ON COMMERCIAL AVIATION SAFETY AUTUMN 2003

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Jeppesen OnBoard. Making Every Mission Possible The Official Publication of THE UNITED KINGDOM FLIGHT SAFETY COMMITTEE

ISSN: 1355-1523 AUTUMN 2003 ON COMMERCIAL AVIATION SAFETY

FOCUS is a quarterly subscription journal contents devoted to the promotion of best practises in aviation safety. It includes articles, either original or reprinted from other sources, related Editorial 2 to safety issues throughout all areas of air transport operations. Besides providing information on safety related matters, FOCUS aims to promote debate and improve Chairman’s Column 3 networking within the industry. It must be emphasised that FOCUS is not intended as a substitute for regulatory information or company publications and procedures. New ETOPS Regulations 4 Editorial Office: The Boeing Company Ed Paintin The Graham Suite Fairoaks Airport, Chobham, Woking, Surrey. GU24 8HX Tel: 01276-855193 Fax: 01276-855195 UKFSC Members List 12 e-mail: [email protected] Web Site: www.ukfsc.co.uk Office Hours: 0900-1630 Monday-Friday

Advertisement Sales Office: DVT - What is all the fuss about? 14 UKFSC The Graham Suite, Part II or, are airliners flying surgeries? Fairoaks Airport, Chobham, Woking, Simon Phippard Surrey GU24 8HX Tel: 01276-855193

Printed by: Woking Print & Publicity Ltd 737-600/-700/-800/-900 Approach Navigation Options 16 The Print Works, St.Johns Lye, St.Johns The Boeing Company Woking, Surrey GU21 1RS Tel: 01483-884884 Fax: 01483-884880 ISDN: 01483-598501 e-mail: [email protected] Web: www.wokingprint.com Air Safety Report Administration made Easier 20 Simon Earthrowl FOCUS is produced solely for the purpose of improving flight safety and, unless copyright is indicated, articles may be reproduced providing that the source of material is acknowledged. Human Factors and Occurrence Reporting Systems 22 Opinions expressed by individual authors or in From a Maintenance Organisation’s Perspective advertisements appearing in FOCUS are those of the author or advertiser and do not C. R. Clark necessarily reflect the views and endorsements of this journal, the editor or the UK Flight Safety Committee. UKFSC Seminar 2003 24 While every effort is made to ensure the accuracy of the information contained herein, FOCUS accepts no responsibility for any errors or omissions in the information, or its consequences. Specialist advice should Front Cover: C17 in RAF livery always be sought in relation to any particular circumstances. Photo kindly supplied by Flight Images

1 Editorial

Changing the Law

prosecute anti social behaviour that sometimes occurs onboard aircraft. This behaviour can be frightening to both passengers and crew. Hopefully this change to the law will increase the success rate of the police in dealing with disruptive passengers and help to deter would be offenders.

Credit for these changes must go to Frank Roy MP but also those crew members who have diligently submitted the disruptive passenger reports that have enabled the number and type of incidents to be monitored. Without their coopertion there would have been no For a number of years the Department of As a result of discussions at these information for analysis. Transport (DfT previously the DTLR) has meetings it was decided that the powers been holding twice yearly discussions of the police were inadequate to deal It is hoped that following the small with aviation industry representative effectively with such disruptive success aircrew will continue to submit bodies on disruptive passenger passengers. A proposal was made to the reports so that we can continue to behaviour. change the law to increase the powers of monitor the situation. It will be interesting the police attending to calls from aircrew to see what effect the changes to the law These meetings resulted in the who have experienced disruptive has. introduction of a disruptive passenger passenger incidents on their aircraft. report that is submitted to the Civil Aviation Authority (CAA) by aircrew The proposed changes to the law were following any disruptive passenger presented to Parliament in a Private incident. The response from airlines and Members Bill by Frank Roy MP for their aircrew to this initiative has been Motherwell and Wishaw. This Bill passed very good. These reports are categorised, its second reading on the 7th February collated and used to produce meaningful 2003 and became Law on the 9th July statistics to monitor and illustrate the 2003. scale of the problem. They are also used to indicate the trend of the incidents of The provision of the new Aviation disruptive passenger behaviour and to Offences Act gives the police greater brief various government officials. powers of arrest of suspected air rage offenders and will help the police

UK FLIGHT SAFETY COMMITTEE OBJECTIVES

■ To pursue the highest standards of aviation safety. ■ To constitute a body of experienced aviation flight safety personnel available for consultation. ■ To facilitate the free exchange of aviation safety data. ■ To maintain an appropriate liaison with other bodies concerned with aviation safety. ■ To provide assistance to operators establishing and maintaining a flight safety organisation.

2 Chairman’s Column

Close Encounters by John Dunne, Airclaims

Runway incursions have been with us for some time now. They are a very real threat to Flight Safety and are increasing in risk exposure as traffic continues to increase.

The CAA has recently requested the aviation industries participation in their “Runway Incursions – Research into Causes” initiative. This research is being conducted in parallel with similar initiatives from other regulators and flight safety bodies.

The UKFSC welcomes this and is fully endorsing and supporting it through our Operational Safety Committee. Most of our members will have received a copy of the CAA’s questionnaire via e-mail and they are urged to ensure that their company responds.

communications error, more significant humans do fail every now and then Those involved in safety management perhaps is that in each event no one (usually at the most inconvenient time) and systems continue to examine the individual involved appears to have had one that does not require judgemental or difficulties of communication and company the total picture of the event that unfolded interpretation skills. Additionally such a procedures with a view to preventing before them. Digging down a further layer system would need to meet the strict similar events. Perhaps it is appropriate on this element we can observe the certification requirements on both sides of for us to reflect where our organisations classic HF issues of confusion and lack of the Atlantic at a cost that is not prohibitive stand in relation to previous ground complete communications – a situation to smaller airports and is demonstrably collisions: Chicago F27 and DC6, poor where everyone has a clear picture of their reliable. weather compounded by communication version of the plan but not that of the other errors. Tenerife, 2 x B747s in poor visibility person and no one in that loop had the compounded by communication errors. overall picture. Paris, MD80 and Shorts S360, at night with visual distractions compounded by This maybe the time to stand back a little communication errors and the Linate (Italy) further from the coal face, reflect a little accident, ground collision involving and and consider the uncomfortable. We are MD80 and an executive jet have been all fallible; we all get it wrong sometimes. made available and highlight poor To paraphrase Lincoln: We can’t all be communication as being a significant right all of the time, but all of us can be contributory factor in the final link of the right some of the time. The problem is accident chain. when we get it wrong at the same instant as someone else who is operating A recent FAA report states that in the somewhere in the same loop as ourselves. period between 1999 and 2002 there were How do we realistically protect against in excess of 1,400 reported runway human fallibility? Perhaps we need to incursions in the USA. The majority of consider developing a simple mechanical these incidents contained an element of system on the established premise that

3 New ETOPS Regulations

Extended-range operations with two- On December 16, 2002, the Aviation The ARAC ETOPS Working Group engine airplanes (ETOPS) rank among Rulemaking Advisory Committee (ARAC) - comprised expert representatives from the safest and most reliable of all flight an advisory committee of the U.S. Federal many of the world’s airlines, airframe and operations. Pending rulemaking by the Aviation Administration (FAA) - presented engine manufacturers, pilots’ U.S. Federal Avaition Administration may to the FAA its findings and associations, regulatory authorities, and expand these reliability enhancements recommendations on extended non-governmental organizations. In and operational protections to all operations (i.e., operations on routes with keeping with its proposal that the extended-diversion-time operations (i.e., the potential for an extended-duration extended-operations protection be flying on routes with the potential for an diversion). Initiated by the FAA tasking applied broadly to protect all airplanes, extended diversion), not just those statement of June 14. 2000, this regardless of the number of engines, the performed with two-engine airplanes. proposed U.S. rulemaking marks the ETOPS Working Group further culmination of more than two years of recommended that the term ETOPS itself As airplane range capabilities continue to global collaboration to review current be redefined to simply mean extended increase, flights across remote regions of requirements for extended-range operations. (See “ARAC ETOPS Working the world are becoming more common. operations with two-engine airplanes Group Participants”). The global aviation community - which (ETOPS) and proposes updated and collaboratively defined and proposed with standardized requirements that will The FAA will evaluate the proposed ARAC U.S. rulemaking - believes that applying embrace all extended-diversion-time findings and recommendations, make ETOPS rules to all extended-diversion- operations, not just those performed with whatever changes it deems appropriate, time operations will raise the industry to a two-engine airplanes. and publish the results in a Notice of higher and uniform standard. Proposed Rulemaking (NPRM) for public

4 review and comment. Following comment 1. ETOPS IS THE STATE OF THE airplanes are not currently required to resolution, the FAA is expected to enact ART IN INTERCONTINENTAL AIR meet the high ETOPS standard. new extended-operations rules, perhaps TRAVEL Nevertheless, some operators already as soon as late 2004. comply with key ETOPS safely ETOPS is the dominant mode of enhancements on a voluntary basis. This This article discusses the reasons behind transatlantic flight operations today and elective application of ETOPS best this global activity and describes the accounts for a rapidly growing practices suggests that the maintenance specific regulatory changes that the component of transpacific and other and operational benefits of ETOPS are ARAC has proposed. operations as well. Since 1985, more than well recognized by the global industry 3 million ETOPS flights have been logged and that operators find them cost THE ETOPS PARADIGM SHIFT using the twinjets of several effective. manufacturers. Today, about 125 When the conservative ETOPS program operators worldwide log an additional began in 1985, its intent was to ensure 1,100 ETOPS flights each day. Of this 2. ENGINE RELIABILITY IS NO that the safety of two-engine airplanes industry total, Boeing twinjets alone have LONGER THE SINGLE FOCUS would match that of three- and four- performed more than 2.6 million ETOPS OF SAFETY CONCERNS engine airplanes on long-range flights, and 94 Boeing operators fly nearly transoceanic routes. Implicit in the ETOPS 1,000 more each day (fig. 1) In the past, concerns about flight safety rules was the initial assumption that focused first and foremost on the turbine-powered airplanes with two This vast service experience reveals that reliability of propulsion systems. When engines were inherently less safe than ETOPS ranks among the safest and most ocean-spanning commercial flight those with three or more engines. As a reliable of all flight operations. This operations began after World War II, that result a separate set of more stringent success results from the preclude and narrow focus was appropriate in light of requirements was deemed necessary for protect philosophy of ETOPS, which the limited reliability of piston engines. operating two-engine airplanes on routes enhances flight operations in two ways: During the 1940s and l950s, in fact, with the potential for an extended- piston engine-related events were the duration diversion. ■ ETOPS-related design improvements predominant cause of airliner accidents and maintenance practices increase and contributed to a worldwide fleet hull- Since then, however, extensive ETOPS airplane systems and engine reliability loss accident rate that was some 60 service experience has brought about a making it less likely that an airplane times higher than today’s. profound revision to that initial thinking. will need to divert from its intended After nearly two decades of highly course and land at an alternate The limited reliability of piston engines led successful ETOPS around the world, the airport. to an operating restriction being placed global aviation community today views on two-engine airplanes 50 years ago. ETOPS in a different light. Characterizing ■ ETOPS operational requirements The intent of the so-called 60-Minute Rule this profound data-driven paradigm shift introduce proactive measures that of 1953 (U .S. Federal Aviation Regulation are the present-day industry perceptions protect the airplane, passengers and [FAR] 121.161) was to bar two-engine that crew should a diversion occur. propeller airplanes, such as the Douglas DC-3, from flying extended routes then 1. ETOPS is the state of the art in This philosophy has indirectly benefited more safely served by four-engine intercontinental air travel. the entire industry. All commercial propeller types, such as the DC-4. That operations today - including those piston-era operating restriction remains in 2. Engine reliability is no longer the performed with three- and four-engine effect at the time of this writing. single focus of safety concerns. airplanes - benefit from gains in the reliability and robustness of airplane During the late 1950s, however, the 3. A uniform standard is desirable for all engines and systems initially achieved transition to turbine power brought about extended operations. through ETOPS programs. a quantum leap in propulsion system reliability. Engine reliability has continued Operators flying three- and four-engine to improve in the jet age, so much so that

5 today’s high-bypass-ratio fan jet engines operational issues (e.g., cargo fire fact, fewer than 10 percent of all are at least 50 times more reliable than suppression capability, weather diversions during extended operations are the large piston engines that inspired the conditions and facilities at alternate airplane related, and fewer than 3 percent 60-Minute Rule. airports) are relevant to overall safety and are the result of an in-flight engine failure reliability on routes with the potential for or shutdown. In general, of course, By the l970s,. advancing technology had an extended diversion. engine failures tend to occur during set the stage for two-engine, turbine- takeoff and initial climb rather than during powered airplanes to safely exceed the 3. A UNIFORM STANDARD IS the cruise phase of flight where ETOPS is 60-min operating restriction. The result DESIRABLE FOR ALL flown. was ETOPS, which began in 1985 with EXTENDED OPERATIONS 120-min diversion authority and the PROPOSED U.S. REGULATORY requirement for an average engine in- All airplanes flown on extended-diversion- CHANGES flight shutdown (IFSD) rate of just 0.05 time routes face similar operating per 1,000 engine-hours. With 180-min challenges in terms of weather, terrain, This paradigm shift created growing ETOPS authority, which followed in 1988, and limitations in navigation and awareness around the world that the an even more stringent reliability target of communications infrastructure. Given that regulatory framework currently governing just 0.02 IFSDs per 1,000 engine-hours the operating environment is common to twinjet and other extended operations was specified. all extended operations and that all should be reviewed. Consequently, the categories of jetliner are safe, the global FAA - which meets its responsibility to In this way, ETOPS drove manufacturers aviation community believes a uniform update regulations through the proven and operators alike to pursue dramatic standard is desirable for extended ARAC process - initiated the collaborative gains in propulsion system reliability. The operations. The global community further ARAC activity previously described. industry met this challenge and bettered recognizes that applying ETOPS it. During the past few years, in fact, the requirements to all airplanes - not just The ARAC-proposed regulations (table 1) average IFSD rate of the worldwide 180- those with two engines - will raise the might change as a result of the current min ETOPS industry to a higher and uniform standard. FAA review and pending NPRM comment processes. We at The Boeing Company So profound has this trend been that Although diversions are rare, any airplane are proud to have participated in this propulsion reliabilities unachievable might someday need to divert to an global ARAC effort, which will make flying just 15 years ago are today routine in airport other than its intended destination even safer and more reliable in the the modern twinjet fleet. for various reasons (e.g., passenger coming years. Pages 8 through 10 detail illness, smoke in the flight deck or cabin, the proposed changes. fleet has typically been at or below 0.01 turbulence, adverse winds, weather, fuel IFSDs per 1,000 engine-hours - twice the leak, cargo fire, in-flight engine failure or reliability required for such operations. So shutdown). Thus, the dual ETOPS ETOPS Authorization profound has this trend been that philosophy of precluding diversions and propulsion reliabilities unachievable just protecting the passengers, crew, and The ARAC has recommended that FAR 15 years ago are today routine in the airplane on those rare occasions when 121.161 (the 60-Minute Rule) and modern twinjet fleet. diversions do occur is applicable to all associated guidance and advisory extended operations, not just those material be revised to In light of these advances, and because performed with two-engine airplanes. the safety and reliability of two-engine ■ Establish the basis and requirements airplanes equal or exceed those of three- As a result of ETOPS, the industry has for operating twin-engine, turbine- or four-engine airplanes, the industry no achieved significant improvements in the powered airplanes beyond 60 min of longer views propulsion system reliability reliability and robustness of airplane flying time (at single-engine cruise as the primary safety and reliability engines and systems. However, such speed with no wind and in standard concern in extended operations. Instead, efforts can never entirely prevent conditions) of an adequate alternate current rulemaking recognizes that a diversions because most are unrelated to airport. variety of airplane systems and the airplane, its systems, or its engines. In

6 ■ Apply this same regulatory framework new regulations and guidance material for operations are defined by distance to an to the operation of turbine-powered ETOPS are unique to extended alternate airport, not by overall length of airplanes with more than two engines operations and demand precise definition flight - and because it invites confusion beyond 180 min (at one-engine- to ensure common understanding and with the similar but unrelated term ultra- inoperative cruise speed with no wind proper compliance. long-range operations, which deals and in standard conditions) of an primarily with flight crew duty time, crew adequate alternate airport and also To encompass all extended-diversion-time rest, and other human-factors issues. make it applicable to all operations in operations, not just those flown with two- polar areas (see Polar Operations. p. engine airplanes, the term ETOPS would 10). be redefined as extended operations (as Communications used in this article) and shall no longer ■ Make the designed and certified mean extended-range operations with Current regulations require reliable operating capabilities of the airplane two-engine airplanes. Another noteworthy communications. Recognizing that type the basis for determining the change is the addition of the term ETOPS advances in technology occur and that maximum diversion authority of that alternate, which is an airport that meets verbal communications can be type. stated requirements for planned diversion particularly valuable, the proposed rule use and at which the weather conditions promotes the adoption of voice ■ Define allowable diversion are at or above the operating minimums communications for extended operations. authorizations for different regions of specified for a safe landing. This new the world based on the overall term would replace the current ETOPS This proposed rule states that the most operational needs of each region. term, suitable, which denotes an alternate reliable communications technology - airport that is both above ■ Apply current ETOPS best practices to required weather minimums Airstaff Associates all extended operations. and available for diversion in association with use. Under the new rules, It should be noted that, although these suitable would no longer Nigel Bauer & Associates proposed ETOPS requirements are have an ETOPS-specific QUALITY MANAGEMENT FOR OPERATORS * consistent for all jetliners, the threshold meaning; where it appears JAR-OPS Quality Systems, documentation & auditing varies at which they would take effect. For in the new regulations and 5 days - LGW - 22 Sep, 24 Nov, 26 Jan two-engine airplanes operating under FAR associated guidance NEW SAFETY MANAGEMENT SYSTEMS Part 121, ETOPS will be in effect - as is material, therefore, it should New enlarged SMS course for air & ground operators currently the case - on routes where the be interpreted only 3 days - LGW - 29 Oct airplane is at some point more than 60 according to its broadly AUDITING IN AN OPERATIONAL ENVIRONMENT * min flying time from an alternate airport. accepted, everday Air & ground operations auditing 3 days - on request or ‘in-company’ For FAR Part 121 operations by airplanes definition. AUDIT IMPROVEMENT WORKSHOP with three or more engines, these new Experience sharing & improvement of audit process ETOPS rules will apply on routes that are It should be noted that long- Ask for details at some point more than 180 min from an range operations (LROPS) is QUALITY FOR SENIOR MANAGEMENT alternate airport. They also will apply to all not proposed as an ETOPS New Course - JAR Quality Management Accountability operations in the polar regions (i.e., the term. Although used by 2 days - ‘in-company’ only areas north of 78 oN latitude and south of some segments of the * Incorporating Nigel Bauer & Associates 60oS latitude). global industry, LROPS IRCA certificated Internal Auditor Training course currently does not appear or For further details including In-Company courses and consultancy have legal standing in the or auditing services please contact: Definitions FARs. The ARAC ETOPS Airstaff Associates: Tel +44 (0) 1780 721223 e-mail: [email protected] Working Group did not Fax +44 (0) 1780 720032 www.airstaff.co.uk The ARAC has proposed that ETOPS- propose adding LROPS Nigel Bauer & Associates: applicable definitions be added to FAR because the term would be Tel +44 (0) 1243 778121 e-mail: [email protected] Fax +44 (0) 1243 789121 www.nb-a.demon.co.uk Part 121. Many of the terms used in the misleading - extended

7 voice based or data link - shall be higher minimums applied before dispatch. an ETOPS fuel reserve to protect the installed in all airplanes operating beyond passengers, crew, and airplane in the 180 min from an alternate airport. One of the distinguishing features of event of a cabin depressurization followed Alternative means of communication must ETOPS is the identification of and reliance by a low-altitude diversion. also be available in the event the most on alternate airports to which airplanes reliable means is not available for any can divert should an unscheduled landing Cabin depressurization is a very rare reason (e.g., lack of satellite coverage). become desirable or necessary, Under event that can occur on any jetliner and is Examples of these communications this proposed regulation, operators flying largely unrelated to the number of technologies (e.g., SATCOM voice link, three- and four-engine airplanes in engines. If it does occur, the flight crew SATCOM data link, HF data link) are given extended operations would be required to must immediately descend to an in the associated guidance material. designate ETOPS alternate airports within appropriate altitude, as defined by 240 min or if beyond 240 min, designate oxygen availability or oxygen systems The proposed rule is not intended to the nearest available ETOPS alternate. capability. A diversion is then generally require operators to continually upgrade required because of the increased fuel existing installations on an incremental consumption of turbine engines at low basis. Rather, the rule is meant to further Propulsion-Related Diversions altitudes and the corresponding reduction the adoption, as appropriate, of new in range. technologies that significantly enhance The ARAC has proposed no substantive the quality and reliability of change to the rule that governs diversion This ETOPS fuel reserve requirement communications. One example of such following an in-flight engine failure or assumes that decompression would innovation is today’s transition from HF shutdown. However, the committee did occur at the most critical point along the radio to satellite-based technologies. offer guidance to further clarify existing route in terms of total fuel consumption (a diversion requirements for two- engine concurrent engine failure is further airplanes in the event of engine failure or assumed if it would add to the total). The Dispatch shutdown. reserve thus calculated would ensure sufficient fuel for an extended low-altitude The ARAC has proposed a new regulation To aid flight crews, the proposed diversion followed by a descent to 1,500 specifying airplane dispatch requirements guidance lists factors (e.g., airplane ft at the alternate airport, a 15-min hold, for ETOPS alternate airports. The operator condition and systems status, weather and an approach and landing. Further would have to select en route alternate conditions en route, terrain and facilities allowance is made for possible airframe airports that meet the weather at the alternate airport) that the pilot in icing and wind forecasting error. requirements set forth in its operations command should consider when deciding specifications. which alternate airport to divert to. To Following extensive review of data related Because alternate airport weather is ensure that safety always remain to the accuracy of wind forecasting, as checked before airplane departure, and paramount the ARAC further identified well as review of the icing scenario based weather conditions can vary over time, factors that shall not be considered on the Canadian Atlantic Storms Program the conservative weather minimums sufficient justification for flying beyond the (CASP II), the ARAC proposed revising required for dispatch are higher than nearest available alternate airport (e.g., the ETOPS fuel reserve requirement. those that would be required to perform additional range capability based on Under this proposed rule, two-engine an instrument approach at that alternate remaining fuel supply, passenger airplanes on extended operations would airport. As proposed, this dispatch rule accommodations beyond basic safety, carry somewhat less reserve fuel than in further requires the crew to verify the maintenance and repair facilities at the the past. Airplanes with more than two continuing availability of a valid alternate available alternate airports). engines would be required to carry an airport by means of en route weather ETOPS fuel reserve for the first time, updating at the beginning of the ETOPS although many three- and four-engine phase of flight. For this en route updating, Fuel Reserve operators do currently carry a the crew would be required to ascertain depressurization fuel reserve as a matter only that the planned alternate is above The ARAC has proposed that all airplanes of internal airline policy. normal landing minimums, not above the flown in extended operations shall carry

8 Maintenance longest potential diversion for that route. that might be encountered during an In particular, each flight shall have extended diversion. The ARAC has proposed making current continuous fire suppression capability for twin-engine ETOPS maintenance a period equivalent to the maximum standards applicable to all airplanes flown planned diversion time plus an additional Polar Operations in extended operations. This would 15 min to cover approach and landing at require three - and four - engine operators the alternate airport. The ARAC has recommended that the to also have an ETOPS maintenance North Polar area (i.e., everything north of program in place before flying routes with Two-engine airplanes flown in extended 78 oN latitude) shall be designated an the potential for an extended diversion. operations have met this requirement area of ETOPS applicability. The same since 1985. In contrast, although all jets designation shall be applied to the South ETOPS maintenance requirements have have fire suppression systems, those with Pole and surrounding region (i.e., significantly reduced the incidence of in- more than two engines are not currently everything south of 6O˚S latitude). flight engine failures. Such events can be required to carry sufficient fire enormously costly and disruptive for suppressant during extended operations Within these areas, ETOPS requirements airlines, which is why some operators of to protect the airplane continuously shall apply to all airplanes, regardless of three- and four-engine airplanes have throughout a maximum-duration the number of engines or distance from already voluntarily raised their diversion. an adequate airport. This proposed maintenance standards to ETOPS levels. requirement recognizes the challenges Passenger Recovery Plan The ARAC has proposed that three- and associated with these areas and sets four-engine airplane operators that do not forth steps to protect diversion. The ARAC has proposed that all extended currently comply with this requirement operators shall develop a plan to ensure shall have six years after ETOPS Polar operators require training and the well-being of passengers and regulations take effect to bring their expertise to support airplane diversions crewmembers at diversion airports. This existing fleets into compliance with this and their subsequent recovery. These plan should address their safety and new rule. operators must consider requirements for comfort at that airport in terms of’ the en route alternate airports, a strategy for facilities and accommodations and their Many airplane systems enhance safety and monitoring of fuel freeze, a retrieval from that airport. during flight. Of these, cargo fire passenger recovery plan and reliable suppression is generally the most time- communications capability. Currently, passenger recovery plans are limited. required only for cross-polar operations. Because diversions can occur anywhere, Applying ETOPS cargo fire suppression Rescue and Fire Fighting however, the ARAC has proposed that requirements to all extended operations every operator flying routes over remote can thus further protect passengers, The ARAC has proposed a rule specifying areas of the world should anticipate the crews, and airplanes on routes with rescue and fire fighting (RFF) possibility of a diversion within those extended diversion times. requirements at ETOPS en route alternate regions and devise a plan outlining how it airports. If adopted, this rule will further would recover the passengers, crew, and ensure the safety of all airplanes when airplane. Performance Data living extended operations, regardless of how many engines an airplane has. The ARAC has proposed that existing Cargo Fire Suppression regulations be modified to require that Before dispatch, ETOPS operators have performance data be available to support always had to designate alternate airports To further ensure safety, the ARAC has all phases of extended operations. Flight that are above ETOPS-specified weather proposed that all time-critical systems crews and dispatchers must have data minimums. In addition, these designated aboard airplanes flown in extended available that describe the specific alternates must provide the necessary operations shall have sufficient capability performance of the airplane in normal and facilities and equipment to ensure the to protect the airplane throughout the non-normal situations, including those safety and well-being of the passengers

9 and crew through-out an extended diversion time for which approval is light of the ARAC, JAA and other efforts diversion, after landing at the alternate sought. The rigor of this practice will taking place around the world, the airport and for as long as they remain at ensure that all airplanes designed to International Civil Aviation Organization that airport before being retrieved. RFF these requirements will have the (ICAO) - a branch of the United Nations - capability is a key element of this necessary redundancy and reliability to is reviewing the current annexes and protection. ensure safe extended operations. associated guidance materials and plans to propose changes as appropriate for all During nearly two decades of ETOPS and To further protect airplanes during airplanes. The Boeing Company supports more than three million ETOPS twinjet extended operations, the ARAC has the harmonization of aviation standards flights around the globe, there has not identified the factors that ensure high among regulatory authorities worldwide been a single landing accident following levels of safety on flights with the potential and actively supports these JAA and an extended diversion from the ETOPS for a long diversion. In the case of two- ICAO efforts. phase of flight. The fact that RFF services engine airplanes, the most significant have not been needed does not mean element is propulsion system reliability. that such an event will never happen. SUMMARY Therefore, the ARAC finds it prudent to Using several methods to assess risk, the formalize RFF requirements for alternate ARAC concluded that diversion time can As airplane range capabilities continue to airports in the regulations. be significantly increased without added increase, and flights become more risk if the IFSD rate is sufficiently low. An common in remote regions of the world, IFSD rate of 0.01 per 1,000 engine-hours expanding ETOPS to embrace all Other Proposed Changes - or twice the engine reliability level extended-diversion-time operations - not required for 180-min ETOPS - has been only those involving two-engine airplanes The proposed regulatory changes determined to allow unconstrained - will raise the industry to a higher and described above would affect FAR Part operations with two-engine airplanes. uniform standard. 121, the section of the FARs governing Currently, the world-fleet average IFSD the operation of transport-category rates for the 767 and 777, which together The proposed U.S. ETOPS regulations airplanes. In response to the FAA tasking perform the majority of ETOPS, are both reflect broad recognition within the global statement, the ARAC ETOPS Working below this threshold. aviation community that ETOPS-related Group also has proposed changes to practices can further enhance the safety other parts of the FARs. Other key elements that support extended and reliability of all operations on routes diversion times are proper testing and with extended diversion times. The In particular, the ARAC has proposed validation of an airplane type (i.e., proposed rules recognize the high changes to FAR Part 25 which governs airframe-engine combination (to ensure standard of safety that has been achieved the design and testing of transport- ETOPS safety at service entry. The Boeing during nearly two decades of highly category airplanes and FAR Part 33, 777 Early ETOPS program processes successful twinjet operations worldwide which governs engine design and testing. provided a successful template on which and are the next logical step in enhancing If adopted, these regulatory modifications to base future such programs. aviation safety. will benefit the development of future Consequently, the design, analysis, and transport airplanes - regardless of the test features from the 777 Early ETOPS The FAA will evaluate these ARAC- number of engines - by formalizing program are incorporated in the proposed regulations, make whatever ETOPS-inspired improvements that have proposed ETOPS regulations. changes it deems appropriate, and been shown in service to further protect publish the results in an NPRM for public airplanes and reduce the likelihood that review and comment. After comment they will need to divert. OTHER INDUSTRY EFFORTS resolution, the FAA is expected to enact the new TOPS rules, perhaps as soon as The ARAC has further recommended that In addition to this ETOPS-related ARAC- late 2004. operators must comply with all rules FAA rulemaking, the European Joint within FAR Parts 25 and 33 when Aviation Authorities (JAA) are developing considering the longest flight and longest standards for extended operations. In

10 ARAC ETOPS Working Group 1 Proposed ARAC Rulemaking and Guidance Participants

ETOPS authorisation Modify existing rule FAR 121.161 to codify ETOPS in the U.S. federal Airlines aviation regulations; describe the redefinition of ETOPS and the updated requirements being U.S.- American Airlines, American Trans Air, proposed for the authorisation of all extended operations. Continental Airlines, Delta Air Lines, Northwest Airlines, United Airlines, United Parcel Service Definitions Add a new rule, FAR 121.7, to add the definitions of ETOPS-applicable terms to and US Airways ensure understanding of and compliance with the updated ETOPS requirements now being proposed. Non-U.S.- All Nippon Airways, along with British Airways, KLM Royal Dutch Airlines, and Communications Add a new rule requiring voice communications, where available, and the Scandinavian Airlines System, representing the most reliable communications technology, voice based or data link, for all extended Association of European Airlines (AEA) operations beyond 180 min; require that another form of communications be available in case communication is not possible with the most reliable technology. Industry Associations European Association of Aerospace Industries Dispatch Add a new rule specifying dispatch or flight-release requirements for weather at (AECMA), General Aviation Manufacturers ETOPS alternative airports; further require that weather be updated at the start of the ETOPS Association (GAMA), International Civil Aviation phase of flight to verify the continuing availability of a valid ETOPS alternate. Organisation (ICAO), National Business Aviation Association (NBAA), Air Transport Propulsion-related diversions Issue new guidance clarifying the requirements for twinjet Association (ATA), National Air Transportation diversion in the event of an in-flight engine failure or shutdown; specify what factors shall and Association (NATA), National Air Carriers shall not be considered sufficient justification for the crew to fly beyond the nearest suitable Association (NACA), and International alternative airport. Federation of Air Line Dispatchers’ Associations (IFALDA) Fuel reserve Add a new rule specifying the reserve fuel to be carried to protect the airplane in the event of a cabin depressurisation followed by an extended diversion at low altitude to Manufacturers an alternate airport. Airframe - Airbus Industrie, The Boeing Company, Bombardier, Cessna, and Maintenance Add a new rule making ETOPS maintenance standards applicable to all Gulfstream airplanes flown in extended operations. Engine - GE Aircraft Engines, Pratt & Whitney, and Rolls-Royce Passenger recovery plan Modify existing rules FARs 121.135 and 121.97 to require all extended operators to develop a plan that ensures the well-being of passengers at diversion Pilots’ Associations airports and provides for their safe retrieval without undue delay. Air Line Pilots Association (ALPA), Independent Association of Continental Pilots (recently Modify existing rule FAR 121.415 to require training for crew members and dispatchers in their merged with ALPA), Allied Pilots Association roles and responsibilities in the operator’s passenger recovery plan. (APA), Coalition of Airline Pilots Associations (CAPA), International Federation of Air Line Cargo fire suppression Add a new rule requiring that ETOPS diversion times shall not Pilots’ Associations (IFALPA) exceed the time limit, minus 15 min. specified in the Airplane Flight Manual for that airplane’s most time-limited system, which is typically cargo fire suppression. Regulators U.S. Federal Aviation Administration (FAA), Performance data Modify existing rule FAR 121.135 to require all ETOPS operators to have Transport Canada, Joint Aviation Authorities the applicable performance data available to support their extended operations. (JAA) of Europe as represented by the U.K. Civil Aviation Authority (CAA), Direction Polar operations Modify existing rule FAR 121.161 to define polar-area zones of ETOPS Générale de l’Aviation Civile (DGAC) France, applicability in which ETOPS requirements apply at all times. This requirement applies to all and Civil Aviation Safety Authority (CASA) operations north of 78°N latitude (North Pole) and south of 60°S latitude (South Pole). Australia

Rescue and fire fighting Modify existing rule FAR 121.106 to require rescue and fire-fighting Other Parties equipment to be available at any airport designated as an ETOPS en route alternate. Air Crash Victims Families Association (ACVFA)

Other proposed changes Modify the rules governing transport-category airplane and Reprinted from AERO magazine by engine design to incorporate ETOPS enhancements that reduce the rate of airplane diversions permission of The Boeing Company and protect airplanes when they divert.

11 Members of THE UNITED KINGDOM FLIGHT SAFETY COMMITTEE

Full members Air Seychelles CAA Capt. Curtis Allcorn Dave Lewis - MRPS Chairman Chrys Hadjiantonis - Safety Data Dept. Airclaims ALAE Ed Bewley - Flight Operations John Dunne Dave Morrison Alison Thomas - Intl. Services

Vice-Chairman Astraeus Ltd Cardiff International Airport flybe. british european Capt. Nick Carter Graeme Gamble Stuart McKie-Smith BAA plc CargoLux Treasurer Francis Richards Capt. David Martin Air 2000 Capt. Martin Pitt BAC Express Cathay Pacific Capt. Steve Thursfield Capt. Richard Howell External Affairs Officer RAeS BAE SYSTEMS Reg. A/C Channel Express Peter Richards Alistair Scott Rob Trayhurn

Aegean Airlines BALPA CityJet Capt. Dimitris Giannoulatos Carolyn Evans Capt. Mick O’Connor

Aer Lingus bmi regional DHL Air Capt. Tom Curran Capt. Steve Saint Peter Naz

Aerostructures Hamble British Airways Dragonair Dr. Marvin Curtiss Steve Hull Alex Dawson

AIG Aviation British Airways CitiExpress Ltd DUO Airways Ltd Jonathan Woodrow Capt. Ed Pooley Capt. Christopher Morley

Air Contractors British International Eastern Airways UK Ltd Capt. Tony Barrett-Jolley Capt. Terry Green Capt. Jacqueline Mills

Air Mauritius British Mediterranean Airways easyJet Capt. Francois Marion Robin Berry Emerald Airways Air Scandic Buzz Stanstead Ltd Capt. Roley Bevan Jonathan Annet Peter Walton European Aviation Air Charter Derek Cottrill ADVERTISING IN THIS MAGAZINE EVA Airways ADVERTISING IN THIS MAGAZINE Richard Lovegrove

Excel Airways Focus is a Quarterly Publication which has a Peter Williams highly targeted readership of 32,000 Aviation FlightLine Safety Professionals worldwide. Capt. Derek Murphy FLS Aerospace (IRL) Frank Buggie IfIf youyou oror youryour companycompany wouldwould likelike toto Ford Flight Europe advertise in Focus please contact: Richard Newton

GATCO Advertisment Sales Office: Richard Dawson Mike Barrett, UKFSC, The Graham Suite, Fairoaks Airport, Goodrich Actuation Ltd Keith Joyner Chobham, Woking, Surrey. GU24 8HX. Tel: 01276 855193 Mobile: 07788 168207 Independent Pilots Association Capt. Mike Nash [email protected]

12 Irish Aviation Authority bmi Eng. Lufthansa Cargo AG Capt. Bob Tweedy Peter Horner Bernd Pfeffer

KLM UK Eng. Bristow Helicopters Condor/Lufthansa & CityLine Andy Beale Capt. Derek Whatling

LAD (Aviation) Ltd Bristow Helicopters Eng. MOD Steve Flowers Richard Tudge DASC Col. Arthur Gibson DASC Eng. Cdr. Ian Peck Loganair Britannia Airways HQ STC MOD - Sqn. Ldr. Paul Cox Doug Akhurst Jez Last RAeS London City Airport Britannia Airways Eng. Peter Richards Simon Butterworth Adrian Vaughan RAeS Eng. London-Manston Airport CHC Scotia Jack Carter Wally Walker Peter Cork

Manchester Airport plc CHC Scotia Eng. Peter Hampson Colin Brown Co-opted Advisers

Monarch Airlines Eurocypria AAIB Capt. Tony Wride Capt. Constantinos Pitsillides Capt. Margaret Dean

MyTravel Cyprus Airways CHIRP Phil Oakes Capt. Spyros Papouis Peter Tait

NATS flybe. british european GASCo Paul Jones Stuart McKie-Smith John Campbell

PrivatAir flybe. british european eng. Royal Met. Society Capt. Boris Beuc Chris Clark Dr John Stewart

Ryanair GB Airways Capt. Gerry Conway Capt. Aaron Cambridge

SBAC GB Airways Eng. Martyn Graham - Secretariat Terry Scott Vic Lockwood - FR Aviation

Servisair Eric Nobbs

Shell Aircraft Cliff Edwards

South African Airways Tshepo Peege

The Boeing Co. Thor Johansen

Thomas Cook Airlines Capt. Graham Clarke

Virgin Atlantic Airways Capt. Jason Holt

Willis Aerospace Ian Crowe

Group members bmi Capt. Ian Mattimoe

13 DVT - What is all the fuss about? Part II or, Are airliners flying surgeries? by Simon Phippard - Barlow Lyde & Gilbert

Since our report in the Spring 2003 issue DVT issue, introduced a Private Member’s promote the health, welfare and well- of FOCUS the lawyers have been busy Bill in Parliament entitled ‘The Aviation being of passengers; and with the passengers’ attempt to appeal Health Bill’ in early July 2003. In fact it against the High Court judgment in the received its first reading the day before (e) for the provision of such information English DVT (Deep Vein Thrombosis) the Court of Appeal delivered its and instruction to passengers as is group litigation. This was unsuccessful, judgment. The bill, if it became law, would necessary to protect and promote although a further bid is in hand to radically alter the relationship between their health, welfare and well-being.” petition the House of Lords for leave to airlines and passengers and impose appeal to our highest Court. In Australia, significant burdens on the industry. The Secretary of State must issue codes we await the outcome of the 28 July of practice defining compliance. appeal hearing in the Povey case, on The bill would impose a primary which we also reported six months ago, obligation upon certain airlines to “protect The bill is curiously drafted in its which was interpreted by some as and promote the health, welfare and well- application insofar as it is expressed to reaching the opposite conclusion from being of their passengers”. That general apply to carriers to whom Warsaw/Hague the English group litigation decision. responsibility would include specific or certain of the Application of Provisions responsibilities: Orders apply. Leaving aside the omission Airline management should be pleased to of carriage subject to other permutations note that the English Court of Appeal was (a) to seek to prevent the occurrence or of the Warsaw system, it is misconceived clear in its conclusions that the law largely aggravation of any injury, illness or insofar as the Convention applies by protects the airlines. The three judges disease; reference not to the carrier, but to the were unanimous in the result and the carriage. The bill would apply to functions Master of the Rolls, Lord Phillips, our (b) for the mental and psychological or activities performed or carried out in most senior civil judge, conceded that he health, welfare and well-being of the UK or on a UK-registered aircraft. was so clear in his conclusions that he passengers; Such activities would include the manner was tempted to dismiss the appeal in a of operation of an aircraft which may be single sentence, as did a bench of the (c) for the provision and maintenance of said to have contributed to a health Ontario Court of Appeal in a recent equipment that is, so far as is problem. It would therefore pose decision. reasonably practicable, safe and particular jurisdictional issues in relation without risks to the health, welfare and to international carriage: many overseas Perhaps because of general disquiet well-being of passengers; aircraft spend the majority of their time about the case, or because of loyalty to a outside the UK, but the activities and constituent, the Welsh Labour MP John (d) for the provision of such information, functions likely to be in issue may be Smith, who has been outspoken on the instruction, training and supervision of performed both within and without the staff as is necessary to protect and UK. One assumes that the political intent

14 is to assume jurisdiction over all carriers necessary to protect the health of their from disgruntled passengers or those on operating to the UK. passengers” – thus imposing obligations the make. The training for all manner of regardless of the condition of a health prevention issues would no doubt There is express provision for an airline to passenger before boarding. Dealing with act as a significant distraction from flight be liable in damages for negligent non- mental health would be enormously crews’ primary responsibility for safety of compliance. If that responsibility conflicts difficult: if there is a responsibility for the passengers. with the existing provisions of the Warsaw mere psychological well-being of regime, the proposed Act would take passengers, is every passenger who The bill does not, however, have precedence and a carrier would be suffers slightly from fear of flying entitled Government support and is therefore unable to limit its liability under Art. 22 in to one-to-one counselling? Or need only likely to struggle to secure Parliamentary any claim for breach of this Act. To that trained psychologists apply to become time. It is listed for a further reading in extent, if the bill as presently drafted cabin attendants? mid-November, but it is thought unlikely to became law, it would put the UK in One should not be deceived by the proceed at that stage or indeed soon conflict with its treaty obligations to other suggestion in some parts of the bill that thereafter. Nevertheless, readers should contracting States to the Warsaw system. measures need only be “reasonably note that Gwyneth Dunwoody, the practicable”. This does not apply in Transport Select Committee chairman, Taken at its most extreme it is plain that if relation to all aspects but more has put her name to the bill. It is, such a bill were to become law the significantly compliance is very difficult to therefore, unlikely simply to disappear impact on airlines would be colossal. It is gauge. Airlines generally now provide quietly. already recognised that not every guidance on self-help in magazines and passenger is truly “fit to fly” in the current in-flight videos: one finds it hard to The reason given by the Master of the cabin environment and many take little or believe that a Secretary of State would be Rolls for not dismissing the DVT appeal in no effective steps to minimise the risks able to resist the temptation to make such a single sentence is perhaps informative. inherent in lengthy or frequent exposure action mandatory and to increase those He had sympathy for the passengers and to the cabin environment, limited as they steps steadily. Even if the codes of believed they deserved a full explanation are. The bill is not limited to the health practice were drafted in such a way as to of why the appeal failed. But he went on issues associated with air travel: airlines limit the specific steps an airline must to observe that the result might be a would have to train their staff “as is take there would in any event be litigation blessing in disguise insofar as it would spare many DVT claimants from pursuing cases “involving difficult issues of causation which would have been very costly to resolve”. The sympathy felt by John Smith MP is an overreaction: not only does it pander to a nanny state approach but there must be a high likelihood of raising all manner of expectations. Passengers may be encouraged to regard a health problem occurring shortly after a flight as grounds for compensation. This may prove just as difficult to resolve, and costly for both passengers and airlines to deal with, as the issues associated with DVT. Better, surely, to put the emphasis on passengers’ own responsibility for their own health.

15 737-600/-700/-800/-900 Approach Navigation Options

work together or separately to improve safety and performance while decreasing operating costs.

Operators will be able to enhance the approach capability of their 737-600/- 7O0/-800/-9O0 airplanes this year with a suite of new flight deck navigation options: Category IIIB Autoland, the Global Navigation Satellite System (GNSS) Landing System, Integrated Approach Navigation, and Navigation Performance Scales.

Together with the excellent existing approach capabilities of the 737, these options offer a flexible navigation solution for airlines that want to increase their competitive advantage by improving airplane safety and performance, decreasing operating costs, and reducing flight crew training requirements through advanced technology.

The new navigation options work together or separately to enable pilots to fly safe, stable, and precise three-dimensional paths that smoothly intercept a variety of final approach legs.

The options improve landing capability in adverse weather conditions, in areas of difficult terrain, and on existing difficult approach paths. In addition, they will allow crews to take advantage of emerging air traffic control technologies designed to improve airport operations.

To help operators understand these navigation options and their features, this article describes

1. Category IIIB Autoland. 2. GNSS Landing System. 3. Integrated Approach Navigation. oeing will soon offer a suite of new dimensional paths that smoothly intercept B 4. Navigation Performance Scales. integrated flight deck navigation options a variety of final approach legs. The that enhance the proven approach Category IIIB Autoland, Global Navigation The article also discusses how the options capability of 737-600/-700/-800/-900 Satellite System Landing System, and procedures are compatible with airplanes. Available in 2003, these Integrated Approach Navigation, and current and emerging approach navigation options enable pilots to fly precise three- Navigation Performance Scales options technologies such as the Instrument

16 Landing System, mixed-mode, and constant-angle nonprecision approaches.

1. Category IIIB Autoland

The new 737-700/-800/-900 Category IIIB Autoland option (fig. 1) provides the same all-weather, precision approach autopilot guidance currently available on other Boeing airplane models.

This option, which is in flight test, will be offered with the 737-700/-800/-900 over- under engine format. The over-under format provides the display space necessary for Category IIIB Autoland system messages. (The 737-600 is not currently being certified for Category IIIB operation.)

2. GNSS Landing System

The 737-600/-700/-800/-900 GNSS Landing System (GLS) option uses Global Positioning System navigation satellites and a Ground-Based Augmentation System (GBAS) to provide signals similar to Instrument Landing System (ILS) signals (fig. 2). Ultimately, the GLS could replace the ILS as the primary means for guiding airplanes to the runway in low visibility. The GLS also might be expanded to support curved approaches. (See “Global Navigation Satellite System Landing System,” Aero no. 21. January 2003.)

The initial 737-600/-700/-800/-900 GLS option supports a Category I instrument approach capability and the ability to complete the approach with an automatic landing. This system is being expanded to support full Category IIIB Autoland and software upgrades for the enhanced software changes. operations. ground proximity warning system (EGPWS), flight management computer The U.S. Federal Aviation Administration Retrofit for the 737-600/-700/-800/-900 GLS (FMC) Ul0.5 software, and common (FAA) plans to deploy GLS ground requires new multimode receiver (MMR) display system (CDS) Block Point 2002 stations in Memphis, Chicago O’Hare, hardware and software, a navigation software. A future curved GLS approach Juneau Alaska, Seattle. Phoenix, and control panel with GLS capability, hardware capability might require autopilot and CDS Houston to support operational evaluation

17 4. Navigation Performance Scales

Navigation Performance Scales (NPS) is a new display feature that integrates the current lateral navigation (LNAV) and vertical navigation (VNAV) with actual navigation performance (ANP) and required navigation performance (RNP). The primary display format of the NPS (fig. 5) can be interpreted easily, thereby allowing the crew to monitor flight path performance relative to flight phase requirements and airplane system navigation performance.

NPS can be especially valuable for approaches with tight airspace restrictions because of terrain, traffic, or restricted areas. LNAV and VNAV with NPS supports Category I approaches down to 0.l0-nmi RNP. NPS also is designed to smoothly transition to an ILS, GLS or IAN approach. (For a detailed testing. The program calls for the glideslope inoperative,localizer only, and description of NPS, see “Lateral and purchase and deployment of as many as backcourse approach types. Vertical Navigation Deviation Displays,” 40 ground stations per year after the initial Aero no. 16. Oct. 2001.) Retrofit of this phase. The FAA projects a total of 160 The IAN function will alert the crew to option involves software updates for the GBAS ground stations are needed in the approach selection or tuning FMC, CDS, and DFDAU. United States. Europe also plans to inconsistencies. For example, if an ILS develop and install GBAS ground stations. station is tuned and an area navigation (RNAV) approach also is selected on the Summary FMC, the flight crew will be alerted and 3. Integrated Approach Navigation the ILS approach mode will take This year, operators will be able to precedence automatically, with the enhance the approach capability of their Integrated Approach Navigation (IAN) is appropriate display format. 737-600/-700/-800/-900 airplanes through an approach option designed for airlines a suite of new flight deck navigation that want to use ILS-like pilot procedures, While the IAN display (fig. 3) is similar to an options: Category IIIB Autoland, GLS, display features, and autopilot control ILS display, there are sufficient visual IAN, and NPS. These options enable laws for nonprecision (Category I) differences to ensure that the crew does pilots to fly paths that smoothly intercept approaches. This option does not require not confuse a nonprecision IAN approach various final approach legs. This additional ground facility support. for a precision ILS or GLS approach (fig. integrated, flexible approach navigation The FMC transmits IAN deviations to the 4). As on all nonprecision approaches, the solution improves safety and performance autopilot and display system. The pilot altimeter is the primary method of ensuring and decreases operating costs. The procedures for IAN are derived from that altitude constraints are honored. options are designed to meet the current current ILS pilot procedures and are and future approach requirements of consistent for all approach types: Retrofit of this option involves software Boeing customers worldwide. Select the approach on the FMC control updates for the FMC, CDS, flight control display unit, tune the appropriate station, computer, and digital flight data Reprinted from AERO magazine by and arm the autopilot approach mode. acquisition unit (DFDAU) and hardware permission of The Boeing Company The IAN function supports the ILS for and software updates for the EGPWS.

18 Managing Maintenance Error - A Practical Guide by James Reason and Alan Hobbs ISBN 0-7546-1591-X

The authors, Professor James Reason industries - aviation, rail and oil. The and Alan Hobbs, are both well respected remainder of the book then specialists in the field of Human Factors comprehensively examines the building and they have produced an easily read blocks that contribute to a management and down-to-earth practical guide to of maintenance error. The concluding managing mainenance errors. Whilst chapter recognises the human fallibility of they draw on examples from a variety of the Manager and provides a message on industries the resulting guide is the management of Error Management. particularly relevant to aviation maintenance. The book is a stimulating read for all professional maintenance practitioners This book is targeted at all those The first part of the book gives the reader and will provide a useful basis for the engineers with a responsibility for the task a sound understanding of the establishment of an essential of managing, supervising or undertaking fundamentals of Human Performance, management tool - Error Management. maintenance activities. Indeed, in this error categories and the local factors that age of increasing maintenance related are known to increase the frequency of Reviewed by: errors in the aviation industry and greater maintenance errors. This is then well Jack Carter C Eng, BSc(Eng), MRAeS emphasis on corporate responsibility it illustrated by examples of maintenance should also be read in the boardroom. involved accidents from 3 different

Letter to the Editor

The Chairman’s column reminds us that accidents still occur from adverse pitch-up trim on take-off.

At the onset of such an occurrence, whether arising from 10 good reasons to join the world’s foremost aerospace society aerodynamic mistrim, misrigging or excessively aft balance ■ over 19,500 members in 100+ countries of the load, isn’t there an immediate remedy in the hands of ■ international network of 70 Branches ■ the pilot? a thriving youth section with more than 4000 members worldwide ■ prestigious headquarters in central London ■ 20 groups focusing on specialist areas within aerospace If one sets up bank, with aileron and rudder, it is likely that ■ 300+ lectures and conferences each year ■ two magazines and one technical journal published monthly sufficient pitch-down moment may be generated by the fin in ■ dedicated careers centre providing expert careers advice the vertical plane to counter the pitch-up moment from fault ■ internationally renowned aerospace library and archive resource ■ the influential voice for the aerospace community trim or balance. Once the aircraft has settled in a controlled turn the crew have time to assess the situation.

Climb rate would be reduced, in the interests of keeping the Find out more: margin of speed over the stall in a turn. Obstacle clearance +44 (0)20 7670 4300 issues may arise too, that could dictate the direction of turn. @ [email protected] But in such an emergency the priority must surely be to buy www.aerosociety.com time and keep the aircraft flying.

Is this simple technique taught in early flying training?

Sincerely, Captain Harry Hopkins

19 Air Safety Report Administration made Easier by Simon Earthrowl

and coherent way so that the event may The system is simple to use, intuitive and be understood by all the readers. This very time saving. Once correctly can at times be very time consuming if configured it will prevent many of the the crew are flying or have gone on leave, errors that Flight Safety Officers spend or are just not contactable. It is many hours checking and conforming. sometimes just not possibly to complete the reporting process within the time The system has been purposefully specified. designed for aircrew, ground crew, and staff who are not skilled typists or With all the tasks that need to be done necessarily computer literate. It has been I recently had the opportunity to look in few Flight Safety Officers have enough made friendly and intuitive, with help detail at a new software product that time to spend on thorough investigation prompts to assist the individual completing makes the submission and administration and analysis of incidents. Maintaining an the report. Pull down selections help of safety reports so easy that I am audit trail of incident management and remove typographical errors as well as surprised nobody had thought to produce analysis becomes almost impossible. acting as a memory aid, pre-filling entries such a product sooner. that are common to an aircraft, and providing a spell checker all save time. We are all aware of the importance of safety in airlines. The ongoing quest by Having assisted the crew or staff with management to reduce the operating completing the report, a local copy of the costs, whilst increasing productivity and report is printed for their personal record. commercial flexibility creates a complex The completed report is now, at the touch environment in which to work. of a button, emailed to all the responsible managers. For example, an ASR report Operational costs reduction has been would be sent to the safety office, duty achieved by reducing turn around times, operations manager and engineering. An improving staff work practices, and audit record is kept to show when the streamlining administration. This may report was filed, and to whom the report result in greater stress for staff as their The requirement to show that a report has was sent. jobs change. been correctly managed, and that all responsible personnel have been Following the ASR example, engineering Flight Safety Officers (FSO) are not informed, as well as showing that all the will carry out an investigation if necessary, immune to these pressures as they too necessary actions have been taken is and can add additional comments to the are expected to be more efficient. Many putting a strain on safety departments. report, as well as identifying any advise that they do not seem to have Additionally, audits of this process are replacement part fitted. The updated enough time to do everything required of becoming more common. Questions report would not be sent to the safety them. The completion and analysis Air such as: How do you know that the ABC officer and the duty operations manager. Safety Reports are one of the time manager was informed of this incident? The engineer would also get a printed consuming areas of the Flight Safety What did XYZ do about this incident when copy for their records. Officers job and a tool that would help to they were informed? Why did it take so create, edit, track and monitor these long? can sometimes be very difficult to reports would greatly enhance the answer and more difficult to prove. With efficiency of the FSO. Currently they have our society becoming every more litigious to transfer hand written and faxed reports this aspect of the job could become into digital format for onward transmission much more important. to other departments and organisations. They have to chase staff to check that It is this whole area that the First Launch’s indecipherable words are corrected and Safety Report System (SRS) is that the report is written in an accurate addressing.

20 The report being emailed is viewed and printed in the airline’s approved format. All fields on the report are now typed, and can be viewed with Microsoft Word. The safety officer can review the report and decide what the appropriate priority of the report should be and what action should In the same way, voyage reports can be and risk management software packages be taken. The report once checked can sent directly to the commercial (e.g. British Airways WinBASIS). be sent to airline management, and if department, and other reports can be necessary to the CAA as an Mandatory tailored to the airline’s requirement. Having had the opportunity to see the Occurrence Report. software in operation there is no doubt in MOR reports are identified where they my mind that it would save many hours of have been raised, and have not been sent tedious work for the pilots, engineers and to the CAA within the prescribed time. the Flight Safety Officer, freeing up time to The administrator is alerted if there are do the more important functions of their any unsent MORs, and additionally if there jobs. The acquisition of such a system is are any MORs that have to be sent to the certainly worth consideration. CAA before start of work the next day. All Air Safety Reports (and optionally Ground Occurrence Reports) can be easily exported into the airlines trending

21 Human Factors and Occurrence Reporting Systems From a Maintenance Organisation's Perspective by C R Clark, Head of Quality and Training flybe. Aviation Services

The main objectives: Follow up verification is a vital part of the 1. Enhance safety. process to ensure corrective actions have 2. Effect positive awareness. been effective. Allied to this investigatory 3. Create an open reporting culture. process is the Quality Management 4. Cost reductions from identified errors. Review (QMR) meeting chaired by the Engineering Director, held on a monthly These objectives are supported by: basis, where issues raised by the 1. Total and ongoing support from senior reporting process are discussed by the management. senior management team. 2. Positive reporting processes. 3. Feedback to all employees. To ensure full employee awareness a 4. Effective investigations. monthly Quality Department Feedback The recent Amendment 5 to JAR 145 5. Employee involvement with corrective Report (QDFR) is issued both on the mandated changes to a maintenance measures. company Intranet and by hard copy giving organisation's responsibilities with regard 6. Analysis of all occurrence reports. visibility to the investigation process and to human factors and occurrence 7. Training programmes tailored to the resultant corrective actions. In order to reporting. Both these important areas organisation. get a measure of the success of the have long been part of the regulation but processes that make up our system, all now clear criteria for inclusion in the To ensure consistency, the well published information is stored on a central Quality organisation's procedures, processes and principles associated with human factors Activity Summary database and then culture have been established. and maintenance error management form analysed to determine rates, trends, the basis of the initiative as well as those repeat hot spots and improvements. Cost For many small to medium sized elements of safety management system analysis is carried out at the investigation organisations compliance with these processes that suit our organisation's stage of each report. An annual review is requirements can seem a daunting task. requirements. also carried out at the beginning of each Investment in the resource needed to year and forms part of the QMR agenda. provide effective systems is difficult to The reporting elements of our system justify when benefits are initially theoretical. consist of Mandatory Occurrence Reports This may seem a labour intensive system Additionally, available statistics to support (MORs) - otherwise referred to as Air but in reality, as long as each department the requirement tend to be global and Safety Reports (ASRs), Engineering plays its part fully, and simple but senior managers view 'accidents' rather Occurrence Reports (EORs) and Error effective processes are maintained, it is than in-house incidents as their guide to Avoidance Programme (EAP) reports. remarkably easy to administer. Two key an organisation's health check. company requirements must be present. MORs/ASRs meet the CAA requirements, Firstly, senior management have to take However, systems that meet JAR 145 with all technically related reports being the lead and be seen to take the lead if requirements can be introduced which investigated and subsequently reviewed the initiative is to succeed. Secondly, a are both cost effective and simple. More by both the Authority and our airline's disciplined approach is essential i.e. time importantly, they greatly enhance safety Flight Safety Committee. EORs are scales must be met and all meetings with the added bonus of giving internal reports raised by any employee on must happen as planned. transparency to an organisation's failures company related occurrences. They do across the spectrum of minor to very not replace the MOR process but record Finally, review the processes regularly, serious. At flybe. Aviation Services, a issues of a non-mandatory nature. Finally, learn from mistakes, listen to employees medium to large organisation spread EAP reports relate to our confidential error and keep them informed at all times. The across the United Kingdom and parts of reporting process and are an integral part ever increasing Human Factor element Europe, the Quality Assurance of the Human Factor initiative. associated with occurrence reporting will Department were tasked with introducing be discussed in a future article. a system to satisfy the requirements and All reports are logged, investigated, benefit the organisation. reviewed and recommendations raised.

22 Human Factors and Occurrence Reporting Systems

Engineering Mandatory Occurrence Reports Occurrence Reports EOR’s which meet CAP382 criteria are raised to MOR’s Internal reports investigated Monthly meetings held with CAA and findings publishe to reporter. and JAR OPS operator. Reports Summarised findings also investigated and findings published published in QDFR to satisfy to reporter. Summarised findings JAR145.60 (b) requirement. also published in QDFR. Satisfies JAR145.60 (a) requirement. Quality Department Feedback Report

Published monthly on Intranet and hard copied to line stations to include:- Relevant EOR ■ Closed MOR’s Relevant EOR & investigation report ■ Open MOR’s MOR investigation findings forwarded ■ Closed EOR’s report findings directly for action to ■ Open EOR’s forwarded directly Technical Services ■ Failed on fit EOR’s for inclusion in ■ EOR’s raised to MOR’s continuation training ■ Additional procedural and airworthiness information Satisfies JAR145.60 (b) requirement

Continuation Training

Technical Services Syllabus reviewed at regular meetings. Feedback from Feedback from QDFR and EAP incidents included in continuation integrated into workpack task training. Satisfies JAR145.35 (d) cards to meet JAR145 requirement. AMC 145.65 (b) requirement Error Avoidance Programme

EAP workshops include experience from incidents and held against appendix 9 to JAR145 criteria. EAP feedback reports published Feedback from Continuation training as monthly. Satisfies JAR145 required by JAR145 AMC145.30 (e) 7 AMC 145.30 (e) requirement. Feedback from Error Avoidance Programme as required by JAR145 AMC145.30 (e)7

S McNair, Quality Manager flybe. Aviation Services

23 UK FLIGHT SAFETY COMMITTEE

ANNUAL SEMINAR 2003

AVIATION SAFETY - THE BALANCE BETWEEN COST AND VALUE

29th/30th September 2003 The Radisson Edwardian Hotel Heathrow

Seminar Objective

Safety Management can be seen as expensive for all forms of Industry. Regulatory obligations notwithstanding, there are many choices that could be made. This Seminar will examine how value judgements are made and attempt to demonstrate how ‘Best Practice’ need not be ‘Cost Prohibitive’.

Programme

29TH SEPTEMBER 2003 1530 – 1700 Registration 2000hrs Seminar Dinner This will take place in the Hotel Foyer After Dinner Speaker - Andre Clerc - Willis Aerospace

30TH SEPTEMBER 2003 0800 – 0900 Registration 1210 - 1240 Discussion

Session Chairman - Ian Crowe, Willis 1245 – 1400 Lunch

0900 – 0910 Welcoming Introduction 1400 – 1430 A Manufacturer’s View John Dunne, Chairman UKFSC Thor Johansen - Boeing

0910 – 0940 Keynote Speech 1430 –1500 Economic Considerations in Designing for Mike Hirst - Loughborough University Safety Kwok Chan/Mike Carver 0940 – 1020 Regulatory Minima Airbus S.A.S Dave Chapman/Dave Wright - CAA 1500 –1530 Development & Use of Non-Mandatory 1020 – 1050 Board Decisions Cost v Benefits Safety Tools & the Benefits Dave Henry - Consultant John Savage - BA

1050 – 1110 Refreshment Break 1530 -1550 Discussion & Summary Simon Phippard 1110 – 1140 Development of an Affordable System Barlow Lyde & Gilbert Mike Wood - flybe. british european 1550 -1600 Closing Remarks 1140 – 1210 Examples from the Space Industry John Dunne, Chairman UKFSC Philip Smaje - InSpace

24 SEMINAR INFORMATION

Hotel Accommodation Hotel Accommodation is not included in the Seminar Registration Fee. If you require accommodation please contact the hotel directly on Tel:(+44 (0) 20 8759 6311) and quote Block Booking Code 0929 UKF when making your reservation. Seminar Dinner Dress for Dinner – Black Tie

If you are unable to attend why not nominate a colleague to take your place. If so, please advise the UKFSC Fairoaks office of any changes prior to the Seminar. ✂

SEMINAR REGISTRATION FORM

Please complete one registration form per person (photocopies accepted).

REGISTRATION INFORMATION (Please print clearly)

First Name: Surname:

Company: Job Title:

Address:

Tel No: Fax No: e-mail:

PAYMENT INFORMATION Seminar Fee: £150 UKFSC Member £200 Non-UKFSC Member

This includes the Seminar Dinner on the evening 29th September, lunch, refreshments and car parking. This does not include hotel accommodation – please see ‘Seminar Information’ above.

Payment is by sterling cheque only. No credit cards are accepted. Bank transfer is available, details on request (please note an additional cost of £6 will be added to cover handling charges). The UKFSC is not VAT Registered.

Sterling cheques should be made payable to UK Flight Safety Committee.

Do you plan to attend the Seminar Dinner on Monday 29th September? Yes No

Do you require a Vegetarian alternative? Yes No

PLEASE SEND YOUR COMPLETED REGISTRATION FORM WITH YOUR CHEQUE TO: UK Flight Safety Committee, Graham Suite, Fairoaks Airport, Chobham, Woking, Surrey, GU24 8HX Tel No: +44 (0) 1276 855193 Fax No: +44 (0) 1276 855195 e-mail: [email protected] Confirmation will be faxed to you on receipt of your Registration Form and payment.

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