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Advancing Mro Safety PSYCHED OUT Understanding Human Error UNPREPARED HEMS Crew Lacked Training NEXT ISSUE All-Digital ASW ON THE LINE ADVANCING MRO SAFETY THE JOURNAL OF FLIGHT SAFETY FOUNDATION OCTOBER 2016 CRITICAL AVIATION SAFETY INFORMATION AT YOUR FINGERTIPS Take advantage of FSF’s new comprehensive online resources As the only independent, impartial and international source for aviation safety, the Flight Safety Foundation takes keeping our skies safe seriously. To ensure the aviation industry has the most up-to-date safety information, FSF has launched a new and improved website — your go-to repository of comprehensive, trustworthy aviation safety information. As safety continues to evolve from reactive to proactive to predictive, FSF members will gain even more insight through expanded online offerings, including curated external content and our own AeroSafety World journal in a new digital-first format for maximum flexibility. Moreover, you’ll be able to interact via an exclusive online community designed to facilitate additional discussion of key safety initiatives. Gain vital insight and help us keep the skies safe by becoming a member today. www.fl ightsafety.org ©2016 Flight Safety Foundation, 701 N. Fairfax Street, Suite 250, Alexandria, Virginia 22314 Visit fl ightsafety.org, information@fl ightsafety.org or call +1 (703) 739 6700 FSF104191m_WebLaunch_PrintAd_FlightDailyFullPg.indd 1 9/13/16 11:03 AM PRESIDENT’SMESSAGE FIGHTING Complacency e in aviation often point to the sterling business of safety improvement for nearly 70 years, safety record in commercial air trans- but we know past achievements are not a guarantee port and business aircraft operations of future success. Aviation safety is evolving, and with justifiable pride. A lot of work so are we. I’m happy to say that the new FSF web- Whas gone into building a robust safety culture that site I discussed in my message last month is just is held in high esteem by other professions and about ready for deployment, and we’re very excited industries around the world. Yet we also have to about the capabilities and flexibility it will give us recognize that a lot more work is needed and that to deliver important safety news and information complacency cannot be allowed to set in. in a more timely and compelling fashion. Complacency, as defined by Merriam-Webster, As a member of the Foundation, you will be is “a feeling of being satisfied with how things are notified as soon as the new website is ready. When and not wanting to try to make them better.” It is you receive the announcement, I encourage you to also a recipe for disaster in flight operations and check it out at <flightsafety.org>. Let us know what in the life of any organization responsible for them. you think about it and how we can make it even bet- We cannot feel satisfied, despite the year-to- ter. Please direct your comments and suggestions year statistical evidence, that, as an industry, we to Frank Jackman at <[email protected]>. are doing a good job. Continued advancements in training, technology, human factors research and in the philosophies that guide the world’s regulatory bodies are essential to improving safety. We must collect, analyze and share data and other information to identify new risks, and we need to be vigilant against the re-emergence of previously identified and mitigated threats. For example, Flight Safety Foundation’s ongoing Global Safety Informa- tion Project (GSIP) seeks to study and facilitate the effective analysis and sharing of aviation safety data in the Pan America and Asia and Pacific regions, but what we already have learned in the past two years — and will share in our GSIP tool kits — will be applicable around the world. Jon L. Beatty Complacency also is a concern for organiza- President and CEO tions like the Foundation. We have been in the Flight Safety Foundation FLIGHTSAFETY.ORG | AEROSAFETYWORLD | OCTOBER 2016 | 1 AeroSafetyWORLD contents October 2016 Vol 11 Issue 8 features 12 IASS 2016 | Emirates, Safety Plan 14 IASS 2016 | Preliminary Agenda 18 CoverStory | Maintenance Safety Lessons 25 HumanFactors | Psychology of Error 12 30 Human Factors | Duty Patterns and Sleep Problems 34 Helicopter Safety | Unprepared HEMS Crew 18 40 Helicopter Safety | Weather Risks departments 1 President’s Message | Fighting Complacency 5 Editorial Page | All-Digital ASW 7 Safety Calendar | Industry Events 2 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | OCTOBER 2016 25 30 34 8 In Brief | Safety News 45 Data Link | On-Board Fatalities Plummet 49 On Record | False Cues Prompt ‘Stall Recoveries’ 55 Smoke FireFumes | Selected Smoke, Fire and Fumes Events 40 AeroSafetyWORLD telephone: +1 703.739.6700 About the Cover The line operations safety audit/ Frank Jackman, editor-in-chief, assessment concept is gaining a foothold FSF vice president, communications in maintenance and ramp operations. [email protected], ext. 116 © Rudi Boigelot | AirTeamImages Linda Werfelman, senior editor [email protected], ext. 122 Wayne Rosenkrans, contributing editor We Encourage Reprints (For permissions, go to <flightsafety.org/aerosafety-world-magazine>) [email protected] Share Your Knowledge If you have an article proposal, manuscript or technical paper that you believe would make a useful contribution to the ongoing dialogue about aviation safety, we will be Mark Lacagnina, contributing editor glad to consider it. Send it to Editor-In-Chief Frank Jackman, 701 N. Fairfax St., Suite 250, Alexandria, VA 22314-2058 USA or [email protected]. [email protected] The publications staff reserves the right to edit all submissions for publication. Copyright must be transferred to the Foundation for a contribution to be published, and payment is made to the author upon publication. Jennifer Moore, art director Sales Contact [email protected] Emerald Media Cheryl Goldsby, [email protected] +1 703.737.6753 Susan D. Reed, graphic designer Kelly Murphy, [email protected] +1 703.716.0503 [email protected], ext. 123 Subscriptions: All members of Flight Safety Foundation automatically get a subscription to AeroSafety World magazine. For more information, please contact the membership department, Flight Safety Foundation, 701 N. Fairfax St., Suite 250, Alexandria, VA 22314-2058 USA, +1 703.739.6700 or [email protected]. AeroSafety World © Copyright 2016 by Flight Safety Foundation Inc. All rights reserved. ISSN 1934-4015 (print)/ ISSN 1937-0830 (digital). Published 10 times a year. Suggestions and opinions expressed in AeroSafety World are not necessarily endorsed by Flight Safety Foundation. Nothing in these pages is intended to supersede operators’ or manufacturers’ policies, practices or requirements, or to supersede government regulations. | | FLIGHTSAFETY.ORG AEROSAFETYWORLD OCTOBER 2016 | 3 MoveMove UUpp toto BaldwinBaldwin M SSAAFFEETTYY PPRROOGG TOOM RRAAM SST MSS CCUU MANUALS FDMFDM •• FOQAFOQA TRAININGTRAINING MANUALS ASAPASAP • • ASIAS ASIAS FORMSFORMS •• REPORTSREPORTS SMSSMS TakingTaking youryour SMSSMS toto newnew heightsheights WhenWhen YouYou ThinkThink ofof Safety Safety .............. ThinkThink Baldwin Baldwin NBAA • Booth #2639 • Nov 1-3 • Orlando, FL +1.843.342.5434 • BaldwinAviation.com EDITORIALPAGE All-Digital ASW am excited to announce that AeroSafety World website features a federated search function that is going all-digital. In order to better serve the will allow a user to input a topic — for example, Foundation’s members and the aviation safety “lithium batteries” — and have results returned community globally, we are no longer going from not only ASW and the Foundation’s data- Ito print the magazine. Instead, we will offer im- base, but also SKYbrary and the Aviation Safety portant safety news, information and features in Network. We also will be able to get the word a responsive, easy to access and search format on out more quickly on important safety issues, and our newly redesigned and relaunched website at then to follow up every month with the in-depth <flightsafety.org>. In addition, by early 2017, we analysis and information that you have come to plan to roll out an ASW app for mobile devices expect from ASW. that will keep our content accessible regardless of Our commitment to aviation safety and jour- whether you are online. nalistic integrity will not change, but the way we The decision to stop printing ASW with this serve our members will, and I think you are going issue was not an easy one, but I firmly believe it is to like what you see. the right one. I have spent large swaths of my more than 30 years in journalism reporting, writing and editing print publications — newspapers, newslet- ters, magazines and even a book. My parents met while working at a newspaper. Ink is in my blood. I understand the loyalty to print. But I also have spent considerable time in various roles in the digital world, and our new website and its dedicated ASW section will al- low us to disseminate critical information and Frank Jackman interact with our members in ways that simply Editor-in-Chief, ASW are not possible with print. For example, the new Flight Safety Foundation FLIGHTSAFETY.ORG | AEROSAFETYWORLD | OCTOBER 2016 | 5 Serving Aviation Safety Interests for Nearly 70 Years OFFICERS AND STAFF Chairman ince 1947, Flight Safety Foundation has helped save lives around the world. The Board of Governors Kenneth J. Hylander Foundation is an international nonprofit organization whose sole purpose is to President and CEO Jon L. Beatty Sprovide impartial, independent, expert safety guidance and resources for the aviation General Counsel and aerospace industry. The Foundation is in a unique position to identify global safety and Secretary Kenneth P. Quinn, Esq. issues, set priorities and serve as a catalyst to address the issues through data collection Treasurer David J. Barger and information sharing, education, advocacy and communications. The Foundation’s effectiveness in bridging cultural and political differences in the common cause of safety FINANCE has earned worldwide respect. Today, membership includes more than 1,000 organizations Vice President, Finance Brett S.
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