify colors.” The report added, “Wherever be colour safe,” and U.S. Federal Avia- The report traced aviation standards there is variation between countries tion Regulations specify that pilots must for color vision to World War I, when the in the interpretation and implemen- “perceive those colors necessary for the British Royal Flying Corps tested appli- tation of medical standards, there is safe performance of airman duties.” cants’ color vision. “Great emphasis was also the potential for aeromedical laid upon perfect color vision because of tourism. Aeromedical tourism oc- Different Methods the importance of picking out the color or curs when an applicant, faced with an The study found that, in all jurisdic- markings of hostile machines, recogniz- unattractive medical assessment from tions, the color vision assessment pro- ing signal lights and judging the nature of one regulatory authority, seeks a more cess begins with a primary screening, and pilots who pass are not subject Aeromedical Decision-Making Model to further color vision assessment (Figure 1). Primary Secondary Further Those who fail the primary screen- Start Screening Screening Investigation ing, however, follow different paths, No No depending on the requirements of the civil aviation authority in the coun- Pass? Pass? Pass? try where they are seeking medical Yes Yes Yes No certification. In some countries, they are denied medical certification at that point, but in others, they undergo a Medical Medical Medical Assessment: Assessment: Assessment: secondary screening before completing Unrestricted Restricted Restricted; or the medical assessment process. Declined The secondary screening practices end in similarly divergent paths — Source: Watson, Dougal B. “Lack of International Uniformity in Assessing Color Vision Deficiency in Professional Pilots.” Aviation, those applicants who pass are issued a Space, and Environmental Medicine Volume 85 (February 2014): 150. medical certificate, and those who fail Figure 1 are either denied certification, granted
34 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MAY 2014 AVIATIONMEDICINE
that applicants who fail on their first Sample Ishihara Plates From a Color Vision Test attempt may undergo alternative tests. The “further investigation” phase is used in two states, and in both, appli- cants who pass are restricted to daytime flights while those who fail are denied medical certification, the report said.
Failure and Inconsistency In five of the 78 states surveyed, appli- cants who fail all phases of tests offered still are granted medical certification with restrictions, usually in the form of prohibitions on airline flying or night operations, the report said. “In one state, an applicant who fails all of the testing offered may be issued a Class 1 medical assessment that allows Notes: People with normal vision should see, in the top line from the left, 12, 74 and 6, and in the bottom line, on the left, 42, and on the right, nothing. However, people with red-green color vision all professional aviation operations deficiency, instead of seeing nothing in the final plate, see the number 2. except left-seat (captain) airline opera- Source: Wikipedia tions,” the report said. “In this state, a profoundly CVD applicant is able to Figure 2 operate as an airline copilot.” certification with specific conditions The most commonly used Ishihara Among the inconsistencies noted such as no night flight, or subjected to test involves the use of a set of 24 plates in the report were that some states did further investigation in the continuing designed to assess color vision. The not comply with their own published assessment process. study found that, in 65 of the 75 states assessment processes, either using a Applicants who pass during the using that set, a single error on the first more liberal pass-fail threshold or ap- further-investigation phase are issued 15 plates results in failure. plying different requirements for new medical certification with conditions. Overall, in 74 of the 78 states, applicants versus experienced pilots. Those who fail either receive a medical applicants who fail the primary Some states evaluated color vision certification with more restrictive con- screening are permitted to move on only as part of the first application for ditions or their certification is denied. to a secondary screening or further medical certification, some tested an- The examination of the assessment investigation, the report said. In the nually, and others conducted the test processes found that, for pilots seek- other four states, failure on a primary every few years. ing a Class 1 medical certificate, all screening results in denial of a medical In addition, the report said, “some states began with a primary color vision certificate. (In one of these four states, also accepted the [color vision] assess- screening. In 66 of the 78 member however, the denial applies only to ment of another state in lieu of their states, the primary screening consists first-time applicants.) own, even when that other state’s CVD of a single test; the remainder use two The secondary screenings typically assessment protocols and outcomes were tests or more. involve the use of optical lanterns and different to their own requirements.” The report said that all but one of other devices designed to test color the states include at least one type of vision by asking applicants to identify ‘Conceptually Sound’ Ishihara pseudoisochromatic plate test the colors, but they may also involve The report said that, although the ICAO (Figure 2) in their primary screenings; flight tests. Sixty of the 74 states allow standard is “conceptually sound and for 88 percent, an Ishihara test was the only one level of secondary screening, relatively concise … [it] is not readily only one in use. but 14 provide two or more levels, so interpreted for practical use. It does not
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MAY 2014 | 35 AVIATIONMEDICINE
indicate which colors need to be perceived common tool for assessing color vision. (six or more incorrectly read plates), readily for safe aviation, or what degrees of Nevertheless, errors on three or more the report said, noting that their goal measurable CVD [fail] to comply.” plates almost always indicate that the presumably is to ensure that no one The document noted that ICAO person being tested has CVD. with normal vision is incorrectly identi- has acknowledged the difficulties of Instructions accompanying the fied as having CVD. clarifying the international color vision 1985 version of the 24-plate CVD test “An argument that the different standard and of providing more specific say that the first 15 plates are used to systems produce similar outcomes criteria for assessing CVD, stating in its determine whether color vision is either cannot be reasonably embraced,” the Manual of Civil Aviation Medicine, “The normal or defective, and, if 13 of the 15 report said. “Two regulatory systems question is where to draw the line.”4 plates are read correctly, color vision will not have remotely similar medi- While a single-step assessment should be considered normal. cal assessment outcomes when one would be easier to administer and less The report said that the states that declines an applicant who makes one expensive, the report said, a two-step set a higher threshold for passing (those error … and another allows unre- process with a second assessment for requiring a perfect reading of all plates, stricted commercial and limited airline those who fail the first step would help or allowing only one error) were al- pilot privileges to an applicant unable reduce the number of false-positives. In lowing more false-positive results — in to pass any CV test.” this way, the report said, the structure which people with normal vision are ICAO provides no specific guid- of the CVD assessment system influ- identified as having CVD. ance on how member states should ences the outcome of assessments. These states may hold “fundamen- determine the pass-fail threshold, the Earlier research found that it is tally different views of the purpose of report said. not unusual for people with normal … testing,” the report said. color vision to misread some plates The same conclusion applies to Notes in the 24-plate Ishihara test, the most states with a lower threshold for errors 1. Watson, Dougal B. “Lack of International Uniformity in Assessing Color Vision Deficiency in Professional Pilots.” Explaining Color Vision Deficiency Aviation, Space, and Environmental Medicine Volume 85 (February 2014): 148–159. eople can see colors because the cones — photoreceptors — in the eye’s retina contain light-sensitive pigments that enable the detection of wave- 2. Watson, citing Gibson, T.M.; Harrison, Plengths associated with red, green or blue light. That information is sent M.H. Into Thin Air: A History of Aviation through the optic nerve to the brain, which distinguishes among many shades Medicine in the RAF. London, U.K.: of color.1 Robert Halt Ltd. 1984. Color vision deficiencies (CVD) occur when one or more light-sensitive 3. ICAO. Annex 1 to the Convention on pigments are missing from the cones. People with CVD typically have difficulty International Civil Aviation: International differentiating among the associated colors. Standards and Recommended Practices The most common deficiency is a red-green deficiency. Blue-yellow defi- — Personnel Licensing, 11th edition. ciency is rarer and often indicates more severe CVD; in most cases, people with Montreal, Canada, 2011. a blue-yellow deficiency also have a red-green deficiency. People with both types of deficiency often see gray areas instead of color. 4. ICAO. Document 8984, Manual of Civil Although the term “color blind” often is used to refer to CVD, very few peo- Aviation Medicine. Part III, “Medical ple are actually “blind” to color. Those who are truly color blind are those with a Assessment,” Section 11.8, “Color Vision.” condition called achromatopsia; they see all colors as black, white or gray. Third edition, 2012. CVD usually is an inherited condition, but it also can result from diabetes, macular degeneration or other diseases, or some medications. Advancing age Further Reading From FSF Publications also can contribute to a deterioration of color vision. “Color Vision Recommendations.” AeroSafety — LW Note World Volume 4 (July 2009): 9. Werfelman, Linda. “Color Deficient?” 1. American Optometric Association. Color Vision Deficiency.
36 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MAY 2014 The Foundation would like to give special recognition to our BARS Benefactors, Benefactor and Patron members. We value your membership and your high levels of commitment to the world of safety. Without your support, the Foundation’s mission of the continuous improvement of global aviation safety would not be possible.
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Bright Prospects BY WAYNE ROSENKRANS
s graduates of multi-crew pilot show acceptance of MPL graduates and that this training will predominate as licensing (MPL) programs gain sometimes a preference for them versus early as 2018. admission to the right seats of traditionally trained first officers. “In October 2000, ICAO convened flight decks in several world The status of MPL programs and an industry meeting in Madrid [Spain] Aregions, the substantial data now be- graduates, including early thinking to review future flight crew licensing ing collected about their performance about desirable improvements, was and training,” said Vincent Galotti, show high rates of completing courses the focus of the ICAO Multi-Crew Pi- deputy director, safety standardization and fulfilling airline expectations, say lot License Symposium in December. and infrastructure, ICAO Air Naviga- officials of the International Civil Avia- Many presenters compared today’s tion Bureau. “The industry meeting tion Organization (ICAO). Moreover, outcomes with the safety-centered concluded that the emphasis placed by comments by captains surveyed at philosophy on which the MPL was de- Annex 1, Personnel Licensing, on ex- MPL-participant airlines typically veloped, and some pioneers predicted perience hours as the means to qualify
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for a professional pilot license was an obstacle tailored to guide students seamlessly from ab to implementing best practices in ab initio–level initio training to airliner type rating using simula- training. From there on, work began to develop tion designed for multi-crew training. … MPL a safer and more efficient training regime for training addresses the increasingly important is- the next generation of commercial airline pilots sue of loss of control in airline operations through with a focus on multi-crew operations.” required upset prevention and recovery training When ICAO approved the provisions that (UPRT) and seeks to reduce the continuing domi- launched the MPL in 2006 — the first new ICAO nance of multi-crew human factors in accidents license in 50 years — safety was at the forefront through embedded threat and error manage- of its lofty objectives, he said. The first was to ment and crew resource management training. produce a higher level of quality in graduates so … Indisputable results [from about 30 airlines] they would contribute to improved safety. “Sec- prove that MPL [is] the better solution, and the ond, it provides for a closer linkage between li- outcomes mean that MPL is the way to go.” censing standards and training standards — and IATA’s information at the end of 2013 showed it’s built on competencies, not on prescription of more than 2,400 students enrolled in MPL hours,” he said. “Third, it uses high-quality flight programs and 800 MPL graduates worldwide. simulation training devices to train in a multi- “Despite the small sample size, operators report crew environment from the beginning, and average/all-around graduates’ performance as introduces a framework of collaborative relation- good as or better than students from traditional ships between the [approved] training organiza- training,” Matschnigg said. “IATA and its mem- tion [ATO] and the airlines, allowing the airline bers, through the Operations Committee, will environment to permeate the training.” push to see MPL implemented worldwide.” Despite ICAO’s confidence in concepts tested earlier, the need for a full-scale opera- Painstaking Evolution tional proof of concept — evaluating whether Decisions about designing the MPL in the early MPL actually would provide an equivalent level 2000s grew out of an ICAO Air Navigation of safety to airline pilots trained under the tradi- Commission meeting with industry in 1997, © Monika Wisniewska|Dreamstime tional approach — was not possible without first said Jim Dow, alternate representative of Canada adopting and applying the standards, Galotti on the Council of ICAO and a member of the said. The first results of this step, a preliminary commission. “It was a very deliberate, collabora- analysis of de-identified data from states and tive, transparent process — a very evolutionary ATOs, provided the first insights. This analysis process,” he said, citing relevant concepts dis- is ongoing and will generate further reports cussed at least since the 1970s and 1980s. “What about MPL program results. you see as you circle backward is a constant Günther Matschnigg, then senior vice effort to look at pilot training questions … be- president of safety and operations for the Inter- cause these questions always have to be asked.” national Air Transport Association (IATA), re- The standards for the MPL found in Annex Multi-crew minded the symposium in a video message that 1 explain the license training scheme, compe- pilot licensing the IATA Training Qualification Initiative dur- tency units, guidelines for program implemen- programs fulfill ing this period has worked to implement new tation, training objectives and threat and error competence-based concepts, including MPL, management. Other ICAO documents provide ICAO’s proof- and evidence-based training as part of modern- guidance to states’ establishment and manage- of-concept izing and harmonizing airline pilot training to ment of a personnel licensing system, including expectations at improve safety and attract younger generations MPL as the most comprehensive training system of people to the industry. aligned with safety management systems. this early stage “MPL is the first airline-dedicated profes- Outside the MPL, ICAO provisions still em- of development. sional pilot’s license,” he said. “MPL training is phasize hours of experience for the commercial
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pilot license as the basis of training a first data from each graduating class to date, Graphs of these data showed that officer. “This is not a performance-based and individual student performance. states introducing the MPL typically have standard. It’s a prescriptive standard that “First off, we wanted to see [if] states enabled its use by incorporating it into prescribes inputs rather than focusing actually were implementing regulations their national regulations. The ATOs thus on outcomes, and it lacks resilience. It’s in conformity with the ICAO standards have state approval. States that have not slow to respond [to change, and among for the MPL,” Fox said. “Having gradu- implemented MPL-enabling regulations regulators, it] invites tinkering with ar- ated from an ATO in collaboration tend to conduct this training only for bitrary numbers. … If 200 hours is safe, with an airline, how did they actually pilots who will work in other states. 250 must be safer,” Dow said. perform in their initial operating expe- “This is a graphic representation rience or line experience? … We’ve ana- [Figure 1] of the training hours by ATO Proof-of-Concept Results lyzed 15 MPL programs to date.” All of that we analyzed,” Fox said. “What we “[Our December report] is an analysis these involved their sponsoring airline find is that the amount of training hours of the data that we received as a result in the student-preselection process, and is fairly consistent. [With the exception of replies to state letters,” said Mitchell every ATO implemented qualification of one discontinued program,] the pro- Fox, chief, ICAO Flight Operations requirements for evaluators as recom- grams pretty well averaged out to about Section. “It is not the only part of this mended by ICAO. 300 hours, with a minimum training proof-of-concept exercise.” ATOs were “These [factors have] figured prom- time of about 240 hours and a maximum instructed to furnish the state licensing inently in the success of this particular training time of around 330 hours.” authority with de-identified informa- license,” he said. “For the final phase of In the final phase of training, actual tion concerning each of four phases of training — the type rating — the evalu- takeoffs and landings are required in their MPL training program — core, ators and the instructors were very the aircraft type in which the applicant basic, intermediate, advanced (type- well-qualified. In the programs that we would be type-rated. ICAO’s PANS-TRG rating) — for each student during and analyzed, nine had airline transport (Procedures for Air Navigation Services– following the program, including any pilot license–qualified evaluators, and Training) specifies 12 takeoffs and land- corrective actions that were necessary. two did not. … All of the evaluators ings. “That can be reduced by the state This first-time analysis on the in the final phase of training were authority once the proof of concept has ICAO website
Total hours Total 200 Diamond and Piper models. The re- sponding ATOs also indicated that some 100 use flight simulation training devices 0 in this phase. Data also show that many ABCDEFGHIJKLMN ATOs use aerobatic aircraft “in the Approved training organization (ATO) program (de-identi ed) core flying phase of the MPL … based MPL = multi-crew pilot license on [the anticipated] requirement for Notes: The International Civil Aviation Organization continues to analyze a new trove of de-identified, UPRT [although this] is not an abso- proof-of-concept data that help to compare MPL programs and their results. lute requirement. In the MPL, we do Source: International Civil Aviation Organization strongly recommend training in inverted Figure 1 flight but we have found through the
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Twenty States Have Approved MPL Programs Provided by an ATO, 2013
ATO = approved training organization States with multi-crew pilot license (MPL) programs Source: International Civil Aviation Organization;Base map: San Jose/Wikimedia 2.0 International Organization;Base Source: CC-SA Civil Aviation research that we’ve done, and the further makes a big difference,” he said. “We we saw [a] maximum of 36 takeoffs development that we’ve done on upset had 586 datasets, meaning trainees. and landings required in type. Three prevention training, that it may not be … In actual hours for completion, the of the ATOs that we analyzed actually something that’s necessary — and many average was about 286 hours actual required at-or-above 24 takeoffs and states do not do that, or they do not have flight time and flight simulation train- landings to reach full competency.” access to aerobatic airplanes.” ing device time. …The deviation from Students’ scores on airline trans- The first set of data from states the planned/programmed amount of port pilot license–level theory testing and ATOs also showed that the “vast hours … was certainly within an accept- were typically 80 percent to 90 percent majority” of the airlines and ATOs have able tolerance. … In terms of the total correct answers. Another area reviewed been training students for the right flight time average — including solo or was the ICAO English language profi- seat of the Airbus A320. “The average pilot-in- co mmand time, sole-[control]- ciency level. “Most ATOs require that class sizes so far have been about 13 manipulator time and dual — the aver- the entrants enter with ICAO proficien- trainees, a minimum of two … and a age amount of actual flight time on type cy Level 3 … but they have to graduate maximum of 27,” Fox said. “The MPL was approximately 85 hours. Remember, at the full operational Level 4.” [students’ high final-check] pass rate is the only actual time on type is that which Other graphs from the data quite exciting, [but] I do have to put a is required for the takeoffs and landings.” analyzed in time for the symposium little bit of a proviso in this. We do not Fox acknowledged the incongruence of showed the nature of graduates’ have data, nor did we collect the data, programming specific amounts of hours deficiencies during their initial line on how many people wash out of train- in performance/competency–based training/line check, also called initial ing programs [i.e., fail and disenroll]. training, and he called it a temporarily operating experience, at their airline. In retrospect, that probably would have needed concession to achieve stakehold- ATOs furnished data on trainees who been a good number to collect, but we er consensus at the time. failed a check (but subsequently passed just don’t have that data.” “The actual takeoffs and landings the check and the full course) or had to All but one of the reporting ATOs required to train to competency was be debriefed for skill-enhancement pur- had a 100-percent pass rate; the other [about 14,] actually a little bit above poses following a particular maneuver. had a 98-percent pass rate. “‘Train for the 12 takeoffs and landings,” he said. “Of [586 dataset] files that we success’ [in a competency-based system] “But we did see deviations. In one case, received, we had about 21 incidents
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where graduates of the MPL program factor in the success of the MPL. The career-long foundation of confidence in had some challenges in the execution failure rate is low [because they train un- their own capability. of a maneuver in actual line training,” til they achieve] the individual’s compe- “UPRT worldwide varies from very Fox said. “That’s not a high percentage tency … the individual’s need. The goal professional, all-attitude recovery training but it is notable. The next [highest- is train to success. … Really, the mark of [to] misunderstandings like [teaching] reported] area was related to workload MPL success is ‘Do the graduates go on aerobatics or spin training [or] classic management. … The vast majority of to an airline career as a professional pi- unusual-attitude maneuvering in normal- these were performance that didn’t lot?’ The vast majority of [these] gradu- category aircraft with regular flight in- quite meet the full-line requirements ates went on to the sponsoring airlines. structors who never received any specific and required a debrief; of the debriefs, … It’s not really surprising.” qualification in this field,” Fabisch said. only about 1 percent per airline actually Some captains were apprehensive The MPL course uniquely embraces resulted in failure on that particular about flying with graduates of the all recommended areas of UPRT — maneuver. That doesn’t mean to say MPL program, he said. “They found, from generic on-aircraft and simulator that the [airline] trainees didn’t go on to however, that they preferred to fly training at the core and basic phases to succeed in their line training, but they with them, as opposed to graduates UPRT in type-rating training. failed that maneuver on one occasion. of conventional training programs. I “[UPRT elements] that exclusively “What we found surprising is that the think that’s also a mark of success.” He can be trained in the real aircraft are graduates [also] had some challenges as- noted that ICAO so far has no data on mainly related to the psychophysi- sociated with monitoring the flight prog- the number of MPL graduates that have ological effects — such as the handling ress in cruise. … The next area where upgraded to captain, or their perfor- of surprise and startle, maintaining the graduates were most challenged had mance in command. the ability to act during reduced and to do with precision approaches and increased g loads [multiples of the normal landings. … These are either a UPRT in Core Phase standard acceleration of gravity] and failure, which represents about 1 percent Harmut Fabisch, a captain representing enabling pilots to perform counterin- of the numbers, or a debrief, which is the IATA as a consultant on UPRT and on tuitive actions such as applying forward vast majority of those numbers.” loss of control issues in MPL programs, elevator in nose-low or even in inverted Comments on the new first officers’ told the symposium that although attitudes,” he said. post-line evaluations showed that a few ICAO standards and guidance do not “The special value of on-aircraft of the graduates had pilot–air traffic specify the phase where this subject is UPRT lies primarily in the human factor control communications problems — to be covered, there are several reasons … to build confidence in a pilot, trust possibly related to English language for including this training early, at the in [her/his] own ability to determine proficiency. core flying-skills phase. the situation correctly and recover These MPL graduates also varied “I’m quite proud about the fact that any aircraft from any attitude or any somewhat in the number of sectors we already had thought about UPRT energy state as long as this is possible … they flew before attaining the airline’s in 2001 during the design phase of the [and] there is no way around using an full qualification to line-performance MPL,” he said. “At that time, loss of aerobatic-certified aircraft for this type standards. The average was 105 sectors, control–in flight was not yet on every- of training. Developing handling skills to with a minimum of 70 to 72 sectors and one’s lips but we had the feeling that this recover from upsets is also very impor- a maximum of 281 sectors. The average was of essential importance and that we tant, but this can all be trained in the sector length was about 1.5 hours, with should include [what was then called simulators. … Most experts among us the line trainee performing about half upset recovery training] in the course. consider a certain maturing process and the pilot-flying duties. … MPL is the only course under ICAO psychological aspects as most important “What we show so far is the MPL Annex 1 which mandates UPRT.” [in the core phase]. … This means that works,” Fox said. “It’s sound. One of the The primary reason for providing UPRT and the core phase are closely factors that we attribute that success to this in the core flying-skill phase is connected because they share the same is [the airline-involved student] prese- because this phase, in great measure, fundamental value. Core-flying confi- lection. We feel that has been a marked deals with human factors and pilots’ dence phase would be a better name.”
42 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MAY 2014 ®
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BY FRANK JACKMAN Commercial Aviation Fatalities Down Sharply in 2013
ommercial aviation, including both jet and 86.4 per year. During that period, there were 94 turboprop operations, suffered 16 fatal ac- fatal commercial aircraft accidents. Sixty-five cidents in 2013 that resulted in 210 fatali- percent involved passenger operations, 31 per- ties, according to worldwide data released cent cargo operations and 4 percent ferry flights, Cin early April by the International Air Transport according to IATA. Association (IATA). While there was one more Runway excursions were the most common fatal accident last year than there was in 2012, type of accident during the 2009–2013 period, the number of fatalities in 2013 fell sharply from accounting for 23 percent of all the accidents, 2012’s total of 414, IATA said. In addition, last IATA said (Figure 3). Those accidents, however, year marked the third consecutive year in which accounted for only 8 percent of 2,585 fatalities fatalities declined from the previous year, and during the period. 2013’s fatality total was less than half of the an- nual average over the five-year — 2009–2013 — Commercial Aviation Fatalities, 2009–2013 vs. Five-Year Average period (Figure 1). Overall, there were 81 commercial aviation ac- 786 cidents involving Eastern- and Western-built air- 685 craft last year, up from 75 in 2012, but still fewer 490 517 than in any of the previous three years (Figure 2). 414 Fatalities Of the 81 accidents, 78 percent involved passenger 210 operations, 18 percent cargo operations and 4 per- cent ferry flights. Just over half of the accidents, 53 2009 2010 2011 2012 2013 5-year percent, involved turboprops. Twenty-one percent average
of last year’s accidents involved a runway excur- Source: International Air Transport Association (IATA) sion, 17 percent a gear-up landing or gear collapse, and 15 percent involved ground damage. Figure 1 IATA defines an accident as an event in which persons have boarded an aircraft with the inten- Commercial Aviation Accidents, 2009–2013 tion of flight; the intention of the flight is limited to 94 normal commercial aviation activities, specifically 90 92 81 scheduled or charter passenger or cargo service; 75 the aircraft is turbine-powered and has a certifi- cated maximum takeoff weight of at least 5,700 kg Accidents (12,500 lb); and the aircraft has sustained major structural damage exceeding $1 million or 10 per- cent of the aircraft’s hull reserve value, whichever is 2009 2010 2011 2012 2013
lower, or it has been declared a hull loss. Source: International Air Transport Association Over the past five years, there have been 432 commercial aviation accidents, or an average of Figure 2
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“Improving runway safety is a key focus of Commercial Aircraft Accidents by Category, 2009–2013 the industry’s strategy to reduce operation risk,”
IATA said. “Information sharing, risk analysis, Percent of accidents training and analysis of the taxonomy of runway Runway excursion 23% safety are all part of the industry’s comprehen- Gear-up landing/gear collapse 17% sive approach to improvement in this area.” Ground damage 13% From 2009 to 2013, 58 percent of all accidents Loss of control–in ight 10% occurred in the runway environment, IATA said. Hard landing 8% Approximately 10 percent of all the commer- In- ight damage 8% cial aviation accidents over the past five years have Controlled ight into terrain 7% Tail strike 6% been categorized as loss of control–in flight (LOC- Undershoot 4% I), according to IATA. “While few in number, Other 2% LOC-I accidents almost always are catastrophic,” O -airport landing/ditching 2% IATA said. Ninety-five percent of the LOC-I Runway collision 0% accidents during the five-year period involved Midair Collision 0% fatalities to passengers or crew. Of the 2,585 fatali- ties suffered in commercial aviation in 2009–2013, Source: International Air Transport Association 1,546, or 59.8 percent, were as a result of LOC-I Figure 3 accidents. Last year, there were eight LOC–I ac- cidents, and all of them involved fatalities. Western-Built Jet Hull Loss Rate, 2009–2013 There were six controlled-flight-into-terrain (CFIT) accidents in 2013, and 7 percent of all 0.8 accidents in 2009–2013, or 31, were CFIT, ac- 0.7 0.6 cording to IATA data. The association said that 0.5 most CFIT accidents occur in the approach and 0.4 0.3
landing phase of flight and are often associ- Hull losses 0.2 ated with nonprecision approaches. Over the per million ights 0.1 past five years, 52 percent of CFIT accidents 0 were known to involve the lack of a precision 2009 2010 2011 2012 2013 approach. “There is a very strong correlation Source: International Air Transport Association between the lack of instrument landing systems Figure 4 or state-of-the-art approach procedures, such as performance-based navigation (PBN), and hull loss is defined as an accident in which the CFIT accidents,” IATA said, adding that it has aircraft is destroyed or substantially damaged established a campaign for states to expedite the and not subsequently repaired for whatever rea- implementation of PBN approach procedures son, including a financial decision by the owner. for runways lacking precision approaches. With the release of its most recent statistics, IATA calculated the Western-built jet hull IATA introduced a new measure for accidents, loss rate for 2013 at 0.41 per million flights, the modern jet hull loss rate. This includes or the equivalent of one per every 2.4 million aircraft approved for production after 1985 and flights, which is nearly double 2012’s rate of 0.21 equipped with a glass cockpit and flight man- hull losses per million flights (Figure 4). There agement system at initial certification. Aircraft were 12 hull loss accidents involving Western- using older technologies are considered “classic.” built jets last year, compared to six in 2012. Last IATA said this definition “reflects the harmo- year’s hull loss rate of 0.41 per million, however, nizing of aircraft manufacturing and certifica- still is lower than the five-year (2009–2013) tion standards and the global manufacturing of average of 0.48 hull losses per million flights. A aircraft components.” The modern jet hull loss
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rate is calculated as the number of accidents per According to IATA, the classic jet hull loss million flights or sectors. IATA also calculated rate last year was 0.71 per million sectors, while the modern jet hull loss rate for the industry as a the overall industry rate was 0.38 per million whole and separately for IATA member carriers. and the IATA member carrier rate was 0.36 per million (Figure 5). Modern Jet Hull Loss Rate, 2009–2013 The most comprehensive of the rates cal- culated by IATA is the all accident rate, which 3.0 Industry modern jet includes substantial damage and hull loss ac- 2.5 IATA member modern jet Industry classic jet cidents for jets and turboprops. The industry 2.0 all accident rate last year was 2.23 accidents per 1.5 million fights, which represents a slight increase
Hull losses 1.0 from 2012 (Figure 6). The IATA member carrier
per million sectors 0.5 all accident rate was 1.57 per million flights in 0 2009 2010 2011 2012 2013 2013, up from 0.74 the previous year and also greater than the five-year average rate of 1.49. IATA = International Air Transport Association The accident rate last year for operators that are Source: International Air Transport Association IATA Operational Safety Audit (IOSA)–regis- Figure 5 tered was 1.46 accidents per million flights, and the rate for non-IOSA-registered operators was All Accident Rate, 2009–2013 3.6 per million. The five-year average rate for IOSA operators is 1.57 per million, while the 6 Industry IOSA five-year average rate for non-IOSA-registered 5 IATA members Non-IOSA operators is 4.24 per million. IOSA is an indus- 4 try standard for airline operational safety audit- 3 ing that assesses airline operational management 2 and control systems and, as of March 2009, is a 1 condition of IATA membership. Accidents per million sectors 0 2009 2010 2011 2012 2013 The Commonwealth of Independent States had the worst performance of any region in terms IATA = International Air Transport Association; IOSA = IATA Operational Safety Audit of the Western-built hull loss rate in 2013 (Figure Source: International Air Transport Association 7), followed by Africa. North Asia, Europe and Figure 6 North America had the lowest rates, all well below the industry Hull Loss Rate by Region average of 0.41 hull losses per million 6.44 2013 flights. IATA member 5-year average carriers as a group also fell below the industry average. Over the past 2.09 Hull losses 2.03 1.51 0.86 five years, Africa had per million sectors 0.70 0.64 0.68 0.68 0.44 0.32 0.41 0.48 0.32 0.15 0.25 0.20 0.00 0.07 0.30 the highest average Africa Asia-Paci c CIS Europe Latin America Middle East North North Asia Industry IATA hull loss rate, followed and the and North America Members Caribbean Africa at a distance by the Middle East and North CIS = Commonwealth of Independent States; IATA = International Air Transport Association Africa. North Asia and Source: International Air Transport Association North America had Figure 7 the lowest rates.
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Risk Roundup BY LINDA WERFELMAN
BOOKS diverse as a Cessna 172, an Embraer EMB-120 Managing Risk: Best Practices for Pilots Brasilia and a Boeing 747, and specific risk- Wilson, Dale; Binnema, Gerald. Newcastle, Washington, U.S.: Aviation mitigation recommendations. Supplies & Academics, 2014. 231 pp. Figures, resources, index. The 10 chapters cover runway incursions; midair collisions; icing, wind shear, inadvertent his book — written, the authors say, to flight into instrument meteorological condi- help pilot-readers “learn from the mis- tions and other weather-related issues; hypoxia; Ttakes of others [because] you will not live the limitations of night vision; visual illusions long enough to make them all yourself” — is and spatial disorientation; and controlled flight a compendium of the risks faced by anyone into terrain. who flies, from new private pilots to seasoned Each chapter examines the nature of the veterans. hazard, as well as the conditions under which The authors — a professor of aviation at it is most likely to occur, “the human aspects Central Washington University in the United that make pilots particularly vulnerable” to a States and an aviation safety consultant in particular hazard and the strategies that a pi- British Columbia, Canada — say the book’s lot could use to mitigate the risk. In addition, title “captures its essence. It documents and each chapter includes a list of resources pro- describes most of the significant risks associ- viding additional information on the subject. ated with flight.” Over the years, most of these risks have Discussions of those risks include descrip- been “managed down to remarkably low tions of related accidents involving aircraft as levels,” the authors say. “Rather than deny the
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MAY 2014 | 47 INFOSCAN
existence of these risks … the key is to acquire the regulatory context for biomathematical a thorough knowledge of them and the strate- models, and explains the science involved in gies necessary to identify, eliminate and/or biomathematical modelling and the limita- reduce them to acceptable levels. Because ‘pilot tions of the models. error’ is responsible for the majority of aircraft “Biomathematical models of fatigue essen- accidents, and because you can’t treat an illness tially make the tacit assumption that changes without first knowing its cause, this book is in levels of fatigue will be paralleled by similar as much about identifying the internal human changes in risk, but the available evidence limitations of pilot performance as it is about suggests that this may not always be the case,” identifying the nature of the external threats to the report says. “It is obviously true that if safe flight.” an individual’s level of fatigue is such that they fall asleep, the risk of failing to respond REPORTS appropriately when required will be high. … However, most accidents seem to occur while Biomathematical Fatigue Models the worker is awake and are linked with slow Guidance Document or inappropriate responses rather than a total Civil Aviation Safety Authority (CASA) of Australia. March 2014. 73 Biomathematical Fatigue Models failure to respond.” Guidance Document pp. Figures, glossary, references, tables. Available from CASA at
Civil Aviation Safety Authority (CASA) Australia his document, an update of CASA guidance typically are based on averages and on measures March 2014
published in 2010, discusses the application obtained from a limited number of people, and
Tof biomathematical fatigue models as com- “individuals clearly differ from one another on ponents of fatigue risk management systems an enormously wide range of factors, many of (FRMS). which may impact on their fatigue and safety “The science and application of fatigue mod- performance levels.” elling continues to evolve, and … this report Another section of the report describes includes a survey of the capabilities of currently seven primary applications for biomathematical available biomathematical fatigue models and fatigue models — forward scheduling, non- discusses important considerations regard- scheduled/irregular operations, work/rest cycles ing the incorporation of such models into an in augmented crew, evaluation of countermea- FRMS,” the report says. sures, individual fatigue prediction, training and Biomathematical models can be used to safety investigation. predict crewmember fatigue levels, taking The document also includes a directory of into account “a scientific understanding of the the seven biomathematical models and explains factors that contribute to fatigue,” the report their various elements “in terms of their internal says. Nevertheless, biomathematical models structures and formulae (components), the vari- have limitations, and these limitations must ables that can be entered into the models (in- be understood to ensure that they are used puts) and the prediction methods or outcomes appropriately. that are produced (outputs).” These elements are The review begins with background used in comparing the seven biomathematical information on how the guidance mate- models to help potential users select one model rial was developed, including references to that is most suitable for them.
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In addition to the report, related information in part because of a new law that raised hiring is available on the fatigue page of CASA’s website requirements for these pilots. Mainline airlines, at
United States Government Accountability Office
Report to Congressional Requesters Aviation Workforce: Current and is changing as fewer students enter and complete
Future Availability of Airline Pilots collegiate pilot-training programs and fewer February 2014 AVIATION GAO-14-232. U.S. General Accounting Office (GAO). Feb. 28, 2014. military pilots are available than in the past.” WORKFORCE 61 pp. Appendixes, figures, tables. Available from GAO at
Congress because of concerns that the United at mainline airlines over the next decade and States might lack a sufficient supply of avail- beyond, the increasing demand for regional air-
T able and qualified pilots, said that researchers lines to address attrition needs and the reported GAO-14-232 had found “mixed evidence” of any shortage. lower number of potentially qualified pilots in The report cited forecasts by the aviation the applicant pool for filling regional airlines’ industry and the U.S. Bureau of Labor Statistics first officer jobs.” that indicated that between 1,900 and 4,500 new If predictions of rising demand come to pass, pilots will be needed each year over the next airlines might be forced to make “considerable decade. Those numbers are consistent with the operational adjustments” to compensate for the airlines’ hiring expectations, the report said. pilot shortage, the report said. The report also cited, as an indication of an Those adjustments might include “employ- adequate pilot supply, earlier studies that have ment pathway partnerships” with pilot schools concluded that there are a large number of U.S. and financial and career support for new pilots pilots working in other countries, in the military as they accumulate flight time, the report said. or in other occupations. “With the mandate to increase pilot quali- “However, whether these pilots choose to fications for airline pilots having only recently seek employment with U.S. airlines depends on gone into effect, opportunities exist to develop the extent to which pilot job opportunities arise new training methods and pathways for students and on the wages and benefits airlines offer,” to gain experience relevant to an airline envi- the report said. “Another study concludes that ronment,” the report said. “It is unclear at this future supply will be insufficient, absent any point what adjustments could occur within the actions taken, largely resulting from accelerating pilot-training system that would help to respond costs of pilot education and training. Such costs to … stakeholders’ concerns about the current deter individuals from pursuing a pilot career.” regulations or if government action may be Researchers found that pilot schools had necessary to enable certain changes. Therefore, fewer students entering their programs and we encourage FAA [the U.S. Federal Aviation attributed the lower enrollment to concerns Administration] to continue its efforts in work- about the high cost of training and low entry- ing with the airline and pilot training industries level pay at regional airlines. The report said in considering additional ways for pilots to build that the regional airlines complained of diffi- quality flight time that contributes directly to culty finding qualified entry-level first officers, working in airline operations.”
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MAY 2014 | 49 59th annual Business Aviation Safety Summit
67th annual International Air Safety Summit
November 11–13, 2014 Jumeirah at Etihad Towers Abu Dhabi, United Arab Emirates
Hosted by:
The 67th annual International Air Safety Summit (IASS) will be held November 11–13, 2014 at the Jumeirah at Etihad Towers, Abu Dhabi, United Arab Emirates. Please visit the website below for hotel information and further details about the event as they become available.
fl ightsafety.org/IASS2014
@Flightsafety #IASS2014 ONRECORD
‘Conflict of Plans’ The captain was focused on landing the 777 and was slow to react when a caution message required a go-around.
BY MARK LACAGNINA
The following information provides an awareness of problems that might be avoided in the future. The in- formation is based on final reports by official investigative authorities on aircraft accidents and incidents.
JETS
CAT III Approach the crew [later told investigators that they] did Boeing 777-200. No damage. No injuries. not feel tired.” nadequate crew coordination and monitor- The English translation of the BEA report ing of flight parameters were key factors in a noted that the flight crew comprised the captain Iserious incident that brought the 777 close to (the pilot flying), a copilot and a relief pilot but the ground during a go-around at Paris Charles did not indicate whether there were passengers de Gaulle Airport the morning of Nov. 16, or cabin crew aboard the aircraft. 2011, according to the English translation of a Low visibility procedures, which included report released in January by the French Bureau increased spacing between arriving aircraft, had d’Enquêtes et d’Analyses (BEA). been in effect for several hours at de Gaulle. As At the onset of the incident, the captain had the 777 neared the airport, the reported runway the airport in sight and was concentrating on visual range for Runway 08R was 400 m (1/4 completing a Category III (CAT III) autoland mi) in fog. Due to the low visibility, the captain approach to a landing when a master caution decided to conduct an autoland approach. Ac- activated, requiring a go-around in accordance cordingly, the crew requested and received radar with standard operating procedure. This re- vectors from air traffic control (ATC) for a CAT sulted in a “conflict of plans of action between III approach to the runway. respecting the operator’s instruction and con- The aircraft was on the glidepath and de- tinuing the landing,” the report said. scending through a radio altitude of 320 ft when The 777 was inbound to Paris from Caracas, the master caution alarm sounded and an amber Venezuela, and had been airborne for 10 hours. warning, “NO LAND 3,” was displayed on the “After a long flight that arrived at 1100 in the engine indicating and crew alerting system. In morning (local time), this may have led to a cer- addition, the green “LAND 3” indications on the tain loss of vigilance,” the report said. “However, primary flight displays changed to “LAND 2.”
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The report explained that this the autopilot, which was still in ap- twin-turboprop military transport, indicated change to the aircraft’s proach mode. The aircraft continued to called for taxi clearance. The crew was autoland system performance would descend on the glideslope. conducting a series of parachute drops not, by itself, have prevented the crew The copilot told investigators that and was using Runway 21 for takeoff from continuing the approach to CAT he was concentrating on changing the because the runway was much closer to II minimums, typically a 50-ft decision flap configuration and was not moni- its parking area. The controller told the height rather than the 20-ft decision toring the flight parameters. The relief crew to “taxi holding point runway … height of a CAT III approach. During pilot called out “pitch attitude” twice correction, taxi holding point Alpha, the investigation, the aircraft manu- before control inputs sufficient for a Runway 21.” facturer determined that under the go-around were made. By this time, The report said that this instruc- existing conditions, the landing could the captain also had disconnected the tion was not in strict accordance with have been conducted safely. However, autopilot and moved the thrust levers proper ATC phraseology, but the C-160 the aircraft operator required that a full forward. crew correctly read back “taxi runway go-around be conducted if any alarm or The 777 reached a radio height of holding point Runway 21 via Alpha.” mode change occurred below 1,000 ft 63 ft before beginning to climb. The The Airbus was lined up and wait- during a CAT III approach. crew retracted the landing gear and ing on the runway about one minute The relief pilot, who was occupy- climbed straight out to 4,000 ft, as later when the controller said, “A319, ing the central observer’s seat, told instructed by ATC. They subsequently wind variable 1 knot, Runway 03, investigators that neither the captain set up for another CAT III approach cleared for takeoff.” nor the copilot immediately reacted to and landed the aircraft on Runway 08R The report noted that the eleva- the warnings, so he called out “warn- without further incident. tion of the 2,950-m (9,679-ft) runway ing.” The copilot subsequently called “This serious incident was due to is higher at the mid-point than at the out “go around.” the inadequate monitoring of flight pa- thresholds; consequently, the crew of By this time, however, the captain rameters by the flight crew,” the report an aircraft positioned at one end of the had acquired visual contact with the concluded. “After the incident, preven- runway has little, or no, ability to see airport. “Having visual references and tion information relating to go-arounds the other end of the runway. Moreover, knowing that the landing was possible, with no TOGA selection was distrib- the tower controllers do not have an his plan of action was to land,” the re- uted among 777 sector pilots.” unobstructed view of the approach end port said. “The ‘NO LAND 3’ warning, of Runway 03. making mandatory a go-around, led to ‘Sorry About That’ As the A319 crew began the take- confusion and to a change in his plan Airbus A319-112, Transall C-160. No damage. off run, the controller realized that No injuries. of action.” the C-160 crew was not holding on The captain initiated a go-around, isual meteorological conditions Taxiway Alpha, as instructed, but had but the procedure was only partially (VMC) with light winds prevailed taxied onto the runway. The controller executed, with inadequate management Vat Zweibrücken Airport in Germa- told the C-160 crew to “hold position” of the autoflight systems, the report ny the afternoon of May 14, 2008, when and the A319 crew to “break up.” said. The captain inadvertently pressed the A319 flight crew requested clear- Noting that “break up” is not a the autothrottle-disconnect switch in- ance to taxi from the gate. A controller phrase used in ATC communications, stead of the takeoff/go-around (TOGA) who was handling ground, departure the report said that the controller likely switch, which would have prompted and arrival operations told the crew meant to tell the A319 crew to “stop an increase in thrust sufficient for a to taxi to Runway 03 and to line up immediately” — that is, to reject their 2,000-fpm climb as well as the selection and wait on the runway, said a report takeoff. The crew did not understand of the autopilot go-around pitch and published in January by the German the “break up” instruction and asked roll modes. He then manually moved Federal Bureau of Aircraft Accident the controller to “say again.” the thrust levers forward and pulled the Investigation. However, by this time, the Air-
control column back, but the control While the Airbus was taxiing bus had accelerated through V1, the input was not sufficient to disconnect out, the crew of a Transall C-160, a maximum speed at which the crew
52 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MAY 2014 ONRECORD
could take action to safely reject the takeoff. After seeing the Airbus pass overhead, the The crew continued the takeoff, and the A319 C-160 crew told the controller that they had passed 400 ft above the C-160. There were been instructed to line up and wait on the 137 people aboard the Airbus; the C-160 had runway. The controller said, “You were cleared a crew of four and an unspecified number of to holding point Alpha.” The crew replied, “OK, passengers. sorry about that.”
TURBOPROPS
Ditching Follows Fuel Exhaustion revealed that, in order to complete the flight, the Beech King Air C90GTX. Substantial damage. No injuries. airplane would have needed to depart with 328 he pilot-in-command (PIC), who had gallons [1,241 L] on board.” logged 2,600 of his 11,500 flight hours in The King Air was cruising over Haiti at T90-series King Airs, had been contracted by 27,000 ft about two hours after departure when an air taxi operator to ferry the newly purchased the PIC noticed that the indicated fuel quantity airplane from Wichita, Kansas, U.S., to Wil- was lower than expected. “However, the pilot lemstad, Curaçao, in the Netherlands Antilles. decided to continue despite his proximity to He was accompanied by an employee of the airports on Hispaniola that were suitable for operator, a 3,650-hour pilot who had recently diversion,” the report said. “By the time he be- completed initial training in the airplane. gan to be concerned about a possible fuel leak The first stop was planned for Fort Lauder- or indication failure, he was once again over dale, Florida, but strong headwinds prompted open water.” a landing in Marianna, Florida, where the King The airplane was about 90 nm (49 km) from Air was refueled, said the report by the U.S. Na- Willemstad when the PIC decided to divert to tional Transportation Safety Board (NTSB). Oranjestad, Aruba, because of “very low indica- After continuing the flight to Fort Lauder- tions” on the fuel gauges. Both engines flamed dale, the pilot requested that the nacelle fuel out due to fuel exhaustion shortly after the tanks be topped off. The PIC told investigators descent was begun. that he monitored the refueling, but surveillance Realizing that he could not reach Oranjes- cameras showed that the line service agent was tad, the PIC ditched the airplane in the Carib- alone when the nacelle tanks were filled. bean Sea. The pilots boarded a life raft and were The pilots stayed overnight in Fort Lauder- rescued about 20 minutes later by the crew of dale and returned to the airport early in the a Royal Netherlands helicopter. The King Air morning of April 3, 2012. The PIC reviewed the subsequently sank. fueling ticket and concluded that 134 gal (507 L) had been pumped into the nacelle tanks, bring- Pyrotechnic Paper Clip ing the total fuel load to 366 gal (1,385 L). ATR 72-212A. Minor damage. No injuries. However, investigators found that only hortly after the aircraft reached cruise alti- 25 gal (95 L) of fuel had been required to top tude, 25,000 ft, during a flight from Vaasa, off the nacelle tanks. The number “134” on SFinland, to Tallinn, Estonia, the morning of the fueling ticket was the line service agent’s Nov. 28, 2011, dark blue smoke began to emerge employee number. from the aircraft communications addressing “Utilizing the information contained on the and reporting system thermal printer. The flight fuel ticket, it was determined that the airplane crew saw a red glow inside the printer. had departed with only 261 gallons [988 L] “The pilots donned their oxygen masks, of fuel on board,” the report said. “Review of started an immediate descent and made the de- performance data in the [airplane flight manual] cision to land at Pori Airport,” said the English
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translation of the report on the serious incident a strong odor in the cockpit and in the front by the Safety Investigation Authority of Finland. of the cabin. No portable fire extinguishers or The crew declared an emergency, reported a passenger oxygen masks were used during the cockpit fire and requested and received radar approach. The pilots landed the aircraft with- vectors to Pori. out further incident, and the seven passengers The pilots initially had difficulty donning deplaned normally. and using their oxygen masks. “The oxygen “A paper clip which showed signs of having masks hampered communication between the been heated was found inside the printer,” the pilots and between the captain and the cabin report said. “The paper clip caused a short cir- crew,” the report said. cuit in the printer. The smoke generation ended The captain instructed the cabin crew to when the printer’s circuit breaker tripped. There prepare the cabin and passengers for an emer- was no actual fire inside the printer. … Immedi- gency landing. The smoke was thick at first but ately after the occurrence, [the operator] banned dissipated during the approach to Pori, leaving the use of paper clips on its entire fleet.”
PISTON AIRPLANES
Fire Erupts Near Oil Gauges Investigators determined that the fire most Beech 58 Baron. Destroyed. Four fatalities. likely began underneath the instrument panel, he Baron was cruising at 9,000 ft in VMC near the direct-read oil gauges. Because of the about 30 minutes after departing from extensive fire damage, however, NTSB was TAtlanta for a charter flight to Hazard, Ken- unable to form a conclusion about what caused tucky, the afternoon of May 25, 2011, when the the fire. pilot told ATC, “We gotta declare an emergency. Got a fire.” Crossed Communications The controller asked him to state his inten- Piper Navajo C. No damage. No injuries. tions, but there were no further radio trans- he Navajo pilot used the common traffic missions from the pilot. The airplane rapidly advisory frequency (CTAF) to broadcast his descended below radar contact. “The time Tintention to taxi to Runway 32 for takeoff interval between the pilot’s declaration of an from Port Hedland Airport in Western Australia emergency and the last radar return from the the afternoon of May 27, 2013. airplane was a little less than one minute, sug- About five minutes later, the crew of an gesting that the fire grew quickly, without much aviation rescue and fire fighting (ARFF) vehicle of an incipient stage,” the NTSB report said. used a portable radio to announce on the CTAF “These characteristics are consistent with a fuel- frequency that they were crossing the runway to fed fire.” return to the fire station. A witness saw a two-engine airplane flying The ARFF vehicle then entered the 2,500-m about 1,500 ft above mountainous terrain before (8,203-ft) runway from a taxiway about halfway it abruptly banked right and pitched nose-down. down the runway, said the report by the Austra- The witness then heard an explosion. lian Transport Safety Bureau. The Baron had crashed in a wooded area The Navajo pilot told investigators that near Murphy, North Carolina, killing the pilot he made the required CTAF broadcasts as he and the three passengers. “The cockpit, cabin, taxied onto the approach end of the runway instrument panel, nose compartment, empen- and began the takeoff. “The crew of the fire nage and inboard sections of both wings were vehicle had not heard any CTAF broadcasts nearly consumed by the post-crash fire,” the [from the Navajo pilot], nor did they see the report said. aircraft when they scanned the runway prior
54 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MAY 2014 ONRECORD
to crossing, possibly due to heat haze,” the area within the range of a radio transmitter in report said. which the signal is not received — may exist in The pilot had not heard the CTAF broad- the vicinity of the Runway 32 threshold.” casts from the ARFF vehicle. During the After the Navajo lifted off, the pilot saw investigation, “Airservices Australia determined the ARFF vehicle crossing the runway. “As the that the transmission power of the portable aircraft was airborne, the pilot assessed the radios was lower than the radios mounted in the safest action was to continue the takeoff,” the vehicle,” which had not been programmed with report said. “By the time [the aircraft] crossed the CTAF frequency, the report said. “The inves- the intersection [at 300 to 400 ft], the fire vehicle tigation also noted that a radio dead zone — an was clear of the runway.”
HELICOPTERS
Helipad Known as Flight Hazard reported to management or via the company’s Bell 206-L4. Substantial damage. One fatality. internal safety notification system.” he pilot was attempting to land the Company records showed that the pilot JetRanger on an oil-drilling platform in had flown to the platform several times and Tthe Gulf of Mexico to pick up a passenger had landed on the jack-up rig two days before the afternoon of May 28, 2012, when the main the accident. “It could not be determined why rotor blades struck the corner of an oil derrick the pilot decided to land on the smaller and that was partially positioned over the helipad. obstructed helipad rather than the jack-up rig’s The tail boom separated as the helicopter spun larger helipad,” the report said, noting that into the water. several workers had tried to signal the pilot not The pilot — who was wearing a seat belt, to attempt the landing on the fixed platform. shoulder harness and life vest — sustained multiple blunt-force injuries on impact and Rotor Snags a Power Line drowned when the JetRanger sank rapidly. The Robinson R44. Destroyed. Two fatalities. NTSB report said that the helicopter’s emer- search was begun when the R44 did not gency external floats had not inflated. return at the expected time from an aerial At the time, the fixed oil-drilling platform A tour launched from Wheatland, Mis- was mated to a jack-up rig, a mobile platform souri, U.S., the afternoon of May 24, 2013. used for maintenance and exploratory drill- The wreckage of the helicopter was found the ing. Although a notice to airmen (NOTAM) next day in a densely wooded area near Cross had not been issued and there were no mark- Timbers, Missouri. The pilot and his passenger ings on the fixed platform’s helipad, the pilot had been killed. knew that this helipad was closed due to the “A power line was found wrapped around proximity of the jack-up rig’s derrick and that the main rotor driveshaft, and a section of the aviation operations were being conducted on power line was found resting on the ground the larger and unobstructed helipad on the leading from the power line pole to the main jack-up rig. wreckage,” the NTSB report said. “There was also nothing in the opera- Investigators determined that the power tor’s flight operations manual that would have line had been suspended about 65 ft (20 m) restricted the pilot from landing under an above the ground and was perpendicular to obstruction,” the report said. “Other company the helicopter’s flight path. After striking the pilots were aware that [the fixed platform] heli- power line, the R44 had descended into trees. pad was a flight hazard due to the encroachment The helicopter was destroyed by the impact of the [jack-up rig’s] oil derrick, but it was never and subsequent fire.
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Preliminary Reports, February 2014
Date Location Aircraft Type Aircraft Damage Injuries Feb. 1 Surabaya, Indonesia Boeing 737-900 substantial none The rear fuselage and landing gear were substantially damaged when the 737 touched down hard and bounced several times on landing. Feb. 2 Fort Lauderdale, Florida, U.S. Learjet 35A none 1 serious, 2 none A line service agent was seriously injured when the Learjet inadvertently moved forward while he was disconnecting a ground power unit. Feb. 3 Gauteng, South Africa Beech King Air 90 destroyed 3 fatal The King Air overran the runway and traveled down an embankment while landing in heavy rain. Feb. 3 Elk City, Oklahoma, U.S. Cessna 525 CitationJet substantial 7 none The ceiling was broken at 200 ft and visibility was 1 3/4 mi (2,800 m) in light freezing rain when the CitationJet struck an electric utility pole, damaging the fuselage and horizontal stabilizer, about 2 nm (4 km) north of the airport during a night instrument approach to Runway 17. The pilot conducted a go-around and landed without further incident in Oklahoma City. Feb. 3 Bellevue, Tennessee, U.S. Gulfstream 690C destroyed 4 fatal The pilot was conducting a second global positioning system (GPS) approach when the Commander veered left and descended into trees. Visibility was 5 mi (8 km), and the ceiling was overcast at 800 ft. Feb. 8 Panacea, Florida, U.S. Robinson R44 substantial 2 fatal, 1 serious Night visual meteorological conditions (VMC) prevailed when the R44 struck trees on takeoff and descended into a marsh. Feb. 11 Aïn Kercha, Algeria Lockheed C-130H destroyed 76 fatal, 1 serious The C-130 was transporting families of Algerian military personnel to Constantine when it struck a mountain about 30 km (16 nm) south of the airport. Feb. 12 Moscow Hawker 700B substantial 2 none The flight crew landed the Hawker on a foamed runway after they were unable to extend the right main landing gear. Feb. 15 Bragança, Brazil Robinson R44 destroyed 2 fatal Rain was reported in the area when the R44 crashed in a forest during a night flight. Feb. 16 Sandhikharka, Nepal de Havilland Canada DHC-6-300 destroyed 18 fatal Freezing rain was reported in the area where the Twin Otter struck terrain at 7,000 ft during a scheduled flight from Pokhara to Jumla. Feb. 17 Funchal, Portugal Boeing 737-800 substantial 182 none A tail strike occurred when the 737 encountered wind shear during approach, touched down hard and bounced. Feb. 17 Rubkona, South Sudan British Aerospace 748 destroyed 1 fatal, 3 serious The aircraft was conducting a United Nations humanitarian fight when it veered off the runway on landing and struck vehicles. Feb. 17 Billings, Montana, U.S. Boeing 737-700 minor 2 serious, 9 minor, 108 none The 737 encountered severe clear air turbulence at 34,000 ft during a flight to Billings from Denver. Feb. 18 Rio de Janeiro, Brazil Robinson R22 destroyed 2 fatal The helicopter crashed in water during a local training flight. Feb. 19 Pearland, Texas, U.S. Beech King Air B100 destroyed 1 fatal Visibility was 5 mi (8 km) in mist and the ceiling was overcast at 300 ft when the King Air struck terrain during a go-around from a circling GPS approach. Feb. 21 Grombalia, Tunisia Antonov 26 destroyed 11 fatal The aircraft struck terrain about 33 km (18 nm) from the airport after the pilot reported engine problems during a night medevac flight to Tunis. Feb. 25 Lukapa, Angola Embraer Brasilia substantial 3 minor, 14 none The flight crew diverted to Lukapa after encountering engine problems during a charter flight from Luanda to Dundo. The Brasilia veered off the runway during a single-engine landing. Feb. 26 Lanai City, Hawaii, U.S. Piper Chieftain substantial 3 fatal, 3 serious Night VMC prevailed when the Chieftain struck terrain shortly after departing on a charter flight.
This information, gathered from various government and media sources, is subject to change as the investigations of the accidents and incidents are completed.
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