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.
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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 | AEROSAFETYWORLD | OCTOBER 2016 | 1 AeroSafetyWORLD
contents October 2016 Vol 11 Issue 8 features
12 IASS2016 | Emirates, Safety Plan
14 IASS2016 | Preliminary Agenda
18 CoverStory | Maintenance Safety Lessons
25 HumanFactors | Psychology of Error
12 30 HumanFactors | Duty Patterns and Sleep Problems
34 HelicopterSafety | Unprepared HEMS Crew
18 40 HelicopterSafety | Weather Risks departments
1 President’sMessage | Fighting Complacency
5 EditorialPage | All-Digital ASW
7 SafetyCalendar | Industry Events
2 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | OCTOBER 2016 25 30 34
8 InBrief | Safety News
45 DataLink | On-Board Fatalities Plummet
49 OnRecord | False Cues Prompt ‘Stall Recoveries’ 55 SmokeFireFumes | 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 AEROSAFETYWORLD OCTOBER 2016 | 3 MoveMove UUpp toto BaldwinBaldwin
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ASAPASAP • • ASIAS ASIAS FORMSFORMS •• REPORTSREPORTS
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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 | 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. Eastham and individuals in 150 countries. Controller, GSIP Grants Administrator Ron Meyers
MEMBERSHIP AND BUSINESS DEVELOPMENT Vice President, Business Operations Susan M. Lausch MemberGuide Senior Manager of Flight Safety Foundation Events and Marketing Christopher Rochette 701 N. Fairfax St., Suite 250, Alexandria VA 22314-2058 USA Manager, Conferences tel +1 703.739.6700 fax +1 703.739.6708 flightsafety.org and Exhibits Namratha Apparao Member enrollment ext. 102 Membership Ahlam Wahdan, membership services coordinator [email protected] Services Coordinator Ahlam Wahdan Seminar registration ext. 101 Consultant, Caren Waddell Special Projects Namratha Apparao, manager, conferences and exhibits [email protected] Donations/Endowments ext. 112 Susan M. Lausch, vice president, business operations [email protected] COMMUNICATIONS Technical product orders ext. 101 Vice President, Communications Frank Jackman Namratha Apparao, manager, conferences and exhibits [email protected] Seminar proceedings ext. 101 Namratha Apparao, manager, conferences and exhibits [email protected] TECHNICAL Website ext. 116 Vice President, Frank Jackman, vice president, communications [email protected] Technical Mark Millam Basic Aviation Risk Standard David Anderson, BARS managing director [email protected] GLOBAL PROGRAMS BARS Program Office: 16/356 Collins Street, Melbourne, Victoria 3000 Australia Vice President, tel +61 1300.557.162 fax +61 1300.557.182 [email protected] Global Programs Greg Marshall
BASIC AVIATION RISK STANDARD BARS Managing Director David Anderson
facebook.com/flightsafetyfoundation Past President Capt. Kevin L. Hiatt @flightsafety Founder Jerome Lederer 1902–2004 www.linkedin.com/groups?gid=1804478
FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | OCTOBER 2016 ➤ SAFETYCALENDAR
OCTOBER 3–4 ➤ USI 2016 Conference. NOVEMBER 1–3 ➤ NBAA’s Business Aviation APRIL 11–13 ➤ Asian Business Aviation Umanned Systems Institute (USI). San Francisco Convention and Exhibition (NBAA-BACE). Conference and Exhibition (ABACE 2017).
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | OCTOBER 2016 | 7 INBRIEF Safety News Small UAS Rules The rules, which took effect in late August, call, among other things, for small UAS aircraft to be flown within the ew rules for the use of small unmanned aircraft sys- visual line of sight of the operator or of a visual observer and tems (UAS) — with aircraft weighing less than 55 lb (25 to be flown during daylight hours, at a maximum ground kg) — have taken effect in the United States, aimed at N speed of 87 kt, and no higher than 400 ft above ground level. establishing a “flexible framework of safety without impeding Air traffic control permission is required for operations in innovation,” Administrator Michael Huerta of the U.S. Federal some airspace. Aviation Administration (FAA) says. Huerta said that the rules create “an environment in which emerging technology can be rapidly introduced while protecting the safety of the world’s busiest, most complex airspace.” Operators of small UAS must hold a remote pilot airman certificate with a small UAS rating or be directly supervised by another individual who has such a certificate. The rules do not apply to model aircraft, most of which must be registered with the FAA and comply with other rules. In a related matter, the FAA’s Drone Advisory Committee — made up of UAS manufacturers and operators, traditional manned aviation organizations, airport operators, govern- ment officials and others — was to hold its first meeting in mid-September. The panel, which will meet at least three times a year, will discuss challenges associated with integrating UAS into the National Airspace System. “Safety is a shared responsibility in which each of us plays a vital role,” Huerta said in advance of the meeting. “We know from experience that the FAA’s policies and overall regulation of small unmanned aircraft will be more successful if we involve a strong and diverse coalition.” © Giuseppe_R | VectorStock
Boost for ICAO Mideast Cooperation the targets established under the ICAO Global Aviation Safety Plan (GASP), as well as associated [Middle East] Regional iddle Eastern member states of the International Civil Aviation Safety Group (RASG) objectives.” Aviation Organization (ICAO) have taken what the The summit was attended by representatives of 54 coun- Morganization calls “bold steps” to strengthen their coop- tries from the Middle East, Africa and other regions. eration toward civil aviation safety goals. During a late August meeting in Riyadh, Saudi Arabia, the Global Aviation Ministerial Summit approved the Riyadh Declaration on Aviation Security and Facilitation in the Arab Civil Aviation Commission and the ICAO Middle East regions. The declaration reaffirms “member states’ need to en- hance regional development and integration initiatives for aviation security while seeking new efficiencies for collabora- tive information sharing and security and facilitation train- ing,” ICAO said. ICAO Council President Olumuyiwa Benard Aliu said the need remains for speedy agreement on a new Middle East/ North African Regional Safety Oversight Organization. “The regional safety oversight approach is fundamentally about pooling resources for shared benefit,” Aliu said. “Here, in the Middle East, it would assist many states with meeting
© Harvepino | iStockphoto
8 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | OCTOBER 2016 INBRIEF
Cell Phone Warning Note7 owners that they should “power down your device and return to using your previous phone.” Company plans called iting reports that a number of Samsung Galaxy Note7 for the Note7s to be replaced with new phones beginning in cell phones have overheated and exploded, civil aviation mid-September. Cauthorities are advising passengers not to turn the phones on or charge them while aboard an aircraft and not to stow them in checked baggage. The U.S. Federal Aviation Administration said in early September that its warning followed “recent incidents and concerns raised by Samsung,” which has stopped sales of the Galaxy Note7 while it conducts “a thorough inspection with our suppliers to identify possible affected batteries in the market.” The company has told owners of Galaxy Note7s that it would issue new replacement devices. The European Aviation Safety Agency issued a similar warning, adding, “Passengers are also reminded of the need to inform the cabin crew when a device is damaged, hot, produces smoke, is lost, or falls into the seat structure.” In a Sept. 10 statement, Samsung said that “a small num- ber of cases” had been reported worldwide and told Galaxy © Leszekkobusinski | Dreamstime
Ground Coordination
he Australian Transport Safety Bureau (ATSB), citing a steps involving the chocks and parking brake were performed collision between an Airbus A330 and an airbridge at out of sequence and without being communicated between TMelbourne Airport during boarding, has issued a notice tractor, engineering and flight crews.” urging improved communication and coordination between airport ground workers. “An aircraft is attended at a terminal bay by people carrying out a wide range of concurrent tasks,” the ATSB said in Safety Advisory Notice AO-2016-028-SAN-001. “Typically, they and their respective organisations work alongside many others, each operating with different processes and to varying contractual agreements. Defining a set of processes that can apply across such varied situations and aligning them well with the other activities can be difficult. … An effective procedure will include steps to ensure that activities are appropriately aligned with other procedures. One way to achieve this is to pause and check if the situation is as it should be, and to inform others of activi- ties that could affect them.” The ATSB cited the March 31, 2016, collision at Melbourne, which occurred after a maintenance technician, having noticed that the A330’s parking brake was set, removed the main chocks early. Other personnel later removed the nose gear chocks with- out checking to see whether the main gear chocks were still in place. “The captain, unaware that no chocks were in place, re- leased the [parking] brake, and the aircraft rolled back, striking the aerobridge,” the ATSB said. No one was injured in the colli- sion, but the A330’s door and the airbridge were damaged. The ATSB said the collision occurred because “the ground and flight crew procedures were not harmonised,” and “key Peter D. Blair | U.S. Navy © Brett Charlton | iStockphoto
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | OCTOBER 2016 | 9 murat sarica
INBRIEF
Updated Emergency Training Urged Proposed Penalties
raining requirements should be regularly updated to ensure that pilots and air he U.S. Federal Aviation traffic controllers receive the most “current and relevant” input on how to handle Administration (FAA) has Temergency situations, the U.S. National Transportation Safety Board (NTSB) says. Tproposed nearly $900,000 In safety recommendations issued in September to the U.S. Federal Aviation in civil penalties against Air Administration (FAA), the NTSB said that the FAA should annually revise required Methods for its alleged operation training to help pilots who experience emergencies, including power losses, fuel emer- of an Airbus EC135 to carry pas- gencies, control difficulties and pilot medical issues. sengers while the helicopter was The recommendations also called on the FAA to develop and require training for not airworthy. air traffic controllers to instruct them on recognizing emergencies, determining what According to the FAA, one of type of assistance is required and taking actions to help pilots resolve the problems. its inspectors discovered during In making the recommendations, the NTSB cited a Jan. 13, 2015, accident in New a November 2014 inspection in Smyrna Beach, Florida, U.S., in which the commercial pilot of a Cessna 152 requested Tampa, Florida, that the heli- help from air traffic control after inadvertently entering instrument meteorological copter’s pitot tubes were severely conditions. The Cessna crashed, and the pilot was killed. corroded. Air Methods was noti- The NTSB said, in its final report on the accident, that controllers “did not act in fied immediately but operated accordance with … FAA guidance that dictates how to assist pilots experiencing this the helicopter, without replacing type of emergency.” or repairing the pitot tubes, on 51 passenger-carrying revenue flights over the next week. The FAA said that “because of the corroded pitot tubes, Air Methods operated the helicopter when it was unairworthy, in vio- lation of its operations specifica- tions, after it failed to correct a known defect in the aircraft and in a careless or reckless man- ner that endangered lives and prop e r t y.” Air Methods has 30 days after receiving the FAA’s formal enforcement letter to respond.
© Boeing
NextGen Coordination Questioned
he U.S. Federal Aviation Administration (FAA) is lacking a “clear process for identifying and coordinating” long-term research and development associated with NextGen — the Next Generation Air Transportation System that will transform the nation’s Tair traffic control system, a government oversight agency says. The Department of Transportation’s Office of Inspector General (OIG) said, in an audit report released in August, that the audit was designed to determine how the FAA had reallocated the responsibilities of the Joint Planning and Development Office, after funding for the office was eliminat- ed by Congress in 2014. Among other responsibilities, the office identified high-priority research and development (R&D) and determined whether the FAA was maintaining an effective method of coordinating with other federal agencies on R&D. The audit found the FAA’s Interagency Planning Office, which was es- tablished later in 2014 to coordinate NextGen R&D throughout the federal government, had begun identifying long-term projects, but “these efforts have not been synchronized with any long-term vision for NextGen.” © U.S. Federal Aviation Administration
10 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | OCTOBER 2016 INBRIEF
SESAR Planning co-founder and active member urocontrol has pledged €500 million (about US$558 million) in the SESAR partnership,” said to advance the Single European Sky Air Traffic Management Eurocontrol Director General E(SESAR) Joint Undertaking (JU) and taken on a larger role Frank Brenner, who also is vice in the project, which is designed to develop a new-generation air chair for the SESAR JU Admin- traffic management system throughout Europe. istrative Board. “I believe that it is only through this type of The financial pledge was part of an agreement signed in collaboration that we can improve the overall performance of Brussels in early September by top officials of Eurocontrol and the European air transport network.” the SESAR JU (SJU). The SJU is responsible for implementing the European The agreement for SJU’s extended mandate, which runs air traffic management (ATM) master plan to upgrade ATM through 2024, “signals Eurocontrol’s continued commitment as throughout Europe.
In Other News …
Nearly a dozen industry groups are calling for action to “preserve the high level of safety in European airspace” by ensuring the safe operation of unmanned aircraft systems (UAS). Among their recommendations are an extensive public awareness campaign and the compulsory registration of all UAS. … Mark Skidmore, CEO and director of aviation safety for the Australian Civil Avia- tion Safety Authority (CASA), plans to leave the agency in October, CASA said. At press time, a successor had not been named.
Compiled and edited by Linda Werfelman.
Safety is Our Guiding Light
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DDIA0389_SafetyTrainingHalfPageAdSep2016_V3.indd 1 2016-09-14 12:14 PM SUMMITSIASS Managing Safety at
SUBMITTED BY EMIRATES
mirates has become synonymous with All our colleagues have access to the com- comfort and luxury, but its priority has pany online safety reporting system called SiD always been safety. Over 50 million pas- and are actively encouraged to use it. We’ve sengers travelled on Emirates last year to its had great success with above-industry-average Eglobal network of over 150 destinations, and as reporting levels. the passenger and destination count continue to grow, managing safety at the airline inevitably Tell us more about safety management at becomes even more critical. Capt. Mark Burton- Emirates. wood, vice president of flight safety at Emirates, The regulatory requirements came into place in shares how he and his team implement and 2012 to enhance safety best practice and compli- maintain a culture of safety. ance within the company. However, Emirates already had an SMS in place long before it was How do you implement a culture of safety required. at Emirates? The Emirates SMS is designed to align Safety in aviation is especially crucial when you with International Civil Aviation Organization are responsible for more 61,000 colleagues and recommendations and meet the regulatory over 50 million passengers each year. requirements of the United Arab Emirates We maintain a culture of safety at Emir- General Civil Aviation Authority. The Emir- ates by making safety the responsibility of all ates SMS has four components and 12 elements employees. Safety is one of our corporate values, that cover safety policy and objectives, safety which is supported by our senior management. risk management, safety assurance and safety Capt. Mark As emphasized by His Highness Sheikh Ahmed promotion. Burtonwood bin Saeed Al Maktoum, chairman and chief The formal structure of Emirates’ SMS is executive, Emirates Airline and vital to effective and safe operation across our Group, our objective is to “protect diverse and expansive organisation. Our safety our customers, staff and assets communication and training ensure that all em- through a ceaseless commitment ployees understand their responsibilities and the to international and all other ap- roles they play in the overall safety of the airline. propriate safety standards.” This The company SMS manual is available on is reinforced by President Sir Tim the company intranet, where all employees can Clark, who has signed our safety access it, both in the office and remotely. policy and is the accountable man- ager for Emirates’ Safety Manage- How does Emirates’ SMS work? ment System (SMS). The success of SMS lies in the hands of every Everyone is encouraged to Emirates employee, and we provide regular identify hazards, intervene if ap- training and communication to encourage propriate and report. employee participation. Group Safety provides
12 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | OCTOBER 2016 SUMMITSIASS Emirates
investigation of safety occurrences, incidents and accidents. These can provide information to identify systematic and human factor issues to assist in the recommendations of mitigations. Our proactive strategy involves the analysis of existing or real-time situations, and this is the primary job of the safety assurance function of our SMS with its audits, evaluations, employee reporting and associated analysis and assess- ment processes. This involves actively seeking hazards in the existing processes. Lastly, our predictive strategy involves gath- ering high quality data to analyze and identify possible future outcomes or events, analyz- ing system processes and the environment to identify potential future hazards, and initiating mitigating actions. Together, the different methodologies help us to learn from past events, assess the current situation and pre-empt future risks.
support and guidance to the various departments How do you think the role of flight safety for the implementation of the company SMS. will evolve in the coming years? This includes assistance in understanding Risk management, safety investigations, de- hazard identification, classification and risk briefs, safety assurance, and safety promotion management; advice on risk assessments; and activities will always be part of what we do. maintenance of the departmental risk registers. In the future, there will be an increasing Group Safety also ensures regulatory compli- focus on the use of big data for predictive safety ance both locally and internationally, constantly management. Data received from safety reports striving to go beyond compliance standards in already goes through detailed analysis, enabling all areas of safety management. us to present useful and relevant safety informa- tion — we are committed to further improve What hazard identification strategies this process. do you have in place? We will continue to be leaders in SMS, We have three strategies — reactive, proactive sharing safety knowledge both internally and and predictive. The reactive involves the analysis externally. of past events. Hazards are identified through Safety is everyone’s business.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | OCTOBER 2016 | 13 November 14–16 Dubai
69th annual International Air Safety Summit Conrad Dubai Hotel
SUMMITSIASS
Organized by November 14–16 Dubai Sponsors PLATINUM
Hosted by
69th annual International Air Safety Summit SILVER
BRONZE
KNOWLEDGE PARTNERS
1000–1030 Morning Break in the Exhibit Marketplace Preliminary Agenda (as of September 9, 2016)
Sunday, November 13, 2016 1030–1200 SESSION I: Updates 0900–1200 FSF International Advisory Committee Meeting General Session Sponsored by The Boeing Company 0900–1200 SKYbrary Supervisory Board Meeting 1035–1100 Standardization Through Cooperation (closed meeting) Capt. Craig Hildebrandt, director, safety and flight operations technical affairs, Airbus 1200–1700 FSF Board of Governors Meeting (closed meeting) Board of Governors Lunch Sponsored by Embraer 1100–1125 An Update to Lithium Battery Transport by Air 1400–1800 Registration/Exhibitor Move-in Capt. Scott Schwartz, Ph.D., director, Dangerous Goods Program, Air Line Pilots Association, International (ALPA) Conference Totes Sponsored by The Boeing Company Hotel Keycards Sponsored by Safran 1125–1150 Justice in a Just Culture 1700–1730 Day One Speakers Meeting Capt. Peter Stein, director of flight operations, Johnson Controls; member, FSF Board of Governors Monday, November 14, 2016 1150–1200 Questions and Wrap-up 0730–1500 Registration/Exhibit Marketplace Open 1200–1330 Lunch in the Exhibit Marketplace Conference Totes Sponsored by The Boeing Company Hotel Keycards Sponsored by Safran 1330–1500 SESSION II: Safety Information 0730–0830 Morning Coffee and Tea in the Exhibit Marketplace Protection General Session Sponsored by The Boeing Company 0830–1000 Welcome and Keynote Address Moderator: Kenneth Quinn, partner, Pillsbury Winthrop Shaw Pittman; general counsel and secretary, FSF Board of General Session Sponsored by The Boeing Company Governors 0830–0850 Welcome 1340–1450 Panel: Protecting Accident/Incident Data and Greg Marshall, vice president, global programs, Flight Evaluating Pilot Mental Health: Safety and the Law Safety Foundation (FSF) Allison Kendrick, principal senior counsel, The Boeing Jon Beatty, president and CEO, FSF Company; chair, FSF Legal Advisory Committee Capt. Bill Curtis, chairman, FSF International Advisory Dr. Jonathan Aleck, head of Legal Service Group, Committee Australian Civil Aviation Safety Authority 0850–0925 Keynote Address Aurelia Grignon, avocat, Soulez Larivière and Capt. Henry Donohoe, divisional senior vice president– Associates flight operations, Emirates; member, FSF Board of 1450–1500 Questions and Wrap-up Governors 1500–1530 Day Two Speakers Meeting 0925–1000 Global Collaboration: Frontline Results 1600–2100 Host Sponsor Event Gretchen Haskins, CEO, HeliOffshore; member, FSF Board of Governors Sponsored by Emirates.
14 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | OCTOBER 2016 SUMMITSIASS
Tuesday, November 15, 2016 0730–1700 Registration/Exhibit Marketplace Open Conference Totes Sponsored by The Boeing Company, Hotel Keycards Sponsored by Safran 0730–0830 Morning Coffee and Tea in the Exhibit Marketplace
0830–1000 SESSION III: Human Factors CONCURRENT TRACK SESSION: General Session Sponsored by Airbus Maintenance and Engineering Moderator: Capt. Harry Nelson, executive operational advisor Moderator: Joseph Barclay, chief executive officer, Inflight to product safety, Airbus; member, FSF International Advisory Warning Systems Predictive Technologies; member, FSF Committee International Advisory Committee 0840–0905 Facilitation and Frustration — Automation in Day-to-Day 0840–0915 Practical Risk Management: The Risk Operations Challenger Program at TAP M & E. Dr. Nicklas Dahlstrom, human factors manager, Emirates 0905–0930 Lessons learned from the Eurocontrol Wake Impact Jorge Leite, vice president, quality and safety, TAP Severity Assessment Flight Simulator Campaign Maintenance and Engineering Capt. Dirk De Winter, Eurocontrol; Vincent Treve 0915–0950 Who Is Loading and Servicing Your Aircraft? 0930-0955 An Approach for Holistic Fatigue Risk Monitoring Control Christopher SanGiovanni, director of ground Tomas Klemets, head of scheduling safety, Jeppesen safety, JetBlue Airways 0955–1000 Questions and Wrap-up 0955–1000 Questions and Wrap-up 1000–1030 Morning Break in the Exhibit Marketplace Sponsored by Inflight Warning Systems 1030–1200 SESSION IV: Training-Part One CONCURRENT TRACK SESSION: General Session Sponsored by Airbus Maintenance and Engineering Moderator: Capt. Greg Wallace, principal safety specialist, Aircraft Moderator: Joseph Barclay Operations, Qantas Airways 1040–1105 Back to Basics: Really Train to Do it During Initial and 1040–1115 “Yes sir, it’s supposed to look like that”: Safety Recurrent Sessions and Culture in Maintenance Capt. Jean-Michel Leclerc Dr. Nicklas Dahlstrom, human factors manager, 1105–1130 Non-Precision and Precision-like Approaches: Low Emirates Practical Talent Risks and Major Incidents 1115–1145 Maintenance Human Factors: Beyond Error to Capt. Andre Vernay, human risks program manager, DGAC France Performance 1130–1155 Virtual Tools for Enhancing Flight Safety Mr. Andy Evans, director, Aerossurance Paolo Manoel Razaboni, manager, Air Safety Department, 1145–1200 Questions and Wrap-up South American Region, Embraer 1155–1200 Questions and Wrap-up
1200–1330 Lunch in the Exhibit Marketplace
1330–1500 SESSION V: Data CONCURRENT TRACK SESSION: General Session Sponsored by Airbus Maintenance and Engineering Moderator: Capt. Joe Gillespie, director of safety and compliance, Moderator: Joseph Barclay Gates Aviation; member, FSF International Advisory Committee 1335–1400 Application and Use of Big Data in an SMS World 1340–1415 Engineering Safety Culture as a Contributor to John De Giovanni, managing director of quality assurance, Operator Safety regulatory compliance and safety, United Airlines Brian Kirby, vice president of engineering and 1400–1425 Big Data: Big Challenges and Big Opportunities chief technical officer, IWS Sally Anne Longstaff, safety analyst, Emirates 1415–1450 Effective Change by Measuring Safety and 1425–1450 Benefits to Automated Data: A Common Causal Taxonomy Compliance Culture and One Data Stream Ron Sims, director technical operations safety, Christopher SanGiovanni, director of ground safety, JetBlue United Airlines Airways 1450–1500 Questions and Wrap-up 1450–1500 Questions and Wrap-up
1500–1530 Afternoon Break in the Exhibit Marketplace
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | OCTOBER 2016 | 15 SUMMITSIASS
Tuesday, November 15, 2016 Continued 1530–1700 SESSION VI: Remotely Piloted Aircraft Systems CONCURRENT TRACK SESSION: General Session Sponsored by Airbus Maintenance and Engineering Moderator: Jon Tree, director of industry relations, Jeppesen; member, Moderator: Joseph Barclay FSF International Advisory Committee 1540–1610 Safety UAS integration challenges: Views and Concerns 1540–1615 Fatigue Risk Management for Maintenance From the Airline Cockpit Organizations Anthony “Jim” Pala, UAS member, Aircraft Operations and Design Group, ALPA Dr. Daniel Mollicone, CEO, Pulsar Informatics 1610–1640 How Much Safety Do Small Drones Embed? 1615–1650 Maintenance LOSA: A Tool for Diagnosis and Dr. Nektarios Karanikas, associate professor of safety and Safety Promotion human factors, Aviation Academy of the University of Christine Zylawski, MLOSA project manager/ Amsterdam Applied Sciences deputy flight safety manager, Air France 1640–1700 Questions and Wrap-up 1650–1700 Questions and Wrap-up 1715–1745 Day Three Speakers Meeting Wednesday, November 16, 2016 0730–1500 Registration/Exhibit Marketplace Open Conference Totes Sponsored by The Boeing Company 1155–1200 Questions and Wrap-up 0730–0830 Morning Coffee and Tea in the Exhibit Marketplace 1200–1330 Lunch in the Exhibit Marketplace
0830–1000 SESSION VII: Training-Part Two 1330–1500 SESSION IX: Go-Around Compliance General Session Sponsored by Embraer General Session Sponsored by Embraer Moderator: Capt. Linda Orlady, president, Orlady Associates; Moderator: Capt. Bill Curtis, Air Canada; chair, FSF International member, FSF Board of Governors Advisory Committee 0840–0905 Presentation to be announced 1340–1405 Pilot Decision Making and Go-Arounds Capt. Harry Nelson, executive operational advisor to Capt. Michael Gillen, ASAP event review representative, product safety, Airbus; vice chair, FSF International United Airlines Advisory Committee 1405–1430 Improving Go-Around Compliance at Porter Airlines 0905–0930 Cognitive Biases and Other Challenges in Going Capt. John Gronlund, manager pilot training, Porter Beyond Human Error in Safety Investigations Airlines Dr. Kathy Abbott, chief scientific and technical advisor 1430–1455 Operational Considerations for Safety Go-Around for flight deck human factors, U.S. Federal Aviation Procedures Administration (FAA); Dr. William Bramble, senior Capt. Bryan Burks, ALPA human performance investigator, U.S. National 1455–1500 Questions and Wrap-up Transportation Safety Board 1500–1530 Afternoon Break in the Exhibit Marketplace 0930–0955 One-Team Cockpit Capt. Christian Popp and Capt. Christof Kemény 1530–1610 SESSION X: Somatogravic Illusion 0955–1000 Questions and Wrap-up General Session Sponsored by Embraer Moderator: Dr. Ratan Khatwa, senior chief engineer – human 1000–1030 Morning Break in the Exhibit Marketplace factors, Honeywell Aerospace; member, FSF International 1030–1200 SESSION VIII: Managing Risk Advisory Committee General Session Sponsored by Embraer 1535–1600 Creating the Somatogravic Illusion in Your Simulator Moderator: Tzvetomir Blajev, coordinator, safety improvement — Early Research Results Initiatives, Eurocontrol; chair, FSF European Advisory Committee Dr. Jeffrey Schroeder, chief scientific and technical advisor, Flight Simulator Systems, FAA 1040–1105 Next Generation Flight Safety Systems: A Business 1600–1625 Reducing the Threat of Somatogravic Illusion and Corporate Aviation Perspective Capt. Simon Ludlow, Dragon Airlines Dr. Ratan Khatwa, senior chief engineer, human factors, 1625–1650 How Flight Crew Can Be Trained on Strategies to Honeywell Aerospace; member, FSF International Counteract Illusions in a Traditional Simulator Advisory Committee Capt. Endre Berntzen, director, crew training, Widerøes 1105–1130 Is Your Crisis Management Program Effective? Flyveselskap AS Gill Sparrow, manager, contingency response, Emirates 1650–1700 Questions and Wrap-up 1130–1155 Higher Risk Operations and Dynamic Risk Management Dashboards 1700–1730 Closing Remarks Ilias Panagopoulos, safety manager, NATO Airlift 1730 IASS 2016 Concludes Management Program
16 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | OCTOBER 2016
COVERSTORY
afety management systems major component of an SMS is risk reporting systems, safety audits and (SMSs) within airlines and main- management, which requires that haz- safety surveys); and a predictive ap- tenance and repair organizations ards to safety of flight be identified and proach (capturing system performance (MROs) have advanced rapidly assessed for risk, and that unacceptable as it happens in real time during nor- Sin the past decade. Conceived by the risk be mitigated to acceptable levels. mal operations, such as observations of International Civil Aviation Organi- International guidance for SMS the performance of the aircraft main- zation and gradually being put into design recommends three approaches tenance technicians (AMTs) during a practice through regulation by national in identifying safety hazards: a reactive heavy check of a large commercial jet. aviation authorities, SMSs soon will be approach (the investigation of acci- As part of its predictive approach, required for airlines around the world. dents, incidents and events); a proactive the Airlines for America (A4A) Mainte- For example, the U.S. Federal Aviation approach (the active identification of nance and Ramp Human Factors Task Administration (FAA) mandates that safety hazards through the analysis Force has extended the line operations all U.S. commercial airlines (Part 121) of the organization’s activities, using safety audit/assessment (LOSA) concept implement an SMS by Jan. 8, 2018. One tools such as mandatory and voluntary to assess maintenance and ramp (M/R)
BY MAGGIE MA AND CHRISTINE ZYLAWSKI
Air France Industries and Boeing describe the behind-the-scenes implementation of maintenance line operations safety assessments.
18 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | OCTOBER 2016 COVERSTORY
AFI leaders presumed that frontline AFI Three-Phased MLOSA Campaign employees are the true experts, and Completed In Progress Scheduled have the best vantage point to observe 1st quarter 2015 2nd quarter 2016 3rd quarter 2016 maintenance operations as they occur Line and Base Maintenance Component Shops Engine Shops and, consequently, to identify the prob- 1,500 AMTs 700 AMTs 600 AMTs lems and fixes. Maintenance failures are not random. There is a clear need to 406 observations ~300 observations ~250 observations understand how the safety threats, the AMTs = aircraft maintenance technicians latent conditions and the errors com- Source: Air France Industries (AFI) mitted eventually come together and Table 1 lead to a reduced safety margin.
operations.1 The FAA and A4A also exemplary AMT behaviors that can be Implementation Begins have published separate versions of M/R reinforced in training. Assisted by Boeing, AFI launched the LOSA implementation guidelines. Boeing Commercial Aviation Ser- MLOSA program after a six-month Through strictly non-punitive, vices offers MLOSA support and train- preparation period and educational peer-to-peer observations, maintenance ing to the international airline industry. campaign by a new project team. Since LOSA (MLOSA) takes “snapshots” of For example, Boeing supported Air 2014, work toward full implementation normal aircraft maintenance opera- France Industries (AFI) to launch an has progressed through three phases tions and helps the MRO to understand MLOSA program in November 2014. for each of the following three AFI safety-related decisions of ordinary business units (Table 1): Line and Base people who are under the influence of Case Study Background Maintenance (in which base mainte- normal, everyday pressures. MLOSA Within AFI, the Flight Operations nance personnel perform, on average, incorporates the threat and error man- business unit carried out a LOSA in 275 C-check or D-check inspections agement (TEM) conceptual framework, 2011, and this assessment was consid- for narrow- and wide-body aircraft which recognizes that safety threats and ered very successful. AFI subsequently each year); Component Shops (which errors are likely to occur in all normal made a commitment to a campaign of support more than 1,300 aircraft world- operations. Compared with traditional recurrent LOSAs for pilots. wide); and Engine Shops (which handle audits conducted by external agencies or In maintenance operations, by 500 visits and 280 thrust reverser over- by internal safety and quality assurance mid-2013, AFI recognized the need to hauls each year). staff, MLOSA “paints” for the organi- complement its existing reactive and Line and Base Maintenance was zation a much more realistic picture of proactive safety programs by capturing the focus of Phase 1, completed in the what is going on. snapshots of day-to-day performance first quarter of 2015. To promote the In addition to identifying safety — i.e., operational difficulties or safety entire program and generate buy-in, threats and errors, MLOSA data can threats in unscheduled or scheduled the MLOSA project team attended or help an organization to estimate — by maintenance — and by developing conducted more than 90 face-to-face a sampling process — the occurrence strategies for dealing with those diffi- meetings with the frontline employees probability; this capability exceeds culties or threats. AFI also renewed its and union groups. Twenty-six AMTs that of most mandatory and voluntary commitment to increase the involve- soon volunteered to become MLOSA reporting systems. The predictive capa- ment of frontline employees and to observers. They were trained by Boeing bility of MLOSA also can help analysts further enhance its safety culture. during a one-day MLOSA observer to discover emerging risks from future One expected outcome was to training course. The course covered the- operational changes expected inside or measurably put into practice the oretical background, classroom practice outside the organization and its opera- slogan “safety is not just for safety and practice observations in hangars. tional environment. Mitigating action professionals within the organization, Based on safety information from therefore can be initiated before the risk it’s a responsibility of everyone in the event investigations and voluntary actually appears. MLOSA also identifies organization.” reporting by AMTs, the project team © Air France Industries France © Air FLIGHTSAFETY.ORG | AEROSAFETYWORLD | OCTOBER 2016 | 19 COVERSTORY
selected a number of maintenance tasks as their controls components removal/installation, cabin primary focus within Phase 1, such as wheel/ systems repair, avionics/mechanical systems brake change, engine change, landing gear ser- troubleshooting, and tooling management. vicing, landing gear removal/installation, flight During the following two and a half months, the 26 observers completed 186 observations Types of Observations in Phase 1 and compiled 406 observation reports. A total of MLOSA Campaign for Line and Base Maintenance 1,500 AMTs at Paris Charles de Gaulle Airport (CDG) and Paris Orly Airport (ORY) were Observation Percentage of Type of Observation Occurrences Total Observations involved in this phase. Table 2 summarizes the Additional threats and errors 18 4.4% distribution of the types of observations. Close-up/complete restore 25 6.2% Each MLOSA observer took this task very Install 67 16.5% seriously. The TEM conceptual framework was Installation test 38 9.4% new to the observers and to those who were Planning 43 10.6% observed. The observers soon found that a sig- Prepare for removal 48 11.8% nificant amount of analysis and paperwork were Prepare to install 43 10.6% required while they conducted and documented Removal 60 14.8% each observation. Once the technicians over- came this step in the learning curve, their work Servicing 48 11.8% took off and produced highly valuable MLOSA Troubleshooting 16 3.9% observation reports. Totals 406 100.0% Phase 2 of MLOSA focused on the Compo- MLOSA = Maintenance Line Operations Safety Audit/Assessment nent Shops. After four months of preparation, Source: Air France Industries this business unit completed its launch of Phase Table 2 2 in the second quarter of 2016. The preparation comprised getting top management and unions A Comparison of MLOSA Observation Forms for Line and Base involved; selecting and training observers; Maintenance vs. Component Shops and Engine Shops customizing observation forms; and creating a Microsoft Excel data-entry form suitable for Line and Base Maintenance Form Component Shops Form Engine Shops Form analysis. The resulting Component Shops form Demographics Demographics Demographics includes three new sections titled “Incoming Planning (A) Incoming inspection check Incoming check Inspection Check,” “Disassembly” and “Assem- Prepare for removal (B1) Prepare for removal bly.” Similarly, a corresponding Engine Shops Removal (B2) Disassembly Removal observation form includes three new sections Prepare to install (B3) Prepare to install titled “Incoming Check,” “Cleaning and Nonde- Install (B4) Assembly Install structive Testing (NDT) Inspection” (Table 3). Installation test (B5) Installation test Installation test Twenty-three observers from CDG and ORY Close-up/complete restore Complete restore Close-up/complete were trained in-house in French, a decision (B6) restore based on prevailing proficiency in this language. Troubleshooting/deferral (C) Fault isolation and repair The observer training was expanded to one- Servicing (D) Servicing and-a half days; theoretical content, classroom Cleaning and non- practice and field practice each took half a day. destructive testing inspection The AFI MLOSA project team created and inte- Additional threat(s) Additional threat(s) Additional threat(s) grated new examples applicable to the Compo- nent Shops environment. MLOSA = Maintenance Line Operations Safety Audit/Assessment The Phase 2 target population comprised Source: Air France Industries 700 AMTs at CDG and ORY. For the two Table 3 airports, 300 observations were scheduled on
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tasks such as avionics components indicators (KPIs) and determine bar- by introducing a new communication overhaul, mechanical/pneumatic/air riers; and setting targets for improve- procedure and tool (Figure 1) to facili- conditioning/flight controls compo- ment (recommendations to AFI). tate coordination and reduce errors due nents repair/overhaul, parts machining, Deployed as subject matter experts, to routine interactions between mainte- NDT inspections, wheel/tire repair or the AMT observers later described nance personnel and flight crews. overhaul, escape slide overhaul, and themselves as “empowered” by their new The revised elements of this task oxygen system components overhaul. MLOSA duties. The observers helped introduced anti-FOD toolboxes dedi- As of this September, 301 observa- the MLOSA project team come up with cated to oxygen bottle/cylinder replace- tions had been completed in the Com- both accurate diagnoses of issues and ment. The toolboxes have specific fitted ponent Shops. AFI has received positive successful solutions to them. They also spaces to help AMTs ensure replacement feedback from the AMTs involved in provided recommendations to improve of each tool used, and they contain the program, and the data produced AFI safety management overall. materials required for leak tests. Other by LOSA observers were considered Through MLOSA, AFI identified improved elements are simplified provi- detailed and of high quality. The next some systemic issues across the board sioning processes for oxygen cylinders step in Phase 2 will be data analysis for — independent of aircraft type or and consumables (e.g., the O-ring for the Component Shops. maintenance task — and correspond- the flared tube), and a working group The MLOSA project team has ing precursor latent conditions. The dedicated to modernize maintenance scheduled Engine Shops — a business MLOSA observations from Phases human factors training. The new train- unit with 600 AMTs — to be the focus of 1 and 2 revealed four predominant ing promotes the desired safety culture Phase 3 during the third quarter of 2016. types of threats, categorized as indi- and emphasizes safety strategies to The schedule calls for 40 observers from vidual factors, organizational factors, prepare AMTs for challenging situations CDG and ORY to be trained and then information/technical documentation in the field. Upon completion of this new to conduct more than 300 observations and tools/supplies. The MLOSA project recurrent training, AMTs sign a pledge of specified tasks such as CF6/CFM56/ team’s diagnosis resulted in a plan of (see “Aircraft Maintenance Technician GE90/GP7200 engine overhaul, engine corrective actions, which was tracked Safety Pledge,” p. 22) that complements line replaceable units repair/overhaul, by AFI safety assessment groups the existing corporate-level safety pledge. engine component NDT inspections, chaired by executive management to and engine test cell inspections. assess effectiveness and outcomes. Lessons Learned AFI specifically was able to capture AFI attributes the MLOSA program’s Data Analysis So Far best practices such as cohesive team- positive outcomes to careful prepara- AFI working groups dedicated to work, compliance with the anti–foreign tion through cohesive teamwork; the MLOSA have performed five major object debris/damage (FOD) plan and steps of safety-diagnostic analysis — self-initiated promotion of safety cul- New Communication Procedure combining manual calculations and ture by many of the observers or by the and Tool for AMTs Minitab statistical analysis software other AMTs. — for the observation data collected with the Excel data-entry forms. These Success Stories steps were factors analysis to deter- The MLOSA program helped AFI mine TEM profiles; detailed preva- identify several systemic issues and, lence (frequency) analysis; statistical consequently, systemic solutions that testing performed to validate cor- can be applied across the fleet. For relations and calculate probability of example, based on Phase 1 findings, threats and errors using multinomial AFI improved its “Change of Oxygen logistic regressions; statistical inter- Bottle/Cylinder” task procedures for AMTs = aircraft maintenance technicians action analysis and transposition to multiple aircraft types (e.g., Airbus Source: Air France Industries the AFI risk model (bow-tie mod- 320/330/340 and Boeing 777/747). This el) to build safety key performance solution used an integrated approach Figure 1
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | OCTOBER 2016 | 21 COVERSTORY
high level of commitment by executive management; the enthusiasm shown Air France Industries by the observers; and the training and Aircraft Maintenance Technician Safety Pledge support received from Boeing. Execu- tive management credits program-level • I incorporate safety as a daily essential in each of my activities. leadership and its self-assessment of • I have a professional attitude for the benefit of safety and regulatory implementation-launch readiness, espe- compliance. cially the preparations for the market- • I ensure continued awareness and I act accordingly. ing campaign, the customized posters • I respect the maintenance standards in the work I carry out. and the special tool kits for recruiting the observers. • If in doubt, I choose safety, and I alert my management. Part of this preparation for MLOSA • I am aware of my limitations and I question myself. launch was a discussion of “what if” • I adopt a transparent attitude; I report my difficulties/malfunctions. scenarios in case the implementation — MM and CZ did not go as planned. For example, the project team members asked themselves, “If AMTs do not accept session of MLOSA observer training to collective safety intelligence derived MLOSA, what should we do?” This risk thank the AMTs for their contribution. from multiple sources of data, and that assessment in turn led to pre-planned Anne Brachet, executive vice each professional has an important role mitigation solutions. president, AFI, told employees at the to play in ensuring flight safety. The MLOSA project team used AFI end of Phase 1, “Involvement of aircraft Currently, the MLOSA manager is Flight Safety Forums as a key venue maintenance technicians in mainte- supported by one project coordinator to promote LOSA and customized its nance safety initiatives is a key factor and two data analysts. The project team communication media and messages to for removing the barriers to flight comprised a human resources–labor audiences from different business units. safety. Our first MLOSA campaign has union specialist (called a social affairs They also had to ensure they were been a tremendous opportunity to col- manager), a human factors–regulatory ready to respond to many questions lect safety-minded data to appraise compliance specialist, a worker- — such as, “How is MLOSA related to our performance and continue safety production specialist, a communication other safety programs?” In the com- promotion within our organization. specialist, a LEAN transformation/ munication campaign rollout, they Commitment deployed by all AFI sub- efficiency expert, and a corporate emphasized a motivational message: ject matter experts to develop this inno- change–management specialist. “Talent wins games, but teamwork and vative initiative supports our common Finally, AMT observers and safety intelligence win championships.” goal to expand our safety culture and, coordinators from CDG and ORY asked Executive management showed therefore, demonstrate AFI KLM Engi- many insightful questions during observ- strong commitment to the program and neering and Maintenance involvement er training. Their practice observations the required changes in several ways. in industry safety standards.” in the Boeing 777 hangars were produc- One example was the co-signing of a Executive management also cited tive for everyone. During actual obser- memorandum of understanding with frontline managers as crucial in vations, the MLOSA project team and AMT labor groups — clearly specifying ensuring that procedures are actually safety coordinators kept in close contact how MLOSA data and results would be followed, and for bringing about true with the observers on a weekly basis. used — by leaders of AFI Engineering cultural changes in which production AMTs came to understand the and Maintenance Management and leaders govern and improve safety underlying safety theory and processes the AFI Quality Assurance Directorate. performance while managing opera- much better over time through their MLOSA also was incorporated into tions. Through the MLOSA campaign, personal participation directly or indi- AFI’s SMS annual action plan. Hervé people in all relevant AFI business rectly. As a result, their perceptions of, Page, senior vice president of mainte- units came to realize, and uniformly and attitudes toward, the MLOSA pro- nance and engineering, AFI, visited each agreed, that flight safety depends on gram became more positive. As trust in
22 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | OCTOBER 2016 COVERSTORY
MLOSA grew, the AMTs became more collecting maintenance safety data — a safety climate change. The project team’s interested in program details and in process made possible by the frontline drive to further refine the AFI program taking part. AMT volunteers, who were selected includes recommending enhancements Because its working groups includ- because of each individual’s desire to to the FAA’s model database for M/R ed flight safety coordinators and safety promote and constantly improve safety LOSA programs.2 The team believes that experts conducting data verification culture. This process carried forward FAA guideline revisions should include and analysis, the MLOSA project team from the Flight Safety business unit’s information on how to set up reporting, was able to summarize results quickly need to obtain an accurate understand- and should explain how to use the FAA and to disseminate best practices and ing of day-to-day operations, and from database in its appendix. tips to the observers. For example, their mantra: “Without data, you are Independent recognition of this 80 percent of an observer’s time/ just another person with an opin- program’s value3 — especially as a case description tasks, they said, should be ion.” The MLOSA program similarly study for others —has encouraged the spent on recording/describing threats, transformed a basic concept into a new leaders of AFI KLM Engineering and errors and consequences; 20 percent of capability — conducting organizational Maintenance to pursue collaboration time/description tasks should be spent self-assessment diagnoses of systemic with other airlines and MROs, to share on recording/describing contextual safety issues. AFI essentially recognized and compare de-identified MLOSA data, information. Moreover, their Phase through MLOSA that such field data and to globally maximize the lessons 1 observations led to creating a new are critical for supporting and improv- learned from all MLOSA programs. task-flow logic (Figure 2) taught during ing the entire SMS. Maggie Ma, Ph.D., is a systems engineering en- Phase 2 observer training, which im- On average, an MLOSA program re- gineer at Boeing Commercial Aviation Services. proves how observers focus their atten- quires an investment of 125 man-hours She supports Boeing customers and other tion and capture the most useful data. per AMT observer. The MLOSA project maintenance organizations on a wide array of team — citing team members’ experi- maintenance human factors safety programs. Christine Zylawski is the deputy flight safety Concluding Insights ence calculating return-on-investment in manager who leads the MLOSA program for In summary, AFI’s MLOSA program other domains — reported a quantifiably Air France Industries. introduced a “bottom-up” process for positive impact on safety culture and The authors will be presenting on MLOSA at the Foundation’s IASS 2016 in Dubai in November. “What to Look For” Logic for MLOSA Observers For more information and to register, go to
2. Ma, Maggie J.; Rankin, William L. FAA Of- fice of Aerospace Medicine. Implementation Guideline for Maintenance Line Operations T R C E R C US R C time Safety Assessment (M-LOSA) and Ramp T R C LOSA (R-LOSA) Programs, Final Report. T = THREAT, R = RESPONSE, DOT/FAA/AM-12/9, August 2012. T R C C = CONSEQUENCE, E = ERROR, 3. For the second consecutive year, Aviation US = UNDESIRED STATE Week selected AFI KLM Engineering and Maintenance for the 2016 MRO of the MLOSA = Maintenance Line Operations Safety Audit/Assessment Year Award in the “Outstanding Airline
Source: Air France Industries Maintenance Group” category
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | OCTOBER 2016 | 23 Cockpit Smoke Protection
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VisionSafe.com 1-844-FLY-EVAS (359-3827) E mergency V ision A ssurance S ystem A FLIGHTSAFETY.ORG and psychological limitations inherent that from arise normal physiological made by crewmembers flight —errors dents are caused by inadvertent errors airline operations. aviation not (GA)flights, commercial by suicide, and involved all general a recent were 10-year caused period accidents United inthe States during 0.3 percent of 2,758fatal aircraft civil any mental disorder. In less than fact, dents, for majority the of aircraft acci- torically have responsible been lthough actions the of pilots his- | AEROSAFETYWORLD 1 most donot from arise 2 Instead, most acci- | OCTOBER2016 Cognitive limitationsinhumanperception, attention, memoryand and are processed before aresponse environment are received by senses the uli, or other information) from the behavior postulates that inputs (stim- to study the of human thought and computer as ametaphor, approach this of cognitive psychology. Using the ing, is which primarily domain the from understanding human- think influence on deck. flight the strategies to help pilots minimizetheir in piloting performance and suggests examines role the limitations these play humanin the condition. This article Understanding human error follows decision makingplayarole inmanyaviationaccidents. ceptors eyes,ears, inthe skin,vestibular with stimulationbegins re of- sensory Figure 1(p. 26).Information processing tors, Christopher Wickens, is found in ofers field inthe aviation human fac - by one of world’s the foremost research- often processing from right to left. people actively search for information, responders to stimuli; external rather, notion that humans are merely passive but purely the rejects also behaviorist astime inputs travel from to left right, that information processing takes (output) is made. The assumes model A more elaborate model, developed BY DALEWILSON HUMANFACTORS
|
25 © DrAfter123 | iStockphoto HUMANFACTORS
item such as extending the landing gear before Information Processing Model landing. Also, research shows that any dis- Information processing tortions upstream in the model (e.g., sensory processing and/or perception) will adversely Attention resources affect downstream cognitive functions such as decision making and response selection and Short-term execution (Table 2, p. 28). sensory Stimuli store Response Lessons learned from aircraft accident (input) Decision and Response (output) Perception response execution investigations reveal how otherwise normal selection everyday human cognitive limitations in perception, attention, memory and decision making play a causal role. The following exam- Working ples highlight some of these limitations. memory Long-term memory Perceptual Errors Memory In clear flying weather, flight crews have Feedback missed or misperceived visual cues neces- sary to avoid a midair collision (MAC) in the Source: U.S. Federal Aviation Administration (FAA). “Wickens’ Model.” FAA Human Factors Awareness Course. Available at
26 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | OCTOBER 2016 HUMANFACTORS
event so common that a cynical adage pilots, and some commercial pilots, Several conclusions and recom- has developed among aviators that says, who attempt visual flight rules (VFR) mendations can be made from an “There are only two kinds of pilots — flight into instrument meteorological understanding of human cognitive those who have landed with the gear conditions (IMC). Compared with performance and its role in aircraft up and those who will.” In addition, a fatal U.S. GA accident rate of less accidents. fatal commercial airline accidents have than 18 percent, some 95 percent of First, there are specific flight occurred because flight crews have U.S. GA VFR-into-IMC accidents in situations in which particular limita- forgotten — whether due to distraction, 2012 resulted in fatalities.4 Empirical tions pose a greater risk. For example, task overload or both — to properly studies and accident investigations conducting a visual landing approach configure the aircraft for takeoff. indicate that decision biases — such in dark-night conditions in clear as invulnerability, optimism bias (the weather increases the likelihood of a Decision Making tendency to be overly optimistic in pilot experiencing a perceptual illusion One of the most complex of mental envisioning the likely outcome of a (e.g., black-hole effect, a threat present operations is decision making. Any decision), and ability bias (a bias that on dark nights when there are no deficiencies in sensory processing, favors the able-bodied and highly ground lights between an aircraft and perception, attention or memory can skilled), overconfidence and escalation the runway threshold) with its risk of lead to poor decisions, but decision bias (leading to entrapment by accep- a CFIT accident short of the runway. making comes with its own limita- tance of increasing risks) — have had Distraction-induced attention and tions. For example, biases are often a part in pilots’ decisions to continue memory failures are also more likely, evident in the decision making of GA VFR flight into IMC.5 and more consequential, during certain phases of flight. Flight crews should, Major Human Senses Involved in Piloting an Aircraft therefore, seek to fully understand the exact nature of these limitations and Human Description Sensation Specialized senses detect specific types of stimuli and are important for the context in which they are likely to pilots to obtain accurate information about their external world. Some rank higher when it comes to flying: Vision and hearing are crucial for flight while manifest themselves on the flight deck. gustation (sense of taste) usually is not. In addition, there are effective Vision Sense of sight. Photoreceptors (rods and cones) in the retina of each strategies that pilots can use to eye are stimulated by light, causing a chemical reaction that converts overcome these cognitive limitations. light energy into neural signals that are sent to the visual cortex via the optic nerve. For example, despite the inherent Audition Sense of hearing. Hair-like receptors in the organ of Corti, located in limitations of the “see-and-avoid” the cochlea of the inner ear, are stimulated by sound waves and create method in detecting traffic in flight, neural impulses that are sent to the auditory cortex via the auditory nerve. best practice strategies exist to Cutaneous Sense of touch. Different types of receptors in the skin specifically sense overcome them: Pilots can utilize an pressure, temperature or pain. effective scanning technique; increase Olfaction Sense of smell. Olfactory receptors located in the nasal cavity aircraft conspicuity (e.g., turn on chemically react to a variety of odors. Specific receptors detect specific landing lights); ensure the transponder smells. is correctly set; use party-line radio Vestibular Sense of balance. Receptors in the cupula, located in the semicircular canals in the inner ear, move in response to angular acceleration information to increase situational while the membrane located in the adjacent otolith bodies moves in awareness; and comply with a variety response to linear acceleration. of rules designed to reduce the chance Somatosensory Sense of overall position and movement of body parts in relation to of an MAC (such as maintaining a each other. Receptors in the body’s skin, muscles and joints respond to gravitational acceleration, providing sense of body position and sterile flight deck). Similarly, there are movement. Sometimes called the kinesthetic or postural sensation, it is practices and procedures designed to more commonly referred to as the “seat-of-the-pants” sensation because accelerations experienced in flight can be confused with gravity. help improve attention and memory while carrying out the tasks involved Source: Dale Wilson in piloting an aircraft: Pilots can use Table 1 effective monitoring strategies, comply
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | OCTOBER 2016 | 27 HUMANFACTORS
Accidents/Incidents Related to Cognitive Limitations
Perception Errors Visual Perception In November 2013, a Boeing 747 Dreamlifter, destined for McConnell Air Force Base in Wichita, Kansas, U.S., unintentionally landed on a 6,100-ft (1,859-m) runway at Col. James Jabara Airport about 8 nm (15 km) north of McConnell. Less than two months later, a Southwest Airlines Boeing 737, on approach to Branson Airport in Missouri, mistakenly landed on a 3,738-ft (1,139-m) runway at M. Graham Clark Downtown Airport, about 5 nm (9 km) north of Branson. The crews of both aircraft were conducting visual approaches at night in visual meteorological conditions (VMC) and thought they saw the correct airport and runway.1 Auditory Perception In February 1989, a FedEx Boeing 747 crashed into a hillside short of Runway 33 at Kuala Lumpur, Malaysia, killing all four occupants. While the 747 was on a nondirectional beacon (NDB) approach, air traffic control provided the following clearance “descend two four zero zero” (2,400 ft), which the crew misinterpreted as “descend to four zero zero” (400 ft).2 Attention Errors All four occupants were killed after a Eurocopter AS350 helicopter crashed in August 2011, following an engine failure due to fuel exhaustion near the Midwest National Air Center, in Mosby, Missouri, U.S. The investigation determined that the pilot missed three opportunities to detect the low fuel status, in part because he was frequently texting on his cell phone, a “a self-induced distraction,” according to the U.S. National Transportation Safety Board (NTSB) report, “that took his attention away from his primary responsibility to ensure safe flight operations.”3 Memory Failures A pilot of a Hughes 369 was killed after loss of control of the helicopter, which struck the water west of the Solomon Islands in December 2008 while attempting to lift off from a fishing vessel. The helicopter mechanic, who witnessed the event, saw the pilot trying to remove the tail rotor pedal lock in flight (unsuccessfully). He had forgotten to remove the lock before takeoff.4 All three passengers were killed in September 2003 when a Cessna 206 struck terrain in Greenville, Maine, U.S., and came to rest inverted after the pilot failed to select the fuel selector in the proper position, resulting in fuel starvation during the initial climb.5 Decision Errors Shortly after takeoff from Springfield, Illinois, U.S., in October 1983, Air Illinois Flight 701 lost electrical power from the left generator. The first officer erroneously shut down the right generator and was unable to get it back on line. All 10 occupants were killed after the crew lost control of the Hawker Siddley 748 while approaching their destination of Southern Illinois Airport in night instrument meteorological conditions. The probable cause of the accident was the “captain’s decision to continue the flight toward the more distant destination airport after the loss of DC [direct current] electrical power from both airplane generators instead of returning to the nearby departure airport,” the NTSB said.6 A Eurocopter AS350 helicopter, operated by the Alaska Department of Public Safety under visual flight rules at night, struck terrain while maneuvering during a search and rescue flight near Talkeetna, Alaska, U.S., in March 2013, killing all three occupants. The pilot, who was not current for instrument flying, became disoriented after flying into instrument meteorological conditions. The NTSB said the probable cause of this accident was “the pilot’s decision to continue flight under visual flight rules into deteriorating weather conditions.”7
Notes: 1. NTSB. Safety Alert SA-033, Landing at the Wrong Airport. March 2014. Available at
Source: Dale Wilson
Table 2
with standard operating procedures Also, airlines can assist pilots by training to avoid committing errors (SOPs) and employ strategies to providing training in formal risk- on the flight deck, most airlines effectively manage mental workload and error-management behaviors. acknowledge that pilots are subject and distractions. While flight crews undergo extensive to the cognitive limitations that all
28 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | OCTOBER 2016 HUMANFACTORS
humans share, and that despite their Whether formally identified as TEM Dale Wilson is a professor in the Aviation best efforts to avoid them, errors made countermeasures or not, airline safety Department at Central Washington University by pilots are inevitable. Rather than systems have evolved to include best in Ellensburg, Washington, U.S. He teaches courses in flight crew physiology, psychology and pretend these errors don’t exist, or practice countermeasures designed to risk management, and writes about flight crew punish pilots when the errors occur, effectively manage risk on the flight safety matters, including co-authoring the recent flight departments can arm pilots with deck. These behaviors are designed book, Managing Risk: Best Practices for Pilots. tools they need to effectively manage to overcome the inherent limitations, error on the flight deck. as noted, in perception, attention, Notes memory and other cognitive process- 1. Wiegmann, Douglas; Shappell, Scott. U.S. Threat and Error Management es, and include: Federal Aviation Administration (FAA) One such approach to reducing risk in •• Adhering to SOPs; Report DOT/FAA/AM-01/3, A Human aviation operations is threat and error Error Analysis of Commercial Aviation •• Complying with sterile flight deck Accidents Using the Human Factors Analysis management (TEM). Used primarily rules; and Classification System (HFACS). by trained observers as an observa- February 2001. Available at
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© arsenik | iStockPhoto 30 | HUMANFACTORS DIFFERENT STROKES space Medical Association. ofHuman journal the Aero the Performance, - of astudy published inAerospace Medicine and of sleep-related problems, according to results P adequate recovery breaks.” sectors and “consecutive duty without periods crossing multiple zones, time multiple flight night early-morning lag, jet flights, wakeups, fatigue with anumber of factors, including over found that pilots groups inboth associate their study,the published September inthe issue. limitstime for two the groups, said report the on sider adopting different regulatory and flight duty pilots ofa review responses by 435Portuguese airline starting and times long duty periods. from acombination of frequent early-morning among short- and medium-haul pilots may stem zones, increased daytime the while sleepiness result of more nighttime across flying more time disturbancessleep inlong-haul pilots may a be along with number the of sectors and hours duty hours over course the of a28-day period, The report noted that previous research has Therefore, aviation authorities should con- The researchers conclusions their based on The report said that incidence higher the of 4 to questionnaires that asked about their ficient and sleep different experience sets face different challenges inobtaining suf- in short- and medium-haul operations long-haulilots fly who and flights those 3 2 1
- adding that study the reinforced findings the and medium-haul flights],” report the said, [short- inpilotswere especially flew who high, of long-haul pilots self-reported fatigue. short- and medium-haul pilots and 84.4percent reported daytime sleepiness, 93.3percent while of pilots and 53.3percent of long-haul pilots self- dition, 61.66percent of short- and medium-haul and 36.9percent among long-haul pilots. In ad- percent among short- and medium-haul pilots reported) prevalence of complaints sleep was 34.2 othersthe were (Table first officers 1,p. 32). percent of long-haul respondents were captains; of short- and medium-haul respondents and 48.4 population,” report the said. percent Fifty-three long-haul] ratios of Portuguese the airline pilots’ female/male and and [small- medium-haul/ division that “corresponds approximately to the 28.05percentwhile were long-haul pilots —a percent were short- and medium-haul pilots made up 97.2percent of respondents; and 71.95 39.05 years, plus or minus 8.14years; pilots male sleepiness and fatigue. self-rating of complaints, sleep scales daytime gender and professional and included category; datasociodemographic such as pilot’s the age, worked.they The questionnaire gathered also and times start their flown, what night hours “The prevalence values“The for reported fatigue Researchers found that subjective the (self- The mean age for study participants was FLIGHT SAFETY FOUNDATION BY LINDAWERFELMAN | AEROSAFETYWORLD | OCTOBER2016
Composite: Jennifer Moore; Sky image: © eosboy | Adobe Stock HUMANFACTORS
Researchers say long-haul pilots face a different set of sleep-related problems than their short- and medium-haul colleagues.
DIFFERENT STROKESof previous studies, with the highest values of “because flight hours and duty hours have an self-reported fatigue and daytime sleepiness approximate value for [long-haul] pilots. The reported by short- and medium-haul pilots. equivalence between flight hours and workload These sleep problems are “commonly at- may be related to the closer association between tributed to diminished sleep caused by the flying a single sector per duty period. When combination of frequent early starts and long looking at [short- and medium-haul] pilots, duty periods,” the report said. “The prevalence their duty hours do not reflect their effective of sleep complaints was higher in [long-haul] workload, given that they require more duty pilots, probably due to the very nature of these time for the same amount of flight time.” flights, often characterized by night flights with The report noted that European laws limit multiple time-zone crossings.” duty time for both groups of pilots to no more The study found significant differences than 100 hours in 28 consecutive days. between the two pilot categories in a number of “With the mean values for duty time achieved areas. in this study, we have already observed high levels Short- and medium-haul pilots “were the of reported fatigue and sleep complaints, and the ones with a higher mean value of duty hours, maximum limits established by law were not even sectors, flight hours and early mornings,” the reached,” the report said. “As such, in our opinion, report said. “Only night flights were higher in these results should be taken into account if the the [long-haul] pilots’ group.” regulatory limits will for any reason be revised.” The authors conceded that, because of the The report suggested that pilots on short- self-reporting nature of the questionnaire, some and medium-haul flights would benefit if they bias was likely, “since it is understandable that were subject to different regulatory limits than the individuals who answered it are the most pilots on long-haul flights. affected, potentially resulting in some overem- “Alternatively, the European aviation authori- phasis within the results obtained.” Neverthe- ties [the European Aviation Safety Agency] could less, they added, “Although these values were follow the example of the American aviation au- self-reported subjective values of sleep, they thorities … who opted for establishing maximum are important tools to quantify and understand values for duty time and … flight time,” the report fatigue in airline pilots.” said, noting that U.S. Federal Aviation Regulations The report said that the findings should be limit flight time to eight or nine hours, depend- considered in discussions of regulatory limits ing on specific sets of circumstances.
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The researchers said that their study could said. “This study heightens the importance of be an important tool in the implementation of defining different strategies to mitigate fatigue, fatigue risk management systems (FRMS) — taking into account all the differences between data-supported systems intended to develop flights. Sleep hygiene techniques — such as schedules that balance crew rest needs against a avoiding caffeine consumption near bedtime company’s operational requirements, as well as and establishing a relaxing pre-bedtime rou- the use of various strategies to manage fatigue. tine — and other fatigue countermeasures are The study “enhances the importance of crew currently contemplated in FRMS. However, reporting and monitoring, allowing a greater these are not yet mandatory policies, resulting in control in the observed variables, especially for insufficient, or simply a lack of, implementation [short- and medium-haul] pilots,” the report in many companies. The study demonstrates the importance of these educational plans in the Flight Variables managing of sleep and fatigue, considering the
Variables Short/Medium Haul Long Haul high prevalence values obtained for sleep and Mean age 37.63 ± 7.62 42.70 ± 8.31 fatigue, for both types of flights.” Other efforts to reduce pilot fatigue may Sex come from improvements in the designs of Male 305 (97.4%) 118 (96.7%) the flight deck and of in-flight rest facilities, Female 8 (2.6%) 4 (3.3%) the report said. For example, the report cited Fatigue Severity Scale (FSS)1 modifications of flight deck seat design, efforts FSS ≥ 4 291 (93%) 103 (84.4%) to allow pilots to exercise while seated and the FSS ≤ 3 22 (7%) 19 (15.6%) development of “intelligent” lighting to “smooth Jenkins Sleep Scale (JSS)2 the day/night light transition between departure JSS ≥ 4 107 (34.2%) 45 (36.9%) and destination airports.” JSS ≤ 3 206 (65.8%) 77 (63.1%) Notes Epworth Sleepiness Scale (ESS)3 ESS ≥ 10 193 (61.7%) 65 (53.3%) 1. Short- and medium-haul flights were characterized ESS ≤ 9 120 (38.3%) 57 (46.7%) as those lasting less than six hours with multiple sectors during a single duty period; long-haul flights Professional category were described as those lasting at least six hours and Commanders 166 (53%) 59 (48.4%) typically made up of one or two sectors. Additional First officers 147 (47%) 63 (51.6%) differences involved the size of flight crews (with Labor variables/28 days two pilots in short- and medium-haul crews and ad- ditional crewmembers in long-haul crews), and the Duty hours 112.11 ± 25.03 73.38 ± 22.29 possibility of resting stations outside the flight deck Flown hours 63.03 ± 14.89 55.67 ± 19.70 for members of long-haul crews. Flown sectors 28.89 ± 9.33 7.15 ± 2.70 2. Reis, Cátia; Mestre, Catarina; Canhão, Helena; Early starts 5.33 ± 3.12 0.72 ± 1.34 Gadwell, David; Paiva, Teresa. “Sleep and Fatigue Night periods 0.91 ± 1.10 3.45 ± 1.88 Differences in the Two Most Common Types of Commercial Flight Operations.” Aerospace Medicine Notes: and Human Performance Volume 87 (September 1. The Fatigue Severity Scale is designed to evaluate the effects of fatigue on a person’s life. 2016): 811–815. 2. The Jenkins Sleep Scale is designed to measure a person’s difficulties in falling asleep and staying asleep. 3. The report cited Caldwell, John A. “Fatigue in 3. The Epworth Sleepiness Scale is designed to measure a person’s level of daytime Aviation.” Travel Medicine and Infectious Disease, sleepiness. Volume 3 (May 2005): 85–96. Source: Reis, Cátia; Mestre, Catarina; Canhão, Helena; Gadwell, David; Paiva, Teresa. “Sleep and Fatigue Differences in the Two Most Common Types of Commercial Flight Operations.” Aerospace Medicine and Human Performance 4. Researchers began by distributing 1,498 question- Volume 87 (September 2016): 811–815. naires, but 1,019 were not returned and 44 were Table 1 considered invalid.
32 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | OCTOBER 2016 Powerful new insights gained Teledyne Controls is helping to from aircraft data are fueling power the global aircraft industry: greater efficiencies and Technology leadership: With over 50 years’ experience and a history 1.310.765.3600 reducing costs. This is the of firsts, we are revolutionizing teledynecontrols.com power of data at work. aircraft data management. New functionality: Creative data usage is driving new benefits for companies and passengers alike. Responsive relationships: Around the globe, we work side by side with customers in support of their vision.
Unlimited Visibility. 34 | investigators say. Canada, crash remote partof night flightina for thechallenging lacked thetraining The HEMScrew HELICOPTERSAFETY ‘Not Ready’ T out Ontario. rotor-wing and through three bases - fixed-wing provides air transportation medical from seven operator,the Ornge Rotor-Wing (RW), which by regulator, the Transport Canada (TC), and crew,”flight TSB the added, pointing to actions accident “went well beyond actions the of this according to regulations, TSB the said. plete flight,” this although were both qualified and instrument-flying proficiency to safely com- paramedics and destroying helicopter. the crashed after its takeoff, killing two pilots and two (EMS)helicopter services emergency medical portation Safety of Board Canada (TSB) says. The Ontario, Canada,into total darkness, Trans the - (VFR)departure rules from flight sual Moosonee, Nevertheless, causes the of May the 31,2013, Neither “the pilot night- possessed necessary — was “not operationally ready” for- avi a remote town inNorthern Ontario, Canada patched to pick up aseriously child from ill he crew of Sikorsky the S-76A—dis- BY LINDAWERFELMAN to persist.” allowed non-conformances and unsafe practices TC’s approach to operator with dealing awilling months identified had been before accident, the resources and to address experience issues that indications that Ornge RW lacked necessary the ments,” TSB the said. However, “despite clear comply with regulations and company require- operator. consistent and ineffective surveillance” of the night.” and, ultimately, asuboptimal crew pairing that to… led some company bypassed being policies and personnel inkey positions inexperienced operations. In addition, “insufficient resources hazards the discuss did not of specifically night operator’sthe standard operating procedures for challenges that the faced they night,” and sufficient and adequate training to prepare them TC that knew Ornge RW to “was struggling The TSB’s report faulted final TC for “in- The TSB said pilots the “had not received FLIGHT FOUNDATION SAFETY |
WORLD AEROSAFETY | OCTOBER 2016
TimesEditrtor CC SA 3.0 | Wikimedia HELICOPTERSAFETY
Emergency Evacuation they were descending and said, ‘Let’s climb.’ The The departure at 0011 local time came about aircraft struck terrain less than one second later.” five hours after Ornge RW first received a The crash came 23 seconds after the first of- request for the emergency evacuation of a young ficer had said he was beginning the left turn. patient from Attawapiskat, Ontario; the heli- The burned wreckage was found several copter would have been flown from Moosonee hours later in a thickly wooded, swampy area to Attawapiskat to pick up the patient, and about 1 mi (2 km) from the runway. then from Attawapiskat to Moose Factory. The first request — at 1900 local time May 30 — Working While Vacationing was turned down because of poor weather in The captain held an airline transport pilot license– Moosonee, as was a second request at 2009. helicopter, with nine type ratings, including one At 2319, however, the captain told the Ornge on the S-76; he also was a licensed maintenance Operations Control Centre that weather condi- engineer. He had 11,500 flight hours, including tions had improved, and he accepted the trip. The 10,800 hours in helicopters, 150 hours as pilot-in- helicopter was fueled for the 108-minute VFR command in the S-76A, 650 hours at night and flight, and the pilots began the pre-start checklist 244 total instrument flight hours. at 0000. After takeoff, as the helicopter climbed He was working as a part-time pilot for through 300 ft above ground level (AGL), the first Ornge RW while on vacation from his full-time officer, who was the pilot flying, began a left turn, job as chief pilot of the Ontario Ministry of and the crew began post-takeoff checks. Natural Resources (MNR) Rotor-Wing division The captain called “30 degrees of bank,” — and periodically had done similar part-time The accident flight and the first officer’s response “indicated that it work since 2001, when he completed his S-76A ended 23 seconds was too much bank, and [he] apologized,” the initial aircraft type course. after the first officer report said. “One second later, the landing-gear MNR helicopter flights were conducted pre- ‘Not …Ready’ began a left turn. warning horn sounded; the captain advised that dominantly as day VFR flights, although night VFR flights also were offered. In 2005, the MNR began using night vision goggles (NVGs) on all planned night VFR flights and on some other N Crash site night flights, provided the NVGs were avail- able and the pilots were trained and current in NVG use. The accident captain was described as instrumental in implementing NVG use at the MNR. Ornge RW had considered introducing Approximate path of accident ight NVGs but, largely because of cost, had decided against such a move, the report said. Although the captain had flown to or from Moosonee on “a few” flights while at MNR and in his previous EMS work, there was no record that he had flown out of Moosonee as pilot-in- command on a night VFR flight “since at least Moosonee 2001, when he first began flying as an EMS Airport pilot,” the report said. In 2008, he completed a pilot proficiency check (PPC) in an S-76A and received a score of 2 on a four-point scale for pilot not flying du- 800 m (2,625 ft) ties, the report said; citing TC’s Pilot Proficiency Check and Aircraft Type Rating Flight Test Guide
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(Helicopter).1 The guide said the score signified that he was at Moosonee Airport during the compliance with the “basic standard” but that teleconference. “major deviations from the qualification stan- The captain typically napped before night dards occur, which may include momentary ex- shifts, and investigators said it was “highly likely” cursions beyond prescribed limits but these are that he had done so during the afternoon before recognized and corrected in a timely manner.” the accident flight. There was no indication that fa- The pilot joined Ornge RW in March 2013, tigue played a part in the accident, the report said. briefly as a first officer because of his limited The captain’s logbook showed that, other recent experience in night and instrument flight than the instrument flight rules (IFR) portion rules operations but ultimately as a captain. His of his recurrent S-76 training in March, he had training record included an entry by an S-76 conducted no IFR flights and undergone no IFR line captain indicating that he had undergone training at Ornge RW. Three flights earlier in “no training to date” in black hole operations. 2013 were identified as IFR training. The logbook However, the chief pilot told accident investiga- also showed no record of actual or simulated tors that he “believed that the training had been IFR flight between 2011 and 2013, the report completed in the simulator,” the report said. said, adding, however, that “there were PPC/IFR His first shifts with Ornge RW were all-day entries in December 2012 and April 2013.” shifts (0700 to 1900) on a rotation from April The first officer held a commercial helicopter pi- 25 to May 4, 2013. The accident flight occurred lot license with endorsements for the S-76 and four during the second rotation, which began May other helicopter types. He had 3,700 flight hours, 23. He worked days for the first week of that all in helicopters, including 158 hours in S-76s, 140 rotation, and his first night shift was from 1900 hours at night and 33 hours in actual or simulated May 30 to 0700 May 31, working with the first instrument meteorological conditions. He complet- officer involved in the accident. ed his training with Ornge RW in September 2012. “This was their first night shift together, and A post-accident review of his records showed aside from the five night takeoffs and landings that he had conducted two night takeoffs and completed during simulator training at the end landings in the 90 days before the accident, and of March 2013, it was the captain’s first night a total of 10 night takeoffs and 11 night landings flight at Ornge RW,” the report said. “At the time during his time at the company. Because of his of the occurrence, the captain had flown ap- limited night flying experience, he typically per- proximately 28 hours on the S-76A since joining formed pilot monitoring duties while the captains Ornge RW in March 2013.” flew the helicopter, the report said. During most of his second rotation at Ornge “Company employees considered the first RW, the captain had been “heavily involved with officer to be highly proficient in daytime VFR op- MNR business,” the report said, noting, for exam- erations,” the report said. “However, he had previ- ple, that on one day, he participated by telephone ously encountered some difficulties at night.” in a 45-minute MNR managers’ meeting and sent The report cited “a night departure into a more than 50 emails — many of them related to black hole in early March 2013, [during which] MNR — between his four Ornge RW flights. the first officer began turning at 300 feet AGL. In the hours before the accident night shift The captain intervened, applied collective thrust began at 1900 May 30, the captain again filed a and directed the first officer to continue climb- number of MNR-related emails and participated ing straight ahead up to at least 500 feet AGL. … in another MNR telephone conference, from The captain of the flight had anticipated that the 0900 until 1215. The report noted that, although first officer would have difficulties because of MNR had consistently approved the captain’s his inexperience in night black-hole operations, requests to conduct EMS flights during his and therefore did not consider it necessary to vacation time, MNR employees were not aware report this.”
36 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | OCTOBER 2016 Transportation Safety Board of Canada swampy area. a denselywooded, soon aftertakeoff, in The crashoccurred FLIGHTSAFETY.ORG at Moosonee included Airport winds from 40 At of time the accident, the weather conditions Limited AmbientLighting duringmalfunction accident the flight. regulations and there was no indication of any equipped and maintained inaccordance with accident, and 48,400landings. It was certified, lated hours 15,600flight at of time the the copter at Ornge RW in2012.It had accumu- in 1980and registered as acommercial heli- The accident helicopter was manufactured | AEROSAFETYWORLD | OCTOBER2016 company’s operations, including that it: accident,the report the said. airports.) tions, but Moosonee was not among those SOPs applied to designated black-hole- loca associated with night operations. flight (Other (SOPs) that would have addressed hazards RW lacked standard operating procedures ture runway.” control after passing end the of lit the depar reference to instruments flight to maintain currence pilots would have required complete reference to surface. the As aresult,- oc the ambient or cultural lighting to maintain visual under night VFRregulations without sufficient said.port “Hence, crew the conducted aflight to maintain necessary cues orientation” re the - able to provide avisible horizon or other visual would have limited ambient the lighting avail- was an occurrence the overcast ceiling,which end of Moosonee’s Runway report 6,the said. have reduced of been because overcast. the but, report the noted, ambient lighting would About 50percent of moon the was illuminated, level andsea an overcast ceiling at 9,000ft. scatteredkm), clouds at above 4,600ft mean degrees at 5kt, visibility of more than 9mi(14 The cited report also other problems inthe The lack of appropriate SOPs contributed to The investigation concluded that Ornge “Exacerbating situation this on night the of Few are cues visual present off departure the • • • • of occurrence.” the conditionsthe encountered on night the crew not operationally being prepared for erational readiness. This “resulted inthe and procedures that apilot’s defined op- “Bypassed and eroded” its own policies flight.” was not for first officer the qualified the pany schedulers “did not that identify … rency requirements.” As aresult, com- company and regulatory night cur flight were accordance “in qualified with both program to designed ensure that pilots Was not using acurrency-tracking HELICOPTERSAFETY - - |
37 HELICOPTERSAFETY
•• Operated “with insufficient and inexperi- systems (SMS) by smaller aircraft operators enced personnel in key positions, which while maintaining an oversight philosophy that allowed unsafe conditions to persist.” presumes all operators can identify safety defi- ciencies and rectify them. The TSB noted that Ornge RW had eliminated pilot manager positions at each base in 2012, when Aftermath it began using a centralized scheduling system. In the aftermath of the accident, Ornge RW The change meant that “knowledge of local operat- implemented dozens of related safety actions, ing areas and crews thus was no longer considered including the adoption of new restrictions for all when scheduling crews,” the TSB said, adding night takeoffs and departures, and new proce- that because little consideration was given to pilot dures for flight in black-hole conditions; prohibi- experience or proficiency, “the company did not tions of turns that exceed standard-rate turns in recognize the risks associated with pairing the night and IFR operations; creation of a program occurrence pilots together on a mission that they to monitor and document “all necessary steps were not operationally ready to conduct.” in a first officer’s progression; and the study and The report also criticized TC’s handling subsequent adoption of plans calling for the use of oversight activities, which “did not lead to of night vision goggles in night VFR operations. the timely rectification of non-conformances The TSB issued 14 safety recommendations, that were identified, allowing unsafe practices including one that calls on TC to “clearly define to persist.” The report added that the training the visual references” required to reduce the risks provided to TC inspectors “resulted in uncer- associated with night VFR flight and another that tainty, which led to inconsistent and ineffective calls for instrument currency requirements “that surveillance of Ornge Rotor-Wing.” ensure instrument flying proficiency is maintained In the year before the accident, TC had by instrument-rated pilots who may operate in repeatedly identified non-conformances involv- conditions requiring instrument proficiency.” ing the company’s pilot training program and In addition, TC should establish PPC stan- did not modify its oversight methods when the dards that “distinguish between, and assess the problems persisted, the report said. competencies required to perform, the differing In a January 2013 inspection, TC identified operational duties and responsibilities of pilot-in- the heavy workload for the Ornge RW operations command versus second-in-command”; require manager and chief pilot, noting that several key all commercial operators to implement a formal positions were vacant when the accident occurred SMS, assess those SMSs regularly and enhance its and that other manager posts had been eliminated. oversight policies to “ensure the frequency and “As a result, many safety-related tasks went focus of surveillance, as well as post-surveillance either incomplete or were not started, including oversight activities, including enforcement, are the rectification of training-related problems; commensurate with the capability of the operator support for pilot trainees; tracking/verification to effectively manage risk,” the report said. of training records, pilot qualifications and pilot This article is based on TSB Aviation Accident currencies; updating and approving company Investigation Report A13H0001, “Controlled Flight SOPs and company publications; and hiring Into Terrain; 7506406 Canada Inc.; Sikorsky S-76A more staff,” the report said. “As a result of these (Helicopter), C-GIMY; Moosonee, Ontario; 31 May 2013.” staffing challenges, unsafe conditions persisted, 2016. Available at
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ImpactsBY ED BROTAK
ll aircraft classifications have Translational lift, for example, oc- significantly affected by the speed and operating limitations subject to curs when there is a secondary relative direction of the wind. the complex effects of weather airflow over the rotor disk. In addition FAA notes in the handbook, “An phenomena, but helicopters are to the forward motion of a helicopter in effective tail rotor relies on a stable Aparticularly susceptible to certain oper- flight, translational lift can be produced and relatively undisturbed airflow.” ating risks that arise from aerodynamic by a surface head wind, and the efficien- Anything that can disrupt airflow into characteristics, flight environments, cy of a hovering rotor system increases the tail rotor can cause problems. This mission profiles and other factors with the speed of the incoming wind. would include variable, gusty winds different from those in the fixed-wing Crosswinds and tail winds, however, and turbulence. community. can decrease lift, meaning that more Wind direction also is important. Air movement (wind and turbu- power is needed for takeoff or hovering. For example, winds from approximately lence), air density and degraded visibil- In these situations, takeoffs involving 60 degrees left of the nose (10 o’clock) ity are of critical concern for helicopter horizontal flight occur at a shallower can blow the main rotor vortex (swirl- pilots. Even the airflow generated by angle than when the wind conditions are ing air generated by the helicopter the helicopters themselves can be prob- absent, which could be dangerous if ob- downwash) into the tail rotor, greatly lematic. In addition, many helicopter stacles are in the flight path. This means increasing the turbulence of the airflow. missions require flying at low levels, that, in some situations, wind direction Any significant tail wind can decrease which increases the risk of collision can be a critical safety factor. tail rotor effectiveness. This decrease with objects or the ground. Another problem — one unique may be due to a loss of translational lift, According to the U.S. Federal Avia- to flying helicopters — is loss of tail requiring more main rotor thrust and tion Administration’s (FAA’s) Helicopter rotor effectiveness (LTE). The purpose generating more torque than the tail Flying Handbook,1 “Wind direction of a tail rotor in a helicopter with one rotor can counteract. The aircraft may and velocity affect hovering, takeoff main rotor is to neutralize the torque also begin to weathervane with its nose and climb performance.” FAA charac- created by the main rotor. If the tail into the relative wind. This can also terizes wind in this handbook as one rotor’s performance is impeded, it can cause an accelerating spin. of “the three major factors that affect lead to an uncontrollable spin (rotation A typical LTE accident occurred on performance.” The other factors are air of the fuselage). The magnitude of the May 29, 2013, north of Fort McMur- density and weight of the aircraft. LTE and difficulty of landing can be ray, Alberta, Canada. The pilot of a Bell
40 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | OCTOBER 2016 Clouds: © nd700 | Adobe Stock effective recovery.”effective height above trees the that precluded an causing aloss of directional control at a zone. The helicopter experienced LTE, relative wind into azimuth critical the wind,tail would which have the placed crosswind to left the andwas exposed operating regime inaflight where it Canada concluded, helicopter “The was The Transportation Safety of Board seriously injuring other the passenger. pilot the killing and one passenger and aircraft, and it crashed into woods, the to right. the The pilot lost control of the landing,ed helicopter the beganto spin licopter. While slowing for an attempt - work with two biologists aboard he the - 206B was conducting survey wildlife FLIGHTSAFETY.ORG sembly and may cause it to detach from significant damage to main the rotor as- rotor blades. Mast bumping can cause is caused by excessive flapping of the and main the rotor drive shaft), which a main rotor blade or rotor the hub contact inboard the between end of bumping copter is mast inflight weather-related situation for aheli- Another potentially high-risk, | AEROSAFETYWORLD 2 | OCTOBER2016 (i.e., estimated airspeed of 115 kt.” byed helicopter’s the light weight and turbulence would have exacerbat been - condition of low of The g. any effect turbulence, likely which resulted ina encountered moderate or greater helicopter the likely when occurred accident mast bump report, “The very crash. According to TAIC’s the final breakup. The pilot inthe was killed fuselage, the struck causing amidair thatdetermined main the rotor blade Investigation Commission (TAIC) The New Transport Zealand Accident Range on New Zealand’s North Island. Robinson R66crashed Kaweka inthe turbulence. with vertical occurs also orcally pilot-induced situations, low g in aweightless state. mechani- Besides dard gravitational acceleration), such as conditionsflight (relative to 1gstan- underdesigns. “low-g” This occurs more likely insome two- ing some —which data indicate may be have attributed been to mast bump- fuselage. Anumber of fatal accidents aircraft.the The rotor may the strike For example, on March 9,2013,a bladed– natural risksconfronting rotorcraft pilots. and airdensityare theleadingedgeof From ameteorologist’s perspective,wind 3 rotor moment rolling aircraft, the and the main rotor produces thrust a strong rangethis of tilt angle or greater, the events to that rollover. lead the will At enough tobe initiate sequence of the tilt angle of five to eight degrees can a lateral roll of aircraft. the An initial it is susceptible to dynamic rollover, during surface the or takeoff landing, and injured two the passengers. resulted inacrash pilot the that killed wave. Arapid, uncontrollable descent helicopterthe into mountain aleeside 10, 2012.Astrong wind gust pushed near Carcross, Yukon, Canada,on July to close R44 IIwas flying aridge line and sightseeing are at especially risk. infirefighting,flown search and rescue, tainous regions, and helicopters being area buildings with is tall such aplace. wind encounters obstacles. An urban iswhich generated prevailing the when teorologists mechanical call turbulence, ters are likely to encounter what me- When ahelicopter is incontact with For example, pilot the of aRobinson Turbulence is common also inmoun- Low-level means flying that helicop- HELICOPTERSAFETY 4
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41 helicopter: Susan Reed; weather vane© brankica | VectorStock HELICOPTERSAFETY
pilot often cannot overcome that force reported as the probable cause of the even more susceptible than airplanes to with the flight controls. One cause of LOC-I accident.7 severe problems. dynamic rollover is a strong crosswind, According to a report published The lift generated by the main rotor which can give the initial sideways in June 2015 and prepared through and the torque generated by the tail ro- push. Takeoffs and landings on slop- cooperation of the Helicopter Associa- tor (in single-rotor helicopters) are de- ing terrain are even more problematic tion International, American Helicop- creased. Takeoffs can be difficult. Risk — with upslope winds and tail winds ter Society International, the General of LOC-I is a strong possibility. Check- increasing the risk of rollover. Aviation Manufacturers Association ing the actual HDA values in advance Adequate visibility is essential to and the Aircraft Electronics Associa- is critical for pilots in these situations. unaided visual helicopter operations. A tion, “Over the period of 2001 to 2013, Loads must be carefully monitored and degraded visual environment increases for single-engine helicopters world- managed. the risk of collisions with buildings, wide, there were 194 accidents related The normal ability to autorotate and towers, power lines and the terrain it- to IMC or CFIT [controlled flight into to land safely in emergency situations also self, especially in mountainous regions. terrain] due to low-level flight to avoid is compromised. Depending on the gross Instrument meteorological conditions weather, with 133 of these accidents weight of the aircraft, the vertical descent (IMC) due to fog or clouds are a major involving fatalities and 326 people rate reduction of an autorotation may cause of a degraded visual environ- [who] lost their lives. None of these not be enough to safely land. Another ment. For example, an Agusta Westland rotorcraft were [equipped with instru- problem with HDA can be low rotor rpm AW109 struck a construction crane in ments required for instrument flight that leads to main rotor blade stall. With dense fog on Jan. 16, 2013, in Vauxhall, rules (IFR) flight]. In fact, IFR-certified HDA, the power output of the engine can London, England. The aircraft crashed single-engine rotorcraft are virtually be significantly reduced. This can lead into a building below, killing the pilot nonexistent in the current fielded fleet. to low rotor rpm even with maximum and one person on the ground (ASW, For multi-engine [rotorcraft] (over the throttle being applied by the pilot. 11/14, p. 32). same period), 54 accidents were related Lift generation can be greatly It is difficult sometimes to avoid, in to IFR [operation], IMC or CFIT due reduced, and the risk of rotor blade a discussion of weather-related rotor- to low-level flight to avoid weather, stall may increase greatly. HDA can craft flying risks, issues that also occur with 46 of these accidents involving also affect tail rotor aerodynamic in airplane flight operations. Spatial fatalities.”8 performance. Thrust and efficiency disorientation, as one case, counts as a Besides operation in clouds and are reduced by the thin air. LTE can very real possibility for helicopter pilots fog during landing or other maneuvers occur especially with heavy loads. For and is often followed by loss of control– close to the ground, the helicopter ac- example, a Bell 407 entered an uncon- in flight (LOC-I). The crash of a Loui- cident record shows that heavy rainfall trollable spin and crashed on Feb. 15, siana Army National Guard Sikorsky can significantly reduce visibility. Even 2012, in Moran Junction, Wyoming, UH-60 Black Hawk helicopter, which worse is the risk during heavy snowfall, U.S., while on a search and rescue mis- killed 11 people on March 10, 2015, in which can produce whiteout condi- sion. The crash resulted in one fatal- Santa Rosa Sound, Florida, U.S., was at- tions with visibility near zero. In drier ity and two serious injuries. The U.S. tributed to spatial disorientation of the climates, dust or sand storms also can National Transportation Safety Board’s pilots due to thick fog.5 reduce visibility, producing so-called (NTSB’s) final accident report cited as So was the crash of an Agusta brownout conditions. the probable cause “the pilot’s failure to Westland AW139 on March 13, 2014, As noted, FAA calls air density a maintain yaw control while hovering at in Norfolk, England, which killed “major factor” in determining safety high density altitude, which resulted in four occupants.6 Five occupants were margins in helicopter performance. a loss of tail rotor effectiveness.”9 killed when a Robinson R66 crashed High density altitude (HDA) — un- With the main rotor of a helicop- in Noxen, Pennsylvania, U.S., on July usually “thin” (low-density) air due to ter displacing so much air, this factor 27, 2013. The pilot of the visual flight the combination of hot temperatures alone can produce safety problems rules (VFR) flight inadvertently en- and/or high altitude — can affect all with weather-like characteristics. Since tered IMC. Spatial disorientation was aircraft, but once again, helicopters are helicopters often land vertically, they
42 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | OCTOBER 2016 © Nightman1965 | iStockphoto accidents, FAA the and University the In terms of weather-related HEMS (HEMS). services emergency medical years, as reported inASW many risk mitigations new in recent that has responded to accident rates with 2013 (ASW, and four serious injuries on Aug. 23, Puma, resulted which infour fatalities an Airbus Helicopters AS332 L2Super cause crash inthe into North of the Sea Vortex ring state was cited as aprobable tional velocity mpm. The transla low airspeed called rate that can approach 6,000fpm/1,829 regardless of power applied, often to a The aircraft continue will to descend capacity lifting the of main the rotor. rotor blades. vortices These dissipate vortices can develop around main the into its own downwash, unusually large power. with state, settling sometimes called airflow that can produce vortex ring years helicopter has been self-generated AeroSafety World articlesthrough the ing area snow has aloose cover. similar situation land ifthe - can occur can reduce visibility to near zero. A produce acloud of dust that inseconds area composed or of dirt sand fine can downwash. to Descending asurface to risks from own exposed their can be FLIGHTSAFETY.ORG One of sector aviation the industry Another problem in discussed When ahelicopter descends 7/16,p. 24). | AEROSAFETYWORLD often initiates cycle. the , is helicopter | OCTOBER2016 - ambulance operators.” quality of go/no-go decisions for air observations capability. It improves the in areas with limited available surface visibility assessment along direct flights planning flight cal tool for ceiling and National Weather is “a Service graphi- HEMS Tool by U.S. the , as described routes/diversion landing facilities.” The destinationprimary and contingency for departure the point, enroute, and ing. factors These should considered be weather such as thunderstorms and ic- for operations), off-airport and severe potential for ground fog (especially cipitation, winds, surface winds aloft, awareness of “ceiling, visibility, pre- rent and forecast weather. factors from appropriate sources of cur includes relevant all specifically which ofbenefits apreflight risk analysis, and brownouts. It emphasizes also the visibility issues, including whiteouts intoflight IMC and other degraded- inadvertentIMC —especially VFR aviationweather.gov/hemst)>. Emergency Medical Tool Services
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On-Board Fatalities Plummet Boeing data show 16 fatalities — all involving people on the ground — stemming from Western-built commercial jet crashes in 2015.
BY LINDA WERFELMAN
n-board fatalities in crashes involving reported 28 accidents involving Western-built Western-built commercial jets1 declined to commercial jets in 2015; six of the accident air- zero in 2015, down from 278 fatalities in planes were destroyed.3 By comparison, in 2014, 2014, according to data from Boeing Com- airplanes were destroyed in three of 29 accidents Omercial Airplanes. The death toll for people on involving Western-built commercial jets. the ground — killed in three separate accidents — Seven of the 28 accidents in 2015 were totaled 16; the comparable 2014 figure was one. considered major accidents — a term defined Boeing’s annual Statistical Summary of Com- by Boeing to describe an accident in which any mercial Jet Airplane Accidents,2 published in July, of these three conditions is met: The airplane
Accidents, Worldwide Commercial Jet Fleet, by Type of Operation
On-board Fatalities All Accidents Fatal Accidents (External Fatalities)* Hull Loss Accidents Type of operation 1959–2015 2006–2015 1959–2015 2006–2015 1959–2015 2006–2015 1959–2015 2006–2015 Passenger 1,525 312 495 48 29,165 (800) 3,133 (82) 717 115 Scheduled 1,404 288 449 45 25,039 3,117 647 118 Charter 121 24 46 3 4,126 16 70 7 Cargo 269 63 80 14 273 (350) 41 (23) 180 37 Maintenance test, ferry, positioning, 124 11 44 3 208 (66) 17 (0) 76 7 training and demonstration Totals 1,918 386 619 65 29,646 (1,216) 3,191 (105) 973 159 U.S. and Canadian operators 571 69 182 11 6,202 (381) 26 (6) 230 25 Rest of the world 1,347 317 437 54 23,444 (835) 3,165 (99) 743 134 Totals 1,918 386 619 65 29,646 (1,216) 3,191 (105) 973 159
*External fatalities include ground fatalities and fatalities on other aircraft involved, such as helicopters or small general aviation airplanes, that are excluded.
Source: Boeing Commercial Airplanes
Table 1
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | OCTOBER 2016 | 45 DATALINK
was destroyed, the accident resulted in multiple Boeing’s data show a total of 386 crashes, fatalities, or the accident involved one fatality including 65 fatal crashes for the 10-year period and substantial damage to the airplane. from 2006–2015, down from 404 crashes and 72 fatal crashes for the previous comparable period 10-Year Accident Rates, by Type of Operation, of 2005–2014 (Table 1, p. 45). On-board fatali- Worldwide Commercial Jet Fleet, 2006–2015 ties in 2006–2015 totaled 3,191, compared with 3,946 for the previous period.
Fatal accident rate From 1959, when Boeing’s record-keeping Hull loss accident rate began, through 2015, data show a total of 1.50 1,918 accidents, including 619 fatal accidents with 29,646 on-board fatalities and 1,216 “external” fatalities involving people outside the airplane. 0.70 0.56 0.59 The fatal accident rate for the 2006–2015
period was 0.29 per million departures, the 0.29 0.23 report said. That figure represents a decline from 0.32 per million departures for the Scheduled commercial All other operations* Total previous 10-year period (Figure 1). The data passenger operations 34.0 million departures 226.8 million departures also show a hull loss accident rate of 0.70 per 192.8 million departures million departures. Boeing uses the term hull
* Charter passenger, charter cargo, scheduled cargo, maintenance test, ferry, positioning, loss to characterize an airplane that is “totally training and demonstration flights. destroyed or damaged and not repaired.” The Source: Boeing Commercial Airplanes category also includes airplanes that are miss- ing or inaccessible. Figure 1 Data show a total of 159 hull Accidents, by Injury and Damage, Worldwide Commercial Jet Fleet loss accidents from 2006–2015, including T 55 fatal accidents and (32% of total) (68% of total) 104 without fatalities 502 accidents with hull loss 471 hull loss accidents (Figure 2). From 1959 27 accidents with 761 substantial damage accidents substantial damage through 2015, data accidents without accidents without substantial show a total of 973 substantial damage damage (but with serious injuries) hull loss accidents, 0 100 200 300 400 500 600 700 800 900 1,000 1,100 1,200 1,300 1,400 1,500 1,600 1,700 1,800 1,900 2,000 including 502 that were fatal. T More than half (17% of total) (83% of total) of all on-board 55 accidents hull loss 104 hull loss accidents fatalities recorded 2 accidents with from 2006 through substantial damage 198 substantial damage accidents 2015 involved loss of 8 accidents without 19 accidents without substantial substantial damage damage (but with serious injuries) control–in flight acci-
0 100 200 300 400 dents — 1,396 (Figure 3). The second-largest
Source: Boeing Commercial Airplanes number of onboard fatalities — 658 — re- Figure 2 sulted from controlled
46 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | OCTOBER 2016 DATALINK
Fatalities by CAST/ICAO Taxonomy Accident Category, Worldwide Commercial Jet Fleet, 2006–2015
2,000 On-board fatalities [Total 3,191] 1,800 External fatalities [Total 105] 1,600 | 1,400 , 1,200 1,000
Fatalities 800 | | 600 400 | | 200 154 9 | | | | | | | 0 LOC-I RE CFIT SCF-PP MAC WSTRW UNK RE RAMP F-NI OTHR RI-VAP (Landing) + (Takeo ) ARC + USOS Number of fatal accidents (65 total) 15 14 14 2 3 1 2 3 7 2 1 1
CAST = U.S. Commercial Aviation Safety Team; ICAO = International Civil Aviation Organization; ARC = abnormal runway contact; CFIT = controlled flight into terrain; F-NI = fire/smoke (non-impact); LOC-I = loss of control–in flight; MAC = midair/ near-midair collision; OTHR = other; RAMP = ground handling; RE = runway excursion; RI-VAP = runway incursion – vehicle, aircraft or person; SCF-PP = system/component failure or malfunction (powerplant); UNK = unknown or undetermined; USOS = undershoot/overshoot; WSTRW = wind shear or thunderstorm. No accidents were noted in the following principal categories: aerodrome; abrupt maneuver; air traffic management/ communications, navigation, surveillance; bird strikes; cabin safety events; evacuation; external load-related occurrences; fire/smoke (post-impact); fuel related; ground collision; icing; low altitude operations; loss of control–ground; runway incursion–animal; security related; system/component failure or malfunction (non‑powerplant); turbulence encounter; wildlife. Note: Principal categories are as assigned by CAST. Airplanes manufactured in the Commonwealth of Independent States or the Soviet Union are excluded because of lack of operational data. Commercial airplanes used in military service are also excluded.
Source: Boeing Commercial Airplanes
Figure 3
flight into terrain accidents, followed closely Notes by 632 onboard fatalities in runway excursion accidents. Fatalities in these three categories far 1. The data include worldwide commercial jet airplanes with maximum gross weight of more than 60,000 lb exceeded all others. (27,217 kg), with two exceptions: airplanes manufac- Nearly half of all fatal accidents from 2006 tured in the Commonwealth of Independent States through 2015 occurred during final approach or the former Soviet Union, because of insufficient (26 percent of all fatal accidents and 27 per- operational data, and commercial airplanes operated cent of fatalities) and landing (23 percent of in military service. Airplanes destroyed by sabotage fatal accidents and 20 percent of fatalities), the or terrorism also are excluded. report said. 2. Boeing Commercial Airplanes. Statistical Summary An additional 12 percent of fatal accidents of Commercial Jet Airplane Accidents: Worldwide and 24 percent of fatalities occurred during Operations, 1959–2015. July 2016.
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12206_AIR_QA_Services_Client_Request_279x215_1.0.indd 1 20/09/2016 17:43 ONRECORD False Cues Prompt ‘Stall Recoveries’ Abrupt pitch changes injured several passengers and flight attendants.
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
Pitot Blocked by Ice report said that he likely was startled by this Boeing 757-200. Substantial damage. Seventeen minor injuries. indication. nbound from Newark, New Jersey, U.S., with “The copilot, believing that the aircraft was 131 passengers and eight crewmembers the about to stall, immediately pushed the control Imorning of Oct. 20, 2013, the flight crew saw column forward and applied full power without only light precipitation on their weather radar as disengaging the autopilot or autothrottle” in accor- they neared their destination in Dublin, Ireland. dance with prescribed procedure, the report said. Investigators later determined, however, “If the copilot had carried out the first ac- that the on-board weather radar likely was not tions of the aircraft manufacturer’s stall recovery adjusted correctly and did not display an area of checklist, which are to hold the control col- heavy precipitation that the 757 would encoun- umn firmly and disconnect the autopilot and ter during the descent to Dublin. autothrottle, it is likely he would have sensed the The aircraft was about 80 nm (148 km) from control loads on the control column, especially Dublin, descending through 25,000 ft in instru- as he applied forward pressure. The control ment meteorological conditions, when it en- loads and pitch rate become more pronounced countered turbulence that the copilot, the pilot as the [airspeed] of the aircraft increases.” flying, described as severe, said the report by the Because he did not follow the procedure, the Air Accident Investigation Unit of Ireland. copilot did not sense the normal control loads. The pilots also saw St. Elmo’s fire form on However, seeing the indicated airspeed increase the aircraft. This phenomenon was described by in the dive, he began to raise the nose and reduce the report as “a visible electrical discharge when power. The indicated airspeed again began to an aircraft is flown through a heavily electrostat- decrease to a low value. Reacting to this indication ically charged atmosphere. It is often associated and to the sound of the overspeed warning, which with nearby cumulonimbus or thunderstorm he misinterpreted as a stall warning, the copilot activity and/or flight through ice crystal.” pushed the control column forward a second time. As the turbulence subsided, the copilot saw The 757’s actual airspeed reached 380 kt — that the airspeed shown on his primary flight about 30 kt higher than the maximum operating display (PFD) had dropped to about 90 kt. The speed. The report said that neither pilot noticed a
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | OCTOBER 2016 | 49 ONRECORD
master caution light or an “IAS [indicat- Brake Slows Takeoff Roll the parking brake is engaged and the ed airspeed] DISAGREE” annunciation, Cessna Citation 550. Substantial damage. No injuries. absence of a parking brake check on the which was triggered by ice crystals that he flight crew detected noth- Citation 550’s “Before Takeoff” checklist. were blocking the pitot tube connected ing abnormal while preparing to to the copilot’s air data computer. Tdepart from Lismore, New South ‘Limited Runway Remaining’ The temporary blockage of the pitot Wales, Australia, the morning of Sept. Airbus A319. No damage. No injuries. tube caused the airspeed indications 25, 2015. However, when the captain efore boarding the A319 for a flight on the copilot’s PFD to be about 100 kt attempted to rotate the aircraft at the from Lisbon, Portugal, to Basel, lower than those on the commander’s appropriate airspeed, 108 kt, the Cita- BSwitzerland, the afternoon of Oct. PFD and on the standby airspeed tion did not achieve a sufficient takeoff 16, 2015, the flight crew discussed the indicator. pitch attitude. weather conditions, which included “Following the second pitch-down “The captain then applied full back- light and variable surface winds, and manoeuvre, the flight crew concluded pressure and reported that the controls the possibility that they would depart that the copilot’s airspeed indications felt very heavy,” said the report by the from Runway 03. were reading incorrectly and that the Australian Transport Safety Bureau Although the automatic terminal commander’s airspeed indications, (ATSB). “Neither the captain nor the co- information service indicated that which agreed with the standby airspeed pilot detected any change in the aircraft’s Runway 21 was in use, the crew subse- indications, were correct,” the report pitch attitude or any indication of pitch- quently used their electronic flight bag said. “Consequently, the commander up on the attitude direction indicator.” to derive performance data for a depar- took control of the aircraft and re- The captain applied full braking ture from an intersection of Runway 03, turned it to stabilised flight.” and reverse thrust to reject the takeoff, which would provide a takeoff distance The cabin crew notified the pilots but the Citation overran the 1,647-m of 3,530 m (11,582 ft). The data then that a number of passengers (later (5,404-ft) runway. The nose landing was entered into the aircraft’s flight determined as 13) and four flight at- gear collapsed, and the aircraft came management guidance computer. tendants had sustained minor injuries to a stop on the wet, grass runway end “During this time, the commander’s from striking portions of the cabin. The safety area. Neither pilot was hurt. attention was distracted by people enter- report said that the injuries likely were Investigators determined that the ing the cockpit,” said the report by the caused by the rapid changes in positive Citation’s parking brake had not been U.K. Air Accidents Investigation Branch. and negative G-load during the “stall- released before takeoff. The resulting Neither pilot later noticed the data recovery” maneuvers. friction slowed acceleration during the discrepancy when they were cleared for “The commander advised [Dub- takeoff roll but was not sufficient to takeoff from an intersection of Runway lin approach control] that they had prevent the aircraft from reaching rota- 21, which provided a takeoff distance of encountered severe turbulence and tion speed. 2,410 m (7,907 ft). that medical assistance was required “Furthermore, the nose-down mo- “The crew considered the takeoff
on arrival because some passengers ment generated by the partial brake normal until the aircraft approached V1, had been injured,” the report said. He pressure probably prevented the aircraft when they noticed there was limited run- also requested that airport fire services [from] rotating sufficiently to become way remaining, but the remainder of the
attend the landing due to an indicated airborne, despite normal nose-up eleva- flight was uneventful,” the report said. (V1 loss of the center hydraulic system. tor deflection,” the report said. “Heat in is defined as the maximum speed during The pilots landed the aircraft with- the brakes due to partial pressure dur- takeoff at which the pilots must take the out further incident. Examination of ing the takeoff run may have reduced first action to stop the airplane within the the 757 revealed that the panel covering their effectiveness when the captain accelerate-stop distance.) the center hydraulic system service bay rejected the takeoff, contributing to the The aircraft, with 147 passengers and had detached and had damaged system runway overrun.” six crewmembers aboard, had lifted off components, including the dump valve, The ATSB recommended that the with 213 m (699 ft) of runway remaining. leading to the loss of hydraulic fluid manufacturer take action to address the “The commander later comment- and pressure. absence of an annunciator showing that ed that this occurrence was a result
50 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | OCTOBER 2016 ONRECORD
of multiple distractions during pre-flight “The commander added that in the future, preparation and some complacency as a result if he is interrupted during a brief or crosscheck of operating from his home base,” the report of data, he will start the process again to ensure said. that it is completed fully.”
TURBOPROPS
Control Lost at Night “As the wings failed, the propellers simulta- Fairchild Metro 3. Destroyed. Two fatalities. neously chopped through the fuselage behind ight visual meteorological conditions the cockpit. At the same time, the horizontal sta- (VMC) prevailed for the cargo flight from bilizers were also positioned broadside against Nthe Dominican Republic to San Juan, the relative wind, and they also failed upward.” Puerto Rico, on Dec. 2, 2013. Nearing the destination, the flight crew was cleared by air Glass Beads Cause Engine Failure traffic control (ATC) to descend from 11,000 ft Cessna 208. Substantial damage. No injuries. to 3,000 ft. he Caravan was climbing through 8,000 ft “During the descent, at about 7,300 ft and after departing from Kahului, Hawaii, U.S., 290 kt, the airplane entered a shallow left turn, Tfor a charter flight the evening of Oct. 21, followed by a 45-degree right turn and a rapid, 2013, when the flight crew heard a loud bang uncontrolled descent, during which the airplane and a grinding sound, and saw sparks emerge broke up about 1,500 ft over uneven terrain,” from the engine’s right exhaust pipe. said the report by the U.S. National Transporta- The engine lost power, and the crew turned tion Safety Board (NTSB). back toward Kahului Airport, 13 nm (24 km) Investigators concluded that the flight crew north. “The crew accomplished the emergency had lost control of the Metro, but they were checklists and elected to perform an emergency unable to determine why. The airplane, which landing on a highway,” the NTSB report said. had no data recorders or downloadable avionics “During the landing roll, the airplane memory, had been loaded properly, and there struck two highway traffic signs, which re- was no sign of an initiating mechanical failure sulted in substantial damage to the right wing.” or abnormality. The pilots and their eight passengers were not “Other similarly documented accidents and injured. incidents generally involved unequal fuel burns, Examination of the engine revealed that all of which resulted in wing drops or airplane rolls,” the blades on the compressor disc had separated, the report said. “However, [the Metro’s] fuel and glass beads and bead fragments were found crossfeed valve was found in the closed position, embedded in the blade “fir-tree” attachment joints. indicating that a fuel imbalance was likely not a This indicated that the compressor disc, fully concern of the flight crew.” assembled, had been cleaned by aggressive bead- The report said it was likely that the breakup blasting, likely when the engine was removed for was precipitated by overstress during attempted repair about two months before the accident, the recovery from the control loss. report said. “With darkness and the rapid descent at a “The engine manufacturer specifies that all relatively low altitude, one or both crewmem- media-blast cleaning be performed with the bers likely pulled hard on the yoke to arrest the [compressor] disc and blades disassembled,” downward trajectory and, in doing so, placed the report said. “The glass bead contamination the wings broadside against the force of the rela- of the fir-tree joints caused the [compressor] tive wind, which resulted in both wings failing blades to be unevenly restrained, and it altered upward,” the report said. the blades’ designed vibration frequency,
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | OCTOBER 2016 | 51 ONRECORD
making them susceptible to the aerodynamic gear was down and locked. However, the right vibrations from the combuster gas flow. main landing gear collapsed shortly after “Therefore, the fatigue fracture of the touchdown. blades was most likely due to the glass bead “Upon contact with the ground, all of the contamination.” right-side propeller blades were sheared, and one blade penetrated the cabin wall,” said the Tire Bursts on Takeoff report by the Transportation Safety Board of Bombardier Q400. Substantial damage. Three minor injuries. Canada (TSB). Three passengers were injured by he inboard tire on the right main landing debris from the propeller impact. gear ruptured as the aircraft reached rota- The Q400 came to a stop off the right edge Ttion speed on takeoff from Calgary, Alberta, of the runway, and the passengers and crew Canada, the night of Nov. 6, 2014. The flight was evacuated using all four exits. There were no scheduled to land at Grand Prairie, but the flight injuries during the evacuation. crew decided to divert to Edmonton. The TSB concluded that the tire rupture During the approach to Edmonton, the on takeoff from Calgary “most likely [was the] pilots received indications that the landing result of impact with a hard object.”
PISTON AIRPLANES
Water in Fuel System “Although the caps appeared to fit satisfac- Britten-Norman Islander. Destroyed. Three fatalities, one serious injury. torily, it was found that the right tank cap did he airport at St. John’s, Antigua, had been not always seal properly, with corrosion on the closed due to thunderstorms and heavy adaptor plate possibly contributing to this con- Train, and was reopened shortly before the dition,” the report said. “A simple experiment Islander was cleared to depart on a visual flight indicated that water could leak past the cap seal rules (VFR) scheduled flight to Montserrat the and into the tank.” morning of Oct. 7, 2012. The report said that the right fuel tank con- The pilot did not drain the fuel system tained a significant amount of water that could sumps during preflight preparations or conduct have been detected if the pilot had checked the power checks before initiating a takeoff to the sumps before takeoff. northeast, toward the sea, from a runway inter- section, said the report by the Eastern Carib- Spatial Disorientation bean Civil Aviation Authority. Beech 58 Baron. Destroyed. Three fatalities. Witnesses saw the Islander climb about 200 arginal VMC, including 6 mi (10 km) to 300 ft, roll right and descend to the ground visibility, a broken ceiling at 1,000 ft and near the runway departure threshold. Two pas- Man overcast at 1,700 ft, prevailed when sengers and the pilot were killed, and another the Baron departed from Midway Airport in passenger was seriously injured. Chicago for a VFR flight to Kansas the night of Investigators determined that the right Oct. 12, 2014. engine had lost power due to contamination Recorded ATC radar data indicated that the of the fuel supply by water. The fuel filler caps Baron entered the clouds shortly after takeoff. on the airplane were of a type included in an Track and altitude then varied substantially equipment modification designed to prevent before the airplane entered a descent exceeding water from entering the fuel system. However, 5,000 fpm and struck the ground. The pilot and the adaptor plates were original equipment and his two passengers were killed. had not been replaced in conformance with the The pilot was certified for instrument flight modification. in multiengine airplanes but had not filed a flight
52 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | OCTOBER 2016 ONRECORD
plan. “The airplane’s avionics and instruments The Twin Comanche was high on the ap- could not be functionally tested due to the extent proach and was flared for landing about 100 of the impact damage,” the NTSB report said. ft above the 980-m (3,215-ft) gravel runway. The NTSB concluded that the probable cause “The aircraft floated and touched down about of the accident was “the pilot’s loss of airplane con- a quarter [of] the way along the runway,” the trol due to spatial disorientation while operating report said. The pilot reduced power to idle and in night instrument meteorological conditions.” applied light wheel braking. The aircraft was about halfway down the Too Late to Go Around runway when the pilot realized that ground- Piper Twin Comanche. Substantial damage. No injuries. speed was excessive. “The pilot determined 15-kt crosswind existed at the airstrip in that it was too late to commence a go-around” Innamincka Township, South Australia, and applied full braking, the report said. “He Awhere a fly-in was being held on Oct. reported that the braking appeared to be ineffec- 26, 2012. “As a precaution, the pilot elected to tive due to the surface of the runway, and the increase the aircraft’s airspeed for the approach aircraft continued beyond the runway end.” by about 5 kts and selected 1/2 flaps,” the ATSB Damage was substantial, but the pilot and report said. his passenger were not hurt.
HELICOPTERS
Dynamic Rollover begin rolling, and under certain circumstances it Bell 206B-3. Substantial damage. One serious injury, cannot be controlled.” two minor injuries.
he pilot made several practice approaches ‘Low Risk, Go Flying’ and landings before beginning flights to Airbus AS350. Substantial damage. No injuries. Ttransport passengers to a rock ledge on efore departing to pick up four seismic workers Mount Cook in Queensland, Australia, on the near Deadhorse, Alaska, U.S., the afternoon morning of Oct. 7, 2014. Bof Oct. 26, 2015, the pilot conducted a risk During the practice landings, he decided assessment of the landing site, where visibility was that resting the right skid on the edge of the between 1 and 3 mi (1,610 m and 4,831 m). ledge was preferable to touching down on the “The assessment fell within the ‘low risk, go uneven surface with both skids. flying’ category, and a VFR company flight plan After transporting five passengers to the was filed,” the NTSB report said. ledge, the pilot returned to pick up some of the The pilot, who was not certified for instru- passengers. The JetRanger was lifted by a gust ment flight, encountered deteriorating weather of wind on touchdown, and the right skid began en route and flat-light conditions at the landing to scrape along the surface of the ledge. The site. “While slowing down to land, blowing snow helicopter then rolled onto its right side, slid and from the main rotor downwash subsequently struck two waiting passengers. reduced the visibility to whiteout conditions One passenger was seriously injured; the with no ground reference, which likely led the other passenger and the pilot sustained minor pilot to experience spatial disorientation,” the injuries. report said. “The roll onto the right side by the helicop- The right skid snagged the ground on touch- ter is consistent with the phenomenon known as down, and the helicopter rolled onto its side. dynamic rollover,” the ATSB report said. “When Damage was substantial, but the pilot was not a helicopter rests on one skid, the aircraft may hurt.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | OCTOBER 2016 | 53 ONRECORD
Preliminary Reports, July 2016
Date Location Aircraft Type Aircraft Damage Injuries July 1 Rybnyi Uyan, Russia Ilyushin 76TD destroyed 10 fatal The air tanker was fighting a wildfire when it struck a mountain slope. July 6 Italy, Texas, U.S. Bell 525 destroyed 2 fatal The experimental helicopter broke up in flight and struck terrain during a developmental test flight. July 11 Montijo Air Base, Portugal Lockheed C-130H destroyed 3 fatal, 4 serious The flight crew was conducting touch-and-go landings when the C-130 veered off the left side of the runway. July 11 Georgetown, Delaware, U.S. Bell 429 none 1 fatal, 3 none The GlobalRanger was engaged in external-load operations when the hoist operator fell from the helicopter after stepping out onto a skid. July 11 Bartow, Florida, U.S. Cessna 310Q substantial 1 minor The 310 descended into a swamp after both engines lost power while on a downwind leg to land. July 11 Hickory, Kentucky, U.S. Bell 407 substantial 1 fatal The helicopter was on final approach when it abruptly banked right and descended to the ground. July 14 Kona, Hawaii Piper Apache destroyed 2 minor The Apache was ditched in the Pacific Ocean after both engines lost power. The airplane sank and has not been recovered. July 15 Elwyn Creek, British Columbia, Canada de Havilland Beaver destroyed 1 fatal A search was initiated after the Beaver did not arrive at Mowdade Lake. The wreckage was found at 5,000 ft in a ravine. July 16 Madrid, Spain Robinson R22 Beta substantial 2 fatal The helicopter struck a power line and descended into a reservoir. July 17 Yakima, Washington, U.S. Bell UH-1H substantial 8 none The Huey helicopter struck terrain at 7,800 ft after losing tail rotor effectiveness during a landing attempt to rescue an injured hiker. July 20 Jinshan City, China Cessna 208B destroyed 5 fatal, 5 serious The float-equipped Caravan struck a bridge during takeoff from a bay. July 21 Plainfield, Illinois, U.S. Piper Twin Comanche destroyed 1 fatal Witnesses reported thunderstorm activity in the area when the Twin Comanche struck terrain in a steep nose-down attitude. July 21 Baldwin, Wisconsin, U.S. Cessna 208B substantial 15 none The pilot rejected a parachute drop due to weather conditions. The Caravan subsequently struck a ditch after overrunning the wet 1,950-ft (595-m) grass runway on landing. July 22 Bay of Bengal Antonov 32 NA 29 NA The An-32 was en route from Tambaram to Port Blair, India, at 23,000 ft when radar data showed that it turned left and entered a rapid descent. The aircraft was still missing at press time. July 23 Byron, California, U.S. Beech King Air A90 substantial 15 none The King Air stalled and entered a spin while nearing the jump zone at about 10,000 ft. The parachutists bailed out after the pilot regained control. He was able to land the airplane at the airport despite the loss of the right horizontal stabilizer and elevator. July 24 Leshara, Nebraska, U.S. Beech B55 Baron destroyed 2 fatal A witness heard abnormal engine sounds and then saw the Baron spin to the ground. The pilot and pilot examiner, who was conducting a check ride, were killed. July 26 Houston, Texas, U.S. Embraer Phenom 300 substantial 2 minor, 1 none Visibility was 3 mi (4,831 m) in rain and surface winds were from 130 degrees at 8 kt when the EMB-500 overran 8,000-ft (2,440-m) Runway 35 at Sugar Land Regional Airport on landing and struck an embankment. Both pilots sustained minor injuries. July 27 Columbia, California, U.S. Cessna 310B substantial 4 fatal Visual meteorological conditions prevailed when the 310 drifted left on takeoff and descended to the ground. July 29 McKinleyville, California, U.S. Piper Cheyenne destroyed 4 fatal The Cheyenne was on an emergency medical services flight at 10,000 ft when the pilot declared an emergency and reported smoke in the cockpit. The airplane struck terrain shortly thereafter. July 31 Kemerovo, Russia Antonov 2R destroyed 3 fatal The An-2 was on a positioning flight from Krasnodar to Irkutsk when it struck a mountain. July 31 Londrina, Brazil Embraer EMB-820 destroyed 8 fatal The Navajo, built under license by Embraer, stalled on approach and crashed into a hangar.
NA = not available This information, gathered from various government and media sources, is subject to change as the investigations of the accidents and incidents are completed.
54 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | OCTOBER 2016 SMOKEFIREFUMES
Selected Smoke, Fire and Fumes Events, May–August 2015
Event Date Flight Phase Classification Subclassification Aircraft Operator May 1 Cruise Air distribution system Smoke 767 Hawaiian Airlines Performed an air turn back due to fumes and smoke in cabin. Accomplished visual inspection of cockpit, cabin and electronics and equipment (E&E) compartments, no defects noted. Accomplished visual check of left and right engines and auxiliary power unit (APU). No defects noted. Ran engines and APU with right pack off. No defects noted. All eight emergency escape slides were deployed. May 5 Descent Air distribution system Smoke DHC8 Horizon Air On descent, crew, captain and first officer smelled faint smoke odor. About one minute later, flight attendant called and said there was smoke in the cabin. An emergency was declared and the airplane landed without incident. Crew accomplished environmental control system health check. Accomplished removal odor from aircraft ducts. Operational check of recirculating fan and all interior lights, no defect found. Aircraft ok for continued service. May 6 Climb Air distribution system Smoke 737 United Airlines Electrical fume smell detected after takeoff throughout airplane. Flight diverted. Ran APU and both engines trying to isolate cause of odor. Determined to be oil while APU bleed is on. Crew confirmed oil was what they smelled. No active external APU leaks noted. APU electrics may be used, not pneumatics. Accomplished fault isolation manual task 49-55-00-810-802, no defects noted; ran APU for an hour, no smell noted in cabin or visual indication of smoke in cabin. Aircraft OK to continue, placard removed. May 6 Cruise Air distribution fan Smoke A320 United Airlines Crew reported faint smell of smoke, followed by extraction fan fault and circuit breaker popped. Found extract fan seized and source of smoke. Removed and replaced fan in accordance with maintenance manual. Operations checked in accordance with manual. May 7 Cruise Cabin cooling system Smoke ATR72 Clearwater Flying Service (121) Approximately 60 nm (111 km) out, the crew detected a strong smoke smell in the cockpit and declared an emergency as smoke began to build in the cockpit. While the crew was running through the checklist for smoke in the cockpit, the smoke lifted and the crew elected to continue to the destination. Aircraft landed without incident. After extensive troubleshooting, the insulation shroud on the entry duct to the right pack was found to be damaged, as well as damaged bearings on the right pack. Deferred both the right bleed valve and the right pack. Turbine cooling en route. Performed leak detection wire check and operations check. Checks were good. Aircraft returned to service. May 10 Cruise Cabin cooling system Smoke EMB-145LR Atlantic Southeast Airlines The crew reported dust or smoke observed in cockpit and noise heard near Row 11 during flight. Pack number 1 overload message after landing. Maintenance inspected and replaced the number 1 pack air cycle machine. Operational checks were good. May 14 Climb Air distribution system Smoke EMB-145XR Atlantic Southeast Airlines Crew reported smoke in cabin after takeoff. Aircraft returned to departure airport. Maintenance inspected and found hose to number 1 recirculation fan muffler causing condensation to pour into the cabin through the lower vents at the center aisle. Maintenance re-secured hose and performed a successful operational check. Aircraft was approved for return to service. May 17 Climb Air distribution system Smoke 757 Delta Air Lines Returned to departure airport due to a report of smoke in the cockpit, declared emergency landing. In accordance with fault isolation manual inspected all cabin lighting fixtures, galley ovens, coffee makers and vents. Inspected APU area, inside ducts from APU to packs all normal. Inspected packs and recirculating fan areas including filters; all found clean without odors. Checked all in-flight entertainment (IFE) and E&E compartments without odors. All circuit breakers found in, ran engines at high power, no issues. Packs and APU running during entire ground time. OK for service. May 26 Climb Air distribution system Smoke MD-88 Delta Air Lines Flight returned to departure airport after smoke accumulated in the cabin and cockpit. The aft lavatory smoke detector also sounded briefly. Maintenance replaced a leaking APU and accomplished the pneumatic system duct burn-out procedures. May 28 Descent Autopilot computer Smoke 767 ABX Air Inc Fumes in cockpit after loss of autopilot. Replaced faulty center flight control computer. June 5 Not Reported Cabin cooling system Smoke EMB-145LR Atlantic Southeast Airlines The crew reported smoke in the cockpit. The aircraft landed without incident. Maintenance removed and replaced both air cycle machines, operationally tested with no defects noted, and the aircraft was approved for return to service. June 5 Descent Air distribution system Smoke CL600 Express Airlines At 10,000 ft, the first officer reduced thrust to flight idle to initiate descent. At about the same time, a puff of smoke entered the cockpit. The smoke went away almost immediately. All engine and environmental control system indications normal, no cautions. Flight attendants mentioned that they did smell something, but it also went away immediately. We weren’t sure if it was burning oil or a stuck valve, but there was no smoke after the first incident. No faults for any associated system noted. Inspected electronics bay and aft equipment bay. No abnormalities noted. Inspected cockpit and cabin lighting system. No faults noted. Performed APU bleed air operations, checked with left and right packs. June 7 Not reported Cabin cooling system Smoke EMB-145LR Atlantic Southeast Airlines The crew reported cabin smoke during flight. The aircraft diverted and landed without incident. Maintenance inspected the aircraft and found the number 2 pack to be on deferral, and the aircraft was approved for return to service. The aircraft returned overnight, where maintenance removed and replaced the number 2 air cycle machine, operationally tested with no defects noted, and the aircraft was approved for return to service. June 7 Cruise Air distribution system Smoke EMB-145LR American Eagle Airlines At cruise, electrical smell in cockpit and cabin was very strong. Emergency was declared, airplane landed and ground evacuation was ordered. Smelled like ozone. Troubleshooting yielded inconclusive results, could not duplicate smell. No other defects noted.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | OCTOBER 2016 | 55 SMOKEFIREFUMES
Selected Smoke, Fire and Fumes Events, May–August 2015
Event Date Flight Phase Classification Subclassification Aircraft Operator June 8 Descent Air distribution system Smoke MD-88 Delta Air Lines Flight attendant reported smoke building in the aft cabin on final approach, accompanied by the aft right lavatory smoke detector in alarm. Visible smoke was observed inside lavatory, so the flight attendant discharged the portable fire extinguisher into the aft lavatory and secured the door. Maintenance found a gasper duct behind the aft lavatory mirror disconnected and emitting mist. The duct was secured and a pneumatic system burn- out was performed. No further visible smoke and no odors noted, so the aircraft was returned to service. June 12 Cruise Cabin cooling system Smoke EMB-145LR American Eagle Airlines At cruise at Flight Level 250, with power in climb thrust, smoke detected in cockpit and cabin. Smoke dissipated after two minutes. After landing, maintenance removed and replaced the number 2 air cycle machine in accordance with the aircraft maintenance manual. Operations checked good. June 17 Cruise Cabin cooling system Smoke EMB-145XR Atlantic Southeast Airlines At cruise, crew noticed smoke in cockpit and cabin. Aircraft diverted and an emergency was declared. Maintenance found right air cycle machine (ACM) making loud squealing noise and smoking. Maintenance removed and replaced the ACM in accordance with the maintenance manual. The unit ops checked good. The aircraft was approved for return to service. June 25 Climb Engine (turbine/turboprop) Smoke EMB-145LR Atlantic Southeast Airlines The crew reported vapor/smoke in the cabin and cockpit when switched to engine bleeds after takeoff. The aircraft returned to departure airport, where it landed without incident. Maintenance removed and replaced the number 1 engine, operationally tested with no defects noted, and the aircraft was approved for return to service. June 29 Unknown Cabin cooling system Smoke EMB-145LR American Eagle Airlines Flight attendant reported smoke in cabin. Observed and smelled smoke in cockpit, smelled electrical in nature. Crew continued descent to nearest suitable airport. Smoke cleared, no other indications. Note Flight Level 250, cruise flight number 2 pack off. Found number 1 pack ACM impeller and exhaust turbine blades broken and grinding against casing. Removed and replaced ACM in accordance with maintenance manual. Operations checked good. No odor noted. July 10 Cruise Cabin cooling system Smoke EMB-145LR American Eagle Airlines Smoke in the cockpit at cruise. Crew declared an emergency and accomplished fault isolation manual task 21-20-00-810-801 for smoke in the cockpit at cruise. Found left ACM nearly seized, causing smoke in cockpit. Deferred left pack inoperative. Operations checked good. Minimum equipment list restored. July 18 Cruise Air distribution system Smoke MD-10 Federal Express At cruise, excessive smoke filled the cockpit. Appeared to come through the ventilation system. Cockpit temperature setting had recently been adjusted to a warmer setting. Temperature control returned to coldest setting. Smoke dissipated during emergency descent. Ran engines individually while operating packs individually and together. Ran engines together with packs operating. All packs operated with no evidence of smoke or odor. Inspected all three packs and pack bays. No defects noted. Inspected avionics and center accessory bays, no evidence of smoke or defects. Replaced both avionics fan filters and accessory bay fan filter. Ran packs for two hours at various temperatures and different isolation configurations, no defects. August 2 Climb Cabin cooling system Smoke EMB-145LR Atlantic Southeast Airlines After takeoff, at 4,000 ft, flight attendant called and said there was smoke in the cabin. Pilot and first officer could see smoke, declared an emergency, and returned to the airport. Maintenance inspection found number 2 ACM seized. Placed on minimum equipment list. Maintenance later removed and replaced ACM with operational check good. Aircraft was approved for return to service. August 2 Climb Engine reverse thruster Smoke 757 Delta Air Lines Performed an air turnback due to smoke on the flight deck. No emergency was declared. Determined odor to be from number 1 engine. Found oil leaking from number 1 engine inboard right thrust reverser open actuator onto and into high stage bleed slip joint. Cleaned and prepped for high power run. Leak and operational check good. Reinstalled outboard thrust reverser on number 1 engine open actuator rod end to facilitate removal and replacement of inboard actuator in accordance with aircraft maintenance manual. Operational check normal. Number 1 engine change accomplished. August 13 Climb Engine (turbine/turboprop) Smoke 777 Omni Air Express Climbing through Flight Level 230, left engine compressor stalled twice, then exhaust gas temperature (EGT) gauge turned yellow, cockpit filled with smoke. Oxygen masks donned. Oil quantity showed zero. Engine was shut down in accordance with severe damage checklist due to accompanying vibration. August 14 Climb Emergency equipment Smoke Falcon 50 Executive Jet Aviation Climbing through 22,000 ft, first officer smelled something burning. Donned the oxygen masks, declared an emergency and landed immediately, performing as much of the appropriate emergency checklist as possible. Checked copilot’s rechargeable flashlight and found it was hot and had an electrical odor. Verified odor with line personnel. Removed and replaced pilot and copilot flashlight assemblies. Operational check good. August 16 Cruise Air distribution system Smoke 757 American Airlines Just after level off, fumes reported in cockpit and cabin suggestive of an electrical fire. Emergency declared, landing uneventful and aircraft not overweight. Found displaced insulation contacted hot duct, secured insulation. Event repeated on next flight with an air interrupt return. Removed and replaced left and right high-efficiency particulate air (HEPA) filters in accordance with aircraft maintenance manual. No findings noted on engine run-up. System checked normal. August 30 Descent Electrical power system Smoke A320 JetBlue Airways Smoke detected on the flight deck during descent through 11,000 ft. Odor of hot plastic, and smoke dissipated briefly and returned at approximately 6,000 ft. Visible light smoke seen beneath captain’s map light. Odor dissipated by landing. Inspected all avionics bay for evidence or wiring damage or defective equipment. No defects noted. Found captain`s electrical outlet in cockpit damaged. Removed and replaced electrical outlet in accordance with aircraft maintenance manual. Operational check OK.
56 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | OCTOBER 2016 Register
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