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n the wake of Air France Flight 447 in mitigating LOC–I, were discussed in long had assumed, given the advanced June 2009 and more recent accidents, a September in London during the Royal state of automation. lot has been said and written about how Aeronautical Society’s International Air- Other issues include how to carve out pilots are trained and about what seems line Flight Crew Training Conference. adequate time in tight training schedules Ito be an erosion of basic flying skills. Many The society’s 80-member International for UPRT and manual handling practice; subject matter experts (SMEs) agree that Committee for Aviation Training in ensuring that training addresses real-life airline flying today suffers from what some Extended Envelopes (ICATEE) focused survival; refinement of flight simulation call “the curse of ubiquitous normalcy,” that on practical solutions that will make a training devices to provide highly accu- is, a professional cultural expectation of difference in LOC-I rather than push- rate cues; UPRT instructor qualification; low-stress operations in which high-risk ing new technology, but the resulting further work on technology-based LOC–I problems are so rare as to need little atten- solutions still require strong indus- mitigation; further study of root causes of tion. The more robust a system becomes, try commitment and support. Several upsets; reaching agreement on contentious the more likely people are to become com- presenters said evidence is emerging human factors issues, such as today’s long placent. This is where important advances that these LOC–I mitigations, where periods of pilots monitoring automation in upset prevention and recovery training voluntarily adopted, already are work- and managing systems; and optimal crew (UPRT) will come into play. ing and leading to entirely new insights resource management during upset pre- Publication of the new International and paradigms for airline pilot training. vention, recognition and recovery stages. Civil Aviation Organization (ICAO) Doc One captain said that “when you There is more to LOC–I than just 10011-2013, Manual of Upset Prevention disconnect the autopilot is where tech- stick and rudder skills. Meaningful guid- and Recovery Training — expected in mid- nology becomes art,” advocating that ance compiled from many sources on the October — signals a major transition for regular practice of manual flying builds various components will be needed to ef- the air transport industry from a four-year problem-solving resilience and a reserve fectively mitigate this threat. Flight Safety period of “expert talk” about mitigat- of cognitive capacity to handle stall/ Foundation stands ready to facilitate ing loss of control–in flight (LOC‑I) to upset situations. Traditional methods new developments and to see that they readiness for worldwide implementation of repeatedly flying familiar maneuvers are shared. of specific changes. It is not the first time and scenarios in flight simulators are no the industry has addressed airplane upset longer enough, some SMEs said, because recovery, and the validity of previous work unforeseeable or extremely rare events — (in which Flight Safety Foundation par- not to mention go-arounds, hand-flown ticipated) has been an influential bedrock visual landings and unreliable airspeed of the new 2013–2014 products. scenarios — today demand a higher Capt. Kevin L. Hiatt Details of the transition over the level of skill, situational awareness and President and CEO next few years, and further steps for resilience than many safety specialists Flight Safety Foundation
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | NOVEMBER 2013 | 1 AeroSafetyWORLD
contentsNovember 2013 Vol 8 Issue 10 features
12 CoverStory | ‘Catastrophic Uncontained Fire’ 12 17 StrategicIssues | BARS Influences Remote Operations 23 FlightOperations | Misjudging Density Altitude Effects
17 28 ThreatAnalysis | Airline Insurance as Safety Asset
33 HelicopterSafety | Bankruptcy Threat Degrades Judgment
38 HumanFactors | New EU Flight and Duty Time
42 SafetyTools | Daily Use of FORAS Software
23 departments
1 President’sMessage | Pilot Training
5 EditorialPage | Fiscal Crisis
7 SafetyCalendar | Industry Events
2 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2013 operations management traffic flow crew policy aircraft procedures
weather
airports 33 38 42
AeroSafetyWORLD 8 InBrief | Safety News telephone: +1 703.739.6700
Capt. Kevin L. Hiatt, publisher, 47 InfoScan | Managing Workload FSF president and CEO [email protected]
51 OnRecord | Close Call on Climb-Out Frank Jackman, editor-in-chief, FSF director of publications [email protected], ext. 116
Wayne Rosenkrans, senior editor [email protected], ext. 115
Linda Werfelman, senior editor [email protected], ext. 122
Rick Darby, contributing editor [email protected]
Mark Lacagnina, contributing editor [email protected]
Jennifer Moore, art director About the Cover [email protected] The fatal in-flight fire aboard this Boeing 747-400F erupted in a main-deck cargo pallet. Susan D. Reed, production specialist [email protected], ext. 123
© Mario Aurich/AirTeamImages.com Editorial Advisory Board
David North, EAB chairman, consultant We Encourage Reprints (For permissions, go to
| | FLIGHTSAFETY.ORG AEROSAFETYWORLD NOVEMBER 2013 | 3 Select the Integrated Air Safety Management Software Solution... SMS IAMS FAA Airline Quality JSA IOSA Flight Control Safety Audits Risk Matrix Safety Integrated JSA Aviation Security IAMS SMS IOSA Environmental JSA FAA Risk Management IAMS SMS SMS IATA Operational Safety Audit Flight Control Job Safety Analysis IATA Risk Matrix Safety Management System Job Safety Analysis FAA IOSA Risk Assessment JSA Integrated Airline Management System IATA JSA Environmental Federal Aviation Administration IOSA IOSA Reporting Airline Industry IAMS Aviation Risk Assessment FAA Airline Safety JSA SMS Safety Audits Aerosafety Risk Management Flight Control Flight Control Safety Audits Safety Audits Reporting JSA Risk Matrix SMS Airline IOSA FAA SMS Airline IAMS IAMS Air Safety IATA Quality Integrated Airline Safety IOSA Reporting Flight Control Job Safety Analysis Aerosafety Safety Audits Risk Management IATA Airline Industry FAA SMS SMS JSA Aviation FAA
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FISCAL Crisis “Two Parties Start Work to Avoid Repeat Crisis” to use its discretionary power to reopen the U.S. aircraft registry. The letter, written by aviation hat headline appeared in the online version attorney Kenneth P. Quinn, who serves on the of the New York Times in mid-October, just Foundation’s Board of Governors and is its general a few days after the U.S. Congress reached counsel and secretary, said in part, “operations of a last-minute agreement that avoided a debt the U.S. Registry are vital to protection of human Tdefault and reopened the partially shuttered U.S. life and property, safety and security.” government. The 16-day government shutdown Aviation safety is a complex, often highly inte- closed federal agencies, parks and museums and grated endeavor that requires constant attention. furloughed hundreds of thousands of federal Safety and risk management do not take holidays. workers — all because the two major political You can’t furlough thousands of inspectors, engineers, parties in the United States can’t work together. pilots, technicians and others in numerous safety- The two sides now have until the end of this year related jobs throughout multiple agencies and not to work out a longer-term solution or face the expect an increase in risk, and that doesn’t take into prospect of another shutdown early in 2014. account the human factors issues that come with What does this have to do with safety? Consider employment instability and the resulting stress. this: After a Spirit Airlines Airbus A319 suffered Unfortunately, budget showdowns are increas- an engine failure — originally reported to be an ingly common here in the United States. Congress uncontained failure — on Oct. 15, the U.S. National and the Obama administration have another Transportation Safety Board (NTSB) had to recall chance to restore some sanity to the situation. Here’s investigators from furlough to look into the mat- hoping that they don’t squander that opportunity. ter, according to published reports. While NTSB As former NTSB Member John Goglia wrote in quickly determined that the engine failure had a recent Forbes article, “I hope that both the FAA been contained, the fact remains that the investi- [U.S. Federal Aviation Administration] and NTSB gators had been furloughed with so many others. can get back to focusing on this [the Spirit engine Investigations that had begun before the shutdown failure] and other significant safety issues.” were slowed or stopped for the two weeks the gov- ernment was idling, which means that potentially crucial findings also could be delayed. A few days before the Spirit event, Flight Safety Foundation was one of nearly 50 signatories on a Frank Jackman letter sent to U.S. Transportation Secretary Antho- Editor-in-Chief ny Foxx urging the Department of Transportation AeroSafety World
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | NOVEMBER 2013 | 5 Serving Aviation Safety Interests for More Than 65 Years OFFICERS AND STAFF ince 1947, Flight Safety Foundation has helped save lives around the world. The Chairman Board of Governors David McMillan Foundation is an international non-profit organization whose sole purpose is to President and CEO Capt. Kevin L. Hiatt Sprovide impartial, independent, expert safety guidance and resources for the General Counsel aviation and aerospace industry. The Foundation is in a unique position to identify and Secretary Kenneth P. Quinn, Esq. global safety issues, set priorities and serve as a catalyst to address the issues through Treasurer David J. Barger data collection and information sharing, education, advocacy and communications. The
ADMINISTRATIVE Foundation’s effectiveness in bridging cultural and political differences in the common Manager of cause of safety has earned worldwide respect. Today, membership includes more than Support Services and 1,000 organizations and individuals in 150 countries. Executive Assistant Stephanie Mack FINANCIAL MemberGuide Financial Operations Manager Jaime Northington Flight Safety Foundation 801 N. Fairfax St., Suite 400, Alexandria VA 22314-1774 USA tel +1 703.739.6700 fax +1 703.739.6708 flightsafety.org MEMBERSHIP AND BUSINESS DEVELOPMENT Member enrollment ext. 102 Senior Director of Ahlam Wahdan, membership services coordinator [email protected] Membership and Seminar registration ext. 101 Business Development Susan M. Lausch Namratha Apparao, seminar and exhibit coordinator [email protected] Director of Events Seminar sponsorships/Exhibitor opportunities ext. 105 and Seminars Kelcey Mitchell Kelcey Mitchell, director of events and seminars [email protected] Seminar and Donations/Endowments ext. 112 Exhibit Coordinator Namratha Apparao Susan M. Lausch, senior director of membership and development [email protected] Membership FSF awards programs ext. 105 Services Coordinator Ahlam Wahdan Kelcey Mitchell, director of events and seminars [email protected] Consultant, Student Technical product orders ext. 101 Chapters and Projects Caren Waddell Namratha Apparao, seminar and exhibit coordinator [email protected] Seminar proceedings ext. 101 COMMUNICATIONS Namratha Apparao, seminar and exhibit coordinator [email protected] Director of Website ext. 126 Communications Emily McGee Emily McGee, director of communications [email protected] Basic Aviation Risk Standard GLOBAL PROGRAMS Greg Marshall, BARS managing director [email protected] BARS Program Office: Level 6, 278 Collins Street, Melbourne, Victoria 3000 Australia Director of Global Programs Rudy Quevedo tel +61 1300.557.162 fax +61 1300.557.182 [email protected] Foundation Fellow James M. Burin
BASIC AVIATION RISK STANDARD BARS Managing Director Greg Marshall
facebook.com/flightsafetyfoundation Past President William R. Voss @flightsafety Founder Jerome Lederer 1902–2004 www.linkedin.com/groups?gid=1804478
FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2013 ➤ SAFETYCALENDAR
NOV. 3–8 ➤ CANSO Global ATM Safety DEC. 10–12 ➤ Multi-Crew Pilot License APRIL 1–3 ➤ World Aviation Training Conference. Civil Air Navigation Services Symposium. International Civil Aviation Conference and Tradeshow (WATS 2014). Organisation. Amman, Jordan. Anouk Organization. Montreal, Canada, Halldale Group. Orlando, Florida, U.S. Zenia Achterhuis,
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | NOVEMBER 2013 | 7 INBRIEF Safety News North Sea Review “The recent accidents have understandably given rise to concerns, particularly with offshore workers who rely so heavily n the wake of five accidents in the past four years, includ- on these helicopter flights,” said Mark Swan, director of the U.K. ing two fatal accidents, North Sea helicopter operations are CAA Safety and Airspace Regulation Group. “We are absolutely under review by a team of regulators and aviation experts. I committed to ensuring that operations are as safe as possible.” The review — by the U.K. Civil Aviation Authority (CAA), In announcing the review, the U.K. CAA noted that the the European Aviation Safety Agency and the Norwegian five accidents — each involving a Eurocopter Super Puma CAA, along with a panel of independent experts — is focus- being flown in support of offshore oil and gas operations — ing on current operations, past incidents and accidents, and occurred despite “considerable effort by regulators, operators offshore helicopter operations in other countries. It will and the offshore industry to minimize the risk of North Sea conclude with recommendations aimed at improving the safety helicopter operations.” of helicopter operations. The most recent accident occurred Aug. 23, when a Eurocop- ter AS332 L2 Super Puma crashed into the sea during an approach to Sumburgh Airport in the Shetland Islands. Four of the 18 people in the helicopter were killed. Earlier in August, the three North Sea operators of Super Pumas had begun putting the helicopters back in the air after a 10-month grounding that followed two nonfatal ditchings in 2012. At the time, they said that modifications had been made to prevent cracking in the main gearbox bevel gear vertical shaft of affected EC225s and AS332s. Such cracking had occurred in each of the two ditched helicopters. The two other accidents involved an AS332 L2 that crashed into the sea 11 mi (18 km) northeast of Peterhead, Scotland, on April 1, 2009, killing all 16 passengers and crew- members, and an EC225 LP that “landed heavily” on the sea 500 m (1,640 ft) from an offshore platform on Feb. 18, 2009, resulting in three minor injuries to passengers.
© Trondur/Dreamstime.com
First Flight
he first U.S. government–approved commercial flight of an unmanned aircraft was completed in mid-September over Alaska’s Chukchi Sea, the Federal Aviation Administration (FAA) says. T An Insitu ScanEagle took off from a research vessel for a 36-minute flight to conduct the surveys of marine mammals and ice that are required by environmental and safety rules before underwater drilling may begin, the FAA said in a Sept. 23 statement. Preparations for the flight and others like it began in May 2012, with development of a plan to designate three blocks of airspace over international waters where small unmanned aircraft systems (UAS) could operate 24 hours a day for research and commercial purposes. That area sees an “extremely low amount of air and ship traffic,” the FAA said. Under the plan, unmanned aircraft take off from coastal launch sites and climb to altitudes no higher than 2,000 ft. “The plan also included developing protocols to operate unmanned aircraft beyond the vision of a pilot or observer (‘beyond line-of-sight’) — a first for small UAS operations,” the FAA said. Two small UAS — the ScanEagle X200 and AeroVironment’s PUMA — received the first civil type certificates from the FAA in late July so that both could be flown commercially. Around the same time, the FAA signed an agreement with ConocoPhillips, which previously had expressed interest in using UAS for its marine mammal and ice surveys. UAS also are expected to be used in the Arctic for scientific research, search and rescue, fisheries and maritime route planning, the FAA said. “The project is giving the FAA and the industry needed experience and a path forward to certify UAS for more commercial operations, both in the Arctic and elsewhere,” the agency said. © Boeing
8 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2013 INBRIEF
Congestion in European Next Steps for Africa Airspace he International Civil Aviation Organi- he European Commis- zation (ICAO) is pressing to expand its sion (EC) is pressuring Comprehensive Regional Implementa- Cyprus, Greece and Italy T T tion Plan for Aviation Safety in Africa (AFI to establish functional airspace Plan) to include technical areas such as air blocks (FABs) — regional air navigation services and aircraft accident traffic blocks that are required investigation. by law to replace the current 27 Bernard Aliu, Nigeria’s representative on national air traffic blocks and the ICAO Council and former head of the create the Single European Sky AFI Plan’s steering committee, told more than (SES). 200 participants at a September briefing in The EC, in a letter of Montreal that the program has been respon- formal notice, asked the sible for recent improvements in aviation © Anton Balazh/123RF three countries to show how safety in Africa. they have complied with the ICAO Secretary General Raymond Benjamin agreed, adding, “To maintain our requirement. momentum, we must now jointly expand our areas of activity and confirm the continued “This legal action should engagement of AFI states and the relevant authorities.” send a strong political message Expansion of the program through 2016 also would allow for a new focus on airports, about our determination to as well as air routes and ground aids, ICAO said. push through the reforms to In a related development, Tony Tyler, director general and CEO of the International Europe’s air traffic control that Air Transport Association (IATA), told representatives of Africa’s aviation community are so badly needed,” EC Vice that the continent continues to face major challenges in several areas, including safety and President Siim Kallas said. infrastructure. “Our airlines and their passen- He cited data showing that in 2012, African airlines had one accident involving a gers have had to endure more Western-built jet airplane for every 270,000 flights, compared with the worldwide average than 19 years of reduced ser- of one accident per 5 million flights. However, no air carrier in Africa — or anywhere else vices and missed deadlines on — that successfully completed an IATA Operational Safety Audit (IOSA) experienced a the route to a Single European hull loss accident with a Western-built jet in 2012, he said. Sky. We cannot afford to con- “It is clear that IOSA is making a difference, not just in Africa but in safety globally,” tinue this way. Europe’s skies Tyler said, adding that the Abuja Declaration, endorsed by the African Union Summit, face a capacity crunch, and the outlines a plan for achieving “world-class safety levels” by 2015. One condition of the reform of our aging air traffic declaration calls for all African carriers to complete an IOSA audit, and Tyler said African control system is too important governments should mandate IOSA for their airlines. … to be allowed to fail.” The EC said it is consider- ing other action to speed the License Deadline implementation of operational FABs. The deadline for their uropean pilots who hold a national pilot license have until April 8, 2014, to convert implementation was December that license to one issued by the European Aviation Safety Agency (EASA). 2012, but by September 2013, E The U.K. Civil Aviation Authority (CAA) issued a reminder in late September, none was fully operational, noting that the conversion requirement applies to commercial and private airplane and Kallas said. helicopter pilots with a CAA license — also known as a non–Joint Aviation Requirements In addition, the EC has license. Those licenses were issued before January 2000. adopted proposals for SES2+ — The CAA said that it was “concerned some pilots would be left with invalid licences if legislative measures designed they failed to meet the deadline.” to accelerate improvements Some exceptions will be made for pilots of aircraft that are considered “non-EASA in the European air traffic aircraft” — for example, ex-military aircraft and some airplanes that are considered “vin- management system, includ- tage” types. For most pilots, however, “the need to convert national licences by April 2014 ing a plan that would make the is part of the standardisation of pilot licensing across Europe,” the CAA said. The process implementation of FABs more is expected to be completed by 2017; after that date, all pilots of EASA aircraft must have flexible. EASA licenses and EASA medical certificates.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | NOVEMBER 2013 | 9 INBRIEF
Pilot Outlook Composite Research
he worldwide expansion of airline fleets and flight schedules will generate he U.S. National Aeronautics and a need for 498,000 new commercial airline pilots and 556,000 new mainte- Space Administration (NASA) Tnance technicians over the next 20 years, Boeing says in its annual Pilot and Thas chosen six companies to Technician Outlook. participate in a program designed to The hiring esti- advance composite materials research Pilot Outlook mates, published in and certification. New pilots by region, 2013–2032 September, say that The participants were among 20 the demand for new firms that submitted research proposals employees will reach Region Pilots to “reduce the time for development, unprecedented Asia Paci c 192,300 8% 3% 3% verification and regulatory acceptance levels because of the Europe 99,700 10% of new composite materials and struc- expected delivery of North America 85,700 tures,” NASA said. tens of thousands The selected companies are Bell Latin America 48,600 of new commercial 39% Helicopter Textron, GE Aviation, Lock- Middle East 40,000 17% jetliners. heed Martin Aeronautics, Northrop “Meeting this Africa 16,500 Grumman Aerospace Systems, Boeing exponential demand CIS 15,200 Research and Technology, and United growth will require Total 498,000 20% Technologies and subsidiary Pratt & innovative solutions Whitney. focused on new NASA’s Aeronautics Research Mis- digital technology to Technician Outlook sion Directorate is responsible for seek- New technicians by region, 2013–2032 match the learning ing solutions to air traffic congestion, requirements of a safety and environmental issues that new generation,” Region Technicians affect the air transportation system. 3% Boeing said. Asia Paci c 215,300 9% 3% The largest Europe 108,200 9% expected growth North America 97,900 in demand will be Latin America 53,100 39% in the Asia Pacific region, where an Middle East 47,600 18% estimated 192,300 Africa 18,000 new pilots and CIS 15,900 215,300 new main- Total 556,000 19% tenance personnel will be needed between now and CIS = Commonwealth of Independent States 2032, Boeing said. Source: Boeing U.S. National Aeronautics and Space Administration/Boeing
In Other News …
The European Aviation Safety Agency and Transport Canada (TC) have agreed to conduct common inspections to ensure that the foreign commercial aircraft that operate within their jurisdictions are in compliance with safety regulations. The two will share information gathered during the inspections in what TC described as “an arrangement to strengthen the safety net around interna- tional air travel.” … The U.S. Federal Aviation Administration (FAA) has upgraded Ukraine’s aviation safety rating to Category 1, which designates full compliance with International Civil Aviation Organization standards and recommended practices. Ukraine had been assigned a Category 2 rating since 2005; Category 2 indicates either a lack of laws or regulations for overseeing air car- riers in accordance with minimum international standards or a deficiency in the civil aviation authority. The ratings are assigned through the FAA’s International Aviation Safety Assessment Program.
Compiled and edited by Linda Werfelman.
10 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2013 ARGUS PROS Your IOSA Experts
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hortly after the Boeing 747-400F Thermal damage to flight control Investigators concluded that the departed from Dubai, United Arab cable supports and oxygen lines, and first officer eventually became spatially Emirates (UAE), a fire erupted in the failure of a crucial air condition- disoriented and lost control of the a cargo pallet containing lithium ing pack, minimized the chances crippled freighter, which struck terrain Sbatteries and other combustible materi- of survival. The pilots attempted to on a military base near Dubai Interna- als. By the time the flight crew received return to Dubai, but the captain’s tional Airport. No one on the ground a warning, a “catastrophic uncontained oxygen supply was cut off, and he was was hurt. fire” raged in the forward main cargo overcome by toxic fumes while trying The investigation of the Sept. 3, deck, and the cockpit soon filled with to retrieve a portable oxygen bottle. 2010, accident generated many safety “continuous blinding smoke,” said the The first officer, alone at the controls, recommendations, including a review report by the Air Accident Investigation had trouble breathing and could not of transport category aircraft fire- Sector (AAIS) of UAE’s General Civil see his instruments or the view out- protection certification standards; Aviation Authority. side the windshield. modification of cargo compartments ‘Catastrophic Uncontained Fire’ A main deck cargo fire fed by lithium batteries led to the uncontrolled descent of a 747 freighter in Dubai.
BY MARK LACAGNINA
12 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2013 COVERSTORY
and pallet covers to better contain fires; Tests performed to date have shown that “the requirements for full-face oxygen masks and thermal runaway of lithium-ion batteries is ca- vision-assurance devices on the flight deck; pable of causing adjacent combustibles to ignite more realistic training for emergencies involv- [and that] in addition to the energy release from ing smoke, fire and fumes; further testing of batteries resulting in combustion, there is an as- of the United Arab Emirates Arab of the United
lithium battery ignition properties; and devel- sociated mechanical energy release,” the report Authority Aviation General Civil opment of packaging and technical instruc- said. “This mechanical energy release is capable tions to ensure safe carriage of lithium batteries of compromising the integrity of packaging and aboard aircraft. creating incendiary projectiles.” The pallets remained aboard the aircraft for ‘Medically Fit, Adequately Rested’ the subsequent scheduled flight from Dubai to The flight crew had begun their assignment for Cologne, Germany. The cargo manifest for the United Parcel Service (UPS) several days earlier flight showed no declared shipments of hazard- with a deadhead flight from Anchorage, Alaska, ous materials. U.S., to Hong Kong, China, via Seoul, South Ko- Also of significance regarding the flight rea. After a layover of 47 hours in Hong Kong, from Hong Kong was a logbook entry about The auto-ignition they flew a different aircraft to Dubai, where resetting the aircraft’s no. 1 air conditioning of lithium batteries they had a 24-hour layover. pack after it failed en route. A ground engineer that had not The captain, 48, had 11,200 flight hours, in Dubai checked the pack, but could not repli- been declared as including 4,054 hours in type. He had flown for cate the failure. hazardous material several regional airlines and a major U.S. airline The freighter, manufactured in 2007 and may have contributed before he was hired by UPS in July 1995. registered in the United States as N571UP, to the fire. The first officer, 38, had 5,549 flight hours, was within weight and balance limits when it including 77 hours as a second-in-command departed from Dubai International Airport at of 747-400s. He had flown as a captain for a dusk, 1851 local time, and proceeded northwest regional airline before joining UPS in June 2006. in visual meteorological conditions over the The report said that neither pilot had a Arabian Gulf. history of accidents, incidents or regulatory The first officer was the pilot flying. He hand violations, and that both were “medically fit and flew the aircraft to 11,300 ft and then engaged adequately rested in compliance with the fatigue the autopilot for the remainder of the climb to regulations in place at the time of the accident.” the assigned cruise altitude, 32,000 ft. During the climb, the engine indicating and Undeclared Hazmat crew alerting system (EICAS) generated a fault Another UPS flight crew had flown the accident message for the no. 1 pack, the same pack that aircraft from Hong Kong to Dubai the night had failed during the flight from Hong Kong before the accident. Pallets loaded in the 747’s to Dubai. The captain reset the pack, and the forward cargo deck in Hong Kong contained a EICAS message cleared. significant number of lithium batteries that were Investigators determined that the no. 1 not declared as hazardous material in accor- pack’s turbine bypass valve, which works in dance with International Civil Aviation Organi- conjunction with the ram air door, had failed zation requirements, the report said. before takeoff, causing the subsequent failure “Lithium batteries have been in the spot- of the pack. light for the past few years due to their possible © Mosab Omar/Reuters involvement in aircraft cargo fires,” and the Fire Warnings hazards posed by the shipment of lithium- About 20 minutes after departure, the flight was metallic and lithium-ion batteries are still not handed off by UAE Area Control to Bahrain fully understood, the report said. East Area Control. The aircraft was nearing its
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | NOVEMBER 2013 | 13 COVERSTORY
assigned cruise altitude two minutes 747-400F Flight Path, Sept. 3, 2010 later when the crew received visual and aural warnings of a fire on the forward main cargo deck (Figure 1). Arabian Gulf “Fire, main deck forward,” the cap- 04:00 05:00 tain announced. He told the first officer, 06:00 03:00 07:00 Elapsed time from fire warning 09:00 11:00 “[All right], I’ll fly the aircraft. I got the 13:00 15:00 17:00 19:00 21:00 02:00 08:00 23:00 25:00 Sharjah radio. Go ahead and run [the checklist].” 00:00 Dubai 01:00 26:00 27:00 Investigators were unable to deter- Sound of 27:45 the fire bell mine conclusively how the fire began, but the report said it might have been Bahrain FIR sparked by the auto-ignition of lithium UAE FIR United Arab Emirates batteries stored in one of the cargo pallets: “Lithium batteries have a his- Source: General Civil Aviation Authority of the United Arab Emirates tory of thermal runaway and fire. … It Figure 1 is possible that a lithium type battery or batteries, for reasons which cannot which called for depressurizing the “hot” but must be keyed with intercom be established, went into an energetic main cargo deck to shut off the ven- switches on the control columns or the failure characterised by thermal run- tilating airflow. The report explained audio control panel, the report said that away and auto-ignited, starting a chain that because this deck is classified as a the pilots’ inability to readily hear what reaction which spread to the available Class E cargo compartment, active fire each other was saying caused some con- combustible material.” suppression is not required there: “The fusion and difficulty in communicating. The captain reported the fire warn- fire extinguishing and fire propagation The captain advised the controller ing to Bahrain Control and said that mitigation is through reducing the oxy- that the cockpit was full of smoke and he needed to land as soon as possible. gen available for combustion through that they could not see the radios. He The controller advised the crew that depressurization of the compartment.” requested and received clearance to de- Doha (Qatar) International Airport scend to 10,000 ft. This might have been was at their 10 o’clock position and 100 Pack Fails Again a mistake, according to the report: “Di- nm (182 km) away, and asked, “Is that The depressurization of the main deck rectly descending to 10,000 ft may have close enough?” involved deactivation of the no. 2 and exacerbated the fire and smoke problem “How about we turn around and go no. 3 air conditioning packs. With due to the extra available oxygen.” back to Dubai,” the captain replied. “I’d these packs shut down, the no. 1 pack The report noted, however, that the like to declare an emergency.” The con- alone provides conditioned airflow to “Fire Main Deck” checklist provided troller cleared the crew to turn right to the upper deck. “This provides a posi- conflicting guidance, with successive a heading of 090 degrees and to descend tive pressure differential between the items on the checklist requiring the to 28,000 ft. At this point, the Dubai upper deck and the rest of the aircraft, crew to “climb or descend to 25,000 ft” airport was 180 nm (333 km) east. preventing smoke or fumes [from] en- and to “plan to land at the nearest suit- “There is no direct information tering occupied areas,” the report said. able airport.” as to why the crew elected to choose However, the no. 1 pack subse- The checklist “does not provide Dubai [rather than] Doha,” the report quently failed again. No discussion of guidance for when or how to transition said. “However, it is likely that at the the failure was captured by the cockpit to landing or the fact that descending time of the initiation of the turn-back, voice recorder, and there apparently early might provide more atmospheric the crew was not yet aware of the full was no attempt to reset the pack. oxygen to the fire,” the report said. extent of the fire and its effects.” The pilots donned their oxygen “There is no intermediate step to verify The captain flew the aircraft on masks and goggles when the cockpit or otherwise assess the condition of autopilot while the first officer con- began to fill with smoke. Noting that the the fire and to evaluate the risk to the ducted the “Fire Main Deck” checklist, microphones inside the masks are not aircraft if a descent is initiated.”
14 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2013 the cockpit.the differential that drew more smoke into operation, could have caused apressure with noport, air conditioning packs in Deck” checklist and that opening the that action is this not on “Fire the Main cockpitin the ceiling. The report noted openswhich asmoke-evacuation port to “pullfirst officer smoke the handle,” worsened captain the when asked the for wiring the system. this Thebulkhead. fire had not damaged of aircraft, the rear the behind pressure hydraulic actuators located tail inthe to elevator the control and servos autopilot, signals electrical sends which what captain the when re-engaged the of elevators the deflection and rudder. had limited on the effect pedals rudder movements of control the column and from damaged the supports, evenlarge controlcreased cable tension resulting dataflight indicated that, due to de- the got control of aircraft.” the Recorded 747, told first officer, the “I’ve barely autopilotthe and was hand the flying controlflight cable support trusses. liners and had caused severe damage to had penetrated main the cargo deck main cargo deck. By time, this fire the cated that fire the had spread to aft the cargo deck, additional warnings indi- warnings about fire the on main the A few minutes after crew the received ‘I’ve Got Control’ Barely to enter instrument the landing system thing through smoke, the he was able was havingofficer trouble any seeing - at Although Dubai the airport. first the approach and landing on Runway 12L optionthe of conducting an autoland The pilots and agreed on discussed ‘I Can’t See’ FLIGHTSAFETY.ORG The cockpit environment may have The control problems abated some- The captain, had who disengaged |
WORLD AEROSAFETY | NOVEMBER 2013 from three the crew oxygen bottles fire damaged some of lines the leading his mask abruptly the when ceased Shortly thereafter, oxygen the flowto temperature high the cockpit. inthe captain the when commented about crewthe received fire the warning, about21,000 ft, minutes seven after if you can. Ican’t see.” captainthe replied. “Give me aheading right], we’re “[All fix. doing our best,” proceed approach directly to final the ment system (FMS). into(ILS) frequency manage flight the - The 747was descending through The controller cleared crew the to T 747-400F Boeing Sources: Boeing, ofCivilAircraft The Encyclopedia including 36ofthecurrent version, the747-8F. of 4,445nm(8,232km). (778cum)andamaximum range of27,467cuft (396,446 kg),acargo capacity lb (26,309kg)thrust, thisversion hasamaximumtakeoffweight of874,000 lb whichreplaced cockpit. glassflight deck, thetraditional three-pilot two-pilot changes, aswell for asthefreighter, thepassenger-carrier was the747-400’s freighter’s cargo capacity, range andfuelefficiency. Among themostsignificant options. Several modifications have beenmadeover theyears to increase the 4,100 nm(7,593km). lb (90,720kg)onitsmainandlower cargo decks, andhasamaximumrange of kg) thrustPratt & upto 200,000 Whitney JT9Dengines, the747-200Fcancarry At press time, haddelivered Boeing 300747freighters nearly worldwide, The 747-400F entered in1993. service With engines producing about58,000 CF6-50andRolls-Royce engines RB211series General Electric soonbecame containers, was introduced three years later. Powered by 41,000lb(18,598 with ahingednosethat israised to loadandunloadcargo palletsand 747entered in1970.Awindowlesshe Boeing freighter service version, system, was which stowed aft inthe his seat to retrieve portable the oxygen controltake of aircraft. the He left then and checklist.” the problems, including [FMS]input the already managing anumber of other tem was stowed. was first officer “The know where portable the oxygen sys- of task-saturation or he because didnot was unable to assist captain the because “I can’t breathe. me oxygen.” Get ward main cargo compartment. mounted of on for the sidewall the The captain told to first officer the The report said that first officer the “I got no oxygen,” captain the said. COVERSTORY - |
Frank Kovalchek/Wikimedia CC-BY-SA 2.0 15 COVERSTORY
cockpit area. The last recorded com- ‘Too Fast and Too High’ The first officer pulled back on his ment by the captain was: “I can’t see.” The 747 was descending through 9,000 control column to arrest the descent, Investigators determined that he was ft at 350 kt as it neared the ILS final ap- but the result was a series of rapid pitch rendered unconscious by toxic fumes proach fix. The crew of another aircraft oscillations and only momentary reduc- shortly after leaving his seat and that relayed the following message: “You’re tions of the descent rate “due to the he eventually succumbed to carbon too fast and too high. Can you make a desynchronisation of the control column monoxide poisoning. three-sixty [i.e., a 360-degree turn]?” inputs and the elevators,” the report said. “Negative, negative, negative,” the The first officer received a relayed Complicated Communications first officer replied. message advising that Dubai Internation- The thick, acrid smoke obliterated the Although the first officer had armed al Airport was 5 nm (9 km) away at his 3 first officer’s view of the instrument pan- the approach mode, the autopilot did o’clock position. “What is my altitude, and el. He also was having trouble breathing not capture the localizer because of the my heading?” he asked. “My airspeed?” because his mask had inadvertently been aircraft’s relatively high speed and alti- Shortly thereafter, the enhanced set to the normal mode, which provides tude. The 747 was descending through ground-proximity warning system gen- a mix of ambient air and 100 percent 4,200 ft at 320 kt and was on a heading erated the first of several “SINK RATE, oxygen, rather than to the emergency of 089 degrees when it passed to the PULL UP” and “TOO LOW, TERRAIN” mode, which provides only pure oxygen. north of the airport. warnings. Recorded data indicated that He advised Bahrain East Area Con- “Sir, where are we?” the first officer the first officer’s control column was trol that he was unable to change radio asked. “Where are we located?” fully aft when the aircraft descended out frequencies due to the limited visibility Through a relay aircraft, the con- of control and struck the ground 9 nm in the cockpit. “Sir, we’re going to have troller asked the first officer if he would (17 km) southwest of the Dubai airport. to stay with you,” he said. “We cannot be able to make a left turn, to fly north The crash occurred 51 minutes after see the radios.” toward Sharjah International Airport. takeoff and 29 minutes after the crew re- Eventually, the freighter flew out The controller advised that the Sharjah ceived the fire warnings. On impact, the of radio range with Bahrain Control, airport was 10 nm (18 km) away. 747 was in a nose-down and right-wing- but the pilot and the Bahrain control- “Give me a left turn,” the first officer low attitude. It struck several street lamps ler were able to relay messages to each said. “What heading?” before coming down on a service road other through other aircraft operating A heading of 095 degrees to Sharjah at the perimeter of the military base, just in the vicinity. The Bahrain control- was relayed, and the first officer ac- outside a densely populated area. ler coordinated via landline with UAE knowledged the information. However, “The right-hand wing struck several Area Control and the control tower at he inadvertently selected 195 degrees buildings and vehicle-parking stands be- the Dubai airport. on the mode control panel. Recorded fore progressing through a line of main- Recorded voice data indicated data showed that the aircraft rapidly tenance storage buildings immediately that the delay inherent in the relay of turned right toward the selected head- prior to the forward fuselage contacting messages was problematic for the first ing while descending through 4,000 an elevated sand bank and additional officer, who repeatedly said that he ft and slowing to 240 kt. The abrupt support buildings,” the report said. “The was “flying blind” and asked for radar and unanticipated right turn might aircraft was completely destroyed by vectors and for information about his have confused the pilot and triggered the ground contact followed by a post- current altitude, heading, airspeed and the onset of spatial disorientation, the accident fire.” distance from the airport. report said. This article is based on AAIS Case Reference Through a relay, the Bahrain control- 13/2010: “Uncontained Cargo Fire Leading ler asked the pilot to change to the guard Loss of Control to Loss of Control Inflight and Uncontrolled frequency, 121.5 MHz, but the first The freighter was flying southwest, Descent Into Terrain — Boeing 747-44AF, N571UP; Dubai, United Arab Emirates; 03 officer apparently was unable to do so. away from both the Sharjah and the September 2010.” The 324-page report, pub- Among the messages relayed to the pilot Dubai airports, when the first officer lished in English on July 24, 2013, is available from the Bahrain controller was to main- disengaged the autopilot. The aircraft from the UAE General Civil Aviation Author- tain his current heading, 105 degrees. abruptly pitched 14 degrees nose-down. ity at
16 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2013 STRATEGICISSUES
BY WAYNE ROSENKRANS
light Safety Foundation’s Basic Aviation other types of industries and flying, program Risk Standard (BARS) Program was veterans say. developed from the outset to standardize “The BARS Program was designed by resource remote-operations risk mitigation within companies, in conjunction with the Foundation, to Fthe natural resource sector (ASW, 3/10, p. 14), mitigate the risk of aviation activities undertaken which focuses on global onshore exploration in support of this sector,” said Greg Marshall, and extraction of minerals, metals, oil and gas. BARS managing director. “The BAR Standard was Approaching 2014, this evolving audit program derived from an amalgam of different standards also extracts precious safety insights from that were adopted by a variety of onshore and off- aircraft operators’ shared data and influences shore resource-sector companies. These different
FSF BARS Program assesses threats to contracted remote operations involving flights to minerals, metals, oil and gas sites. © BHP Billiton
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Australian Incidents
ne example of an aviation incident in 2012 involved “The pilot of [the AS350] only became aware of [the a fly-in fly-out charter operator and a privately 1900C] when he heard the co-pilot transmit ‘KFN aborting,’” Ooperated helicopter — both engaged in remote the report said. The helicopter pilot previously had heard operations for Australia’s natural resource sector. On Sept. only one garbled radio transmission. 6 at 1300 local time, the pilot of a Eurocopter AS350 B2 heli- The report said that causal factors included the helicop- copter crossed Runway 05 about 200 ft above ground level ter pilot feeling pressured to immediately fly to the survey and 200 m (656 ft) in front of a departing Beech 1900C at site to evacuate the injured person. “In his haste to transit Newman Aerodrome, an unmanned/uncontrolled airfield to the site, he had turned right across the runway when the located 5.5 nm (10.2 km) from the iron-mining town of normal procedures required him to turn left,” the report said. Newman in Western Australia.1 ATSB determined that a number of hangars constructed The pilot-in-command (PIC) flying the 1900C, seeing the west of the general aviation apron obstructed pilots’ view from helicopter taxi toward the runway when the airplane was that apron to the threshold of Runway 05, and that the han- about 300–450 m (984–1,476 ft) down the runway and at gars probably had blocked VHF radio transmissions between 80 kt, and believing that the trajectories of the two aircraft the incident aircraft. Information about the risk of radio- would conflict if the 1900C became airborne, rejected the transmission blocking, as well as revised helicopter departure takeoff at about 120 kt, said the final report of the Australian procedures, were scheduled to be published. ATSB currently is Transport Safety Bureau (ATSB). conducting investigations into several other incidents involv- “After ferrying personnel from Rhodes Ridge [a massive ing charter aircraft associated with the resource sector.2 iron-ore deposit] to a survey site about 28 km [15 nm] north- Preliminary information said that on May 17, 2012, the east of Newman, the pilot of [the AS350] flew to Newman flight crew of a de Havilland Canada DHC-8 that had depart- Aerodrome to refuel and to have a minor unserviceability ed from Perth received a ground proximity warning system rectified,” the report said. “After waiting some time, the pilot warning about 10 nm (16 km) from Laverton Airport during was advised that one of the people at the survey site had their approach to Granny Smith Airport, all in Western Aus- been injured and required evacuation.” tralia. They continued the unstable approach and landed at Pilots of both aircraft had made very high frequency the airport located at the Granny Smith Gold Mine. (VHF) radio transmissions about their positions and inten- On Oct. 19, 2012, at 1530 local time, the flight crew of a tions on the common traffic advisory frequency. “As the Fokker F-28 Mk 100 that had departed from Perth encoun- [1900C] commenced the takeoff roll, the [PIC] heard the pilot tered wind shear during final approach and subsequently of [the AS350] transmit a taxi call but did not expect the heli- made a hard landing at Nifty Aerodrome, also in Western copter to commence a takeoff,” the report said. The helicop- Australia. Serious damage was reported. A newspaper said ter initially taxied across the apron, entered the runway strip, that 26 fly-in fly-out workers arriving at the Nifty copper then turned left to conduct a takeoff parallel to Runway 05. mine were aboard but no occupants were injured. On Jan. 10, 2013, air traffic control advised the flight crew of an Embraer ERJ 170 descending through 18,000 ft to land at McArthur River Mine airport, Northern Territory, that the
23 aircraft was 6 nm (11 km) left of track and diverging. “The Newman Aerodrome Elevation 1,712 ft crew detected an error in their manual input of data into the 1,760 ft FMS [flight management system],” the report said. 1,798 ft 2 1 3 — WR 4 A 2,072 x 30 m (6,798 x 98 ft) Location of B new hangars Eurocopter Notes AS350 B2 path 1. ATSB. “Airspace related event involving Beech 1900C, VH-KFN, and 1,743 ft Aerospatiale AS350 B2, VH-VRW, Newman aerodrome, Western VOR/DME Australia, 6 September 2012.” ATSB Transport Safety Report, Aviation Occurrence Investigation AO-2012-118, April 23, 2013. 05 Beech 1900C path Elevation 1,724 ft 2. ATSB. Investigation numbers, in order, AO-2012-170, AO-2012-137 Australian Transport Safety Bureau Safety Transport Australian and AO-2013-10. Adshead, Gary. “‘Hard landing’ grounds plane.” The West Australian, Oct. 24, 2012.
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standards were derived from experience or search and rescue response/capability on findings from resource-sector audits, born of accidents, too many of which, un- cannot be provided consistent with the in addition to the introduction of our fortunately, were fatal. The BAR Standard anticipated exposure.” A non-hostile Internet-based Safety Alert system for represents the best practice across both environment is one in which “a success- aviation-related safety events reported by BMOs [BARS member organizations] ful emergency landing can be reasonably the resource sector. The latest statistical and non-member organizations. A cur- assured, and the occupants of the aircraft data from audit analysis will be summa- rent benchmarking exercise against other can be adequately protected from the el- rized and prepared for broad release by standards is validating this. ements, and search and rescue response/ December 2013.” “Within many companies, safety is capability can be provided consistent the number one priority for all person- with the anticipated exposure.” Value of Auditing nel, and many workplace safety risks These terms have serious practical Traditional audits in the resource sector associated with mining activities are well effects on BMOs’ remote operations. have been broad-based, attempting to known. What is less well known are the “The significance of hostile versus non- cover all aspects of an aviation opera- risks that exist within aviation operations, hostile is illustrated in the selection of tion — including activities involving particularly those that are conducted at aircraft for passenger-carrying opera- little risk — once per year, Marshall remote locations in often-inhospitable tions, ensuring one-engine-inoperative said. “Not only are these expensive, environments. A number of unrelated performance at the ambient conditions they may also offer very little value be- aviation activities have risk profiles simi- being operated in,” Ross said. “BHP cause the low-risk or inconsequential- lar to those of the resource sector and this Billiton operates in hostile environ- risk activities are being assessed.” means that BARS can easily be adopted ments in the Andes mountains of Chile, Today’s BARS program has essen- within those other sectors as well.” deep-water offshore locations and the tially a two-step assessment process. A The latest data for the global heavily forested/jungle environments of BARS audit of the aircraft operator at resource sector show flight operations Indonesia and West Africa.” its home base assesses internal systems still increasing as minerals/metals/ Gradually, the significant aviation to ensure that the necessary controls energy exploration and extraction safety events (see “Australian Incidents,” — the proven mitigators of risk — are extend into extremely remote areas. p. 18) in the resource sector are being established. Then, an operational review “The global resource sector continues better reported and tracked by the BARS is conducted of the “identified, higher- to increase its reliance on contracted program, and the information is being endpoint risks at a frequency determined aviation activities in remote areas not used to assist BMOs in checking their by the level of relative risk,” he said. frequently serviced by regular public own aviation assurance controls and in “These reviews are undertaken by transport services,” said Cameron Ross, supporting further development of the either the BMO’s in-house aviation risk group manager aviation safety, BHP BAR Standard when reviewed by the manager or by a competent aviation Billiton, a BARS Program member and participating resource-sector members. specialist contracted to provide special- benefactor. “Large production mine “BARS hasn’t yet been identified by a ist advice,” Marshall said. “Low-risk sites, such as those in Western Australia national government as a source of data activities can be excluded from reviews supporting the iron ore business, are that can assist with the identification when the activities offer little, if any, typically serviced by dedicated, high- of risk areas within certain regions or value. In some cases, operational re- capacity charter aircraft. Globally, fly-in countries,” Marshall said. “However, the views may not be needed.” fly-out operations operate in extreme Foundation has signed a memorandum At BHP Billiton, contract aircraft cold weather and remote desert and of cooperation with the International operators’ remote operations have been jungle environments, each with their Civil Aviation Organization to facilitate enhanced by collective lessons derived own added risk factors.” the exchange of de-identified data to from de-identified/aggregate findings of BARS defines a hostile environment support regional risk oversight. This is BARS audits. “The data are in, and lack as one in which “a successful emer- currently in the formative stages. Within of procedures for stabilized approach gency landing cannot be assured, or the industry, the Foundation has already is a good example of a finding that has the occupants of the aircraft cannot be commenced the publication of de- been successfully closed for many opera- adequately protected from the elements, identified data from a macro perspective tors,” Ross said. “This is in line with FSF
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ALAR [approach-and-landing accident reduc- sector–contracted aircraft will minimize traffic tion] work, and is a key control in the prevention conflicts and promote operational efficiency.” of these accidents. Emergency-response planning — which includes comprehensive flight following Safety Alerts — is always a challenge for remote area opera- BARS audits, from their beginning, have been tions, and often discussed during an audit and sensitive to threats of high common interest to the operation pre-start phase. BMOs: runway excursions, fuel exhaustion, fuel “The ability to review a BARS audit report contamination, controlled flight into terrain, allows a BMO to readily understand those aspects incorrect loading, collision on ground, collision of the operator’s risk-control design that meet the in air, structural or mechanical failure, weather, prescribed audit protocol. This is the first step in medical evacuation, and preparation for aircraft any assurance process and an important one for accidents. BMOs’ experiences have validated the industry. An intended benefit of the program these priorities heading into 2014, but also have is the data collected from the audit process, which prompted concentration on helicopter external — in addition to tracking industry accident data load, offshore and night vision system (NVS) — allows the Flight Safety Foundation to provide operations to keep pace with industrywide best meaningful feedback to the BARS program’s practices. NVS are widely used in helicopter Technical Advisory Committee in regard to the emergency medical services, and a number of BAR Standard and to the program.” BARS-audited aircraft operators provide con-
Over the years, a number of companies tract medical retrieval for the resource sector, Resource-sector in the resource sector also monitored traf- Marshall said. workers commute fic growth within areas of remote operation, The BARS Safety Alert system and BAR- to remote field especially those in which national or regional Soft online-discussion forums — set to be assignments under air navigation service providers could have dif- introduced in a website upgrade by the end fly-in fly-out contracts ficulty providing services. Ross said that a new of 2013 — will become especially valuable for between their network of ground stations has begun to change delivering/exchanging safety information rel- employer and BARS- the situation, for example, in the northwestern evant to remote operations. accredited charter part of Western Australia. Nationwide automatic “The Safety Alert system has been reserved aircraft operators dependent surveillance–broadcast (ADS-B) for reporting significant aviation safety-related (above, Port Hedland, avionics coverage takes effect in 2014. events, and only a few such alerts have been Western Australia; p. “The use of ADS-B, both onshore and released since its introduction,” Marshall said. 17, Andes mountain offshore, is widely supported by BHP Billiton, “One of these was actually supplied to us by range, Chile). and its implementation in Western Australia has a non-member in the interest of safety dis- had a very positive effect on our activities,” he semination. Initially, the forums will allow us said. “Satellite flight following, TAWS [terrain to introduce a Fixed-Wing Working Group awareness and warning systems], GNSS [global and a Rotary-Wing Working Group in which navigation satellite system] approaches and industry participants review and discuss the any controls that reduce the likelihood of VFR various BARS elements, and will seek feedback Marshall [visual flight rules] flight in degraded visual on improvements to the BAR Standard.” conditions are supported.” “ADS-B will be a significant contributor to Closed Loop safety,” Marshall added. “For example, the huge Analyses of BARS safety audits of aircraft opera- growth in aviation support of mining in the tors and BMOs’ feedback show that risk controls Pilbara region brought about congestion prob- have been effective elements of safety manage- lems over much of the controlled and uncon- ment systems (SMS), the BARS veterans say. trolled airspace, which is outside radar coverage. “The whole philosophy of SMS is to improve
ADS‑B avionics fitment to some of these resource the resilience of organizations and to make Rosenkrans Wayne
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© BHP Billiton
systems safer,” Marshall said. “Audit analysis by region and country.” Such used for the benefit of the entire indus- findings have proven to be a very good an independent effort gradually can try. The effectiveness of each control is benchmark in this area. The number of encompass exposure data (such as continuously tested through the review findings emanating from our deep-dive accurate total departure numbers) of incident and accident data, and audit has increased over previous audits that have been missing for calculating where applicable, involves amending undertaken using traditional meth- accident/incident rates. and updating the BAR Standard.” ods. In some parts of the world, the The BARS Program also strongly At the remote field level, he said, BARS audit is often the first time that promotes the use of specific technolo- BHP Billiton’s involvement in creating an aircraft operator has experienced a gies as a best practice and helps the and sustaining the BARS Program has comprehensive review of its operations. safety specialists at aircraft operators benefited aviation risk mitigation in the Our key P1 [highest priority] and P2 make the business case for them in transportation of workers to remote min- [second-highest priority] findings must remote operations. “TAWS/EGPWS ing operations; geophysical surveys; heli- be closed — and by prescribed dates.” [Enhanced Ground Proximity Warning copter external load flights; photographic Eventually, in a manner similar to Systems] and GNSS approaches, where missions; medical evacuation flights; and an International Air Transport As- published, are significant contributors providing appropriate aircraft rescue and sociation Operational Safety Audit for to safety in remote locations — espe- firefighting capability at company-owned airlines, the BARS Program envisions cially where these occur in challenging and company-operated airports. capability to compare safety outcomes environments,” Marshall said. The company’s offshore safety in remote operations among BARS- “We are seeing this data start to interests also are compatible with many accredited and non-BARS-accredited emerge,’’ Ross said. “But I do see the aspects of the BARS Program’s evolu- operators over the years. “This process independence of the Foundation and tion in supporting remote operations. has already commenced,” Marshall the BARS Program Office presenting “BHP Billiton operates offshore in the said. “An initial report was produced in a massive opportunity for the resource United Kingdom, Trinidad, the Gulf of 2012, and a new report will be pub- sector to gather data and collate it in a Mexico, Australia and various explora- lished in late 2013. As audit volume non-identifying manner that doesn’t tion sites internationally,” Ross said. increases with the growth of the BARS implicate resource companies and “Offshore helicopter operations have Program, so, too, will the depth of aircraft operators — it’s data that can be their own unique hazards, particularly
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when operations go farther offshore in of aviation safety risks and how they are operators such as in fire fighting, rescue deep water, where search and rescue, to be addressed by non-technical, on- of mining personnel, and the delivery of aircraft endurance and survivability shore and offshore personnel, Ross said. food, supplies and people who provide factors become tested. Cold-water “Among other controls, the importance on-site expertise at remote sites. operations provide additional chal- of flight following, manifesting, search- The current courses have been lenges. Fortunately, there are large and-rescue capabilities and emergency delivered to resource sector attendees global helicopter service providers who response planning are all explained in in Yellowknife, Nunavut (the Canadian understand these risks and provide the detail with examples,” he said. arctic territory, ASW, 9/13, p. 16); Saska- equipment and personnel to service The Helicopter External Load Opera- toon, Saskatchewan; and other parts of these requirements.” tions course was developed to provide Canada. “This is expected to continue,” a standard training course for ground Marshall said, as the BARS Program Course Work personnel and aircrew. The course — al- revises and adds courses that tap into ex- One notable offshoot of the BARS though designed initially for exploration pertise in extremely cold environments. Program that now influences remote activities such as carrying under-slung Two courses under development operations is facilitating continuing loads of remote-site drilling equip- — Aviation Coordinator for Offshore education for BMOs and aircraft opera- ment — in practice has attracted diverse Personnel and Aviation Risk for Manag- tors. “Such education and training is operators from other industries. ers — are being designed to fill other vital to develop and support a desired The course “simply relates to any knowledge gaps among some personnel safety culture, particularly in remote load that might be hooked onto an in the resource sector. “A beta version field operations,” Marshall said. aircraft,” Ross said. That means it also of the Aviation Coordinator for Offshore Aviation Coordinator course training supports mission readiness for unex- Personnel course was held in Houston has been beneficial in raising awareness pected emergency roles for helicopter in October,” he said.
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n Aug. 2, 2007, a Robinson R44 II Subsequent examination of the engine and helicopter crashed in the mountainous airframe indicated no anomalies that would terrain of west central Washington state, have contributed to the crash, the final report U.S. The crash and subsequent fire took said. The 41-year-old commercial pilot had Othe lives of the pilot and three passengers who more than 2,000 hours in helicopters and was were touring logging sites. Witnesses said the certified as a helicopter instructor. No evidence helicopter lifted off, climbed straight up and of alcohol or drug impairment was found. The turned left. This put the aircraft into a slight weather, suitable for visual flight rules (VFR) tailwind. They said that, after traveling a few operation, was not a factor. hundred feet, the helicopter began to wobble The accident environment, however, in- and yaw back and forth. It then descended volved what is known as high density altitude. quickly, striking the ground. There was an The clear-cut area of the logging site from explosion and the helicopter was immediately which the helicopter took off was at an eleva- engulfed in flames. tion of 4,961 ft (1,512 m). The temperature at
BY ED BROTAK Into THIN AIR Actual air density must be considered to reduce risk of degraded thrust and lift in takeoffs, landings, cruise and flight path changes. Susan Reed
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | NOVEMBER 2013 | 23 FLIGHTOPS
Topics featured in presentations included, “Elevation vs. Air Pressure, Temperature and Density”; “Types of Altitude”; “Airspeed, True vs. Indicated”; “Distant Obstacle Clearance”; Density altitude: 9,609 ft and “Takeoff Distance.”2 In their basic training, pilots are taught that “high, hot and humid” air can cause perfor- mance problems for their aircraft. However, the number of accidents and near-accidents that continue to occur indicate that the hazards asso- ciated with high density altitude are not always well understood or fully appreciated. Numerous harrowing videos on the Internet show pilots struggling to control their aircraft in high den- sity altitude conditions. To fully understand the problem of high
, 1984. Manual Pilot Private density altitude, it is necessary to go back to the basics of atmospheric density, pressure and altim- Indicated altitude: 5,429 ft etry, using air pressure as the gauge of altitude. 93° F, 29.45 in Hg Atmospheric pressure (measured with a barometer) is simply a measure of the weight of a column of air above a point. The more air Source: Jeppeson Sanderson. Source: above the point, the greater the pressure. At In this situation, the the time was above 70 degrees F (21 degrees sea level, the entire atmosphere is above and temperature is higher C). The density altitude was calculated to be pressure is greatest. The average (mean) sea than standard and 6,841 ft, meaning the air was as “thin” (less level pressure is 29.92 in Hg (1013 hPa). At the pressure is lower dense) as it would normally be at 6,841 ft. The higher altitudes, there is less air above and the than standard. The U.S. National Transportation Safety Board pressure decreases —very rapidly, even expo- resulting air density (NTSB) concluded the probable cause of the nentially. If we assume, reasonably enough, at 5,429 ft equals accident to be “the pilot’s improper planning/ that pressure decreases with height at the same 9,609 ft in terms of decision in attempting a downwind takeoff rate everywhere, pressure indicates altitude. standard atmosphere. under high density altitude conditions that The standard altimeter is really just an aneroid resulted in a loss of control and impact with barometer set to read pressure as altitude. terrain. Contributing to the accident was the But the pressure at sea level is not always helicopter’s gross weight in excess of the maxi- 29.92 in Hg. It varies, primarily because of mum hover out of ground effect limit.”1 the movement of surface weather systems, the High density altitude conditions are a common high- and low-pressure areas seen hazard for all aircraft, not just small, propeller- on standard weather maps. This is why pilots driven ones. The Boeing Co. considers the check the altimeter setting at the airport. This is threat to be so important that it held a three- the actual pressure adjusted to mean sea level. day conference in October 2007 in conjunc- Entering this reading on the altimeter enables tion with the Civil Aviation Administration of it to calculate the above sea level (ASL) altitude China, concerning “High and Hot Operations.” by comparing the unadjusted actual pressure It used multi-engine airplanes as examples. It (what meteorologists call station pressure) to the also stressed the effects on jet engines, in par- adjusted sea level pressure. ticular the reduction in thrust at high altitude The term pressure altitude describes this (i.e., above 25,000 ft). type of height approximation. The ASL altitude
24 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2013 tional Standard Atmosphere has atemperature “nonstandard” The mean Interna case? inthis - fored anonstandard temperature. What does altitude perature on air density, we termdensity the use cant concern. elevation that low air density- becomes asignifi temperatures high when combine with high aircraft operation at low-elevation It’s airports. at any height, but seldom causes problems in occurs 50 degrees F(10degrees C).This effect air densities nearly 10percent lower than air at tures near 100degrees F(38degrees C)produce concept(the hot behind air Tempera balloons). - profound.be Hot air is less dense than colder air for performance. flight changes inhumidity are usually not significant ture. However, differences inair density due to less dense thanair drier at same the tempera- air.of dry So, air with humidity higher is slightly vapor weighs less than gaseous the constituents moist air air water because is less densethan dry moisture content). to popular Contrary belief, temperature and humidity (water vapor or level. with sea and air the density is 40percent lower compared Paz, elevation the Bolivia, (4,061m), is 13,325ft level. At Alto El the International at Airport La sity there is 30percent lower compared with sea inNorth highestthe airport Air America. den- Colorado.Leadville, At (3,026m),it 9,927ft is Mountains in County sits Lake Airport the pared level. Further with sea Rocky back inthe ASL, air the density is 18percent lower com- Denver International (1,655m) 5,431ft Airport, is directly related to altitude. For example, at as pressure increases, and density the of air the ids are compressible. air the density So increases a major concern for pilots. Air is afluid, and- flu of about ASL. 1,800ft 28.00 inHg, would this apressure equal altitude value. For example, measured ifthe pressure is would typically determine agiven pressure FLIGHTSAFETY.ORG FLIGHTSAFETY.ORG To keep pilots aware of of tem effects the - Temperature on other the effects, hand, can pressure,Besides air density is by affected Air pressure is directly related to air density, , which is, which pressure the altitude correct- | AEROSAFETY WORLD WORLD | NOVEMBER 2013 NOVEMBER the thinner air. thinner the air Less intake means less power altitude, there because are fewer air in molecules power is adversely by affected density high generates engine’s the combustion that turbine engine. The reciprocatingthe or performancethe of First,ties. it affects aircraft capabili- has major on effects altitudes. typically found at high low-densitythe air pilot experience will posite. It means the density, just op the - It not does misleading, though. The term could be sity altitude situation. to it den- as ahigh in air density, we refer significant decrease tion and temperature high produces asafety- calculations for easier operational conditions. pressure altitude and temperature to make the apps, have produced been for pilots to enter only tables and graphs, and as well devices as digital pressureactual and temperature. Typical current formula to determine density altitude, given the cant inair decrease density. There is aspecific altitude- inthat This is is 8,200ft. asignifi case F (32degrees C)or evenhigher. The density sun, temperatures surface to can 90degrees rise much greater. temperatures during asummer day can be below C). But is this assuming ground the is 5,000ft ASL5,000 ft would 41degrees F(5degrees be Using data, standard these the temperature at above km) (6.4degrees Cper 1,000ft it.F per with temperature the decreasing 3.5degrees of 59degrees F(15degrees C) at surface, the The air density When combination the of- eleva high With ground the absorbing heat from the . If ground the surface mean high is at then 5,000ft, Tenzing-Hillary Airport passengers ontheir Mount Everest. Its in Lukla,Nepal,is used primarilyfor sea levelis9,200 way toandfrom elevation above FLIGHTOPS ft (2,800m). |
25 © fotoVoyager/iStockphoto FLIGHTOPS
generated unless corrective measures are taken. temperature to takeoff distance and rate of Second, the thrust produced by a propeller, climb. Pilots can check conditions at their loca- turbine blades or rotor blades is reduced due to tion before takeoff and arrival and make the the thinner air. And finally, the lift generated needed adjustments. by the wings of airplanes or the rotor blades of Problems with high density altitude are not a helicopter is a function of air density. In high restricted to takeoffs. For landings, the true density altitude conditions, less lift is produced. airspeed is greater in thin air, even though the High density altitude creates two significant indicated airspeed is less. This can lead to exces- effects on takeoffs. First, it takes longer for an sive landing speed, increased rollout distance aircraft to become airborne. In the worst case and the possibility of a runway excursion. scenario, an airplane pilot can run out of run- Even in cruise flight, problems can occur. way before the plane lifts off, which can lead to In August 2006, a Piper PA-28R-2-1 Arrow was A drawing of a a runway excursion. To avoid this, it is advisable flying through mountainous terrain northwest typical online density to check the takeoff performance chart in the of Salida, Colorado. The experienced pilot altitude calculator. pilot’s operating handbook. found himself trapped in a box canyon, unable to gain enough altitude to escape. The plane crashed, killing the pilot and seriously injuring the one passenger. Salida itself is at an elevation Elevation feet meters 5429 of 7,083 ft (2,159 m). Due to warm tempera- Air temperature deg F deg C 93 tures, the density altitude was over 9,000 ft Altimeter setting inches Hg mb 29.45 (2,743 m). In most incidents and accidents, there are Dew point deg F deg C 68 a number of causal and contributing fac- tors. At times, the combination of factors has Calculate Reset exceeded the pilot’s or flight crew’s ability to break the causal chain of an accident, even when they respond as trained to a situation. Density altitude 9609 feet 2929 meters In some of the events described above, the Absolute pressure 24.099 inches Hg 816.1 mb NTSB determined that the airplane was over- loaded, which exacerbated the effect of the Relative density 74.77 % 74.77 % high altitude conditions. Financial concerns can tempt those in the aviation business to Susan Reed load to the maximum or even a little beyond. A sudden wind shift or a slight pilot miscalcu- In addition, the climb rate after takeoff is lation can also put the aircraft in jeopardy. In reduced compared with low density altitude. such cases, high density altitude can severely The initial flight path is flatter than usual. reduce the margin of error.
This is of particular concern because at many Edward Brotak, Ph.D., retired in 2007 after 25 years high‑altitude airports, the terrain rises quickly as a professor and program director in the Department after the runway end. The U.S. Federal Aviation of Atmospheric Sciences at the University of North Administration (FAA) says that pilots should Carolina, Asheville. check the operational data section of the aircraft Notes owner’s manual or the pilot’s operating hand- book developed by the aircraft manufacturer 1. NTSB SEA07FA223. <1.usa.gov/1eN9LdO>. to see how aircraft performance is affected by 2. Civil Aviation Administration of China/Boeing, air density. In lieu of these sources, some pilots “High and Hot Operations” seminar, Oct. 23–25, use the Koch chart, which relates altitude and 2007.
26 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2013
THREATANALYSIS
Rather than just a necessary cost of doing business, insurance can be a safety asset.
They’ve Got You COVERED BY MARIO PIEROBON
nsurance pricing for air transport decreased, mostly because of the avail- a risk and set a premium, insurers focus worldwide is subject to sudden and ability of huge financial capacity to on various parameters of the airline such hardly predictable adjustments. The absorb losses and strong competition. as number of aircraft, fleet value, age of increase in premium costs after the Airlines voluntarily purchase insur- aircraft, revenue passenger kilometers ISept. 11, 2001, terrorist attacks and, ance coverage or are required to by law and area of operation. more recently but less severely, after the because insurance is the most cost- Apart from collecting sufficient ag- June 2009 crash of Air France Flight 447 effective financial risk protection against gregate premiums to cover occasional in the Atlantic Ocean illustrate how avia- the consequences of major accidents. major losses, insurers need to account tion insurance premiums can fluctuate Airlines typically self-insure most of for administrative costs and add a profit because of unforeseeable events. Since their non-catastrophic, attritional losses. margin. Insurers tend to underwrite the immediate aftermath of Sept. 11 Insurance contracts are generally written based on historical experience: If an — when insurance premiums reached so that airlines pay any damage below insured party has had a major occur- levels eight to 10 times higher than agreed deductibles and insurers pay any rence, premium charges tend to rise at
today — premiums have considerably damage above deductibles. To evaluate policy-renewal time. © skodonnell/iStockphoto
28 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2013 THREATANALYSIS
On the contrary, continuous pressures that characterize the complex organizations “dedicated to providing improvement of an aircraft operator’s aviation environment.2 thought leadership through the devel- risk profile because of the absence of Integrated risk management (IRM; opment of frameworks and guidance on losses or improvement in the overall Figure 1, p. 30) is a principle derived enterprise risk management, internal safety standard may lead to premium from recent developments in risk control and fraud deterrence.” decreases over time and consequently management theory in the insurance The figure illustrates the value lower airline operational costs. industry and the financial world. It is “a of strengthening the direct relation- systematic assessment and analysis of all ships between objectives — what an Learning From Insurance risks in an organization.” IRM analysis is entity strives to achieve by strategy, The International Civil Aviation conducted from the bottom up as well as operations, reporting and compli- Organization’s (ICAO) new Annex 19, the top down to provide all the informa- ance and risk management, what Safety Management Systems (SMS) tion essential in determining a com- is needed to achieve the objectives. becomes applicable in mid-November, prehensive view of risk. IRM provides These relationships can be visualized and regulators such as the European significant input into the development as a three-dimensional matrix. The Aviation Safety Agency (EASA) al- of strategic plans, marketing initiatives, risk-management components are ready have clarified that SMS imple- financial plans and resource invest- represented by the horizontal rows, mentation will be required in Europe ments, as well as airline safety. the organization’s units by the vertical over the next few years. Risk-manage- Included is the assessment of risks rows and the categories of objectives ment policy and procedures of an SMS that are common to most organizations by the third dimension.5 allow a structured way of identifying — for example, strategic risk (market and handling all risks, particularly dynamics, resource allocation); finan- Data Collection those that are unacceptable under all cial risk (capital structure, liquidity, The insurance industry continually circumstances. credit); operational risk (assets, people, performs statistical analyses of data Risk management as a business technology); compliance risk (legal, collected to assess the risks that in- practice distinguishes between all risks regulatory, best practices); environmen- surers underwrite. In the airline busi- and those that can be kept under control tal risk (petroleum products, hazardous ness, there was not always this level by the organization, and only the mitiga- materials); corporate citizenship/image/ of sophistication in managing risk tion of the latter is worth expending reputation risk; and project risk.3 — and although many airlines already significant resources. Risk management, IRM is important in aviation have adopted comparable predictive with cost-benefit analyses, allows for a because it provides the best framework capacity, others still rely exclusively measurement of the returns on invest- for considering the connections among on qualitative (that is, non-data-driven) ment from alternative control and miti- risks. As IATA has said, “In order to observations and experience. gation options and so allows for efficient maximize the value of the organiza- Learning from the insurance indus- allocation of resources.1 tion, it is important to recognize that try’s example, an airline willing to man- Aligning the internal risk manage- risks are interrelated and thus cannot age risks with state-of-the-art methods ment approach with the external ob- be viewed and managed in isolation. As needs to start by developing (or refining) servations and experience of insurance such, risk management is not a one- a system that includes routine flight data providers can give airlines the benefit man show; it is a collaborative effort monitoring and a database of past safety of an enhanced perspective for decision throughout the organization.”4 occurrences (including near-misses and making. Risk management integration employee concerns) by which to assess (Figure 2, p. 31) can be seen as a the risks it faces. It must also develop Integrated Risk Management multidirectional process in which any systems to identify and implement risk- As the International Air Transport Asso- component can influence others. The control measures. ciation (IATA) has noted, an airline is a visualization shown is derived from the The development or refining of the “system of systems.” Management teams Committee of Sponsoring Organiza- reporting system and of the database must continuously adjust to dynamic tions of the Treadway Commission, needs to account for data quality, and financial, competitive and operational a joint initiative of five private-sector this is ensured only by a taxonomy.
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If the aim is to generate consistent minor occurrences or near-misses may with a ‘just culture’ might not be a big and repeatable results, the taxonomy be reduced, although results still could challenge. Other organizations are used in the observational programs must influence the insurer’s risk profile of the more reluctant to share such data. Data be well defined, easily understood and operator. sharing is just the top of a sound and applied by those responsible for record- Data collection is, however, a very established safety culture within an ing the observations. The taxonomy’s sensitive area, said Reto Inderbitzin, organisation. framework has to be in active use by CEO of Inderbitzin Comprehensive “In addition, performance analysis personnel in terms derived from their Solutions, a consultancy. “Everybody is an important management task of operational language. It needs to support would agree on collecting data, but a properly working quality assurance the human factors model of human er- would be less enthusiastic if it comes to process. Incidents and accidents are ror and to provide data that can support disclosure,” he said. “Some other open performance indicators. Some of them the SMS risk management components.6 questions with regard to data collection may even be safety performance indica- Such database development and on- are what happens to the data collected, tors and therefore part of an overall going analysis by the airline is normally who benefits from the collection, if safety performance assurance program. highly regarded by insurers, which es- results are shared or kept under tight A company with a transparent and tan- pecially are interested in data collection wraps and what the consequences for gible safety culture would not hesitate related to safety occurrences, monitoring the discloser are. to share the required information with mitigation outcomes and systematically “Nobody likes to admit inadequacies its insurance partner and would most addressing concerns of personnel. In or issues within their area of account- likely create increased appreciation and fact, if the insurer considers the avail- ability if they do not receive support in understanding.” ability and quality of the airline’s internal exchange for shared data regarding such data sufficient, its normal scope of on- issues. Establishing a data collection and Analytical Expertise site investigation of claims in the case of sharing mechanism in an organisation It is critically important in SMS that a reporting system and a safety database be suitable for the interpretation of An Integrated Airline Management System collected data. One of the biggest chal- lenges in this regard is “to acquire or train personnel who possess the skills SECURITY QUALITY and knowledge in these disciplines,
PERSONNEL and an understanding of the tools and CABIN MAINTENANCE analysis methods used in them,” said SMS specialists Alan Stolzer, Carl Hal- FINANCIAL DISPATCH ford and John Goglia. “Unfortunately, Integrated these are not skills that the typical avia- tion manager currently has.”7 MARKETING CARGO AMS To acquire and develop the ana- lytical expertise needed, look at the GROUND FLIGHT HANDLING measures used by the U.S. National
SUPPLIER DOCUMENTATION Aeronautics and Space Administra- tion (NASA) to enhance the agency’s SAFETY ENVIRONMENT probabilistic risk assessment (PRA) expertise. PRA is one of the most sophisticated risk management ana- lytical techniques in aerospace, estab- AMS = airline management system lished by NASA as a decision-making Source: International Air Transport Association support tool following the 1986 Space Figure 1 Shuttle Challenger disaster.
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“Real PRA expertise cannot be de- ownership and with the rigid bilateral It is therefore necessary to determine veloped overnight,” a NASA document agreements then in place, it meant that the quantum beforehand, such as a lost said. “If in-house experts do not exist an airline was as likely to have an aircraft bulkhead per aircraft type. This will in initially they must be hired or groomed damaged overseas as it was to damage the end lead to safer ground handling,” through training and transfer of technol- another airline’s aircraft at its home base, said Busk. ogy. They have to be able to build PRA said Ivar Busk, manager of insurance at In order to update the limits to the li- knowledge and experience and stimulate SAS Scandinavian Airlines. ability of ground handling companies to cultural changes so that the progressive Very much as insurance contracts reflect current industry needs, the Asso- organization can use these resources to — covering only major losses and ciation of European Airlines (AEA) has make sound and cost-effective safety catastrophes — stimulate an airline to proposed to amend the IATA Standard improvement decisions.”8 generate operating efficiencies to reduce Ground Handling Agreement. “The pro- The following steps have guided more frequent minor losses, making posals from AEA have been presented NASA in PRA development: service providers more accountable for to the IATA AGSA (ground handling the damages they cause can improve the contract group) but, not surprisingly, • “Transfer PRA technology to quality and safety of contracted services. the requests were not accepted with managers and practitioners as “In my experience over the years, I immediate effect,” said Busk. “Ground soon as possible; have become convinced that if a ground handling companies want to discuss the • “Develop or acquire PRA ex- service provider pays more of the dam- matter without any time constraint, but pertise and state-of-the-art PRA age, including consequential losses up to at least they recognize that some changes software and techniques; a certain limit, then we will see a more need to be done.” The European Com- proactive engagement from the service mission in its latest update of Regulation • “Gain ownership of the PRA provider. The difficulty is to value the 261/2004 has expressed “that national methods, studies and results in consequential loss without going too far. law and contractual provisions may order to use them effectively in the management decision process; Relationship Between RM Objectives and RM Components
• “Develop a corporate memory of the PRA project results and data on which to build future capabili- ties and experience; [and,] Internal Environment
• “Create risk awareness in pro- Objective Setting grams and projects that will Event Identi cation eventually help to develop a risk- informed culture for all programs Risk Assessment and activities.”9 Risk Response Negotiating With External Suppliers Control Activities One area of great concern for airline risk Information and Communication managers is that in practice, third parties Monitoring under contract are almost never liable for consequential damages to an airline’s RM = risk management aircraft during the rendering of services Note: The risk management components are represented by the horizontal rows, the organization’s such as ground handling. This status units by the vertical rows and the objectives’ categories by the third dimension. of things dates back several decades to Source: Committee of Sponsoring Organizations of the Treadway Commission when such services were usually provided by in-house companies under the same Figure 2
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not restrict the air carriers’ right to it is operating to recognized stan- Open Opportunity seek compensation from a third party dards, it would then be more flexible More than 20 years ago, to implement responsible for delays or cancella- with regard to individual premiums,” quality management systems, expertise tions. This provision aims to create an said Inderbitzin. “It is all about the was brought into the airline sector from economic incentive for third parties to relationship. Professional insurance the manufacturing industry. Today, risk find ways to reduce traffic disruption.” brokers who are acting on behalf of management expertise is required for This is in line with what airlines want airlines develop and maintain an inter- the full functionality of an SMS, an area to see implemented, said Busk. relationship to achieve a trustworthy in which insurance companies as well and efficient day-to-day contact, as risk management consultants should Long-Term Partnering which will eventually also assist in be invited to contribute. Airline safety directors and their risk [case of] a claim.” Senior airline managers and risk managers can benefit from knowledge managers have a unique opportunity that today’s considerable competitive- International Safety Standard to exploit today’s strong competition ness in the aviation insurance market, Achieving a recognized registration in the aviation insurance market, characterized by a strong availability such as under IOSA (IATA Op- which already is making a wealth of of capital as noted, has motivated erational Safety Audit) or IS-BAO risk management expertise, tools and several aviation insurance providers (International Standard for Business methods more accessible to airline to launch collaborative services to Aircraft Operations) is generally partners.
enhance risk management. This is an positively regarded by underwriters. Mario Pierobon works in business development attempt to develop a more stable and The International Business Aviation and project support at Great Circle Services in longer-term partnership with cli- Council (IBAC) reports that “approxi- Lucerne, Switzerland. ent airlines, instead of these airlines mately one-third of IS-BAO registered shopping for the lowest premium deal operators report significant insurance Notes every 12 months. savings as a result of registration, and 1. ICAO. Safety Management Manual. 2009. “Global Aerospace Underwriting the number is growing.”10 2. IATA. Integrated Airline Management Managers, for example, runs a program Inderbitzin has a similar per- System for Air Transport — Operators. called SM4 which allows its custom- spective when airlines and business 2007. ers to attend safety assurance and risk aviation operators come to negotiate 3. Ibid. prevention seminars,” said Inderbitzin. insurance contracts. “Although I can- “The benefit is not specifically that of not speak for all the insurers, as each 4. IATA. Integrated Risk Management Guidance Manual. 2010. a reduced insurance premium, but of one has its own individual perception, obtaining up-to-date know-how from it is certainly a positive element to 5. Committee of Sponsoring Organizations high-level speakers and recognized recognize an organization which has of the Treadway Commission. Enterprise Risk Management/Integrated Framework industry experts, and also nurturing demonstrated its compliance to stan- (Executive Summary). September 2004. a network of personal contacts which dards like IS-BAO or IOSA,” he said. would otherwise be hard to develop. Carl Norgren, formerly an airline 6. Stolzer, A.; Halford, C.; Goglia, J. Safety Management Systems in Aviation. Putting this learning opportunity into training captain and currently an avia- Farnham, Surrey, England, and the context of a long-term business tion safety consultant, added, “Espe- Burlington, Vermont, U.S.: Ashgate. 2008. relationship, the program provides the cially in comparison to other operators 7. Ibid. customer with a more solid outcome in the non-commercial or corporate than selecting insurance coverage upon aviation sector, where the regulator re- 8. NASA. Partial excerpt from Probabilistic premium level only.” lies on individual accountability rather Risk Assessment Procedures Guide for But long-term partnership with than a stringent set of regulations or NASA Managers and Practitioners. Washington, D.C.: NASA. 2002. an insurance provider typically does standards, an accreditation is a visible eventually offer benefits in terms of and comprehensible commitment to 9. Ibid. premium costs. “If an insurer knows safety and risk management standards 10. IBAC. Building an Aviation Safety and how the client is organized and that recognized and accepted worldwide.” Security Culture. Pamphlet, no date.
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The operator’s financial predicament prompted its founder to continue a medical flight into IMC, the NTSB says. U.S. National Transportation Safety Board Safety Transportation National U.S.
BY LINDA WERFELMAN pressingconcerns
he founder and president of a charter improper decision to continue visual flight operation succumbed to self-induced into night [IMC], which resulted in controlled pressure to complete the flight of a Mayo flight into terrain.” Clinic doctor to procure a heart for trans- The report cited as a contributing factor the Tplant when he flew his Bell 206B into instru- pilot’s self-induced pressure, which stemmed ment meteorological conditions (IMC) and largely from millions of dollars in financial crashed, the U.S. National Transportation Safety losses related to the downturn in the national Board (NTSB) says. economy and the knowledge that the Mayo The pilot, the doctor and a medical techni- Clinic — his largest customer — had been cian were killed when the helicopter struck the “identifying other aviation companies that ground near Green Cove Springs, Florida, at might better fulfill its needs.” 0554 local time on Dec. 26, 2011. Therefore, the report added, “the pilot In its final report on the accident, the would have been highly motivated to complete NTSB attributed the crash to “the pilot’s trips as requested so that he could demonstrate © Rame435/Dreamstime
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | NOVEMBER 2013 | 33 HELICOPTERSAFETY
the reliability of his service. … The pilot likely varied from 450 to 950 ft above ground level, with wanted to make the most of every revenue- calibrated airspeed between 100 and 110 kt. generating opportunity.” The last three radar returns indicated that the helicopter had turned right about 45 degrees and Flight Request descended about 300 ft, nearly on a direct course The pilot received a call from a company sched- to Shands Cair. The accident site was about 0.5 uler about 0335 informing him of the clinic’s nm (0.9 km) south of the last radar return. request for a flight from the Mayo Clinic Heli- When the helicopter failed to arrive at Shands port in Jacksonville to Shands Cair Heliport in Hospital, it was reported overdue, and search Gainesville, about 60 nm (111 km) southwest. A and rescue operations began. The wreckage was few minutes later, he reviewed weather reports found about 1000 in a remote wooded area. for airports along the flight route, and at 0423, he arrived at Northeast Florida Regional Airport Founder, President and Pilot (SGJ) in St. Augustine. The 68-year-old pilot — also the founder, presi- He left SGJ about 0517 for Jacksonville and ar- dent, owner and director of operations of SK Jets rived about 0530 after an uneventful repositioning — had learned to fly when he was 16 and held flight. He picked up his two passengers and de- an airline transport pilot certificate with ratings parted, contacting air traffic control at 0549. Over for single- and multi-engine airplanes, and a the next few minutes, the helicopter’s altitude commercial pilot certificate and flight instructor certificate with ratings Bell 206B Flight Path for rotorcraft and instrument helicop- ter. He had 11,343 Jacksonville 0 flight hours, includ- Mayo Clinic ing 3,646 hours in Heliport helicopters and 1,648 hours in Bell 206s. His 95 total time included
295 3,288 hours of night Atlantic Ocean experience and 3,259 hours of instrument experience. He had flown 10.7 hours, including 3.1 hours at night, in the 90 days FLORIDA before the accident St. John’s River and 2.5 hours, includ-
Green Northeast ing one hour at night, Cove Florida Springs Regional in the 30 days before Airport the accident; none of St. Augustine that flying involved instrument time. He Accident site 95 did not fly during the seven days before the accident. Source: U.S. National Transportation Safety Board He had been the Figure 1 pilot of an earlier
34 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2013 HELICOPTERSAFETY
of the Mayo Clinic Heliport; and at Gainesville Regional Airport, 5 nm (9 km) northeast of the destination heliport. Ceilings were reported at 7,000 ft at SGJ and Craig and 1,600 ft at Gainesville. By the time the helicopter departed from SGJ, there was a broken ceiling at 900 ft. At 0553, the ceiling at Craig had dropped to 700 ft. The TAF at Gainesville for the flight’s estimated time of arrival at Shands Cair called Board Safety Transportation National U.S. The Bell 206B crashed in a wooded area near Green Cove Springs, Florida, after flying for visibility of more than 6 mi (10 into night instrument meteorological conditions. km) and an overcast ceiling of 800 ft, with a “temporary condition” around accident flight involving an Agusta The helicopter was not certified the arrival time of IMC, with 4 mi (6 A109 that departed from St. Augustine for instrument flight rules flight and km) visibility, mist and an overcast on Dec. 22, 2007, and was cut short not equipped with a radio altimeter or ceiling of 400 ft. because of a 400-ft ceiling and 2.5-mi autopilot. It had a global positioning Airmen’s meteorological informa- (4.0-km) visibility. The helicopter was system (GPS) receiver and a VHF om- tion in effect at the time of the accident substantially damaged when its tail nidirectional range unit that provided warned of IMC with mist and fog. Sat- rotor struck trees during the return to localizer and glideslope indications, ellite images at 0602 — the time closest the fuel pump area. The accident was but the GPS had not been upgraded to to the accident — showed low clouds not reported to the NTSB until Jan. 15, provide terrain/obstacle warnings. and stratus over the site. 2008, and the agency noted conflicting The report said that a former SK reports on whether it occurred during Weather Data Jets helicopter pilot told accident the helicopter’s approach to the depar- There was no indication that the pilot investigators that the area near the ture airport or while taxiing. had contacted a U.S. Federal Aviation accident site was swampy and “suscep- “According to current and former Administration (FAA) Flight Service tible to fog. employees at SK Jets, a different heli- Station for weather information before “He added that once fog developed, copter pilot had turned down the flight the flight, but his laptop computer had the area was a ‘black hole’ at altitudes of due to the poor weather,” the report been opened to an aviation weather 200 to 400 ft agl [above ground level], added. “Following that accident, the website, indicating that he had viewed and a flight in these circumstances was [accident] pilot successfully completed aviation routine weather reports and effectively in IMC.” an FAA reexamination.” terminal area forecasts (TAFs) for The SK Jets general operations The accident helicopter was manu- the airports along his planned flight manual specified visual flight rules factured in 1979 and had accumulated route. The service he used was not night weather minimums of a 1,000 ft 11,173 total hours. The helicopter was among those approved in SK Jets op- ceiling and 3 mi (5 km) visibility, “un- maintained in accordance with an FAA- erations specifications. less otherwise approved by the director approved manufacturer’s maintenance Closer to his departure time, he of operations or chief pilot.” There was program, and its last inspection before called the Gainesville automated no restriction preventing the accident the accident was completed Dec. 1. It surface observing system, which was pilot — also the director of operations was flown 3.5 hours after that inspec- reporting 7 mi (11 km) visibility and a — from approving his own deviation tion before the accident. broken ceiling of 1,400 ft. from the policy. The Rolls-Royce (Allison) 250-C20B Information current at the time of his The report noted that U.S. Federal turbine engine had accumulated 11,054 search of weather data reported visibility Aviation Regulations Part 91 prohibits hours total time and 167 hours since an of 10 miles at SGJ; at Craig Municipal helicopter flight in Class G uncon- overhaul in 2005, when it was installed. Airport, about 7 nm (13 km) northwest trolled airspace at or below 1,200 ft at
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night unless visibility is at least 1.0 mi said that they were “not worried about duty,” the report said. The company (1.6 km). repercussions for making safety-orient- subsequently instituted a rotating duty Other company pilots said that, ed decisions,” the report said, and the schedule, and he heard no further com- although they would have accepted the most recent FAA principal operations plaints about the issue. He added, how- flight, based on the weather reports, inspector (POI) said SK Jets seemed to ever, that pilots who left the company they also would have had a back-up be a “normal” operator. had numerous complaints about how it plan, such as using ground transporta- However, two former company was operated; when he asked managers tion, in case the flight could not be pilots who had witnessed the 2007 ac- to make changes, they complied. completed. cident said they had concerns about the The former airplane pilot also told There was no record that the ac- company’s safety culture. investigators that pilots had been told cident pilot had made such arrange- “They cited management efforts not to use aircraft logbooks to note ments, the report said, noting that to cover up the [2007] accident and maintenance issues. “They had been helicopters were the preferred method threats of retribution that they experi- advised to instead write up issues on of transportation because “shorter enced for reporting the accident to the adhesive notes and leave them inside transportation times increased the odds FAA,” the report said, noting that both the logbooks so that the company could of a successful operation.” pilots — one of whom flew airplanes decide when and if it would address the SK Jets had a flight risk analysis and the other, helicopters — had left maintenance issues,” the report said. tool (FRAT) that called on pilots to the company about three years before complete preflight forms designed to the 2011 crash. Recession determine whether a flight should be “The former company fixed-wing Pilots and managers who worked at SK canceled because of risks, but one pilot pilot said that, when company manag- Jets at the time of the accident blamed told investigators that he did not use ers discovered that he had reported the the economic recession, which began in the forms “because the grading criteria accident to the FAA, they assigned him 2008, for a decline in business. During typically yielded such low risk scores more difficult work schedules and pres- the bankruptcy filing that followed the that they would never result in a flight sured him to fly in situations that made accident, the company indicated that it being canceled,” the report said. A him feel unsafe. He further stated that if had lost several million dollars in the FRAT form was not found for the ac- pilots refused such flights, the company three years before the crash, and that it cident flight. would fire them and make them repay had $1.3 million in assets and $9 mil- their training expenses. He added that lion in debt. Company History the chief pilot and general manager Mayo Clinic representatives had no- SK Jets was founded by the accident tried to intimidate younger pilots by ticed the delays in aircraft maintenance, pilot in 1997 and, at the time of the threatening to provide negative reports including the A109 that had been down accident, had four airplanes and three to future employers.” for maintenance since August 2011, and helicopters, including an A109 that had The former helicopter pilot said an official said that he was “concerned been down for maintenance for four that company pilots were “always on about the company’s finances because months. The accident helicopter had call, and managers urged them to fal- of its apparent inability to service been leased to the company several sify duty time records to indicate that aircraft in a timely manner.” As a result, days before the accident. they had received rest periods when he had identified other companies that The company ended flight opera- they were not flying.” The former “could better fulfill the Mayo Clinic’s tions and filed for bankruptcy protec- airplane pilot added that pilots were air transportation needs”; the accident tion in February 2012. “retroactively considered to be in a rest pilot was aware of his concerns and A former director of safety, director period when not called for a flight” had scheduled a meeting with him in of maintenance, chief pilot and others while on call. January 2012 to discuss Mayo’s require- told NTSB investigators that they had A former FAA POI said that he had ments, the report said.
no particular safety concerns and be- received pilot complaints about sched- This article is based on NTSB accident report lieved that the company had a positive uling and had told managers that they ERA12MA122 and supporting docket informa- safety culture. Former company pilots “could not continuously keep pilots on tion. The report is available at
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oting amid a flurry of pilot fatigue stud- plan approved by Parliament, said during the ies and flight crew surveys, the European parliamentary debate. Parliament has approved a plan intended The changes will “bring a series of clear safety to strengthen and standardize flight and improvements in crew protection against fatigue,” dutyV time limitations (FTL) and rest require- according to the European Aviation Safety ments for pilots and cabin crewmembers. Agency (EASA), which developed the plan. Parliament’s support for the new plan took European Union (EU) Vice President Siim the form of a vote in early October in which it Kallas praised Parliament’s vote as “a victory for rejected — 387–218, with 66 abstentions — a common sense.” recommendation from its own Transport and But critics, including pilot organizations, Tourism Committee to disapprove the package said the new requirements will not do enough to of changes. The committee had sought to return limit pilot fatigue. the matter to the European Commission (EC) The measure includes provisions to reduce to develop an alternative package with greater the allowable length of night flight duty to 11 protections against crew fatigue. hours, down from 11 hours and 45 minutes; to “Every single national safety regulator sup- reduce allowable flight time in 12 consecutive ported these measures,” Brian Simpson, chair- months to 1,000 hours, down from 1,300 hours; man of the committee and a supporter of the and, twice each month, to increase weekly rest Putting Fatigue to a Vote BY LINDA WERFELMAN European Parliament approves changes in flight and duty time limits. © Original illustration: User 4x6/Istockphoto.com User illustration: © Original Moore Jennifer Illustration adaptation:
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by 12 hours — to two days, up from one-and-a- associations in 37 European states, complained half days. In addition, combined airport standby that Parliament’s support for the changes was time and flight duty time will be limited to 16 “not a ‘victory for common sense’” but rather “a hours; current policies differ among member victory for in-transparency, commercial inter- states, some of which impose no limit. Another ests and short-sightedness.” provision will allow up to five days of rest at Philip von Schöppenthau, secretary general home base in case of flights involving “significant of the ECA, added, “The rules have been rushed time zone crossing”; current provisions allow two through the EU Parliament after the … trans- days of rest or, in some member states, less. port committee firmly rejected them. Europe The effort to modify FTL regulations began has lost a unique opportunity to be a forerunner more than five years ago, EASA said, noting on flight safety, to have safe, science-based rules, that the agency will now begin working with based on best practices.” representatives of pilots, cabin crews, airlines The ECA said the new rules are plagued by and national aviation authorities on details of “safety loopholes” that could actually allow night implementing the changes. flights of 12 hours and 30 minutes and situa- National aviation The next step is for the EC to formally enact tions in which pilots complete flights after being authorities will the regulations, which will begin to take effect awake for 22 hours or more. at the end of the year and will become fully ap- “With this approval, the [Parliament] took have an enhanced plicable in 2015. a step away from a precautionary approach, EASA Executive Director Patrick Ky said Par- ignored scientific expert advice and put passenger role in monitoring liament’s vote means that “Europe now has one of safety at risk,” ECA President Nico Voorbach said. pilot fatigue. the strictest FTL rules in the world.” His agency The British Airline Pilots Association will “continue to pursue its objective to promote (BALPA) asked the government in the United the highest safety standards in civil aviation.” Kingdom not to approve the measure, which Before the vote in Parliament, Kallas, a lead- BALPA says represents a weakening of existing ing proponent of the changes, complained that U.K. safety standards. opponents had invoked “misleading scare stories and false claims” in their campaign against the ‘Greater Oversight’ new regulations. The U.K. Civil Aviation Authority (CAA), But both advocates of the newly approved however, said that it “welcomed a decision by package of changes and critics said they were the European Parliament to support harmonised motivated by safety concerns and a desire to flight time limits for pilots across Europe and limit fatigue in the cockpit. give regulators far greater oversight of fatigue.” The CAA added that, under the new regula- ‘Safety Loopholes’ tions, national aviation authorities will have an The European Cockpit Association (ECA), enhanced role in monitoring pilot fatigue, and which represents 38,000 pilots in national pilot will have access to relevant airline flight data.
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“This will allow regulators to analyse roster AEA Acting Secretary General Athar Husain and shift patterns to identify problems on spe- Khan noted that the AEA “has been constantly cific sectors or routes,” the CAA said. supporting the proposal” and credited members CAA Chief Executive Andrew Haines added, of the European Parliament with recognizing “Pilot fatigue is a real risk in the aviation indus- that “one harmonized set of rules for the com- try, and we take the management of fatigue very mon aviation market will benefit passengers’ seriously. Fatigue has multiple causes and must safety.” be managed in a practical, hands-on way, not Simon McNamara, director general of the simply by asking airlines and pilots to comply European Regions Airline Association, called with a set of timetables. Responsibility for man- the Parliament’s action “excellent news.” aging fatigue is three-fold: effective regulation, proactive management by airlines and profes- Admitting to Fatigue sional behaviour and reporting by pilots.” Parliamentary action followed the publication The CAA also said that it plans a research of a number of reports on fatigue among airline project to increase understanding of the causes pilots. of fatigue. One of the most recent was a report on a 2012 survey of Portuguese airline pilots that said ‘Crucial Milestone’ that more than 90 percent reported having made Organizations representing European airlines fatigue-related mistakes in the cockpit, and two- praised Parliament’s approval of the new regulations. thirds said that they had more than once been The Association of European Airlines (AEA) so tired that they should not have been at the characterized the vote as a “crucial milestone in controls (Table 1).1 Europe’s aviation safety.” The report, published in the August is- sue of Aviation, Space, and Environmental Perception of Fatigue* Medicine, was based on responses to a survey that was distributed to the total population Question Never Once Few Times Frequently of 1,500 commercial airline pilots working Do you feel so tired that you 60 87 234 75 think you should not be at (13.2%) (19.1%) (51.3%) (16.4%) for Portuguese airlines. Researchers obtained the controls? what they considered to be 456 valid respons- Yes No es from survey recipients who were com- Has it ever happened that 417 39 manders (captains) or first officers between you have made mistakes (91.4%) (8.6%) the ages of 20 and 65 who were on active in the cockpit as a direct consequence of fatigue? duty and had flown during the previous six Never Once Few Times Frequently months. Have you ever reported 372 50 28 6 Although they admitted having been yourself unfit for flight as (81.6%) (11%) (6.1%) (1.3%) fatigued in the cockpit, 82 percent of those ques- a result of accumulated fatigue? tioned said they had never reported themselves Minimum Maximum Mean + or - SD as “unfit for flight as a result of accumulated How many human factors 0 14 0.38 + or - 1.15 fatigue,” and 11 percent said they had done so confidential reports have 371 1 only once, the report said. you made in the last six (81.4%) (0.2%) Pilots also were asked to assess their fatigue months? using the nine-item Fatigue Severity Scale, SD=standard deviation developed to evaluate fatigue associated with a *Based on responses in 2012 from 456 captains and first officers for Portuguese airlines. multitude of medical disorders. Pilots who flew Source: Reis, Cátia; Mestre, Catarina; Canhão, Helena. “Prevalence of Fatigue in a Group of Airline Pilots.” Aviation, medium- and short-haul flights — those less Space, and Environmental Medicine Volume 84 (August 2013): 828–833. than six hours long with multiple segments — Table 1 reported higher levels of fatigue than those who
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flew long-haul flights — those lasting longer In the survey of U.K. pilots, nearly one-third than six hours but typically consisting of no of respondents said that they had not reported more than two segments, the report said. their fatigue “because they were too tired to file a report.” Forty-one percent said they “could see Common Problem no benefit in doing so,” 14 percent “did not want An earlier collection of pilot fatigue studies to make a fuss,” and 13 percent “did not want — assembled by the ECA in its 2012 Barom- the management to have a less positive opinion eter on Pilot Fatigue2 — concluded that “pilot of m e .” fatigue is common, dangerous and an under- The report added, “Another striking aspect is reported phenomenon in Europe. … It is more that those who have already filed a report do not widespread than expected, and, at the same feel motivated to do it again. It could either be ‘Pilot fatigue is time, it is significantly underreported by pilots because they have already felt negative conse- ... significantly themselves.” quences or have seen no results.” The document cited studies conducted be- The report said that the national surveys underreported tween 2010 and 2012 by ECA member associa- confirm the findings of previous scientific and tions in Austria, Denmark, France, Germany, medical researchers, who identified types of by pilots the Netherlands, Norway, Sweden and the flight operations that have the strongest associa- themselves.’ United Kingdom. The studies surveyed more tion with fatigue — for example, “night duties, than 6,000 European pilots, asking them to as- disruptive schedules, long flight duties and long sess the level of their fatigue. work days (e.g., standby plus flight duty).” More than half of those questioned said The report cited, in addition to recent ac- that their fatigue interfered with “their abil- cidents in which pilot fatigue has been singled ity to perform well while on flight duty,” the out as a probable cause or a contributing factor, report said. a May 2012 event in which an Air Berlin flight “A common indicator of the problem is crew made an emergency landing in Munich that fatigued pilots are prone to fall asleep because of pilot fatigue. The report did not dis- or experience episodes of micro-sleep in the cuss details of that event, but published reports cockpit. In the U.K. (43 percent), Denmark (50 at the time said that the German air accident percent), Norway (53 percent) and Sweden (54 investigation bureau reviewed the May 5 request percent), the surveyed pilots reported falling for clearance to land by the Airbus A330 pilots, asleep involuntarily in the cockpit while flying. who had told air traffic control that they wanted In the U.K., a third of the pilots [were] said to to land as soon as possible because they were have woken up finding their colleague sleeping feeling “extremely fatigued” as they approached as well. Sixty-five percent of Dutch and French Munich after a flight from Palma de Mallorca, pilots stated they have trouble with ‘heavy Spain. They landed 12 minutes after they made eyelids’ during flight.” the request.3 More than 80 percent of German pilots, and more than 60 percent of those in Sweden, Nor- Notes way and Denmark, said they had made mistakes 1. Reis, Cátia; Mestre, Catarina; Canhão, Helena. because of fatigue, the report said. “Prevalence of Fatigue in a Group of Airline Pilots.” Nevertheless, most of the pilots questioned Aviation, Space, and Environmental Medicine Volume in the eight surveys said they would not report 84 (August 2013): 828–833. the problem to their employers or declare 2. Available at
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operations management traffic flow crew policy aircraft procedures
weather
airports
BY DANNY C. HO, CHI-BIN CHENG, HUAN-JYH SHYUR AND MICHAEL HADJIMICHAEL
Custom-designed logic trees in FORAS models focus one airline’s risk assessment before hundreds of daily departures, approaches and landings.
uring the September 1997 meeting of the enables knowledge domain experts to deal with a Icarus Committee, an expert team affiliat- small number of risk factors at a time, reducing ed with Flight Safety Foundation, members the complexity of their work. agreed to form the Safety Index Working The FORAS model contains a great number DGroup to develop a safety-metrics model with of risk factors; to illustrate, only a small portion which an airline can monitor and measure opera- of the FORAS model dedicated to approach and tional safety performance. The model developed landing risk value (ALRV) assessment is pre- into a software system called the Flight Opera- sented (Figure 1, p. 43). The ALRV assessment is tions Risk Assessment System (FORAS).1 broken down into three sub-groups: crew func- The goal in developing FORAS was to create tionality, aircraft functionality and sector threat. a quantitative index for proactively assessing These sub-risks are further subdivided aviation risk, focusing on the recognition of risk into more detailed sub-risks. For example, factors involved in aviation safety instead of em- crew functionality includes inter-crew com- phasizing accident rates. Full technical details munication, pilot experience and pilot fatigue. were published in 2009.2 FORAS developers As noted, the automated breakdown process adopted a mathematical model to synthesize a continues until all measurable risk factors are variety of inputs (risk factors), including infor- obtained — in this example, experience pairing, mation on crew, weather, management policy rank composition and communication profi- and procedures, airports, traffic flow, aircraft ciency. These data are available from the airline’s and relevant operations. crew and roster databases. In FORAS, risk assessment is tackled with a divide-and-conquer strategy. A given risk category FORAS Model Development is broken down into a small set of sub-risk catego- In 2005, EVA Airways collaborated with Michael ries, and each sub-risk is further broken down to a Hadjimichael (then working at the U.S. Naval Re- set of risk measures. This process terminates when search Laboratory) to develop the first practical directly measurable risk factors (operational data) application of the FORAS model to monitor the
Trees in the FORAS associated with a flight are obtained. This scheme approach and landing risk of each flight. An EVA Illustration: DrAfter123/istockphoto.com © Original Moore Jennifer Illustration adaptation:
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Airways team interviewed pilots, safety man- agers, dispatchers and maintenance engineers Small Portion of the FORAS Model for Approach and Landing Risk Assessment and discussed the risk factors that contribute to approach and landing risk and the relationships among these risk factors. The FORAS model for ALRV assessing this risk then was successfully imple- C1 A1 S1 mented at EVA Airways as an online system. crew aircraft sector functionality functionality threat Currently, the approach and landing risk of each flight is computed by FORAS two hours and 30 minutes before its departure, and the C2 C3 C4 inter-crew pilot pilot resulting risk value is shown on a Web-based communication experience fatigue interface. During its years of experience in using the FORAS model, EVA Airways has gained T1 T2 C5 experience rank English insights about the causal relationships among pairing composition pro ciency risk factors and their contribution to approach ALRV = approach and landing risk value; FORAS = Flight Operations Risk Assessment and landing risk. This experience also identified System a need to revise the original model. Source: Chi-Bin Cheng and Huan-Jyh Shyur In 2009, EVA Air launched a research project with the Department of Information Manage- Figure 1 ment of Tamkang University, to revisit the risk FORAS System Architecture factors and develop a new software system that allows users to construct a new model or change Back-End System an old model easily. The new software system Flight Model tree operations has been implemented online at EVA Airways construction data and offers great flexibility and convenience MFs setting Node Fuzzy Model whenever the system administrator needs to parameters inference testing setting engine revise the model. Rules setting
A Two-Part System Publish The FORAS software model application is com- posed of two parts, called the back-end system Central database and the front-end system (Figure 2). The back- end system provides a user-friendly interface for Front-End System the user to construct a FORAS tree as required Administrator FORAS portal Flight query functions by the model (Figure 3, p. 44). Each node in the tree represents a risk factor Interruption Real-time risk and is associated with a set of parameters that report report specify the node’s characteristics. The informa- Detailed tion is used in online reporting and risk assess- report ments. The back-end system uses information CRFs Drill-down from the model to identify legal input data identification Trend analysis analysis (that is, data conforming to software-embedded rules), parameters for which missing input data are acceptable and parameters that are control- FORAS = Flight Operations Risk Assessment System; MF = membership function CRF = critical risk factor lable. When missing data are allowed, risk-index Source: Chi-Bin Cheng and Huan-Jyh Shyur computation proceeds with default values. Controllable parameters are variables that may Figure 2
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bottom level of the user-constructed tree to Model Construction Interface the top. Taking Figure 1 as an example, the risk value of inter-crew communication is inferred from three risk factors — experience pairing, rank composition and English proficiency; in turn, the risk value of crew functionality is inferred from inter-crew communication, pilot
1 2 experience and stress level. Finally, the ALRV is inferred by the FORAS model from crew functionality, aircraft func-
3 tionality and sector threat. This logical inference procedure is based on a conditions-consequence 4 relation, also referred to as a causal relation. For 5 example, in inferring the inter-crew communi- cation risk (a consequence), experience pairing,
1 Model tree 2 Data range 3 Invalid condition rank composition and English proficiency are the determining conditions. 4 Attribute (controllable/uncontrollable) 5 Missing data default value
Source: Chi-Bin Cheng and Huan-Jyh Shyur The Rules In each airline’s FORAS model, the relation Figure 3 between a condition and a consequence is expressed by rules. A rule is used to describe Rule-Setting Module the degree of the resulting risk under various conditions of its causes, and such conditions are assessed in a linguistic manner. As an example of the simplified user-interface 1 language of the FORAS model, a typical rule — in this case, part of a logical assessment of the inter- crew communication risk — would be, “If T1 is ex- perienced, T2 is ideal and T3 is poor, then C2 is 4.” In plain English, that means, “While planning 2 a specific flight, if the airline safety specialists rank the condition called flight crewmember ex- perience pairing (T1) as ‘experienced’ (from their predefined scale of possible ratings); they rank 1 Rule setting in a list format 2 Rule setting in a table format the condition called flight crew rank composi-
Source: Chi-Bin Cheng and Huan-Jyh Shyur tion (T2) as ‘ideal’; and they rank the condition called flight crew communication proficiency (T3) Figure 4 as ‘poor,’ then the FORAS model must use the be controlled by flight dispatch or by a sched- value “4” wherever the inter-crew communica- uling action to decrease flight operation risk. tion risk value is required in the model’s trees and These possibilities include crew and aircraft algorithms. In this way, that risk value — selected factors. Weather is an example of an uncontrol- by the specialists using a predefined scale from 1 lable factor. to 10 (the greater the number, the higher the risk) The risk-assessment functionality in the — will be applied consistently by the FORAS FORAS model is obtained by a series of infer- model, representing the specialists’ overall per- ence procedures moving upward from the ceived risk value for inter-crew communication.
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The formulation of such rules is based on Membership Function–Setting Module experts’ knowledge and group decision making. Rules of this type have the advantage of being easy to express and understand for the knowledge- domain experts from whom the knowledge base is derived. In particular, evaluating conditions in a linguistic manner alleviates the difficulty of quan- tifying an uncertain or subjective judgment that 1 doesn’t lend itself to precise numerical expression. 2 The back-end system contains a rule-setting module, where the setting of rules can be in either a rule format or a table format (Figure 4, p. 44).
Rules Into Equations The last thing needed to make such rules work 3 together in risk assessment is to define math- ematical equations that quantify the linguistic terms in the rules. This definition of equations is based on the values of the conditions, which the
FORAS model’s designers call the membership 1 Types of membership functions 2 Membership function parameter setting function of the risk factor. Membership functions 3 Membership functions in graphic form interpret the airline’s plain-language linguistics terms (such as “high experience”) as specific Source: Chi-Bin Cheng and Huan-Jyh Shyur numerical input values. Figure 5 The back-end system in the FORAS software also contains a module for membership function– that identifies which factor contributes most to the setting, where typical functions are provided and risk of interest (Figure 7, p. 46). presented in a graphic form (Figure 5). After a FORAS tree has been built by the air- EVA Airways’ Risk Assessment line using the back-end system, it is “published” EVA Airways so far has constructed two FORAS to a central database. The front-end system then models to construct two risk assessment models, retrieves the tree and its associated parameter set- one for routinely assessing approach and land- tings (input data) from the database to compute ing risk and one for assessing departure risk. the risk value of a flight. This risk assessment of Both models are run online for about 200 flights a flight is computed two hours and 30 minutes every day worldwide. before its takeoff. Based on FORAS reports, safety manag- In a snapshot of the online risk report of actual ers evaluate the overall level of risks for these flights (Figure 6, p. 46), various “traffic light–style” aspects of their operations, and analyze the ef- signals clearly indicate the risk status of a flight (a fects of management decisions on this risk level. green light means Normal, yellow means Warn- With the trend analysis function of the system, ing and red means Alert). If desired, the user can managers can track various risks over time. The click on the computer display of the flight to read critical, risk factor–identification function as- a detailed risk report that lists the risk values of all sists the safety managers to identify the risk fac- nodes in the tree associated with that flight. On tor that contributes most to the risk of interest. this screen, users can also request further analysis, Theoretical concepts and implementation issues including a drill-down analysis, a trend analysis of of this system were presented at an FSF Interna- the risk of interest and a critical risk factor analysis tional Air Safety Seminar in 2011.3
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The EVA Airways’ software application of the cloud platform, and that individual airlines FORAS model is installed on a cloud-computing will access the risk-assessment service by se- platform to enable sharing FORAS models within curely sending encoded flight data to the cloud the airline industry in the future. The plan is to platform. For data security, the cloud platform establish a community-computing, cloud-based would not keep the flight data or their com- system, run by a third-party non-profit organiza- putational results. Users could customize their tion, with a multi-tenant infrastructure shared risk models (including trees) by setting model among several organizations with common parameters via a Web interface to the front-end computing interests. system. For airlines that intend to operate the The authors envision customized FORAS FORAS model on their own, a private cloud- models constructed and maintained on the computing platform can be built based on the same architecture. FORAS development was originated by Real-Time Risk Assessment Report Flight Safety Foundation, and originally was funded by the U.S. National Aeronautics and Space Administration, the U.S. Naval Research 1 Laboratory and EVA Airways. 3 2 Currently, EVA Airways plans to share the latest FORAS model version with interested airlines to promote this proactive and quantita- tive safety management concept and tool. This promotion of the FORAS model will be non- commercial, in which airlines that are interested 1 Query conditions 2 Risk value of a flight 3 Risk status of a flight in acquiring the system will pay an amount to
Source: Danny C. Ho the FORAS Association based on their fleet size. Plans call for the FORAS model fund to be Figure 6 managed by a committee of trustees. The fund will be utilized to set up FORAS scholarships Detailed Risk Assessment Report and FORAS awards, and to sponsor the future
2 3 4 development of the FORAS model, as well as other aviation risk management initiatives.
Notes
1. Hadjimichael, Michael; Deborah M. Osborne; David Ross; Diana Boyd; and Barbara G. Brown. “The Flight Operations Risk Assessment System: 1 Proceedings of the 1999 ASE Advances in Aviation Safety Conference.” Daytona Beach, Florida, U.S., pp. 37–43.
2. Hadjimichael, Michael. “A Fuzzy Expert System for Aviation Risk Assessment.” Expert Systems with Applications, 36, pp. 6512–6519. 2009.
1 Detailed risk report 2 Drill-down function 3. Ho, D.C.; H.-J. Shyur; C.-B. Cheng; W.-H. Yeh; 3 Critical risk factor analysis 4 Trend analysis function S.-C. Kao. “The Enhancement and Implementation of the Flight Operations Risk Assessment System Source: Danny C. Ho (FORAS).” In Flight Safety Foundation, Proceedings of the 64th International Air Safety Seminar, Figure 7 Singapore, 2011.
46 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2013 INFOSCAN
MANAGING
Workload 3.0 © Alan Radecki|Wikimedia CC-BY-SA Researchers examine the cockpit task-management abilities of single pilots of very light jets.
BY LINDA WERFELMAN
REPORTS high workload management. The goal was to determine how the pilots managed their work- Single-Pilot Workload Federal Aviation Administration load, what types of problems they encountered Management in Entry-Level Jets DOT/FAA/AM-13/17 and why, what workload management tech- Washington, DC 20591 DOT/FAA/AM-13/17. Burian, B.K.; Pruchnicki, S.; Rogers, J. et al. Single-Pilot Workload Management in Entry-Level Jets U.S. Federal Aviation Administration (FAA) Office of Aerospace niques could be characterized as best practices, Barbara K. Burian1 Shawn Pruchnicki2 Jason Rogers3 Bonny Christopher2 Medicine. September 2013. 127 pp. Appendixes, figures, tables. and how the pilots benefit from, or experience Kevin Williams3 Evan Silverman2 Gena Drechsler, Andy Mead, Carla Hackworth3 Barry Runnels3 Available from the FAA at 1 problems associated with, automation and ad- NASA Ames Research Center Moffett Field, CA 94035 2San Jose State University med_humanfacs/oamtechreports>. San Jose, CA 95112 3FAA Civil Aerospace Medical Institute vanced technologies. Oklahoma City, OK 73125 September 2013 his report chronicles a study that examined The study also was designed to produce Final Report task and workload management by 14 pilots baseline data for use in future studies involving Tof entry level jets (also known as very light the FAA’s Next Generation Air Transportation jets) to evaluate pilot errors during high-work- System (NextGen). load events. “To facilitate analysis,” the report said, The researchers — from the U.S. National “the major high-workload tasks during the Aeronautics and Space Administration Ames cruise portion of flight were grouped into four Flight Cognition Lab and the FAA Flight Deck events. Approximately two-thirds of the tasks Human Factors Research Laboratory at the Civil within the four events were accomplished by Aerospace Medical Institute — observed the the participants with no difficulties. Though all pilots as they conducted an experimental flight in participants committed a variety of errors dur- a Cessna Citation Mustang flight training device. ing all four high-workload events (e.g., readback Eight pilots owned and operated Mustangs, error, airspeed violation), most errors were not and the other six were professional pilots who directly related to overall task success.” flew Mustangs on the job. Nevertheless, the report said that, in the The experimental flight consisted of two legs first event — “setting up the automation to flown under instrument flight rules and with intercept the 208-degree Broadway radial FLIGHTSAFETY.ORG | AEROSAFETYWORLD | NOVEMBER 2013 | 47 INFOSCAN following the completion of the departure workload. Research is needed to evalu- procedure out of Teterboro [New Jersey, U.S.] ate the cost-benefit tradeoffs of pilots in leg one” — the researchers discovered “a programming an expected, but not significant effect on task performance success confirmed, instrument approach while related to hours of experience.” still at cruise; The research also revealed that, for pilots • “During periods of automation mode who had difficulty with the tasks, “some type changes (e.g., level off at top of climb), of error” involving their use of Garmin G1000 pilots should briefly refrain from other avionics was to blame. “Consistent with that tasks and monitor the automation and finding is the result that half or more of the aircraft behavior to make sure the aircraft participants were unsuccessful or had prob- performs the action as intended; [and,] lems accomplishing the three major tasks that involved the greatest amount of programming,” • “When deferring a task until a later the report said. time, we suggest that pilots take a mo- The report noted that, because of the low ment and form an explicit intention number of participating pilots, the “statistical about completing the task and when. power” of the exploratory study was limited, and For example, say to yourself, ‘Report to the findings could not be generalized to apply to ATC when I level out at cruise.’ External pilots other than those who participated. memory aids or cues, such as placing The report suggested several related topics an incomplete checklist between the for future research, including determining the throttle levers or on your lap, can also “optimal balance between time spent monitor- assist with recalling the need to perform ing automation and time spent focusing on deferred actions.” other tasks” and examining whether “pilot auto- mation use and errors committed [are] associ- FAA’s Controller Scheduling Practices ated with frequency of use or the use of different Can Impact Human Fatigue, Controller Office of Inspector General Audit Report avionics systems in other aircraft.” Performance, and Agency Costs FAA’S CONTROLLER SCHEDULING PRACTICES CAN IMPACT HUMAN FATIGUE, U.S. Department of Transportation Office of Inspector General (OIG). CONTROLLER PERFORMANCE, AND AGENCY The report included several recommenda- COSTS Federal Aviation Administration Report Number: AV-2013-120 Report no. AV-2013-120. Aug. 27, 2013. 29 pp. Appendixes, figures. Date Issued: August 27, 2013 tions for workload management and the use of Available from OIG at 48 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2013 INFOSCAN The OIG’s review was based on an exami- be made early in 2014 on whether to adjust the nation of a sample of 32,814 shifts for 403 con- facilities’ operating hours. trollers at 20 facilities over a 16-week period. “We found 279 cases where controllers did ELECTRONIC MEDIA not have the required nine hours of off-duty time between an evening shift and the following day Maintenance for Fire Reduction FLIGHTSAFETY.ORG | AEROSAFETYWORLD | NOVEMBER 2013 | 49 ONRECORD Close Call on Climb-Out A misunderstanding of an altitude assignment led to a near collision between a civilian freighter and a military helicopter. 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 Nonstandard Departure Clearance commander’s first rotation through Brize Airbus A300-605R, Boeing Vertol CH-47D. No damage. No injuries. Norton, but the copilot had been there a tower controller’s use of nonstandard air number of times,” the report said. “Both were traffic control (ATC) communications Turkish nationals with a good working knowl- A phraseology in a departure clearance edge of English.” and an A300 flight crew’s misunderstanding The copilot, the pilot monitoring, was of an initial altitude assignment resulted in handling ATC communications. The ground the freighter coming within close proxim- controller issued taxi instructions to Runway 26 ity of a Chinook helicopter that was orbiting and a departure clearance specifying a standard above the military airfield, according to the instrument departure procedure that included report by the U.K. Air Accidents Investigation an initial climb to Flight Level (FL) 080 (ap- Branch (AAIB). proximately 8,000 ft). The incident occurred in visual meteoro- After the copilot read back the clearance, logical conditions (VMC) at RAF Brize Nor- the flight crew briefed the departure proce- ton Aerodrome in Oxfordshire, England, the dure and entered it into the flight management afternoon of Nov. 18, 2011. Visibility was greater system, with 8,000 ft selected as the initial target than 10 km (6 mi), and surface winds were from altitude. “The commander intended to use the 180 degrees at 8 kt. There were a few clouds at autopilot engaged with the ‘Profile Mode’ to be 1,800 ft and a broken ceiling at 12,000 ft. selected after takeoff,” the report said. “In this The A300 was of Turkish registration. The mode, the autopilot follows the horizontal and crew, comprising two pilots and a loadmas- vertical profile of the departure and levels off at ter, had flown the aircraft to Brize Norton the target altitude.” that morning and were preparing to return The pilots decided that there was sufficient to Istanbul with a load of cargo. “It was the runway available to begin the takeoff from the FLIGHTSAFETY.ORG | AEROSAFETYWORLD | NOVEMBER 2013 | 51 ONRECORD Echo intersection, and the copilot made instrument training flight with four “climb-out restriction,” the phraseol- the request. The ground controller crewmembers aboard. ogy does not appear in the civilian or instructed the crew to taxi to Echo and The controller did not persist in military sections of CAP 413, Radio- to establish radio communication with obtaining a full readback of the instruc- telephony Manual, the report said. “It the tower controller. tion. He told the crew to line up and does appear in other military docu- “Having changed frequency, the wait on the runway at the Echo inter- ments, but these are not available to next information the crew were expect- section. The crew then was cleared for civilian pilots.” ing to be passed was either to line up at takeoff from Runway 26. According to CAP 413, the proper Echo or to continue the taxi to hold- The A300 was on initial climb phraseology for the altitude restriction ing point Foxtrot, from which the full when the crew was told to contact the would have been: “Climb to altitude length of the runway is available for departure controller. At the time, the two thousand two hundred feet.” takeoff,” the report said. helicopter was at 3,500 ft and entering Moreover, the document requires On initial contact, the tower con- a holding pattern at a nondirectional flight crews to state the altitude troller issued an altimeter setting and beacon near the departure path of through which they are passing and told the crew that they would have a Runway 26. their assigned altitude on initial “climb-out restriction, two thousand The departure controller, expecting contact with departure control. The two hundred feet.” the freighter to level at 2,200 ft, advised A300 crew did not do this. If they The pilots misunderstood the the crew that “traffic” (the Chinook) had, it “would have immediately instruction. “The crew, who were was at their 1 o’clock position, 1,000 ft alerted the controller to the fact that expecting taxiway- and runway- above and on a similar heading. The the aircraft would not level at 2,200 related information, interpreted the copilot replied that they had the heli- ft,” the report said. [‘two thousand two hundred feet’] to copter in sight. After the incident, Brize Norton be the runway length reduction when The A300 was climbing through authorities revised their control- entering the runway from holding 2,200 ft at about 3,000 fpm when the lers’ handbook to eliminate the term point Echo,” the report said. “Al- controller asked the crew to report “climb-out restriction” and to require though both pilots were familiar with their “passing [current] altitude.” The departure controllers to remind the term ‘climb-out restriction,’ they copilot said, “Now above two thousand flight crews of their altitude assign- did not register the information as nine hundred.” The controller told the ments if they are not stated on initial an altitude and therefore did not read crew to immediately stop the climb. contact. back the phrase.” The copilot replied they were climbing The copilot read back only the al- through 3,400 ft in compliance with Impromptu Aerobatics timeter setting and repeated the request a traffic-alert and collision avoidance Cessna Citation 550B. Destroyed. Two fatalities. for takeoff from the Echo intersec- system (TCAS) resolution advisory. he flight crew departed from tion. The tower controller asked the “The returns from the two aircraft Prague, Czech Republic, the night A300 copilot to confirm the climb-out were seen to merge on the ATC radar Tof Feb. 14, 2010, for a positioning restriction. The copilot replied, “Yes, display,” the report said. “According to flight to Karlskrona, Sweden. The pilot- good, copied, thank you.” TCAS data from the A300, the mini- in-command (PIC), 27, had about 1,700 The controller said, “I need you mum lateral separation between the flight hours and had been employed by to say back, climb-out restriction two A300 and the Chinook was 0.11 nm the aircraft-management company in thousand two hundred feet.” [0.20 km] and the minimum vertical 2009. The copilot, 32, had about 1,600 “Yeah, two thousand two hundred separation was 496 ft.” flight hours and had been with the feet copied,” the copilot said. The Chinook was in a left turn company since 2005. The report said that the copilot when the crew saw the A300 pass While climbing to the assigned likely still related this to runway length. overhead. The crew later filed an Air- cruise altitude, FL 330, the PIC The climb restriction actually had been prox report. mentioned that she had not flown issued to provide vertical separation Although the freighter crew was at night for a long time. The copilot, from the Chinook, which was on an found to be familiar with the term who was hand flying the airplane, 52 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2013 ONRECORD said, “Have you already experienced provided no visual references for the report said. “With a runway distance a roll during night?” unauthorized maneuver. of 2,680 ft remaining, the airplane During the ensuing conversation, could have stopped or gone around the pilots “no longer paid appropriate Seat Detaches on Overrun uneventfully with appropriate use of all attention to airmanship and engaged in Gulfstream G150. Substantial damage. One serious deceleration devices.” something neither they nor the airplane injury, three minor injuries. However, the ground spoilers did could handle,” said the English transla- he G150 was en route from Stuart, not deploy on touchdown. Investigators tion of the accident report published Florida, U.S., to Key West, Florida, found that the spoilers had been armed in September by the German Federal Tthe night of Oct. 31, 2011. The for the landing and were not able to Bureau of Aircraft Accident Investiga- destination airport had one runway and determine conclusively why they did tion (BFU). was reporting surface winds from 360 not deploy. “At no time during the conversa- degrees at 12 kt, gusting to 17 kt, 10 mi “The landing procedure stated tion did the PIC exercise her lead- (16 km) visibility and broken ceilings at to activate the thrust reversers after ership role,” the report said. “The 1,000 ft and 1,400 ft. nosewheel touchdown and then apply impression arose [from the cockpit ATC cleared the flight crew to con- the [wheel] brakes, as necessary,” the voice recording] that the PIC encour- duct a visual approach to Runway 27, report said. “However, the PIC only aged the intention of the copilot [to which was 4,801 ft (1,463 m) long and applied the brakes. Further, no callouts roll the aircraft].” 100 ft (30 m) wide. “The flight crew were made to verify ground spoiler or Neither pilot had received train- lost sight of the runway due to some reverse thrust deployment.” ing in aerobatics, and the airplane low stratus clouds and discontinued the The report said that likely due of was not certified for aerobatic flight. approach,” said the report by the U.S. the absence of deceleration provided The report said, however, that the National Transportation Safety Board by spoiler deployment, both pilots recorded conversation also indicated (NTSB). “The controller then instruct- perceived incorrectly that the wheel that both pilots “had flown aerobat- ed them to overfly the airport and enter brakes were not working properly. ics in the past with other airplanes of a right downwind leg for Runway 27, “The procedure for a (perceived) the company.” which they did. failed brake system would have been The copilot leveled the Citation at “During the second approach, they to activate the emergency brake, which FL 270 and attempted to roll it. “The again temporarily lost sight of the run- neither pilot did.” nose moved upward until a pitch angle way due to clouds while turning from The PIC applied takeoff power and of about 14 degrees was reached [and] the base [leg] to the final leg; however, announced that he was initiating a go- the airplane began to roll about its lon- they were able to visually reacquire the around, but the second-in-command gitudinal axis to the right,” the report runway on final approach.” said that it was too late to go around. said. “Within 4 seconds the airplane According to the report, the PIC The PIC returned the throttles to idle reached the inverted flight attitude, recognized that they were going to and applied reverse thrust. “The PIC’s and in another 4 seconds it rolled land long but continued the ap- delayed decision to stop or go around another 90 degrees. … During the roll, proach. The G150 touched down on resulted in about a 22-second delay the pitch angle decreased to almost the main landing gear at 120 kt, the in thrust reverser activation, which –85 degrees, which is almost a verti- reference landing speed, and 1,650 ft resulted in the runway overrun,” the cal nosedive. The computed airspeed (503 m) from the approach threshold. report said. increased significantly.” When the nose landing gear touched One of the passengers was seriously The airplane struck terrain near down 2.4 seconds later, there was injured when his seat detached as the Reinhardtsdorft-Schöna, Germany, about 2,680 ft (817 m) of runway airplane traveled over a ditch, struck a just north of the border of the Czech remaining. gravel embankment, crossed a service Republic. BFU concluded that the pilots “Landing distance data revealed road and came to a stop at the edge of a had lost spatial orientation and control that the airplane required about 2,551 pond 816 ft (249 m) from the runway. of the Citation while attempting to roll ft [778 m] to stop at its given weight Investigators determined that the airplane on a moonless night that in the given weather conditions,” the maintenance personnel had not FLIGHTSAFETY.ORG | AEROSAFETYWORLD | NOVEMBER 2013 | 53 ONRECORD installed the seat properly. It was an aft-facing As the crew returned to the airport, they seat that had been installed in a forward-facing felt a slight airframe vibration and noticed position, and the shear plungers in the frame that the fuel quantity in the left wing tank of the seat had not been lowered into the seat was decreasing rapidly. “The flight remained track. “The improper installation most likely in the traffic pattern and returned to [the resulted in the passenger’s seat separating from airport] for an uneventful landing with a fuel the seat track and exacerbating his injuries,” imbalance of about 1,000 lb [454 kg],” the the report said. report said. Investigators determined that a new left Fuel, Hydraulic Leaks on Takeoff main landing gear trunnion had been installed Cessna Citation 560XL. Minor damage. No injuries. six weeks earlier and that maintenance person- hortly after the flight crew retracted the nel had not secured the aft pivot pin correctly. flaps on takeoff from Nantucket, Massachu- This resulted in separation of the aft portion of Ssetts, U.S., the afternoon of Oct. 29, 2012, the trunnion from its fitting. “The end of the aft the tower controller advised that fuel was pour- trunnion punctured the interior of the gear well, ing from the left wing. “The crew also noted resulting in damage to surrounding structure hydraulic and stabilizer annunciator lights and a and damage to the fuel cell and hydraulic line,” gear unlocked indication,” the NTSB report said. the report said. TURBOPROPS Intruders Force Go-Around ‘Very Loud Noise’ on Takeoff Cessna 208B. Destroyed. One fatality, one serious injury. Let L-410 Turbolet. Substantial damage. No injuries. he flight crew was conducting an unsched- he aircraft was lifting off with 10 passengers uled cargo flight to a gravel airstrip at 6,950 and two pilots from the runway at Ronald- Tft in Bilogai, Indonesia, the morning of Nov. Tsway Airport on the Isle of Man the after- 26, 2011. A curved approach was required due noon of Nov. 5, 2012, when the flight crew heard to hills near the runway. a very loud noise. The Grand Caravan was at 94 kt and just “Suspecting an engine failure, the command- about to touch down when the crew saw local er closed the throttles and landed ahead on the villagers walking along the right side of the remaining runway,” the AAIB report said. The 590-m (1,936-ft) runway. The crew initiated noise reduced substantially at the low power a go-around, and the aircraft entered a left setting, and the crew taxied the Turbolet to a climbing turn in a nose-high attitude. The parking area and shut down the engines. Caravan then stalled and crashed in a corn ATC discontinued operations on the runway field, killing the copilot and seriously injuring but re-opened it after an inspection revealed no the pilot. debris. In its report, the Indonesian National “After the incident, [the commander] com- Transportation Safety Committee (NTSC) mented that the event was unlike any he had noted that the airstrip is surrounded by experienced previously while flying or during agricultural fields and that farm work- training,” the report said. “In particular, he ers often cross the runway to gain access remarked on the very high level of noise and the to them. As a result of the accident, NTSC absence of yaw [typical of an engine failure].” recommended that the runway be fenced to The copilot described the noise as “terrible.” prevent intruders or that a warning system The left Walter M601E engine showed no be installed to alert people to aircraft arrivals external evidence of damage, but a tear-down and departures. inspection revealed that a balance plug on the 54 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2013 ONRECORD centrifugal compressor disc had broken and intakes and first-stage compressors, as well as separated from the disc. on the fuselage and windows. “After the salt was “Balance plugs are used to balance the rinsed away with water, the engine efficiencies compressor disc and are screwed into the disc improved greatly, and no other anomalies were beneath the compressor blade roots,” the report noted,” the report said. said. “Following an investigation by the engine manufacturer, it was concluded that the broken Flight Displays Go Blank balance plug had failed due to a fatigue crack. … Jetstream 41. Minor damage. No injuries. The damage to the engine was contained within bout one hour into a flight with 12 pas- the engine casing and was insufficient to cause a sengers and three crewmembers from significant loss of power.” ASouthampton, England, to Aberdeen, Scotland, the morning of July 18, 2012, the Jet- Salt Causes Compressor Stalls stream entered IMC, icing conditions and light Lockheed WP-3D Orion. No damage. No injuries. turbulence at FL 220. Twenty minutes later, the he Orion, operated by the U.S. National attitude director indicator display in the com- Oceanic and Atmospheric Administration, mander’s electronic flight instrument system Twas orbiting at 3,000 ft over the Atlantic (EFIS) went blank. Ocean in night instrument meteorological con- The commander, the pilot monitoring, ditions (IMC) on Nov. 9, 2007, when compres- re-engaged the autopilot and conducted the sor stalls and tailpipe fires occurred in three of “Symbol Generator Failure” checklist, which did the four engines. not remedy the situation. Shortly thereafter, the The incident occurred 540 nm (1,000 km) other three EFIS screens went blank. east of St. John’s, Newfoundland, Canada, ac- “The commander took control and flew the cording to a report published by NTSB in May. aircraft with reference to the main altimeter and The no. 3 engine malfunctioned first, followed standby instruments,” the report said. The crew moments later by the no. 4 and no. 1 engines. The declared an urgency and diverted the flight to aircraft commander (AC) told the flight engineer Newcastle. The EFIS displays began to return to (FE) to shut down the no. 3 and no. 4 engines, ap- normal after the aircraft descended into VMC. parently due to fire warnings for those engines. The Jetstream subsequently was landed at New- The AC and FE noticed a power loss and an castle without further incident. ‘The commander increase in turbine inlet temperature in the no. 1 Investigators found that an electrostatic tran- engine, but there was no fire warning. “The AC sient absorber (transzorb) in the left windshield flew the aircraft directed the FE to pull back power on the no. 1 heating system had failed, as designed, when with reference to engine,” the report said. “Believing that he heard it was exposed to a high-voltage static charge the order to shut down the no. 1 engine, the FE that had accumulated on the windshield either the main altimeter pulled the emergency shutdown handle for the during the incident flight or previously. How- no. 1 engine. ever, the failed transzorb had retained a residual and standby “While operating single-engine at 800 feet charge and thus had not protected the avionics instruments.’ and 140 knots, the AC called for the immedi- systems, as it was designed to do. ate restart of the no. 1 engine. With the suc- The transzorbs had reached two-thirds of cessful restart of the no. 1 engine, the airplane their service life when the left inboard unit began a slow climb on two engines.” The crew failed. After they were replaced, the EFIS equip- subsequently was able to restart the other two ment and the windshield heating system func- engines and return to St. John’s for an unevent- tioned normally. “The aircraft was subsequently ful landing. returned to service, and no further defects An examination of the Orion revealed regarding the EFIS system were reported,” the significant buildups of salt on all the engine report said. FLIGHTSAFETY.ORG | AEROSAFETYWORLD | NOVEMBER 2013 | 55 ONRECORD Preliminary Reports, September 2013 Date Location Aircraft Type Aircraft Damage Injuries Sept. 1 Telluride, Colorado, U.S. Beech 1900D substantial 12 none The left main landing gear collapsed on landing. Sept. 2 Harford, Pennsylvania, U.S. Cessna T-50 Bobcat destroyed 2 fatal A witness said there was a severe electrical storm in the area when the Bobcat struck trees and crashed while maneuvering for a night landing at a private airport. Sept. 4 Jersey, Channel Islands, U.K. Cessna 303 Crusader destroyed 2 fatal Low visibility in fog prevailed when the 303 crashed in a bay during final approach. Sept. 7 Moscow, Russia Bombardier CRJ200ER substantial 11 none The flight crew was unable to extend the main landing gear on approach to Vnukovo Airport and landed the CRJ with only the nose gear extended. Sept. 7 Amistad, New Mexico, U.S. Bell 206L-3 substantial 2 minor The LongRanger descended and landed hard after the pilot initiated a steep right turn to avoid colliding with large birds while cruising at 300 ft during a public use flight. Sept. 8 Bangkok, Thailand Airbus A330-321 NA 302 NA At least 12 of the occupants were injured when the A330 veered off the right side of the runway while landing in night visual meteorological conditions (VMC). Sept. 8 Doylestown, Pennsylvania, U.S. Piper Navajo substantial 1 none The pilot said that the brakes on the left main gear did not function normally on landing. The Navajo veered off the left side of the runway, collapsing the landing gear. Sept. 9 Viña del Mar, Chile Dornier 228-202K destroyed 2 fatal The Dornier was on a positioning flight when it struck power lines and crashed in a field during an approach in fog. Sept. 16 Detroit, Oregon, U.S. Bell UH-1B substantial 1 fatal An in-flight breakup occurred before the helicopter struck the ground while carrying an external load of logs. Sept. 18 Sovetsky, Russia Antonov 2R substantial 7 NA Three occupants were injured when the biplane landed hard during a passenger flight. Sept. 19 Idaho Falls, Idaho, U.S. Beech King Air C90 destroyed 3 NA The pilot and two passengers were injured when the King Air stalled and crashed in an open field after experiencing a technical problem on approach. Sept. 19 Canton, Mississippi, U.S. Eurocopter AS350-B2 substantial 4 minor The emergency medical services helicopter lost power and touched down hard in an open field during an autorotative landing. Sept. 21 Cordes Lake, Arizona, U.S. Bell UH-1V destroyed 2 fatal The helicopter crashed after the main rotor assembly separated during a private flight in VMC. Sept. 23 Sandpoint, Idaho, U.S. Piper Aerostar 602P substantial 1 minor, 2 none The pilot said that the brakes did not function normally on landing. The Aerostar overran the runway and collided with localizer equipment. Sept. 24 Lyon, France Cessna 421C destroyed 4 fatal The 421 stalled shortly after takeoff and crashed near the airport perimeter fence. Sept. 25 Hudson Bay, Ontario, Canada Cessna 208B destroyed 1 fatal The Grand Caravan departed from Sault Ste. Marie for a local solo training flight and crashed in the bay 1,200 km (648 nm) north. Sept. 27 Zurich, Switzerland DHC-8-402Q substantial 65 none The flight crew was unable to extend the nose landing gear on approach and landed the Dash 8 with the nose gear retracted. Sept. 29 Rome, Italy Airbus A320-216 substantial 151 none The flight crew was unable to extend the right main landing gear on approach to Fiumicino Airport. No injuries were reported in the subsequent landing. Sept. 29 Santa Monica, California, U.S. Cessna CitationJet CJ2 destroyed 4 fatal The CJ2 veered off the right side of Runway 21 on landing, traveled through a parking lot, crashed into a hangar and burned. 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. 56 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2013 e Foundation would like to give special recognition to our BARS Benefactors, Benefactor and Patron members. We value your membership and your high levels of commitment to the world of safety. Without your support, the Foundation’s mission of the continuous improvement of global aviation safety would not be possible. bars benefactors benefactors patrons MULTIPLE AVIATION INDUSTRY SEGMENTS. ONE MESSAGE: SAFETY. If the entire aviation industry should collaborate on one thing, it is safety. 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