AeroSafety WORLD
UAS OUTLOOK Unmanned vehicles may rule UPSET INNOVATION Integrating technology into training FLIGHT ATTENDANT INJURIES Risk greater on short-haul flights
TURBULENCE COOPERATE AND AVOID
THE JOURNAL OF FLIGHT SAFETY FOUNDATION MARCH 2014 April 16–17, 2014 Sheraton San Diego Hotel and Marina San Diego, California
Speakers: Chuck Aaron, Chief Helicopter Pilot and Director of Maintenance, Red Bull, N.A. Sergei Sikorsky, son of aviation pioneer Igor Sikorsky
For details, visit our Web site at flightsafety.org/BASS2014 To register or exhibit at the summit, contact Namratha Apparao, tel: +1.703.739.6700, ext. 101, [email protected]
To sponsor an event, contact Kelcey Mitchell, ext. 105, [email protected] To receive membership information, contact Susan Lausch, ext. 112, [email protected] To advertise in AeroSafety World magazine, contact Emerald Media Cheryl Goldsby, [email protected], tel: +1 703.737.6753 Kelly Murphy, [email protected], tel: +1 703.716.0503 PRESIDENT’SMESSAGE AreasFOCUS et me start with a heartfelt “Thank best-known product. More than 40,000 Our goal is to make data protection you!” to Kevin Hiatt. As you may tool kits have been produced and distrib- concerns a thing of the past. know, Kevin has assumed the lead uted in the last two decades, and dozens Advancing safety in challenging opera- safety and operations role with the of workshops on the subject have been tions — This is perhaps the least known of LInternational Air Transport Association conducted. But times change, technology our activities, but also one of our fastest- (IATA). Under Kevin’s leadership, Flight changes, and thinking needs to be up- growing safety improvement opportunities. Safety Foundation continued to expand dated. So the Foundation and its experts The Foundation, in concert with some of its safety footprint and to skillfully execute have been revisiting the go-around process the largest natural resource companies its mission as the leading independent, in order to update best practices. We’ve in the world, has embarked on an effort impartial and international voice of avia- studied recent events, updated guidance to reduce the risks of flying in support of tion safety. and provided status reports at recent con- mineral and mining operations, oil and gas It is now my honor to serve as the ferences, and we will do the same in 2014. production and specialty air charters. We Foundation’s acting CEO and president In fact, we are a primary sponsor for the have invested heavily in our Basic Aviation while the search is under way for a perma- Regional Airline Association’s Approach Risk Standard (BARS) products, which nent new leader. While leadership transi- and Go-Around Safety seminar scheduled include worldwide best practice audit tion is a time of change, it is not a time to for March in Orlando. standards and training programs. Hun- be stagnant or stationary. The Founda- Safety data sharing and protection — dreds of audits have been accomplished, tion’s temporary leadership, supported by We have demonstrated the need, business and we are poised for further growth into the full Board of Governors, is committed process and safety value for expanded the humanitarian-support arena. This is to carrying on our vital mission, and, to sharing of industry safety data, with a some of the most immediately impactful that degree, has dedicated considerable focus on gathering, analysis and dissemi- work in which the Foundation engages. time to setting the 2014 priorities for the nation. We are convinced of the utility of Flight Safety Foundation is poised advancement of safety. Your continuing data sharing as a means to improve safety in 2014 to expand its safety presence in support of the Foundation allows for work and are committed to its expansion across the areas noted above and many others. to advance in the following areas: the globe. The Foundation is uniquely Thank you for your continued member- Unstable approaches and go-arounds positioned to bring together states, regula- ship, endorsement and commitment to — The past year provided several vivid tors, operators and data analysis experts to aviation safety on all fronts. reminders of what can happen if pilots facilitate the rapid development of safety make the wrong decisions and continue improvements. In 2014, we will continue unstable approaches. This is not a new extending our reach to a broader interna- concern, but rather one the Foundation tional community and to other sectors has been engaged with since 1992. Many of aviation. With this expansion comes Kenneth J. Hylander would say that the FSF Approach and a need for greater understanding of the President and CEO (Acting) Landing Accident Reduction Tool Kit is our principles of safety data protection. Flight Safety Foundation
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MARCH 2014 | 1 AeroSafetyWORLD
contents March 2014 Vol 9 Issue 2 features
14 CoverStory | Turbulence Report Automation
20 CoverStory | Unforeseen Turbulence Encounters
24 CabinSafety | Injury-prone Flight Attendants
28 FlightTraining | LOC-I Technical Solutions
33 SafetyRegulation | Over the UAS Horizon
38 SafetyOversight | Shortage of CAA Inspectors 14 departments
1 President’sMessage | Focus Areas
5 EditorialPage | By The Numbers
7 SafetyCalendar | Industry Events 20 9 FoundationFocus | BARS Update
2 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MARCH 2014 24 28 33
10 InBrief | Safety News
44 DataLink | Another Record Year
47 InfoScan | Human-in-the-Loop Studies
51 OnRecord | Undetected Touchdown 38 AeroSafetyWORLD telephone: +1 703.739.6700
Frank Jackman, editor-in-chief, FSF director of publications [email protected], ext. 116 About the Cover Standing lenticular clouds warn of possible strong, mountain-wave turbulence. Wayne Rosenkrans, senior editor [email protected], ext. 115 © Larry Gevert/Dreamstime.com Linda Werfelman, senior editor [email protected], ext. 122
We Encourage Reprints (For permissions, go to
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BY THE Numbers
t now is apparent that 2013 will go evidence that supports the idea that safety record but “continue to experience down as one of the safest years in avia- when fatal accidents occur, more pas- somewhat higher accident rates com- tion history, particularly in terms of sengers and crew are surviving those pared to larger jet aircraft operations.” the number of fatalities in commercial accidents than ever. In part, this likely Andrew Herdman, AAPA director Iair transport operations. According to is due to the type of accidents that are general, went as far as to say that “… preliminary data released by the Inter- occurring. Crashes on approach and greater attention also needs to be fo- national Civil Aviation Organization landing are more survivable than con- cused on turboprop aircraft operations. (ICAO), the number of fatalities suffered trolled flight into terrain (CFIT). Ac- We need firm regulation to ensure that in scheduled commercial operations fell cording to ICAO, seven of the nine fatal all carriers operate to the highest in- by more than 50 percent in 2013 from accidents it counted last year were dur- ternational standards, including wide the previous year, despite the fact that ing the approach or go-around phases deployment of automated terrain aware- the number of fatal accidents remained of flight. But credit also is due to the ness warnings systems (TAWS) for all the same year over year (see “Another way airplanes are designed, built and commercial operations.” Record Year,” p. 44). certificated, from the strength of the According to Burin, over the past The numbers don’t match up exactly seats, to the materials used in the cabin, several years, there have been 38 CFIT because different organizations include to the training of crews. accidents involving 14 turbojet airplanes or exclude different types of aircraft from Unfortunately, the decline in fatali- and 24 turboprops. Of those 38 aircraft, different types of operations in tabulating ties is not shared evenly across all op- only three were equipped with operat- accidents and calculating accident rates, erational types. In his “Year in Review” ing TAWS and in those three cases, the but the European Aviation Safety Agency article in the February issue of Aero- system provided 30 seconds or more of (EASA) had a similar message: the num- Safety World, Foundation Fellow Jim warning of the impending collision with ber fatalities suffered worldwide last year Burin noted that the 22 major turboprop the ground. was down significantly from the yearly accidents in 2013 were about average for average for the period 2003–2012. While that sector of the industry and repre- EASA’s calculations also had the number sented a modest regression from 2012’s of fatal accidents declining last year, the record year. In releasing limited data relative decrease in fatalities far outpaced on the safety performance last year of the drop in fatal accidents. its member carriers, the Association of Frank Jackman We haven’t done an in-depth statisti- Asia Pacific Airlines (AAPA) said that Editor-in-Chief cal analysis, but I think there is growing turboprop operations maintained a good AeroSafety World
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MARCH 2014 | 5 Serving Aviation Safety Interests for More Than 65 Years OFFICERS AND STAFF Chairman ince 1947, Flight Safety Foundation has helped save lives around the world. The Board of Governors David McMillan Foundation is an international non-profit organization whose sole purpose is to President and CEO (Acting) Kenneth J. Hylander provide impartial, independent, expert safety guidance and resources for the Chief Operating S Officer (Acting) William G. Bozin aviation and aerospace industry. The Foundation is in a unique position to identify General Counsel global safety issues, set priorities and serve as a catalyst to address the issues through and Secretary Kenneth P. Quinn, Esq. data collection and information sharing, education, advocacy and communications. The Treasurer David J. Barger Foundation’s effectiveness in bridging cultural and political differences in the common cause of safety has earned worldwide respect. Today, membership includes more than ADMINISTRATIVE 1,000 organizations and individuals in 150 countries. Manager of Support Services and Executive Assistant Stephanie Mack MemberGuide FINANCIAL Flight Safety Foundation Financial Operations 801 N. Fairfax St., Suite 400, Alexandria VA 22314-1774 USA Manager Jaime Northington tel +1 703.739.6700 fax +1 703.739.6708 flightsafety.org Member enrollment ext. 102 MEMBERSHIP AND BUSINESS DEVELOPMENT Ahlam Wahdan, membership services coordinator [email protected] Senior Director of Seminar registration ext. 101 Membership and Namratha Apparao, seminar and exhibit coordinator [email protected] Business Development Susan M. Lausch Seminar sponsorships/Exhibitor opportunities ext. 105 Director of Events Kelcey Mitchell, director of events and seminars [email protected] and Seminars Kelcey Mitchell Donations/Endowments ext. 112 Seminar and Susan M. Lausch, senior director of membership and development [email protected] Exhibit Coordinator Namratha Apparao FSF awards programs ext. 105 Membership 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 Namratha Apparao, seminar and exhibit coordinator [email protected] COMMUNICATIONS Website ext. 126 Director of Emily McGee, director of communications [email protected] Communications Emily McGee Basic Aviation Risk Standard Greg Marshall, BARS managing director [email protected] GLOBAL PROGRAMS BARS Program Office: Level 6, 278 Collins Street, Melbourne, Victoria 3000 Australia Director of tel +61 1300.557.162 fax +61 1300.557.182 [email protected] Global Programs Rudy Quevedo Foundation Fellow James M. Burin
BASIC AVIATION RISK STANDARD BARS Managing Director Greg Marshall
facebook.com/flightsafetyfoundation
@flightsafety Past President Capt. Kevin L. Hiatt Founder Jerome Lederer www.linkedin.com/groups?gid=1804478 1902–2004
FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MARCH 2014 ➤ SAFETYCALENDAR
MARCH 4–5 ➤ Air Charter Safety Symposium. APRIL 1–3 ➤ ERAU Unmanned Aircraft MAY 21–22 ➤ Asia Pacific Aviation Safety Air Charter Safety Foundation. Ashburn, Virginia, Systems Workshop. Embry-Riddle Aeronautical Seminar (APASS 2014). Association of Asia U.S. Bryan Burns,
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MARCH 2014 | 7 IATA’s Safety Strategy is a comprehensive approach to identify organizational and operational safety issues. FOUNDATIONFOCUS
UPDATE Greg Marshall, BARS Program Managing Director
inety-one audits were conducted Marshall said last year in announcing through Apple’s App Store. The tool, in 19 countries last year under the silver level. Aircraft operators that which can be used with iPads and the auspices of Flight Safety proceed to their third-year audit and iPhones, includes built-in checklists that Foundation’s Basic Aviation Risk close their findings in the same manner can be used by auditors or other per- NStandard (BARS) Program, bringing progress to gold status. sonnel when conducting field reviews to 252 the number of audits conducted In reviewing the program’s other to verify procedures, the existence of or planned in 29 countries since BARS 2013 achievements, Marshall said BARS equipment and the adequacy of facilities. was launched in 2010, according to data currently has 23 member organizations In May, Version 5 of the BAR provided by the BARS program office and that three more are expected to join Standard is expected to be released, in Melbourne, Australia. in the first quarter of 2014. Two auditor as are the two volumes of the Version The 2013 audits resulted in 44 P1 accreditation courses were conducted 5 BARS Implementation Guidelines. A (highest priority) findings, 1,381 P2 in 2013, an updated BARS Procedures new suite of documents, tailored to findings and 140 P3 findings, and the Manual was released, as was an updated specific user groups, will be produced average closure rate was 98 percent for BARS Auditor Guide. Other releases in- to replace the current BARS Procedures P1, 92 percent for P2 and 45 percent for cluded the BARS Aerial Work audit cat- Manual format. the P3 findings, which are recommenda- egory and protocol and Volumes 1 and 2 The protocols expected to be re- tions for improvement only. The BARS of the BARS Implementation Guidelines. leased include the BARS Maintenance program office published 87 initial audit Two new courses were developed and Repair Organization audit category reports and 85 final audit reports. Sev- and made available last year — the Avia- and protocol, and a new aerodrome enteen operators achieved “gold” status tion Coordinator for Offshore Personnel audit category and protocol. and 16 achieved the new “silver” status, course and the Helicopter External Load BARS was established by Flight which was introduced in 2013. Operations for Ground Personnel course. Safety Foundation, in conjunction with The silver level recognizes aircraft In addition to the BARS member the global natural resource sector, to operators that have maintained con- organizations expected to join this year, improve safety in operations involving tinuous registration for two years and Marshall said the introduction of new remote and hazardous environments. have closed out all of their findings by audit protocols and additional tools and The program aims to raise aviation the originally planned due date. “The guidance materials — all designed to safety standards by assisting resource introduction of this status level recog- assist organizations with the manage- companies with the management of nizes aircraft operators that have placed ment of aviation risk for their employ- aviation risk for their personnel. The considerable effort in acquitting their ees — are on tap for 2014. International Council on Mining and findings in a complete and timely man- For example, the operational review Minerals supports the use of BARS to ner,” BARS Managing Director Greg tool is newly available as an application improve safety.
WWW.FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MARCH 2014 | 9 INBRIEF Safety News Category 2 Rating for India NTSB Pushes Helicopter Safety
ndia has been downgraded to a n “unacceptably high” number of helicopter accidents has
Category 2 rating under the U.S. prompted the U.S. National Transportation Safety Board IFederal Aviation Administration’s A(NTSB) to add improving helicopter safety to its annual (FAA’s) International Aviation Safety “Most Wanted” list of transportation safety improvements. Assessment program. “In the last 10 years, 1,470 accidents occurred involving he- The rating, which signifies that licopters used as air ambulances, for search and rescue missions India’s oversight of civil aviation Jennifer Moore and commercial helicopter operations such as tour flights,” the safety “does not currently comply with the international NTSB said, adding that the accidents killed 477 people and safety standards set by the International Civil Aviation caused serious injuries to 274 others. “Safety improvements to Organization (ICAO),” means that Indian carriers will not address helicopter operations have the potential to mitigate risk be permitted to begin any new service to the United States. to thousands of pilots and passengers each year.” Existing service may continue, however. The NTSB reiterated its call for implementation of sound The FAA said it would work with India’s Directorate Gen- risk management practices, especially for inspection and eral for Civil Aviation to identify actions that must be taken to maintenance; flight risk regain a Category 1 safety rating, which signifies compliance evaluation programs with ICAO safety standards. and formal dispatch and The Indian government has begun addressing the flight-following pro- issues identified during the FAA’s September 2013 assess- cedures for emergency ment of Indian aviation safety oversight, the FAA said, not- medical services heli- ing that 75 additional full-time inspectors have been hired. copters; and improved The FAA’s International Aviation Safety Assessment training that includes program evaluates the civil aviation authorities in all scenarios involving countries where air carriers operate to the United States inadvertent flight into to determine whether those authorities meet ICAO safety instrument meteoro- oversight standards. logical conditions.
© mezzotint/123RF.com
Continuing Risks
he Transportation Safety Board of Canada (TSB) has “Two minutes later, the DHC-8 entered Runway 28 without reiterated its call for action to reduce the risks of runway stopping, while the King Air was nearing takeoff speed. The Tcollisions, citing its new report on an Aug. 29, 2011, occur- King Air aborted the takeoff and while slowing down, veered rence in which a passenger airplane was taxied across an active right on the runway centerline and passed about 40 ft [12 m] runway as a twin-engine turboprop was taking off. behind the DHC-8.” No one was injured, and damage was minor, but the TSB The King Air received minor mechanical damage that the said that it was “concerned that unless better defenses are put in TSB said was related to the airplane’s rapid deceleration. There place to reduce these occurrences, the risk of a serious collision was no damage to the DHC-8. between aircraft remains.” Using criteria established by the International Civil Avia- The agency noted that the risk of collisions on runways is tion Organization, Transport Canada and Nav Canada, the TSB cited on its Watchlist of transportation safety issues that present characterized the occurrence as “extremely serious,” noting that the greatest risks to Canadians. it would have resulted in a collision if the King Air crew had The TSB said that the 2011 occurrence followed the landing not rejected their takeoff and veered to the right. of a Sky Regional Airlines Bombardier DHC-8-402 with 29 Data show that between 2001 and 2009, there were 4,140 people aboard at the Montreal/Pierre Elliott Trudeau Airport. runway conflicts across Canada. “Not all 4,140 occurrences “The ground controller gave the crew taxi instructions to involved a risk of high-speed collision,” the TSB said. “However, the gate, which included stopping before Runway 28 until in- in those that did, the outcomes could have been catastrophic.” structed to cross it,” the TSB said. “The DHC-8 flight crew read Changes implemented after the occurrence included im- back the instruction correctly, meaning that they understood proved signage on the taxiway on both sides of the runway and and would comply. Meanwhile, the air traffic controller cleared the creation of a local runway safety committee. In addition, a Beech King Air with three crewmembers aboard to take off Sky Regional modified its checklist to limit distractions during on Runway 28. taxiing, the TSB said.
10 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MARCH 2014 INBRIEF
Night Flight Review
purred by the fatal 2011 crash of a Eurocopter AS355 F2 in dark night conditions in South Australia, the Australian SCivil Aviation Safety Authority (CASA) has begun a review of regulations concerning night visual flight rules (VFR) flight. CASA said its primary focus is “the need for a defined external horizon to be visible for aircraft attitude control.” CASA’s review follows the issuance by the Australian Trans- Australian Transport Safety Bureau port Safety Bureau (ATSB) of a report on an Aug. 18, 2011, crash 145 km (78 nm) north of Marree that killed the 16,000- CASA said that its review is intended to clarify the term hour pilot and his two passengers. The ATSB said the pilot “visibility” in dark night conditions and to develop additional probably was spatially disoriented and that factors contributing guidance material that emphasizes “the importance of main- to his disorientation probably included the dark night condi- taining a discernible external horizon at night.” tions that prevailed at the time (ASW, 2/14, p. 23). In a separate discussion of accidents that occur during In describing its project, CASA noted that the ATSB report flight under night VFR, the ATSB said that pilots could effec- had characterized dark night visual meteorological conditions tively manage the risks inherent in night VFR flight, in part by (VMC) as “effectively the same” as instrument meteorological ensuring that they remain current and proficient and by ensur- conditions. ing that the aircraft is appropriately equipped. “The only real difference,” the ATSB said, “is that, if there “Always know where the aircraft is in relation to terrain, and are lights on the ground, they can be seen in VMC. In remote know how high you need to fly to avoid unseen terrain and ob- areas, where there are no lights or ambient illumination, there stacles,” the ATSB said. “Remain aware of illusions that can lead is no difference. Pilots cannot see the ground and have no to spatial disorientation — they can affect anyone. Know how to external cues available to assist with their orientation.” avoid and recover from illusions by relying on instrument flight.” 59th annual Business Aviation Safety Summit
67th annual International Air Safety Summit
Hosted by:
flightsafety.org/IASS2014
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MARCH 2014 | 11 INBRIEF
European–Asian Pact
he European Commission and the Association of Southeast Asian Nations (ASEAN) say they are taking Tsteps to enhance cooperation on aviation safety and other related issues. A February summit meeting in Singapore included dis- cussion of aviation safety regulations and the potential for cooperation between ASEAN and the European Union. “ASEAN is developing, by 2015, an ASEAN single aviation market, which will have many similarities to the single aviation market that the EU has successfully created Jet Request/wikimedia over the past two decades,” the EU said. “The summit will Proposed Penalty offer an excellent opportunity to explore the potential for a closer cooperation between the two regions, including the he U.S. Federal Aviation Administration (FAA) has prospect of an ‘open skies’ agreement.” proposed a $150,000 civil penalty against Talon Air for The EU noted that air traffic between the EU and Tallegedly violating Federal Aviation Regulations when it ASEAN totaled 10 million passengers in 2012, and projec- allowed four pilots to fly the company’s Hawker 4000 “without tions indicate that half of the wordwide growth in air proper training or examinations.” traffic over the next 20 years will involve operations in the The FAA says that the pilots flew at least 64 times in Asia-Pacific region. 2011 and 2012 while they were not qualified to serve as The agenda included discussion of air traffic manage- crewmembers. ment issues and the possibility of a comprehensive air The company has 30 days from its receipt of the FAA transport agreement between the EU and ASEAN. enforcement letter to respond.
12 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MARCH 2014 INBRIEF
R44 Fuel Tank Retrofitting
iting seven accidents in the United States and Australia involving Robinson R44 helicopters, the U.S. National CTransportation Safety Board (NTSB) says owners and operators of R44s should be required to implement fuel tank retrofitting outlined in a manufacturer’s service bulletin. The NTSB said that, in each of the seven accidents, “impact forces were survivable for the occupants, but fatal or serious injuries occurred because of a post-crash fire that resulted from an impact-related breach in the fuel tanks.” The most recent accident, still under investigation, involved an R44 II that struck a fueling structure at Corona (California, U.S.) Municipal Airport on Nov. 25, 2012; fire and an explosion followed. The pilot was killed. The NTSB said that since 2008, it has investigated three other R44 accidents involving a breach of the fuel tanks, followed by leaking fuel and a fire. Since 2011, three similar R44s were involved in similar accidents in Australia, the NTSB said. All of the accidents should have been survivable, “with minor or no injuries to the occupants,” the NTSB said. “How- ever, the accidents in the United States … resulted in two fatalities and two serious thermal injuries, and the accidents in Australia resulted in eight fatalities and one serious injury.” dhnikkel/wikimedia Robinson Helicopter Co. issued Service Bulletin (SB) 78 in 2010, advising owners and operators of R44s with all-aluminum inform R44 owners and operators about the revision and the fuel tanks to retrofit the helicopters with bladder-type fuel availability of bladder-type fuel tanks. tanks that are “designed to contain fuel and prevent it from Robinson said that, although a number of retrofits have spilling out of the tank after a survivable impact.” The SB said been completed, some owners have delayed having the work the corrective action should be taken by Dec. 31, 2014. done, sometimes citing the absence of a formal requirement. Later, Robinson moved up the completion date to April The Australian Civil Aviation Safety Authority issued an 30, 2013. In December 2013, the U.S. Federal Aviation Admin- airworthiness directive in 2013 (AD/R44/23) requiring opera- istration issued Special Airworthiness Bulletin SW-13-11 to tors to comply with a revised service bulletin, SB-78B.
In Other News …
The European Commission has published rules for operational suitability data (OSD), intended to ensure that data needed for safe aircraft operations is available to — and used by — aircraft operators. Types of data in the OSD category include aircraft reference data to support qualification of simulators, a minimum syllabus for training in pilot type ratings, and the master mini- mum equipment list. … The U.K. Civil Aviation Authority (CAA) has merged its airspace and safety functions, now under the jurisdiction of the Safety and Airspace Regulation Group.
Correction A note in a figure accompanying a December 2013–January 2014 ASW article about line operations safety audits (LOSA; “Intentionally Noncompliant,” p. 17) incorrectly stated the number of airlines involved in the LOSA observations dis- cussed in the article. The note in Figure 1 should have said that the observations took place at more than 70 airlines. Additionally, James Klinect, chief executive officer of The LOSA Collaborative, said, in a clarification after publication of the article, “It’s not really how a flight crew responds to intentional noncompliance (INC) errors that dictates INC mismanagement. It’s the outcome, regardless of how a crew responds. … In LOSA we call bad outcomes, regardless of response, mismanagement.”
Compiled and edited by Linda Werfelman.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MARCH 2014 | 13 COVERSTORY
BY WAYNE ROSENKRANS
irlines by now should be benefiting from in flight. That program would be founded on both meteorological forecasts of atmo- automated turbulence reporting supplemented by spheric turbulence and today’s actionable human reports PIREPs.” intelligence about the real-time effects Among its recommendations, the AC said Aof that turbulence on large commercial jets. that U.S. Federal Aviation Regulations Part 121 Unfortunately, say several turbulence-detection air carriers should consider the installation of the pioneers in the United States, the industry is still Turbulence Auto-PIREP System (TAPS). (Prod- missing a key piece — enough airline participa- uct names were removed in November 2007.) tion — needed to accelerate progress in reducing, TAPS was developed by Paul Robinson and his if not eliminating, unexpected encounters with AeroTech Research staff under the U.S. National in-flight turbulence. Such encounters still take Aeronautics and Space Administration’s Turbu- a steady toll in injuries and, in the rarest cases, lence Prediction and Warning System project. fatalities (see “Bumpy Ride Ahead,” p. 20). Robinson describes TAPS as a robust, on- In February, specialists from American Air- board technology that uses the same vertical lines, WSI Corporation and AeroTech Research accelerometer that sends data to the digital briefed ASW about their perspectives of related flight data recorder and ties into the aircraft’s technology, experiences of pilots and dispatchers, existing aircraft communications addressing and lessons learned in this safety quest while gain- and reporting system (ACARS). Essentially, ing operational efficiencies as air traffic grows. reports now are generated, transmitted to airline Eight years ago, an ASW article (ASW, 9/06, dispatch, further processed for different users Aviation Weather p. 20) described several new technologies that and retransmitted to ACARS printers on nearby Center’s Ellrod Index had become mature enough for operational use, aircraft based on which flight crews would ben- graphical forecast a point made then by the U.S. Federal Aviation efit from the information. shows (at white Administration (FAA) in Advisory Circular (AC) In the 2006 article, ASW called TAPS “a new arrow) a possible 120–88A, Preventing Injuries Caused by Turbu- system now in limited use that automatically area of severe lence. A major theme of the AC is the importance reports turbulence encounters to ground stations, turbulence at about of constantly communicating turbulence infor- with the promise that eventually the reports Flight Level 220; a mation. The AC said, “In the past, the practice of routinely will be data-linked into flight decks.” A U.S. widebody jet rerouting has been met with limited air carrier new generation of aircraft turbulence-detecting encountered severe acceptance, primarily because of the inaccuracy radars then coming on the market, using software turbulence here of first-generation turbulence forecast products, patented by AeroTech Research called ETURB, over Vermont, U.S., the subjectivity inherent in pilot weather reports also was ready to complement TAPS. Today, WSI at FL 330 on Jan. (PIREPs), if available, and the operational costs of exclusively licenses TAPS, and it forms part of 16, 2014, resulting rerouting. … The most promising way to capture a WSI commercial product called Total Turbu- in minor injuries to and convey [real-time] information is through a lence, an integrated suite of turbulence awareness, five unsecured flight comprehensive program of reports from aircraft forecasting, detection and mitigation technology attendants.
14 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MARCH 2014 COVERSTORY
Automated, airplane-based reports help participating flight crews to avoid turbulence encounters.
Aviation Weather Center, U.S. National Oceanic and Atmospheric Administration
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MARCH 2014 | 15 COVERSTORY
Just west of Chicago tailored to the various people responsible for information. We validated that functional- O’Hare International airline turbulence-safety programs. ity. TAPS is additive to the preflight forecast Airport, Total information so, therefore, we are flight-planning Turbulence–equipped American Airlines’ Experience our routes around known and predicted areas of aircraft are green David H. Clark, a captain with American turbulence or significant weather — as we have and non-equipped Airlines and manager of American’s Connected for many years — with some very sophisticated aircraft are red Aircraft Program, said the company implement- tools. They are generally very accurate, but the on a moderately ed the Total Turbulence product as the launch weather system and the environment are very convective day; two partner in November 2012 and, as of November fluid, so there are still opportunities for unex- non-equipped aircraft 2013, had 364 of its Boeing airplanes equipped pected change.” encounter TAPS with this product, including the TAPS feature. The airline’s most significant improve- moderate-turbulence This strategic safety and business decision essen- ments in turbulence avoidance have occurred reports (yellow tially was test results–driven, he said. “At a high in transoceanic flying, a result attributed to the stacked chevrons) level, the key factors were that during testing, we capability of Total Turbulence to compensate for inside of a WSI had looked at the rate of events for turbulence, sparse real-time data available over the ocean, turbulence advisory especially severe turbulence,” Clark said. “Our compared with during U.S. domestic operations. area (purple ring). rate of severe turbulence events had gone down, “Even domestically, it’s helped,” he said. “Not only especially with the aircraft that have TAPS. We are our aircraft reporting turbulence events back got a more timely alert for that type of activity, to our dispatch, but then we can retransmit those and therefore avoided it. When the rate went occurrences to aircraft in the vicinity, sometimes
down, we attributed that at least in part to TAPS well before they’re known. TAPS reports come to © WSI Corportation
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the ACARS printer, and often pilots can change “Another equipped Boeing 777, in an area of altitude to try to avoid that area.” unexpected moderate or severe turbulence, sends The latest version offers a color graphical a TAPS report, and that report ultimately can be interface and increased flight deck functionality shared with all aircraft in the vicinity,” Clark said. through an electronic flight bag (EFB) appli- “That gives us a heads-up alert that we would cation called WSI Pilot Brief on Apple iPads, like to avoid that area. So the reporting aircraft according to WSI. A number of U.S. airlines are is 100 nm [185 km] ahead at the same altitude, in discussions with the FAA to gain operational same course. The flight crew says, ‘Let’s talk to approval of these and similar capabilities, Clark our dispatcher.’ The dispatcher says, ‘I think your said. “That is the plan we’re working on now,” best bet now, based on that report, is to climb he said. “All parties involved — the regula- 2,000 ft. So they do. There’s never a guarantee tory agencies, the airlines and manufacturers that will avoid the moderate or severe turbulence — are working well together, and I think we’re encounter, but at least we have additional tools to in agreement. It’s just a matter of working out improve the chance that we’ll avoid it or at least the details. The concept is to have connectiv- minimize the impact of turbulence.” ity airborne such as traffic flow information on In the airline’s experience, flight crews nor- top of that. It really helps to see that real-time mally have sufficient time to obtain air traffic turbulence picture in addition to the text of control (ATC) clearance to respond to a turbu- aircraft reports. Graphical user interface would lence threat. “Generally it works out — most be an option; I think that would be a fair way to of the time, yes, not all the time,” he said. “The The more information put it. I would hesitate to say that it will entirely Atlantic crossing has become very congested, so replace ACARS; for the foreseeable future, we there are times where it takes some time to coor- they have about will continue to have ACARS for other reasons.” dinate a course or altitude change. Therefore, turbulence and the At the industry level, this technology would the more notice we have, the better.” become optimally effective if more aircraft and American Airlines has not specifically stud- earlier TAPS alerts more airlines would report and disseminate this ied how Total Turbulence affects a flight crew’s quality of turbulence information, Clark said, use of seat belt signs or public address system reach them, the adding, “That’s the real vision. Although we’re a announcements to cabin crews as an adjunct more effectively WSI launch partner to test the concept and the to its fundamental policy and emphasis that all initial rollout, as airlines around the world adopt occupants wear seat belts/harnesses at all times they are able to seat the technology, that’s when we’ll really maximize while seated. Nevertheless, pilots have been able the value. I look forward to increased participa- to infer intuitively that the more information the passengers and tion from other carriers because more participa- they have about turbulence and the earlier TAPS tion means more data, better data — and that alerts reach them, the more effectively they are flight attendants will be of benefit to all participants. But it takes able to seat the passengers and flight attendants and reduce the time and money to equip.” and reduce the risk of injuries. “That is a standard policy, and, believe me, it risk of injuries. A Typical Flight works,” Clark said. “Clear air turbulence is most In everyday use, exploiting enhanced turbu- difficult to avoid but doesn’t happen very often. lence-avoidance intelligence has proved straight- We do, unfortunately, run through unexpected forward for American Airlines flight crews choppy air, and a lot of our passengers are glad operating 364 Total Turbulence–equipped flight they did have their seatbelt on.” decks of Boeing 737s, 757s and 767-300s. A Flight crews also are trained to use all the now-typical scenario is a 777 flight crew return- turbulence-mitigation tools available, and to ing from Tokyo Narita Airport to Dallas-Fort take the conservative approach by turning on Worth International Airport during a normally the seatbelt signs, at a minimum, and/or asking convective time of the year. flight attendants to take their seats if the captain
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MARCH 2014 | 17 COVERSTORY
considers that warranted. “These flight due to the sensitivity of the equipment, and post-flight tools and for immedi- crew actions may be caused simply by the system may register an alert that ate expertise to support the improved hearing another aircraft crew on the this was moderate or even, theoretically, turbulence identification and forecasts, radio reporting that they are in turbu- severe. The duration was too short to according to Mark D. Miller, the com- lence,” Clark said. “TAPS gives us a lot really call it ‘severe,’ but it registers that pany’s senior vice president and general more specific detail in terms of where way. A crewmember would say, ‘I don’t manager for aviation. The company they’re located.” even remember that.’” became more deeply involved in the As to U.S. flight crews’ obligation For the pilots of encounter air- turbulence aspects of aviation weather to provide turbulence PIREPS to ATC, craft, another value of TAPS during services in recent years partly because that has not changed because of TAPS flight is improved calibration of the of the prevalence of turbulence-related equipage. “For the foreseeable future, I pilot’s subjective judgment of whether injuries among North American air don’t think it will,” Clark said. “There moderate or severe areas of turbulence carriers and Asia-Pacific air carriers could be a point in time where all were encountered. “As you consider that face related geographic and clima- aircraft around the world are equipped the length of a 777, what may feel like tological challenges, Miller said. and we share this data in a real-time light turbulence to me as captain could The technical merits of TAPS, as environment. What’s important is that be fairly significant with that center of documented in scientific literature, ATC still gets those reports because gravity moment arm to passengers and described in the FAA AC and as- TAPS reports right now are going to flight attendants,” he said. “So it has sessed by WSI’s and American Airlines’ a dispatcher and back to the airplane, also helped them calibrate — or even due diligence processes, drove WSI’s not necessarily being shared with air better, to verify — turbulence impres- decision to make it a core capability of traffic controllers.” sions.” In a post-flight conversation Total Turbulence. As of January 2014, WSI representatives expressed to with a dispatcher who can access the three WSI-client airlines (including ASW interest in, one day, widely dis- raw TAPS data, the captain often may American Airlines) were operating 465 seminating TAPS reports, including learn that what he or she reported as Boeing and Airbus aircraft equipped to ATC. “I hope that happens,” Clark severe turbulence empirically registered with TAPS. said. “I think it will someday. That as moderate turbulence. “In terms of the core reporting would really make this capability so As to the value of turbulence- capability, we felt very confident in the much more useful.” avoidance resources provided to the technology in terms of a sensible mea- Although Total Turbulence has aviation community at no cost by the sure of turbulence, automatically and features useful for post-flight analysis U.S. National Oceanic and Atmospheric objectively reporting turbulence that the of turbulence encounters — such as Administration’s Aviation Weather aircraft was experiencing,” Miller said. archived-data replay after the event, Center
18 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MARCH 2014 “In a maintenance context, when we talk about Total Turbulence, [event replay is partly] why it’s more than just an observation coming off an aircraft. Fusion Replay is basically a warehouse where we [store for up to 92 days] all of these data from all of the TAPS reports, PIREPS, all of the National Weather Service guidance, and all of our own guidance.” In combination with the airlines’ own flight data monitoring programs, this facilitates “post-event analysis … as a tool to train and inform, so that going forward, they can continue to improve their policy and proce- dures around these types of events,” he added. Total Turbulence is available in the WSI Fusion component, a real-time flight manage- ment platform used by dispatchers. “As soon as there’s [a TAPS-reported] event, the dispatcher © WSI Corportation gets an alert for not only the flight that’s been Miller concurs with Clark about the A graphical display of impacted but any other flights that may be tra- evolving resources the U.S. government now en route turbulence versing that area,” he said. “So within a minute has arrayed against the threat of hazardous hazards — including or two [dispatchers, for example] get a list up turbulence encounters. “They clearly do good a polygonal area on their screen showing three other flights that work in the Aviation Weather Center, and of WSI-forecasted they’re responsible for and that will soon be some of the products and research they do [in turbulence in that area of reported turbulence. They can their mission] are exceptional,” Miller said. — includes immediately send an ACARS message up to the “WSI draws on this foundation for the tools we superimposed aircraft notifying the crews. [The] text message provide our own meteorologists.” TAPS reports of basically has the pertinent details, closes that Subscriber airlines get access to reports moderate turbulence communication loop between the dispatcher generated by their own aircraft and deidentified (yellow stacked and the pilot, and informs them what action to aircraft of other operators that are participat- chevrons) and light take to reduce the impact.” ing and contributing to the network, he added. turbulence (green WSI also ingests all TAPS reports and alerts “Once we can work through some [integration] stacked chevrons) into its forecasting operation. “Our meteorolo- challenges, our vision would be that all the stake- that immediately help gists are continually monitoring and issuing holders would have access to [TAPS] informa- flight crews avert our own SIGMETS [significant meteorologi- tion,” Miller said. “Definitely our vision is to get the hazards and also cal information] based on transport category many aircraft equipped and to enable the use and improve forecast- aircraft around the globe for turbulence … display of this data to all the critical stakeholders service accuracy. convection, volcanic ash, icing and dust in … to make this data available to ATC and also certain areas where dust is an issue. … They contribute … through Aviation Weather Center.” basically compare [alerts] against any guid- Since the American Airlines deployment, ance they already have issued like SIGMETs or WSI, as noted, has added two other airlines — even forecast guidance, called flight planning one an unidentified large U.S. carrier that has guidance. … They … continually improve the deployed Total Turbulence and the other an guidance [with amendments] delivered through Asia-Pacific-based carrier that is in the final a platform like WSI Fusion or WSI Pilotbrief to stages, he said. “I fully expect the number of keep the pilots and dispatchers on the same page aircraft flying with TAPS to double this year,” … a common situational awareness or common Miller said. “With a network, we’re trying to get operating picture.” as many observations as we can.”
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MARCH 2014 | 19 COVERSTORY
BY ED BROTAK
Unforeseen turbulence encounters carry risk of serious incidents.
n March 5, 1966, British Over- Even though today’s jetliners benefit encounters. Turbulence is the number seas Airways Corp. (BOAC) from newer designs to withstand turbu- one cause of injuries to passengers — Flight 911, a Boeing 707, lence, pilots still are expected to avoid and especially to flight attendants — in departed from Tokyo’s Haneda conditions where severe or extreme nonfatal accidents. In a typical year, U.S. OAirport for Hong Kong Kai Tak Inter- turbulence is possible. And although pilot reports (PIREPS) of moderate or national Airport. In clear skies, the crashes primarily caused by turbulence greater turbulence average 65,000, and flight crew attempted to fly over Mount have become rarer since the Flight 911 reports of severe or greater turbulence Fuji (approximate elevation 12,400 ft). accident, they still occur, and serious in- average 5,500.1 But with strong winds and an approach cidents are common. The U.S. National What do we mean by turbulence? In to the mountain from the leeside, the Transportation Safety Board (NTSB) terms of airflow, meteorologists focus airplane encountered a particularly se- estimates that nearly three-quarters of all on laminar flow and turbulent flow. vere mountain wave over Gotemba City weather-related accidents/incidents are Laminar flow is a flat, regular, smooth at 16,000 ft. The turbulence encounter due to turbulence. The U.S. Federal Avi- flow of air that moves in the same was so extreme that the aircraft experi- ation Administration (FAA) reports that direction at the same speed. Turbulent enced in-flight structural breakup. All dozens of airline passengers have been flow is chaotic, with air moving in ran- 124 people aboard were killed. injured in recent years by turbulence dom directions and at varying speeds.
20 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MARCH 2014 COVERSTORY
In the real world, we see both occurring altitudes, and aircraft type, and should clouds or roll clouds. At other times, the at the same time. When the turbulence include whether the aircraft was operat- air may be deceptively clear. becomes more dominant, then there ing in clouds or clear air. In this system, Convective turbulence can be as are problems. In terms of aerodynam- the reported turbulence intensity (light, innocuous as a faint updraft on a warm ics, turbulence is a sudden change in moderate, severe or extreme) and dura- day or as potentially destructive as the airflow that abruptly affects the altitude tion (occasional, intermittent or continu- violent updrafts and downdrafts in a and/or attitude of the aircraft. ous) are determined subjectively by the thunderstorm. For many operational For this article, we are concerned pilot (see “Smooth Operators,” p. 14). purposes, convection — caused by ver- only with the vertical variations in Turbulence can be broken down tical currents (thermals) that develop airflow. The term turbulence often also into three major categories by cause: in air heated by a warm surface below is used in conjunction with rapid varia- mechanical, convective and wind shear. — can be simply considered warm tions in horizontal wind speed — that Mechanical turbulence occurs when air rising and cool air sinking. Glider is, wind gusts. Also, by limiting this ar- airflow encounters a physical impedi- pilots, for example, know where to find ticle to naturally occurring turbulence, ment (Figure 1). The air flows around, the rising thermals that help keep their we will not address similar problems over and, if the object is off the ground, aircraft aloft. Cumulus clouds are con- such as wake turbulence, jet engine under the obstacle. But when the air is vectively produced. Airliner occupants blast or helicopter rotor downwash. forced around an object, the flow often may experience a bumpy ride from the becomes more turbulent. Waves and minor vertical motions, even through Refresher on Basics even vortexes can form downwind of the a small “fair weather” cumulus cloud, Turbulence can occur anywhere in the object. Depending on the wind direction but prolonged flight in these conditions atmosphere, from ground level to near and speed, buildings at an airport, for would be considered an undesirable the upper limits of standard high-level example, can cause turbulence that can ride-quality event. en route charts, typically above Flight affect aircraft takeoff/landing perfor- Level (FL) 350 (approximately 35,000 ft). mance on a runway, or — if surface winds To give pilots a better idea of what they exceed 50 kt — flight at altitudes greater Mechanical Turbulence are dealing with, turbulence is described than 3,000 ft above ground level (AGL). in terms of intensity for reporting and Mountain waves, such as the one forecasting. Light turbulence causes just that destroyed Flight 911, fall into the brief and slight changes in altitude and/ category of mechanical turbulence. On or attitude. Moderate turbulence is of the windward side of a mountain, the air greater intensity and also may cause is forced upward. It will then sink on the changes in airspeed, but the aircraft re- leeside. Often vertical waves are formed. mains in control at all times. Severe tur- These waves can break like ocean waves
bulence can cause large, abrupt changes and generate significant turbulence. Turbulence caused by obstacle in altitude and/or attitude and can cause Although single mountains can produce large changes in airspeed. The aircraft waves, mountain ranges have greater may be temporarily out of control. With effects on airflow and are more prone to extreme turbulence, an aircraft can be significant mountain waves. The waves tossed about violently and may incur can propagate a great distance from the structural damage. mountain source, up to 100 mi (160 km) In the United States, pilots are urged, or more downwind. At times, a set, or in the common interest of safety, to re- train, of waves is established in the lee of port encounters with moderate or greater the mountain. And the induced waves turbulence to air traffic control (ATC) can extend higher than the mountains Mountain waves
in a PIREP. According to FAA guid- that produced them. Sometimes these Source: Ed Brotak ance, ATC expects turbulence reports waves are marked by visually striking
U.S. National Aeronautics and Space Administration National Aeronautics U.S. to include location, altitude or range of cloud formations, such as lenticular Figure 1
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MARCH 2014 | 21 COVERSTORY
Frontal zones, where two differ- extend below the cloud base and often cal cruising altitude for longer flights and ing air masses collide, are frequent reach the ground, where the winds often a flight phase when the seat belt breeding grounds for turbulence, so become horizontal, creating a threat of signs are not illuminated, and where the much so that “frontal turbulence” is wind shear. These rapid changes in wind passengers and cabin crew are not wear- often included as a separate category to speed and direction were associated with ing seat belts and may well be moving emphasize its importance. With colder a number of major aircraft accidents in around the cabin. Technically, CAT also air being denser, the warmer air is the 1960s and 1970s. With widely used can be present in nonconvective clouds. forced up over it, often producing verti- automated detection of wind shear and A major cause of turbulence at these cal waves and vortexes that generate escape-maneuver education, pilots and upper levels is the jet stream. This fast- turbulence. Fast moving cold fronts are ATC personnel should now be well aware moving river of air often is concentrated usually the most turbulent. of the risks, and wind shear–monitoring between 30,000 and 35,000 ft above sea The turbulence within thunder- equipment such as Doppler radar and level. Wind speeds in the core of the jet storms is well documented. Professional lidar (light detection and ranging) have stream can exceed 200 mph (320 kph) pilots, even those operating large com- become standard at many larger airports. and may approach 300 mph (480 kph) in mercial jets, know to avoid the associated Dangerous turbulence also can oc- some cases. The turbulence in these situ- turbulence. The updrafts and downdrafts cur above thunderstorm clouds. United ations is generated by the wind itself, and in the strongest thunderstorms can ex- Airlines Flight 967, a Boeing 777-200, is a result of wind shear. ceed 100 mph (160 kph). The turbulence was en route from Washington to Los For flight operations, we often think generated can structurally damage even Angeles on July 20, 2010. Flying over of wind shear as a low-level phenomenon. the strongest aircraft. Don’t be misled by an area of developing thunderstorms in Often in that case, it’s a quick, unexpected the “hurricane hunter” missions you hear Kansas, the plane hit severe turbulence change in wind speed and/or direction about. The tropical convection, even in a while cruising at 38,000 ft, seemingly associated with a thunderstorm down- powerful tropical cyclone, isn’t nearly as well above the storms. The flight crew draft. Technically though, wind shear is strong as in midlatitude thunderstorms. landed the airplane in Denver, where 21 the change in the vertical component of Disturbingly, there still are numer- people were taken to hospitals for their wind speed or wind direction. ous accidents with pilots miscalculating injuries. Meteorologists who studied the A jet stream, however, is a three- the danger of the destructive turbulence event believe a gravity wave (ASW, 2/10, dimensional weather system. It’s not just within these storms. For example, on p. 32) generated by the storms may have a flat ribbon of strong winds at one level March 25, 2010, the experienced pilot of been the cause of the turbulence. in the atmosphere. It has a vertical ex- a Eurocopter AS350 B3 on an emergen- tent, and strong winds may reach down cy medical services flight, attempted to Jet Stream Factors thousands of feet below the jet stream outrun an approaching line of thunder- Although not as severe as thunderstorm core. But as you move away from the storms and return to base in Browns- turbulence or strong mountain waves, core of the jet, the wind speeds decrease. ville, Tennessee, U.S. The squall line, conditions known as clear air turbulence This sets up the wind shear. Once again, moving at 61 kt groundspeed, apparently (CAT) pose a much greater threat for overtook the helicopter. The aircraft air travelers. Typically, these encounters Cross section of jet stream showing crashed in an open field 2.5 mi (4.0 km) occur above 15,000 ft AGL. As the name areas of turbulence. from its destination, killing the pilot and implies, CAT usually is not associated
two nurses aboard. NTSB investigators with cumuliform clouds and is, thus, Tropopause looked at weather data and concluded unable to be detected in advance using Clear air turbulence “the helicopter likely encountered severe the pilots’ eyesight. It doesn’t show up turbulence from which there was no on conventional on-board weather Jet Tropopause 120 possibility of recovery, particularly at radar. Often, it isn’t forecast. And the 90 Strong 60 low level” (ASW, 3/12, p. 45). worst incidents associated with CAT turbulence 30 kts Turbulence caused by thunderstorms have occurred at FL 300 or higher. Of all Front
is not restricted to the area within the turbulence-related incidents, two-thirds Cold air Warm air
cloud itself. Strong downdrafts can occur at or above this level. This is a typi- Atmospheric Research © University Corporation for
22 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MARCH 2014 COVERSTORY
area with its core centered near the strongest wind shear and maximum A 250-mb chart (~34,000 ft) shows the polar jet 39,000 ft. turbulence. The jet streaks themselves stream to the north and the subtropical jet stream There are two major jet also move or propagate along the jet axis. to the south. Teal and purple shading indicates streams at upper levels of the But they move at much slower speeds stronger winds and locations of jet streaks. atmosphere above Earth’s than the winds themselves, usually at 20 Northern Hemisphere — the to 40 kt. Closer to Earth’s surface, low- polar jet and the subtropical level jets (ASW, 11/12, p. 32) could also jet. The polar jet is tied in with produce turbulence. the polar front, the dividing To forecast turbulence in the United line between warm, tropical air States, the online Aviation Weather
and cold, polar air. Seasonally, Center
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | MARCH 2014 | 23 CABINSAFETY
Flight attendants working primarily on short- haul trips may be more prone to workplace accidents than their long-haul colleagues.
BY LINDA WERFELMAN
24 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MARCH 2014 © Nguyen HuyKham/Reuters D all medical and medical humanall resource records, as well a large airline. The MORE cohort data included cupational risks health facing employees the of an expansive study to designed analyze- oc the Health Risks inEmployees (MORE) cohort, ered through Monitoring the Occupational flights.”between beverages or and meals) short turnaround times (e.g., serving offrequency on-board services byacterized arelatively workload: high ahigh medium-haul operation the because is char “Short-haul is quite different from long- and of short-haul the operation,” report the said. may explained characteristics be by specific the incidence of accidents during short-haul flights on average year, per presumable the increased short-haul hours compared to long-haul hours accidents. uling of cabin crewmembers and work-related gested short-haul between asimilar link - sched among workers airline inthe industry. of circadian rhythm situations —also common quality sleep poor and quantity, and adisruption irregular schedules between nection and fatigue, airline industry. studies note Other also acon- —twoules situations that are common inthe work who those long hours or irregular- sched increased rate of work-related injuries among workers inother industries have an identified Medicine. issueber of Aviation, Space, and Environmental according to study, the published- Decem inthe ofwith occurrences occupational accidents, haul may flights have anegative association crewmembers. FLIGHTSAFETY.ORG The report was based in part on inpart The report data was based gath- “Because cabin crewmembers fewer fly The researchers said that work their sug- The researchers noted that studies of Conversely, frequent assignments to long- of on-the-job accidents involving cabin short-haul and flights an increased risk connection frequent between work on utch researchers may have found a |
WORLD AEROSAFETY 1,2 | MARCH 2014 MARCH - occupational accident.” lower the flights, risk of their an experiencing accident, and more the exposure to long-haul crewmembers of an experiencing occupational to short-haul risk to the higher the cabin flights, ofoccurrence accidents. …The more exposure short-haul proved flights predictive to be for the cidents. Its conclusion was that “the number of schedules and of occurrence the on-the-job ac- to investigate exposure between to links flight children. were more likely to report without than those pational accident, and that with children those than older their counterparts to- report an occu younger cabin crewmembers were more likely female crewmembers hours, 100flight per that hadbers “significantly fewer” accidents than and 12percent had more than one employer. Twenty-seven percent were employees, full-time —95percentall —lived Netherlands. inthe unmarried, and 60percent had children. Almost were 41years old or younger, 56percent were study,in the 81percent were women, 54percent hours.100 flight noted amean number of accidents of 0.012per 100cabin4.5 per crewmembers. The report also said,port an calculating annual accident rate of reported at least one accident that year, re the - Atotal of 289cabinservice. crewmembers had were reported to airline’s the occupational health involved cabin crewmembers in2009and that reports ofviewed occupational all accidents that excluded. pregnantbecame after Jan. 1,2009,and were 2005, except for female cabin crewmembers who werewho working for company the on Jan. 1, crewmembers of —all cabin the crewmembers MORE the reviewed records of 6,311cabin Jan. 1,2005.The occupational accident study as work schedules, for airline employees since The report said that study this was first the Results showed that cabin male crewmem- 6,311cabinOf the crewmembers included The occupational accident study re also - SAFETY CABIN |
25
Susan Reed based on image by Torsten Henning CABINSAFETY
These accidents were primarily falls, slips reporting on-the-job accidents, which may have and tripping, and the resulting injuries typically allowed for underreporting; and the scarcity of were sprains, strains, bruises and burns, the information about circumstances surrounding report said. the reported accidents. Data did not show what type of flight each “Information on which type of flight the crewmember was working on when an ac- accident happened and at what time during the cident occurred, the report said. Nevertheless, flight it occurred was not available,” the report the report added, “It can be hypothesized that said. “Further, although the characteristics of the they predominantly occurred during short- short-haul operation might have played a role haul flights.” in the reported accidents, there was no objective Data showed that 71 percent of the involved information available about the involved work- employees said that their accidents were related load (the number of on-board services or the to on-board customer service. Other causes number of rest breaks during these flights).” were reported as “the landing or taking off of the The report said additional research is airplane (6 percent) and turbulence during the needed to determine what types of changes in flight (3 percent).” short-haul scheduling — such as a reduction in In addition, other workload factors, “such duty times or numbers of flights or an increase as time on task, lack of rest breaks and stress- in the number of days off — might reduce the ful work,” were identified as contributing to an number of accidents. Research also should increased risk of on-the-job accidents. examine gender and other factors to determine “Since the results of this study indicate that whether they might explain differences in ac- the risk of experiencing an accident increases cident occurrence. ‘The components with increased exposure to short-haul flights, Because so many of the accidents occurred it can also be hypothesized that the cumula- while cabin crewmembers were involved with of the short-haul tive exposure to short-haul flights might lead on-board services, accident-reduction efforts to more fatigue accumulation, compared to should be focused on that area, with goals of duty days … cumulative exposure to long-haul flights,” the developing more specific accident-prevention trigger fatigue report said. strategies, the report said. At the airline that was the focus of the study, among the crew.’ the long-haul schedule for cabin crewmembers Notes involved several duty days, including at least one 1. Van Drongelen, Alwin; Boot, Cecile R.L.; Pas, L. layover, followed by several days off. Short-haul Willemijn et al. “Flight Schedules and Occupational schedules involved three or four duty days, fol- Accidents Among Cabin Crew: A Longitudinal Study.” Aviation, Space, and Environmental Medicine lowed by one or two days off. Volume 84 (December 2013): 1281–1285. “It is known that the components of the short-haul duty days (up to four flights a 2. The report defined short-haul flights as lasting less than four hours, medium-haul flights as lasting at day, long working hours, early starts and late least four hours but less than eight hours, and long- finishes) trigger fatigue among the crew,” the haul flights as lasting eight hours or longer. report said, citing earlier research on fatigue in short-haul operations. “It is, therefore, possible Further Reading From FSF Publications that the days off in between are not sufficient FSF Editorial Staff. “Study of Airline’s Flight Attendants to recover from the days on duty, thereby Finds More Than Half of Injuries Affect Muscles and inducing a cumulative fatiguing effect and Bones in Back, Neck, Shoulders.” Cabin Crew Safety increasing the risk of accidents over successive Volume 37 (July–August 2002).
duty days.” FSF Editorial Staff. “Working in, Around Aircraft Cabins The researchers said their study had several Requires Awareness of Fall Prevention.” Cabin Crew limitations, including the voluntary nature of Safety Volume 35 (January–February 2000).
26 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MARCH 2014 university of southern california presents
Safety Management Systems for Remotely Piloted Aircraft
The presence of Remotely Piloted Aircraft (RPA) in our airways is on the rise and, with them, comes the need for heightened knowledge and best practices in Safety Management Systems (SMS).
USC Viterbi School of Engineering is offering a timely course May 5-9, 2014, in developing and implementing SMS—taught by RPA safety experts from NASA, U.S. Customs and Border Protection, the U.S. Air Force, Alaska Airlines, and USC.
Among those who will benefit from attending are professionals with a background in RPA or unmanned aircraft systems, including pilots, engineers, safety program and insurance managers, law enforcement, and aviation community members seeking to understand how SMS will May 5-9 be applied to RPAs moving forward. 2014 for more information: http://viterbi.usc.edu/aviation
USC_Viterbi_Aviation_Safety_ASW fullpage_Ad_2014.indd 1 1/30/14 6:27 PM FLIGHTTRAINING
Behind the ScenesBY WAYNE ROSENKRANS
elivering airline pilot training Crew Training Conference, held in less likely. Nevertheless, when we put to mitigate the risk of loss of September 2013 in London by the human beings in the cockpit, there are control–in flight (LOC-I) partly Royal Aeronautical Society. Overall, the all sorts of potential, possible interac- depends on technical innovations specialists voiced confidence in current tions and some things that we cannot Dthat mesh precisely with new regula- or imminent technical capability to predict by design. … We can create, with tions, standards and expert guidance support this training. help from our simulator manufacturers, (ASW, 7/13, p. 27, and 8/13, p. 34). Michael Varney, a captain and a really immersive environment where Behind-the-scenes details provide senior director, flight crew training, the pilots feel 90 percent that they’re evidence of progress to date on these Airbus, told the conference, “The fact really in the airplane — and that they innovations, as seen by some of the is that over decades, we have looked really have to deal with the situation.” international specialists involved, and at these sorts of statistics [for LOC-I, offer insights on what constitutes accept- controlled flight into terrain, ground Technical Solutions able results from key hardware-software collisions and runway excursions] and Analyses of technological possibilities solutions, and their limitations. fixed the problems on an engineering have clarified the research and develop- For many years, the effectiveness basis instead of looking behind what ment priorities and the benefit-to-cost of existing engineered solutions for the root causes of the problems are. … ratios, said Jeff Schroeder, chief scien- accident prevention was the subject As we design-out known problems and tific and technical adviser, flight simu- of wide-ranging debate, some special- we improve the reliability of our already lation systems, U.S. Federal Aviation
ists told the 8th International Flight very reliable system, failures are much Administration. He spoke as chairman Brandligt/AirTeamImages.com © Andras
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of the Research and Technology Group of the and get trained on the various stall models, and International Committee for Aviation Training then we checked them after they had trained in Extended Envelopes. The committee, a four- to proficiency in recovering from several [stall] year initiative of the Royal Aeronautical Society, scenarios on the type-specific stall model devel- disbanded in late 2013. oped by The Boeing Co.” There’s no longer a question that conducting high-altitude stall prevention training in flight False Success simulation training devices (FSTDs) offers the Mismatching a technology to a training ele- highest benefit-to-cost ratio for operators, he ment may create the risk of a negative transfer said. This has been the flight regime where stalls of training, he said. Another committee concern in transport category airplanes have happened was that a pilot might attempt to recover from a recently, and where recovery is the most chal- high-altitude stall when the aircraft actually was lenging. Practice applying the most effective not stalled. Such a scenario might be prompted response — based on first reducing angle-of- inadvertently by activation of the stick shaker attack — instills confidence and reinforces the during moderate turbulence. current procedure, he said. “The pilot misconstrues that as a stall condi- “Because of the roll damping, the ensuing tion and then places the nose down, executes recovery to get back to safe flight can expose a full recovery in the sparse air [but then gets] some deficiencies with a rare number of pilots,” into pilot-induced oscillations in the recovery, Schroeder said. “In the United States, we have to varying in [g loads, the positive or negative Upset do full-stall training and, based upon some recent multipliers of normal gravitational accelera- experience, it looks like that appears to be feasible tion],” Schroeder said. “The worst case that we prevention, in simulators. … No airplane stalls the same way saw went between 0.2 g and 2.2 g. If you’re not recognition twice, and … our proposed modeling specifica- paying attention to the barber pole [minimum- and recovery tion [has] a component of randomness that goes speed amber and red bands on a Boeing speed specialists into the models so that it’s consistent with the tape, for example] going up and down and oscil- variation [flight crews] will see in the airplane.” lating — your angle-of-attack is changing, your identify critical The group first sought expert opinion — lift is changing and your load factor is chang- technical often from test pilots highly experienced in stall- ing — you might think this was a pretty good enhancements. ing the same aircraft types — to rate the realism recovery. And it wasn’t.” created by new software algorithms installed in Accurately simulating recovery from a full an FSTD, then conducted technology demonstra- stall is one of the areas where simulation engi- tions, evaluations and experiments. In Novem- neers still need to spend time, he said. Further ber 2010, for example, the group assessed a new work also is needed to improve the buffet real- representative stall model algorithm that, unlike ism so that buffeting progressively changes to typical algorithms, was not based on flight test reflect depth of entry into the stall region of the data (see “Configurable Model,” p. 30). aerodynamic envelope; the feedback to instruc- “[In 2013,] we did an experiment that tors; the mathematical modeling of recovery; involved looking at four different types of stall and the modeling of the effects of icing on stall. models, one being an unmodified [algorithm] “Roughly, we have about 50 different aircraft that is delivered with the simulator now,” Schro- [variants] that we probably have to make models eder said. “Ten test pilots — nine of whom had for … in the United States, across about 300 stalled an actual [Boeing] 737 airplane, one over simulators in the air carriers,” he said. “Most of 500 times — evaluated [these] so we had a lot the [upset prevention, recognition and recovery of confidence [in] the opinions that we were training] can be done today, especially on the pre- getting on the model fidelity. In another part of vention side, with our existing tools. … By 2018, the experiment, I had 40 747 line pilots come in everybody in the United States that flies [Federal
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Aviation Regulations] Part 121 [air car- cover, for stall in icing conditions, the The group also did an exhaustive rier] operations will have to comply.” types of automation mismanagement, fidelity-requirement analysis, deciding stalls-without-warning and aircraft nose- the specific level for every combination Enter the Matrix below-horizon scenarios commonly seen of device and training element. Each A key factor in the group’s progress in in NTSB accident data, he added. task was characterized as practical, aca- closely aligning technical capabilities with Airline pilots have long needed demic or both, and separately assigned the committee’s 176 training elements to be trained on “what lies beyond to mitigation levels within upset aware- was a comprehensive training matrix the stick shaker,” Crider said. If this ness; recognition and prevention; and/ (Table 1, p. 31), said Dennis Crider, chief training is effective, the various cues or recovery stages, said David Shikany, technical adviser, vehicle simulation, U.S. to imminent stall and stall can be associate technical fellow, aerodynam- National Transportation Safety Board transformed — by qualified instruc- ics stability and control, flight simula- (NTSB). “The matrix contains train- tors using appropriate technology — tion, The Boeing Co. ing elements necessary for the pilots to from sources of confusion to familiar “We took each training task, and [acquire] skills to recognize and recover inputs that rapidly trigger the correct we looked at it from the point of view from in-flight upsets,” he said. They also response. of the cues that were required,” Shikany said. “The awareness and the alerting Configurable Model cues were relevant to the control forces, the instruments and the audio cueing that is associated with [the all-attitude ind tunnel experiments for modeling high-altitude stall have proven to exposure] training task. The control be equally or more important than relying on flight test data to create a forces and the motion cueing both play Wnew configurable simulation, according to one conference presentation. a role in the pilot’s ability to control the “What we’re trying to do, working with the U.S. Federal Aviation Administration, aircraft in order to be able to carry out is to postulate the potential of configuration geometry types to simplify the stall model deployment,” said John Ralston, president of Bihrle Applied Research. “The the training task. And motion cueing reason for doing this is to try to minimize the amount of model-specific work that has a major physiological effect in the needs to be done in order to accomplish this. This also gives us an approach to all-attitude exposure training task. So [modeling] where we might not have available the original equipment manufac- we carried this out for all of the 176 turer [flight test] data to support the stall model development.” tasks, and once we’d done that, we then The wind tunnel experiments aimed to develop a stall model configurable for felt that we could go back and link most of the aircraft that have a “swept low wing, low tail, underwing-engine con- figuration,” he said. “We wanted to identify the requisite model architecture that [each required cue] to the FSTDs.” would capture the stall features [and type-specific baseline data,] configuration- He cited the awareness level of representative reductions in the static and dynamic stability in both longitudinal training for high-altitude stall as an and lateral directional axes; reductions in control effectiveness; [enhanced buffet;] example. “There’s going to need to be and an asymmetric behavior that also characterizes rolloff,” Ralston said. This is a representative level of fidelity in the not a generic model but rather a model that can be adjusted in real time inside an flight model — in the control forces in engineering simulator based on a subject matter expert’s recommendations. Nonlinear characteristics such as stable-versus-unstable roll damping have the cockpit, for example — to be able been relatively difficult to identify from flight test data but can be readily identified to meet the learning objective … to un- in the wind tunnel; nevertheless, wind tunnel test data also have limitations, he said. derstand the relationship between high An enhanced stall model demonstration of the technology, using a alpha [angle-of-attack] and increased Sim Industries Boeing 737-800 device, was conducted for the Research and induced drag,” Shikany said. A diagram Technology Group of the Royal Aeronautical Society’s committee, said Dave produced by the group shows that the Gingras, vice president, Bihrle Applied Research. The enhanced modeling was implemented by transitions between existing and new algorithms as necessary, industry already has devices that meet and running the blended simulation externally on modern computer hardware that level of fidelity. so that the relatively low computing power of legacy flight simulation training devices would not be an issue. ‘Genetic Code’ — WR In parallel with the fidelity work, the group assigned a code to each detail
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‘Genetic Code’ Examples From FSTD Feature-Fidelity Analysis
Feature of Flight Simulation Training Device Academic Practical Device level and structure layout Cockpit model Flight handling Ground systems Aeroplane and forces controls Flight Sound cue cue Visual Motion cue – ATC Environment – navigation Environment – weather Environment – aerodromes Environment – IOS Miscellaneous Training Element Example Fidelity Level Needed for Training Element Learning Objective High-AOA performance considerations X X FTD R R N R R R R N N N N N N Understanding of the relationship between high AOA and increased induced drag Demonstration of stall recoveries, altitude loss, recovery with reduced thrust/ High-altitude stall X X FFS S S1 N S S R R R2 N N N N S1 power and other performance differences associated with high-altitude flight New FSTDs Example Fidelity Level Needed for Proposed Device Legend for ICAO Fidelity Codes Type VII+ S S1 S S S1 R S R2 N S R2 R S1 Type GAD G R N G R G R2 R3 N N N N S1 Lowest Fidelity Highest Fidelity Type SPD S S2 S S S R S R3 N S R R S1 N------G------R------R1------R2------R3------R4------S ------S1------S2 Type SDD G G N G G G R2 R4 G S G G G
ATC = air traffic control; AOA = angle-of-attack; FFS = full flight simulator; FSTD = flight simulation training device; FTD = flight training device (other); g = standard gravitational acceleration; ICAO = International Civil Aviation Organization; IOS = instructor operating station; N = none or fidelity not applicable; G = generic fidelity (ICAO’s lowest level of required fidelity for a given FSTD feature); R = representative fidelity (ICAO’s intermediate level of required fidelity); S = specific fidelity (ICAO’s highest level of required fidelity); GAD = g-awareness device (proposed); SPD = spin device (proposed); SDD = spatial disorientation device (proposed); VII+ = Proposed enhancement of ICAO Type VII FSTD (for full stall); X = training element relates to this kind of training Note: These two training elements are examples of 176 in the training matrix prepared by a committee of the Royal Aeronautical Society. All were analyzed partly to identify the needed level of FSTD-feature fidelity to achieve upset prevention, recognition and recovery learning objectives. Similarly, feature-fidelity levels for these four additionally recommended device specifications were identified by the committee’s Research and Technology Group.
Source: Research and Technology Group, International Committee for Aviation Training in Extended Envelopes
Table 1 of the capabilities of commonly used devices,” he said, describing how the training objectives that will be required FSTDs, said Joris Field, training sys- group distilled the desirable leftover to be performed on the airplane due to tems specialist, National Aerospace codes into a Type VII+ device, a g- psychological or physical effects.” Laboratories Netherlands. awareness device, a spin device and a “How do we simulate all this?” “[We took] all the fidelity require- spatial disorientation device. “For the asked Itash Samani, head of global ments for the various features and Type VII+ device, there were 18 [codes] FSTD regulations, CAE. “The level of essentially aligned them into a device,” primarily associated with training tasks the [current standard Type VII, a ‘Level Field said. “Unfortunately, the 176 tasks related to the stall. … The Type VII+ D+’] device is our starting point [and] that are in that matrix resulted in over device does require some additional what is commonly out there.” 40 unique ‘genetic codes.’ … [Instead enhancements to the flight model In the near future, the industry also of] standardizing down to seven de- primarily for stall, control forces, flight can look forward to accurate represen- vices, you would [have to] turn all those control forces, stick pusher, motion tation of stall behavior in icing condi- unique genetic codes into 40 different buffet, environment, weather and the tions with new Type VII models instead devices.” The solution in some cases IOS [instructor operating station]. … of today’s unrepresentative, artificial was to “roll up” similar sets of codes One of the things we’ll have to be aware increases in aircraft weight and drag as into what he called “a common genetic of [is that if] the training objectives a proxy. New models will include loss of code or set of fidelity requirements that change, those device requirements will lift; increasing drag; change in the stall could satisfy a number of the tasks” have to change also. … Over three- angle-of-attack, which prevents normal first by using today’s ICAO Type II, quarters of the training in that matrix stall warnings; changes in the pitching Type V and Type VII FSTDs. can be accomplished with today’s moment of the aircraft; and decreased “Then we found that we had to devices plus some enhancements. … control effectiveness, and changes in essentially come up with four new There always will be a subset of those control forces, he said.
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Flight Safety Foundation Member Enrollment Membership/Donations/Endowments BARS Program Office Headquarters: Ahlam Wahdan Susan M. Lausch Level 6 | 278 Collins Street 801 N. Fairfax Street, Suite 400 membership services coordinator managing director of membership Melbourne VIC 3000 Australia Alexandria, Virginia U.S. 22314-1774 Tel.: ext. 102 and business development GPO Box 3026 Tel.: +1 703.739.6700 [email protected] Tel.: ext. 112 Melbourne VIC 3001 Australia Fax: +1 703.739.6708 [email protected] Tel.: +61 1300 557 162 Fax: +61 1300 557 182 flightsafety.org Email: [email protected] © Digitalstormcinema/Dreamstime.com Over the Horizon the Over F emissions. and environmental issues such as noise and andprivacy related considerations; social safety concerns; regulatory issues; and policy challenges, including crowded skies and other sible with numerous deals after industry the and crewdelivery flight augmentation. such as transportation the of cargo, package forcalling expanded UAS roles areas innew FLIGHTSAFETY.ORG Those roles,Those however,- only pos will be United States by 2035,with projections manned commercial aircraft in the (UAS) are likely to outstrip of those lights of unmanned aircraft systems |
WORLD AEROSAFETY | MARCH 2014 MARCH challenges that must industry the overcome. tasks likelythe on taken to be by UAS and the Federal Aviation Administration (FAA) describe and and Development U.S. the (JPDO) Office tation Systems Center, U.S. the Joint Planning Johntion (DOT) A.Volpe National Transpor months by U.S. the Department of Transporta- 5,000 additional aircraft equipped with UAS forces to have expect 14,000 UAS, along with data(DoD) indicate that, by armed 2035, the airspace, and U.S. Department of Defense primarilyused in war zones and inrestricted A collection ofA collection reports issued inrecent Historically, UAS aircraft, have military been UAS willruletheskies. Industry expertsforesee adaywhen 1,2,3 -
BY LINDAWERFELMAN REGULATIONSAFETY |
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Unmanned Aircraft Systems — Total Forecast 2015–2035 other first respond- ers — will add about 200,000 34,000. Total Public (DoD Included) The greatest surge 180,000 Total Commercial in UAS numbers, 160,000 however, is forecast 140,000 in the commercial market, which by 120,000 2035 is expected to 100,000 be fielding 175,000 80,000 unmanned aircraft. Number of vehicles “The majority of 60,000 these vehicles will be 40,000 low-cost and dedi- 20,000 cated to specific new and emerging tactical 0 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 market applications,” Year the Volpe report said. “The source of supply
DoD = U.S. Department of Defense of these vehicles will
Source: John A. Volpe National Transportation Systems Center come initially from the radio controlled Figure 1 (RC) type vehicle makers, as opposed to technology that will allow for “pilot augmenta- the suppliers of DoD and public agency aircraft. tion or optional pilot replacement.” Unmanned After an initial surge or upswing in commercial aircraft will represent 70 percent of the U.S. sales, reduced growth is expected, as needs for military’s fleet in 2035, up from 25 percent early adopters and innovators are met. As UAS today, the Volpe report said. usage becomes more mainstream, DoD suppli- The report forecast an even more sweeping ers are expected to seriously enter the com- expansion in non-military use of UAS by fed- mercial market, which will encourage changes eral, state and local governments (Figure 1). in business models … . These changes should Today, federal agencies — including the again accelerate market growth through 2035.” Central Intelligence Agency, Department of Many of these public and commercial Homeland Security, and National Aeronautics unmanned aircraft will be among the small- and Space Administration (NASA) — operate est UAS vehicles — from the nano, micro and about 125 UAS. As the FAA resolves its exist- small categories — weighing anywhere from ing regulatory challenges within the coming less than 1 lb (0.5 kg) to 55 lb (25 kg, see “UAS months, other federal agencies — including Categories,” p. 36). those within the Department of Agriculture, Department of Commerce and Department of Laying the Groundwork Energy — will begin acquiring UAS, pushing the The FAA continued laying the groundwork for federal fleet to about 10,000 by 2035. the eventual merger of UAS into the National By 2015, U.S. states and territories probably Airspace System (NAS) with its selection in will operate a few hundred UAS, but those num- December 2013 of six UAS test sites to be used bers will expand to 10,000 by 2035, and munici- for research into certification and operational palities — especially their police departments and requirements (ASW, 2/14, p. 9).
34 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MARCH 2014 Texas A&M University–Corpus Christi modifications, report the said, adding, “The first civilian the aircraftbe to undergo these navigation system and autopilot.” ply braking of and functions into all these tie a control raise surfaces, and flight lower gear, ap- manned manage aircraft. throttle, the Servos UAS integrated can technology be into existing flight,” Volpe the report said. is capable of human-piloted and autonomous tionally piloted aircraft (OPA) where aircraft the to provide pilot the with apilot’s assistant, to op- fromtechnology UAS to cockpit the experience ing arange of possibilities, from “transfer of augmented assistance flight present —afield - areing all potential for uses UAS, along with crop dusting and livestock tracking and herd- and of some and types lifting hauling. deliveries to remote locations, operations logging tions, such aircraft inmaking used could be said, adding that, incommercial civilian opera- delivering slinged cargo Volpe the pallets, report stan, and is operated remotely, picking up and to resupply used has been U.S. troops inAfghani- havewhich operations. roots their inmilitary on take anumberwill of roles, new some of As UAS move into commercial they the fleet, Crew Augmentation test sites. to provide safety oversight for operations inthe establishment of asafe testing environment and Anthony Foxx said. our nation’s skies,” U.S. Transportation Secretary introduction of advanced this into technology information about how to best ensure safe the ofbecause ability their to provide “valuable system safety requirements —were selected and-avoid capabilities, failure testing mode and controlin air traffic operations, UAS sense- manned aircraft categories, changes necessary research topics, including standards for un- FLIGHTSAFETY.ORG General aviationGeneral aircraft presumably would “Using an automatic control flight system, Routine power line and pipeline inspections, For example, Kaman’s Unmanned K-MAX The FAA’s near-term to role aid be inthe will The sites on focus arange will —which of |
WORLD AEROSAFETY | MARCH 2014 MARCH ing World War I,and UAS have played an The of first use unmanned aircraft came dur UsesExpanding workload than second the manned pilot.” redundancy andnecessary can assume greater controlflight system augmentation provides the operations ….In concept, this automatic the crews reducedflight could be to single-pilot pilotthe becomes safety the observer.” workloadthe significantly can be reduced and pilot can from shift manned operations to UAS, where pilot the is incapacitated. ifthe Likewise, enjoy confidence the of assistance case inthe UAS safety package, pilot the and passengers can parachute aircraft to [Cirrus] the line. With a safety capability change, not adding unlike a of autonomous landing create will asignificant addition of aUAS operating package capable Eventually, report the said, “two-person - REGULATIONSAFETY Texas A&M–Corpus vehicles forflight. operating oneof one oftheirUAS The universityis the sixUAStest sites authorized Researchers at Christi prepare by theFAA. |
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increasingly prominent role in military opera- Comprehensive Plan tions. Public, non-military UAS, however, have That complete picture is presented in the operated on a limited basis in the NAS since JPDO’s Comprehensive Plan — a collaborative the early 1990s, gradually taking on missions in effort involving the Departments of Trans- such areas as agricultural monitoring, border portation, Defense, Commerce and Home- surveillance, search and rescue, and disaster land Security, NASA, the FAA and industry response. representatives. With a combination of technological advanc- “The continued safe integration of UAS in es, increased interest in using UAS and a 2012 law the NAS and increased NAS access for UAS will that included provisions for the phased expansion be driven by incremental advances in research of UAS operations, the FAA and other govern- and development … (including test ranges), ment agencies have begun working toward devel- rulemaking (including operational approval and oping a complete picture of what will be involved airworthiness standards) and development of in integrating UAS into NAS operations. UAS-related technologies,” the plan said. “Safe integration will lead us from today’s need for accommodation of UAS through individual UAS Categories approvals to a time when standardized/routine integration into the NextGen [the Next Genera- lobally, civil aviation authorities have not agreed on how to clas- tion Air Transportation System, the ongoing up- sify unmanned aircraft systems (UAS), but a report by the U.S. grade of the NAS] environment is well defined.” GDepartment of Transportation’s (DOT’s) John A. Volpe National The plan outlined six goals aimed at facili- Transportation Systems Center recommends several categories that tating the safe integration of the smallest UAS it says are consistent with those used by U.S. military and research vehicles into the NAS. personnel.1 Three of these recommended categories are expected to be Two of these goals call for routine opera- covered by the notice of proposed rulemaking (NPRM) that the U.S. tion of small — less than 55 lb — UAS vehicles Federal Aviation Administration plans to issue later this year: in visual line-of-sight flights. Public UAS — • Nano refers to the smallest UAS vehicles, those that weigh less those operated by various non-military federal, than 1 lb (0.5 kg) and are less than 1 ft (0.3 m) long. They would state and local government entities — would fly below 400 ft above ground level (AGL) at less than 25 mph be the first to begin operations, followed by (40 kph) and have an endurance of one to two hours. Nano civil UAS. The FAA expects to issue a notice of devices could perform surveillance in urban areas, transmitting video or images of camera views to an operator. proposed rulemaking later this year concerning regulations. • Micro UAS vehicles, weighing between 1 lb and 4.5 lb (2 kg) and less than 3 ft (0.9 m) long, would have speeds up to 25 mph and Two additional goals call for routine opera- could be flown below 3,000 ft AGL. They, like nano UAS vehicles, tion of larger UAS vehicles, again with the public also could be used for surveillance. UAS beginning operations before their civil • Small UAS vehicles, weighing between 4.5 lb and 55 lb (25 kg) counterparts. Another goal calls for establishing and less than 10 ft (3 m) long, can fly higher (up to 10,000 ft), acceptable levels of automation in UAS, and the faster (50 to 75 mph [80 to 121 kph]) and longer (one to four sixth goal calls for fostering U.S. leadership in hours) than nano and micro UAS vehicles. Besides surveillance, UAS capabilities and in standards development. they could be used for product deliveries. Heavier UAS vehicles — in several categories ranging up to 12,500 lb The Comprehensive Plan said that, although (5,670 kg) or more — will be the subject of later NPRMs. it sets forth “the overarching interagency goals, — LW objectives and approach to integrating UAS into Note the NAS,” each department or agency involved
1. DOT, John A. Volpe National Transportation Systems Center. Unmanned in development of the plan will work toward Aircraft System (UAS) Service Demand, 2015–2035, DOT-VNTSC-DoD-13-01. those goals and some may develop complemen- Report prepared for the U.S. Air Force. September 2013. tary agency-specific paths toward achieving the common goals and objectives.
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The FAA’s Integration of Civil airborne systems, although actual use kph] poses little, if any, collision risk to UAS in the NAS Roadmap is one such of an airborne system is considered a airborne aircraft or persons or property individual plan, discussing the agency’s long-term goal. on the ground,” the report said. proposals for achieving its goals in con- Human factors research involves nection with UAS development. both pilots and air traffic control (ATC) Early Incidents “Ultimately, UAS must be inte- “and how they will interact to safely In their early years, however, UAS have grated into the NAS without reducing operate unmanned aircraft,” the FAA been involved in a handful of incidents existing capacity, decreasing safety, report said. “In the near term, data will and non-fatal accidents investigated by negatively impacting current opera- be collected to permit analysis of how the U.S. National Transportation Safety tors or increasing the risk to airspace pilots fly UAS, how controllers provide Board (NTSB). users or persons and property on the service involving a mix of manned The NTSB issued its first investiga- ground any more than the integration aircraft and UAS and how pilots and tive report on a UAS crash in 2007, of comparable new and novel tech- controllers interact with each other, combining its findings on the April nologies,” the roadmap said, noting the with the goal of developing pilot, ATC 25, 2006, accident involving a General FAA’s key roles in developing regula- and automation roles and responsibili- Atomics Aeronautical Systems Preda- tions, guidance material and training ties concepts.” tor B with 22 safety recommendations requirements. On the same subject, the JPDO (ASW, 12/07, p. 42). “The process of developing regula- report suggested research topics that Changes in accident investiga- tions, policy, procedures, guidance included effective human-automation tion procedures as more UAS enter material and training requirements is interaction and UAS operational and the NAS — and as more of them are resource-intensive,” the roadmap said, technical risks such as inability to avoid involved in accidents — probably will calling on government agencies and in- a collision and/or maintain positive be minimal, NTSB Member Robert dustry stakeholders to support the con- control of a UAS vehicle. Sumwalt said. tinuing evolution of UAS operations. “There will be differences, but the The FAA said that its plans call for ‘Early Adapters’ methodology used is essentially the an incremental approach to implement- Overall, the Volpe report said, com- same,” he said, noting that — just as ing the regulations that will guide the mercial market use of UAS will begin in investigations of manned aircraft industry. after the regulatory policies are imple- accidents — the most frequently cited “The FAA expects to gain experi- mented, perhaps sometime in 2015, probable causes of the early UAS occur- ence in applying the existing airwor- with micro UAS vehicles — similar to rences involve human factors. thiness regulations during the type the RC vehicles now used by hobby- certification process with early UAS ists — being deployed by “innovative Notes adapters,” the report said. After that, the users and early adapters.” 1. DOT, John A. Volpe National Transporta- agency will revise airworthiness regula- As noted, the second accelerated tion Systems Center. Unmanned Aircraft tions as necessary for UAS safety. influx of UAS into U.S. airspace is not System (UAS) Service Demand, 2015–2035, likely until around 2022, as manu- DOT-VNTSC-DoD-13-01. Report pre- pared for the U.S. Air Force. September Sense-and-Avoid facturers that have been accustomed 2013. The FAA will focus research on to producing devices for the military sense-and-avoid systems, control expand to the commercial market. 2. JPDO. Unmanned Aircraft Systems (UAS) Comprehensive Plan: A Report on the Na- and communications, and human By then, the FAA and others will tion’s UAS Path Forward. September 2013. factors, the report said, adding that have conducted further research on The JPDO’s members represent several this research will aid in establishing risks associated with very small UAS U.S. government departments and agen- performance limits and in evaluat- vehicles, including the risks of colli- cies involved in development of NextGen. ing technologies and procedures for sion in the air or on the ground. 3. FAA. Integration of Civil Unmanned NextGen. “A Micro vehicle of foam and balsa Aircraft Systems (UAS) in the National Sense-and-avoid research is di- construction weighing less than 4.5 lb Airspace System (NAS) Roadmap, First rected at developing ground-based and [2 kg] traveling less than 20 mph [32 Edition. November 2013.
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Act
BY MARIO PIEROBON
Shortages of qualified safety inspectors increasingly inhibit regulators. © filo/istockphoto.com © TAlex/vectorstock.com
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n its 2013 annual report on the Univer- “The considerations of the ASC are derived sal Safety Oversight Audit Programme from the EU Safety Assessment of Foreign Air- (USOAP), the International Civil Aviation craft (SAFA) check findings and ICAO’s USOAP Organization (ICAO) noted that of the reports,” says Silvano Manera, a former director eightI critical elements laid out in the program, general of Italy’s Ente Nazionale per l’Aviazione technical personnel qualifications and train- Civile (ENAC), the CAA. ing ranked last in terms of satisfactory imple- “The SAFA program is targeted to actual mentation by ICAO contracting states. The operations, while ICAO’s USOAP is directed to civil aviation authorities (CAAs) in a variety states and the ban is activated when evidence of countries, both developed and developing, exists that ICAO standards are not met either by have found that hiring, training and retaining a carrier or the respective civil aviation author- qualified aviation safety inspectors is an ongo- ity. Some cases exist when a carrier meets high ing challenge.1 industry standards such as IOSA (the Inter- The ineffectiveness of aviation safety over- national Air Transport Association’s [IATA’s] sight in some states and regions of the world has Operational Safety Audit), but it is still banned led North American and European authorities because its registry state is deemed unable to to act essentially as watchdogs of global avia- provide acceptable oversight, with staffing inad- tion safety oversight. For instance, on Jan. 31, equacies normally being one of the main issues,” 2014, the U.S. Federal Aviation Administration says Manera. (FAA), under its International Aviation Safety The shortage of oversight staff actually rep- Assessment (IASA) program, announced that it resents a threat for the whole aviation industry. had downgraded India to a Category 2 rating, In the growing air transport system of the Asia signifying “that India’s civil aviation safety over- Pacific region, aviation safety oversight can be sight regime does not currently comply” with anywhere in the USOAP range of 10 percent the international standards set by ICAO. In its effectiveness to 100 percent effectiveness. Most September 2013 IASA assessment, FAA identi- states within the Asia Pacific region have fied 33 problem areas — mainly related to staff been rated 50 to 60 percent effective from the shortage and training issues. India’s Directorate standpoint of personnel and the capability for General of Civil Aviation (DGAC) subsequently them to do their oversight, says Kim Tretheway, hired 75 new safety inspectors. chief technical adviser of ICAO’s Co-operative In May 2013, the European Commission Development of Operational Safety and Con- (EC) updated for the 22nd time the European tinuing Airworthiness Programme, Southeast Union (EU) air safety list, better known as the Asia.2 EU blacklist, of airlines that are subject to an More mature aviation markets also are operating ban or operational restrictions within having a hard time filling all budgeted aviation the European Union (EU). Decisions to ban safety inspector slots. In late 2012, for example, foreign carriers or subject them to operating re- senior officials at Transport Canada said they strictions are based on the unanimous opinion were having a difficult time filling all 880 bud- of the EU Air Safety Committee (ASC), which geted safety inspector positions and that there consists of aviation safety experts from the EC, were around 100 vacancies.3 Also, an audit by from each of the 28 EU member states, as well Canada’s auditor general found that Transport as from Norway, Iceland, Switzerland and the Canada had failed to conduct planned inspec- European Aviation Safety Agency (EASA). The tions of hundreds of aviation companies desig- Commission’s decisions about changing the list nated as ”higher risk” operations, according to also must be supported by the European Parlia- a published report. In addition, the audit found ment and the Council of Ministers before they that 67 percent of air carriers, maintenance can take effect. companies and large airports were inspected as
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scheduled under annual surveillance “Retention of qualified inspectors flight operations inspectors usually plans in 2010–2011.4 has been an issue due to the lack of have non-flying status, which may con- The global shortage of aviation salaries commensurate with industry tribute to fewer candidates being will- safety inspectors led the U.S. delegation counterparts or similar inspector posi- ing to engage in a pure oversight role. to ICAO to present an item related to tions at other authorities in the region, this matter at the ICAO 38th Assem- as well as early retirement requirements Applying Pressure bly, held in late September and early set by the national government,” says All ICAO member states and signers of October 2013. “A global shortage of the ICAO working paper.7 the Convention on International Civil qualified aviation safety inspectors In addition to financial reasons, Aviation (known as the Chicago Con- has become evident as ICAO mem- some observers suggest that staff vention) are obligated to implement the ber states continue to enhance their shortages at aviation safety inspector- organization’s aviation safety require- capabilities in aviation safety oversight. ates may also be caused by a stronger ments. To fulfill its ICAO obligations, This shortage is evident through a high workplace dynamism in the private each CAA, and especially its operations number of inspector vacancies and sector. The theory is that aviation and continuing airworthiness inspec- the movement of trained and qualified safety professionals may be stimulated torate, is responsible for implementing inspectors to other authorities or to by a relatively fast-changing and less the ICAO requirements on behalf of private industry. Inspectors perform bureaucratic work environment in the national government.9 a core function of an aviation author- private-sector, market-competitive There are no supranational bodies ity and have direct impact on aviation organizations. Manera says that in a bu- that can supersede or can discharge safety,” says an ICAO working paper.5 reaucracy, dynamism can be inversely national responsibilities when it comes proportional to the state’s level of to ensuring that state or regional CAAs Causes of Shortage economic development —and this may have adequately staffed operations and Manera says there are two parallel partially explain why sufficient aviation airworthiness inspectorate activities. macro socio-economic reasons why safety inspectors can be difficult to hire “ICAO sets and recommends standards; there is this shortage of inspectors. “On in aeronautically developing countries. sometimes it ‘urges’ contracting states the one hand, there are aeronautically But focusing only on remuneration to provide local actions to reach those developed countries where attrition/ and working conditions as reasons standards, but legislative and executive retirement rates cannot be matched by for inspector shortages would be too powers reside within national bodies, new hiring because of [a] shortage of limiting, says Manera. The shortage which are set up by the states,” says public funding. Budget cuts due to the of qualified aviation safety inspectors Manera. economic downturn do not allow the also is caused by difficulty in ensuring “IATA and other industry bodies ... hiring of enough skilled people,” he adequate levels of training. “Authority propose international standards for the said, adding that “training costs are a inspectors need different and addition- whole industry. They foster the spread- factor, too.” al skills, other than what can be found ing of those standards, too. But due On the other hand, there are aero- in the private sector. In aeronautically to the [cited] reasons, such industry nautically developing countries in places developed countries, it is often the case standards and bodies cannot, although like Africa, Asia and South America that training is needed even for highly appreciated, substitute state legislation where hiring locally cannot keep pace skilled people,” he said. [or for] the role of local CAAs,” adds with rapid aviation growth, according Some authorities “face the challenge Manera. to Manera. of maintaining a training program to However, some regulatory enti- And then there is the issue of ensure that inspectors have initial and ties are capable of pressuring national public sector salaries. “Inspectors recurrent training, and that inspectors governments. For example, Gaetani are mostly on civil service pay scales, [may not] use the latest requirements said that EASA, on behalf of the EC, significantly lower than in the private and practices due to a lack of knowl- is responsible for the oversight of EU sector, making it extremely difficult edge or resources.”8 states’ CAAs. “Several kinds of [EASA] to attract recruits or lure professionals Francesco Gaetani, former manager inspections are made to assess the away from airlines.”6 of regulations at Alitalia, added that uniform implementation of rules on
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regulation of aviation safety in Europe. One of have not been able, up to now, to find a legally the items inspected, similar to those in ICAO’s suitable and acceptable form of ‘role substitu- USOAP, is the adequacy of a CAA’s ability to tion’ for the discharging of responsibilities,” says perform its oversight function: the availability Manera. “On the one side, there is a synergy in and qualification of inspectors are verified ac- certification activities across the Atlantic, but, cording to the complexity of a member state’s on the other side, both entities (the United civil aviation system,” says Gaetani. States and the EU) require ‘re-certification’ of Numerous auditing programs also are in third country operators, worsening and increas- place to ensure that aviation safety inspector- ing the need of inspection activities.” ates’ staffing levels are adequate: USOAP, IOSA, Regulators need to collaborate more, share ISAGO (IATA Safety Audit for Ground Opera- expertise and work toward avoiding duplica- tions), SAFA and FAA’s IASA. “The existing au- tion of inspections. CAAs not only inspect their diting programs contribute to target the whole own country’s aircraft but also those of foreign aviation system of a given country: starting airlines that operate in the state; as a result, from high-level state legislations down to actual the aircraft are subject to multiple inspections. operations, existing programs help to define This could be avoided if states recognized each what the gaps are, where they are and what other’s approvals, says Alan Foo of the CAA of should be done to overcome negative outcomes,” Singapore.10 Regulators need to says Manera. Changing Contract Provisions “On a global scale,” adds Gaetani, “ICAO per- collaborate more, forms inspections of contracting states within In an article published in late 2012, Foo won- the framework of USOAP. Recently EASA and dered about the possibility of attracting pro- share expertise ICAO have agreed to share concerns and join ficient inspectors by turning safety regulatory resources to conduct USOAP activities. This bodies into statutory entities not tied to govern- and work toward program is especially helpful to emerging coun- ment pay scales, thereby narrowing the disparity avoiding duplication tries with a developing civil aviation system.” between government salaries and airline salaries. An industry feedback mechanism on inspec- Aviation safety regulators “need to be of inspections. tors’ activities could also be helpful to raise the governed bodies, but having them separated as bar with regard to inspectors’ qualifications. corporate entities means they can have differ- “Airline industry bodies could provide a con- ent pay scales and not be subject to the overall structive feedback to authorities by commenting government budgetary framework,” he said in on inspectors’ oversight activities, in particular the article. “The money is available there, either when inspectors are found to be lagging behind through channelling it from passenger service both technological and operational progress. charges or having certification costs. It’s got to In addition, such organizations could organize be paid for.” dedicated forums for inspectors (similar to the The CAA of Singapore itself became a one on the SAFA program organized by IATA) statutory body in 1984; as such, it is not tied to where operational issues and developments are government pay structures, and it says that it discussed in a friendly and productive environ- can offer more competitive salaries, especially to ment,” says Gaetani. its flight operations inspectors.11 Another possible solution could include Sharing Expertise the contracting of outsourced personnel. “An An important step toward alleviating the lack of easy-to-implement solution is that of contract- inspectors could be mutual inspection recogni- ing qualified industry personnel with flexible tion between states. contracts. For instance, inspectorate capacity “The FAA and EASA conduct regular meet- can be increased through the part-time use of ings to deepen mutual recognition, but they active auditors from the industry,” says Manera.
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“With the use of contracted per- in inspecting ‘first things first’ and to as international airlines. “There might sonnel, advantages could be double- perform short quality-driven inspec- be a period of time ahead of us where ended: You pay them only when you tions instead of quantity-driven ones,” a less-mature SMS could compel au- employ them, and the rest of the time, says Manera. thorities to believe that safety perfor- they keep themselves current working mance is being improved while it is in the front line as part of a perma- A Self-Evaluating Industry actually not. The underlying reason nent job.” Aviation safety inspectors typically is that operational risk assessment are expected to accomplish many of is hard to perform effectively and Standards for Employment the daily technical and safety func- even harder to verify by inspectors The general qualifications for initial tions of a CAA as required by ICAO. [who] are not adequately qualified employment of aviation safety inspec- They represent the national govern- and up-to-date. Even if one of the tors are outlined in ICAO Airworthiness ment, and their role is critical to SMS’s elements is the requirement Manual (Doc 9760), Part II.12 maintaining international aviation of a thorough documentation of the “Talking about the validity of safety standards. As a result, some SMS’s activities, the suitability of an ICAO’s documents, we should keep in experts conclude that lack of quali- operational risk assessment can- mind that rules require a lot of time fied aviation safety inspectors directly not be easily assessed by inspectors to be produced, approved and become impacts aviation safety.13 without an in-depth knowledge of the binding. ICAO’s rule-making process The global scarcity of aviation safety organization’s operational activities,” is lengthy due to its own nature, with inspectors also coincides with the concludes Gaetani. around 200 member states contributing implementation of safety management Notes to rule making,” says Manera. systems (SMS) worldwide. Can SMS The standards outlined in the implementation be considered a tool, 1 ICAO. Assembly 38th Session Technical Airworthiness Manual are provided for at least in part, for reducing potential Commission, Agenda Item 31: Aviation reference. Additional considerations aviation risks associated with less Safety — Emerging Issues Global Shortage of Aviation Safety Inspectors, A38-WP 101 should guide the hiring, training and frequent CAA inspections? In the long TE/32, 16 August 2013. retention of inspectors. run, this may be the case. The manual was designed to “The introduction of systemic meth- 2 Ballantyne, Tom. “Poor pay key to inspector shortage,” Orient Aviation October 2012. provide “guidance to states on how ods of self-evaluation of safety perfor- they could meet, at a minimum, the mance, like SMS, is a strategic decision 3 Schmidt, Sarah. “Transport Canada ICAO airworthiness standards. Guid- taken by aviation legislators in order to admits to shortage in civil aviation inspec- tors,”
inspectors. Similarly, success in retain- cant amount of human resources, but 4 Ibid. ing inspectors depends on state-level it [still has a long way] to come,” says 5 ICAO. activity and is not within the scope of Manera. “Recently produced European ICAO’s mission and role,” reported an Aviation Safety Regulations (i.e., third- 6 Ballantyne. ICAO spokesperson. country operator regulations) still en- 7 ICAO. “In order to save time and resources visage on-site document (paper) checks 8 Ibid. and to prioritize actions, authorities even when more reliable databases are and states ought to fully apply the same available in house.” 9 Ibid. logic that they expect from the industry Gaetani says an SMS is a powerful 10 Ballantyne. when rules are imposed by govern- tool when properly used, but that full 11 Ibid. mental bodies. A strong and efficient implementation is needed for an SMS analysis of data flowing in towards au- to produce results, and this can take 12 ICAO. thorities could drive ‘limited’ resources years in complex organizations such 13 Ibid.
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DATALINK
BY FRANK JACKMAN Another Record Year 2013 will go down in history as one of the safest years in commercial aviation.
oth the International Civil Aviation operations remained steady at nine, the Organization (ICAO) and the European number of people who died in those accidents Aviation Safety Agency (EASA) have re- declined dramatically from 2012. Accord- leased preliminary analyses of worldwide ing to ICAO data, there were 372 fatalities in Baccident data showing 2013 to be one of the 2012, but that number dropped 53.5 percent to safest years in airline history. 173 last year (Figure 1). Of the nine total fatal The statistics indicate that 2013 “was the accidents worldwide in 2013, seven occurred safest year ever recorded” in terms of fatalities during the approach or go-around phases of in scheduled international air transport opera- flight, ICAO said. tions, according to ICAO. While the number of The ICAO statistics refer to scheduled com- fatal accidents involving scheduled commercial mercial operations involving aircraft having a maximum takeoff weight of more than 5,700 kg Global Fatalities Trend in ICAO Data, 2009–2013 (12,500 lb). “These results are no surprise given the 800 level of commitment our sector demonstrates, 700 year-in and year-out, to improving the safety 600 of the global air transport network,” ICAO 500 Secretary General Raymond Benjamin said in 400 releasing the report in January. “Recent years
Fatalities 300 have seen a tremendous increase in the level of 200 100 cooperation and partnership on aviation safety 0 priorities and we are now seeing the fruits of 2009 2010 2011 2012 2013 these efforts borne out by these remarkable Year 2013 outcomes.”
ICAO = International Civil Aviation Organization Over the past five years (2009 through 2013)
Source: International Civil Aviation Organization fatalities have increased once, spiking to ap- proximately 700 in 2010 from fewer than 500 in Figure 1 2009, ICAO data show. Since then, the number
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of fatalities has decreased three consecutive Fatal Accidents and Fatalities by ICAO Region, 2013 years and fallen more than 75 percent overall. According to ICAO, 60 percent of all 6 80 fatalities in 2013 were attributed to accidents Fatal accidents 5 in narrowbody jet airplanes, while 37 percent Fatalities 60 4 were attributed to accidents involving turbo- 3 40 prop aircraft and three percent were attributed 2 Fatalities
to accidents involving widebody jets. accidents Fatal 20 1 When broken down by ICAO regional 0 0 aviation safety group (RASG) areas of re- RASG-AFI RASG-APAC RASG-EUR RASG-MID RASG-PA sponsibility, the statistics show that the Pan Regional Aviation Safety Group Region American region (RASG-PA) had the most fatal accidents with five, but that Europe AFI = Africa; APAC = Asia/Pacific; EUR = Europe; ICAO = International Civil Aviation Organization; MID = Middle East; PA = Pan American; RASG = Regional Aviation Safety Group; (RASG-EUR) had the most fatalities with Source: International Civil Aviation Organization more than 60 (Figure 2). The Middle East region (RASG-MID) did not have any fatal Figure 2 accidents in 2013. Africa (RASG-AFI) and the Asia/Pacific region (RASG-APAC) had one European Fatal Accidents per Month, 2012 and 2013 each, and Europe had two. Effective implementation of ICAO’s safety 30 2012 2013 2003–2012 average oversight critical elements by member states 25 under the Universal Safety Oversight Au- 20 dit Programme increased to 61.7 percent in 15 2013 from 61.1 percent in 2012, ICAO said. 10
RASG-AFI, RASG-MID and RASG-PA saw accidents of fatal 5 Cumulative number Cumulative increases in effective implementation, while 0
July RASG-APAC and RASG–EUR had small April May June March August decreases. JanuaryFebruary October September NovemberDecember The steady state of the rate of fatal ac- Month cidents in 2013 compared with 2012 comes against a backdrop of what ICAO described as Source: European Aviation Safety Agency a “marginal” increase in scheduled commer- Figure 3 cial air transport departures in 2013 over the previous year. According to figures released by since 2003 is 27 fatal accidents, EASA said ICAO in mid-December, the number of depar- (Figure 3). tures last year reached 33 million, establishing EASA also noted a “significant reduction” in a new record and surpassing 2012’s figure by the number of fatalities worldwide, with 224 in more than one million flights. Scheduled pas- 2013, which declined about 68 percent from the senger traffic grew 5.2 percent in 2013 over the yearly average of 703 between 2013 and 2012. previous year. “Europe continues to have one of the stron- According to the data released in January gest safety records in the world, however this by EASA, there were 17 fatal accidents involv- positive picture cannot be taken for granted,” ing large commercial air transport airplanes said Patrick Ky, EASA’s executive director. “As worldwide in 2013, which is fewer than in any traffic over European skies and worldwide other year in the past decade by this count, but increases, we need to continue our efforts to more than announced by ICAO, which counted maintain and even improve aviation safety,” he only scheduled operations. The annual average said in releasing the EASA numbers.
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There were no fatal accidents involving large operate to the highest international standards, commercial air transport airplanes in EASA including wider deployment of automated ter- member states in 2013, a year in which those rain awareness warning systems for all commer- states performed approximately 6 million com- cial operations.” mercial air transport flights and carried more than 800 million passengers, the agency said. U.S. GA Fatal Accident Rate ‘Flattens Out’ General aviation (GA) in the United States — Asia Pacific Carriers Count 2013 as Safe Year which includes some business aviation activity The Association of Asia Pacific Airlines (AAPA) — suffered 259 fatal accidents resulting in 449 also has weighed in with an assessment that fatalities in 2013, according to data released by 2013 was the safest year ever in terms of com- the U.S. Federal Aviation Administration Jan. mercial airline jet fatalities. AAPA, which is the 27, 2014, when Administrator Michael Huerta trade association for scheduled international met with general aviation leaders to “jump start airlines based in the Asia Pacific region, said efforts for this year’s flying season.” According there were seven major accidents involving to FAA, Huerta and GA leaders agreed to work large Western-built commercial airline jets in together to raise awareness to prevent weather- 2013, and that those accidents resulted in 115 related accidents for the upcoming period of fatalities. According to AAPA calculations, that highest activity. FAA also said it is working with represents a loss rate of one major accident for industry on a prototype program to use de-iden- every four million flights. tified GA operations data in its Aviation Safety Asia Pacific carriers suffered three major ac- Information Analysis and Sharing program to cidents involving large Western-built commer- help identify risks before they become accidents. cial airline jets in 2013, resulting in 24 fatalities, The number of fatal GA accidents had AAPA said. The organization went on to say that gone down over the past decade, but so have turboprop operations maintained a good safety total GA flight hours, likely due to economic record, but experienced somewhat higher ac- factors, according to FAA. Fatal accidents cidents rates compared to jet aircraft operations. from controlled flight into terrain have been AAPA also said that many of the turboprop op- reduced by more than 50 percent over the past erations “are carried three years when compared with the previous out in more challeng- three-year period, the agency said. U.S. General Aviation Fatal Accidents, ing environments and FAA preliminarily estimated the GA fatal 2010–2013 conditions, which can accident rate for fiscal year 2013 (the year ended
300 be considered a con- Sept. 30, 2013) at 1.07 per 100,000 hours flown, tributory factor.” The with 259 fatal accidents and 449 fatalities. In fis- 275 association did not cal 2012, the GA fatal accident rate was 1.09 per 250 provide statistics on 100,000 hours flown and there were 267 fatal
225 turboprop accidents accidents (Figure 4). or fatalities. According to FAA, the five leading causes 200 Andrew Herd- of fatal GA accidents in the 2001–2011 period Number of accidents 175 man, director general —more recent data were not available — were of AAPA, said that loss of control–in flight, controlled flight into 150 2010 2011 2012 2013 greater attention terrain, system component failure–powerplant, Fiscal year needs to be focused low-altitude operations and “unknown or unde-
Notes: U.S. government fiscal year is Oct. 1 through Sept. 30. on turboprop aircraft termined.” The next five causes on the list were
Source: U.S. Federal Aviation Administration operations. “We need “other,” fuel-related, system component failure— firm regulation to nonpowerplant, midair collisions and windshear Figure 4 ensure that all carriers or thunderstorm.
46 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | MARCH 2014 In the Loop Researchers examinemethodsofplanning a simulator-based studyofpilotworkloadmanagement. BY LINDA WERFELMAN BY LINDA FLIGHTSAFETY.ORG Washington, DC20591 Office of AerospaceMedicine DOT/FAA/AM-14/1 3 2 Samuel Cotton Barbara K.Burian Kevin M.Gildea Evan Silverman Rogers Jason A. Shawn Pruchnicki Gena Drechsler Bonny Christopher Kevin W. Williams Management Data and Planning,Studies: Design, Experimental Simulation Aviation Human-in-the-Loop 1 Final Report January 2014 Mountain View, CA 94035 San Jose,CA 95192 Oklahoma City, OK73125 Federal Aviation Administration NASA Ames ResearchCenter San JoseStateUniversity Civil Aerospace MedicalInstitute 2 2 1 1 1 1 2 3 2 |
WORLD AEROSAFETY Administration Federal Aviation T ceived workload; U.S. National Aeronautics and analysis; instantaneous self-assessment of per data that methods collection included voice tion Mustang training and flight device with through the study also will be used as baseline used through be study the will also ment of Next the Generation Air Transportation Simulation Studies:Experimental Planning, Aviation Human-in-the-Loop al. U.S. Federal Aviation Administration (FAA) Office ofAerospace System, known as NextGen. pilots light Information of jets. very gathered data inupcoming studies related to develop- the FAA at
47 © CAMIOKC/Wikimedia CC-BY-SA 3.0 INFOSCAN
human-in-the-loop simulation study and so that the performance and decision-making the methods used to collect and analyze the activities of pilots match what would be found if results. An earlier report discussed the obser- they were flying an actual aircraft.” vations recorded during the simulator study, which the authors said produced baseline data 2012 Aerospace Medical Certification that will be used in future NextGen research Statistical Handbook (ASW, 11/13, p. 47). DOT/FAA/AM-13/25. Skaggs, V.J.; Norris, A.I. U.S. Federal Aviation In this report, the researchers said that they Administration (FAA) Office of Aerospace Medicine. December 2013. chose to use the instantaneous self-assessment 42 pp. Figures, tables. Available from the FAA at
ful planning and execution of the study,” the the FAA’s medical cer- Final Report report said. “There are numerous background tification records from materials that must be developed and multiple 2007 through 2012; data sources that must be considered.” medical data were taken Overall, the report said, human-in-the-loop from the most recent medical examinations, flight simulation studies can collect “literally, and only pilots with current medical certificates thousands of variables, many times a second were included in the data set. over the duration of a flight that could last sev- Data on AMEs were selected from the Avia- eral hours.” The amount of time spent planning, tion Medical Examiner Information System. analyzing and reporting study details can far The handbook shows, in a series of figures outstrip the time spent actually conducting the and tables, each certificated pilot’s age, date of study, the report said. issuance of medical certificate, height, weight, “When pilots perform flights in the real body mass index (BMI), gender, selected medi- world, they do not simply show up at the airport, cal conditions, special issuances and FAA region jump in the plane, start the engine and take off,” of residence. the report added. “There are many steps involved The findings, as of Dec. 31, 2012: in planning and executing the flight. The safety of • Some 581,850 pilots, all at least 16 years the flight depends critically on the performance of age, held FAA medical certificates — of these steps. When conducting a flight simula- 32.7 percent had Class 1 certificates, 21.6 tion study, one intention of the researcher is to percent had Class 2 certificates, and 45.7 make the flight experience as realistic as possible percent had Class 3 certificates;
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• Seven percent of certificates required a being transmitted by ADS-B ground stations special issuance; and other aircraft. • The most common medical condition was In addition, the agency “has not established “hypertension with medication,” reported a public-private incentive program for installing by 11.3 percent; NextGen avionics equipment on aircraft,” the report said. • The average age of these pilots was 42.9 The report added that the FAA also has years, 93.5 percent were men; failed to meet a number of deadlines for submit- • The mean BMI for male certificate-hold- ting reports and plans involved in NextGen ers was 27.2, and the mean female BMI implementation. was 24.1. The FAA’s problems in meeting the law’s The handbook also includes data on 3,427 requirements can be attributed in part to pro- active AMEs, about half of whom were family grammatic and organizational challenges, the practitioners. Nearly 90 percent were men, their report said. average age was 60.2 years, and 52.6 percent did “According to FAA officials, the act’s provi- not themselves have a pilot’s license. sions are difficult to execute, as they require coordination among multiple programs, resolu- FAA Made Limited Progress in Implementing tion of complex technical and operational issues NextGen Provisions of the FAA Modernization and collaboration with industry stakeholders,” and Reform Act of 2012. the report said. “For example, FAA’s delays with AV-2014-027. U.S. Department of Transportation Office of Inspector issuing guidelines and regulations for ADS- General (OIG). Jan. 28, 2014. 19 pp. Appendix, exhibits. Available B In are due, in part, to the need to finalize from the OIG online at
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ONRECORD Undetected Touchdown Leads to Tail Strike Perceiving that the A320 was still airborne, the crew decided to go around.
BY MARK LACAGNINA
The following information provides an awareness of problems that might be avoided in the future. The in- formation is based on final reports by official investigative authorities on aircraft accidents and incidents.
JETS
Rapid Pitch-Up tower controller advised the crew that the winds Airbus A320-200. Substantial damage. No injuries. were from 160 degrees at 2 kt. he A320’s main landing gear contacted the The A320 was 1,000 ft above the ocean when runway at Japan’s Sendai Airport so softly on the captain began a left turn onto final approach Tthe morning of Feb. 5, 2012, that none of the to Runway 27. The first officer subsequently usual sensory cues was clearly evident. Believ- called out a radio altitude of 500 ft as the aircraft ing that the aircraft was floating too far down descended on the ILS glideslope, and the captain the runway, the captain decided that it would be replied “stabilized,” indicating that all perfor- safer to go around than to continue the landing. mance parameters were within the limits for The captain had progressively increased a stabilized approach and that the aircraft was back-pressure on his sidestick to maintain the configured properly for landing. flare attitude, and he moved the stick fully aft The aircraft crossed the runway threshold at while initiating the go-around. As a result, 50 ft and at 138 kt — about 3 kt above the target the A320 pitched up substantially and the tail airspeed. The captain initiated the flare at about struck the runway, said the Japan Transport 30 ft, as prescribed by standard operating proce- Safety Board in its final report on the accident. dures, and brought the throttles to idle. Damage to the rear fuselage was substantial, but Recorded flight data indicated that the none of the 166 occupants was hurt. The crew aircraft “floated” about 10 ft above the runway subsequently landed the aircraft without further before the main landing gear touched down incident. about 2,297 ft (700 m) from the threshold of Visual meteorological conditions (VMC), the 9,843-ft (3,000-m) runway. The touchdown with light surface winds from the southeast, pre- was soft, with a change in vertical acceleration vailed at Sendai, and the flight crew had decided of 0.06 g, compared with an average of 0.19 g to conduct a visual approach, backed up by the recorded for the last 13 landings. No sounds instrument landing system (ILS), to Runway 27. typical of touchdown were captured by the Inbound from Osaka, the aircraft neared Sendai cockpit voice recorder. The first officer was from the south, over the Pacific Ocean. The looking out the windshield and did not notice
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the instrument panel indication of Examination of the 737 revealed began to feel numb, and he could not automatic spoiler deployment. that the smoke and sparks had originat- think clearly. Believing that the aircraft was still ed from electrical arcing across the pins After donning oxygen masks, the airborne, the captain said “oh, no good” of a spare galley connector that was PIC’s condition improved somewhat. and then announced “go around.” With receiving electrical power although its “He felt physically ill [and] was at the the application of go-around power, circuit breaker was pulled and collared. upper limit of what he thought he spoiler retraction and full-aft sidestick, The report noted that the connector could do while manually flying the the pitch angle increased rapidly from “was positioned close to damp sound- airplane with the assistance of the flight 1.8 to 12.7 degrees. insulation material.” director,” the report said. The copilot’s During the subsequent climb-out, a A similar incident had occurred a condition worsened. “He did not feel purser told the crew that a loud sound year earlier to another aircraft in the capable to actively influence the course had been heard and that an unusual operator’s fleet. Maintenance action was of events and just hoped it would be impact had been felt in the cabin. Sus- ordered, “but the operator’s mainte- a successful landing,” the report said. pecting a tail strike, the captain decided nance systems allowed the task to be “Both pilots described their condition to enter a holding pattern while the closed prior to completion of the recti- shortly before touchdown as surreal runway was checked for debris. Airport fication work” on the aircraft involved and like a dream.” personnel found a large white scrape in the 2013 incident, the report said. The landing was successful, and mark about 3,740 ft (1,140 m) from the Following that incident, “the connector the pilots subsequently were taken by approach threshold. was removed from the aircraft and the ambulance to a hospital for medical During the brief hold, the crew wires capped and stowed.” treatment. “In the hospital, both pilots detected “no particular body vibrations were examined and released after about or other irregularities [and] decided ‘Surreal’ Approach two hours,” the report said. “Blood and to land at Sendai Airport as planned,” Airbus A319-132. No damage. Two minor injuries. urine tests were not made.” the report said. An examination of the nbound from Vienna, Austria, with The PIC resumed flying duties A320 revealed a large abrasion on the 152 passengers and five crewmembers four days after the incident; the copilot lower rear fuselage and deformation of Ithe night of Dec. 19, 2010, the flight said that he remained unfit to fly the rear pressure bulkhead. crew was turning base for a landing at for seven months due to illness and Afterward, both pilots said that Köln/Bonn (Germany) Airport when post- traumatic stress disorder. The never before had they been unable to they detected a “strange, strong and pilots’ symptoms were analyzed by the recognize when an airplane touched unpleasant” odor. They queried the German Airforce Institute of Aerospace down on landing. purser, who reported that there was no Medicine. Possible causes included abnormal odor in the cabin. inhalation of carbon monoxide, in- Smoke, Sparks Prompt Evacuation “A short time later, during inter- secticide or deicing fluid; ingestion of Boeing 737-300. Minor damage. No injuries. cept of the extended centre line, both contaminated food or drink; lack of ox- he six crewmembers were prepar- pilots noticed an adverse effect on their ygen; and cardiological disease. Further ing the 737 for a ferry flight from physical and cognitive performance,” analysis of possible factors such as oil, TLondon Gatwick Airport the morn- said the report on the serious incident hydraulic fluid and rain repellent leaks, ing of March 1, 2013, when the senior published by the German Federal Bu- and electrical system malfunctions was cabin crewmember saw smoke and reau of Aircraft Accident Investigation performed by the BFU. However, no sparks near a forward overhead locker. (BFU) in December 2013. definitive conclusion was reached about “After ordering the cabin crew to The pilot-in-command (PIC), 35, the cause of the pilots’ illness. leave the aircraft, the flight crew carried said that his first sensation was an “in- Maintenance technicians who out the QRH [quick reference hand- tense prickling in his hands and feet.” examined the airplane shortly after it book] drills and declared a mayday be- He then experienced tunnel vision was parked detected a “strange odor” fore leaving the aircraft,” said the report and severe dizziness. The copilot, 26, although the cockpit windows had been by the U.K. Air Accidents Investigation said that nausea “hit him like a punch opened. “The technicians estimated Branch (AAIB). to his stomach.” His arms and legs it was highly likely caused by deicing
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fluid,” the report said. “The technicians definite- However, further inspections of the airplane ly ruled out oil, fuel and electrical smell.” (The and a functional check flight did not reveal the A319 had been deiced prior to its departure source of the odor that had partially incapaci- from Vienna.) tated the flight crew.
TURBOPROPS
Attention Lapse on Landing High Speed Leads to Excursion Fairchild Metro III. Substantial damage. No injuries. Cessna 425. Substantial damage. Three minor injuries. he flight crew was conducting a cargo flight the he pilot conducted a global positioning sys- morning of March 7, 2013, to Dublin (Ireland) tem (GPS) approach the morning of March TAirport, which had about 1,200 m (3/4 mi) T28, 2011, to Runway 22 at Hemphill County visibility in fog and an overcast at 300 ft. The pilots Airport in Canadian, Texas, U.S., which had said that the Metro broke out of the clouds at about surface winds from 140 degrees at 5 kt, 5 mi (8 650 ft during the ILS approach to Runway 10. km) visibility and an overcast at 600 ft. “As per normal procedure after landing, the “The airplane broke out of the clouds direct- first officer, who was the pilot flying, gave the ly over the end of the runway,” said the report by controls to the captain … so that he [the first of- the U.S. National Transportation Safety Board ficer] could complete the ‘Leaving the Runway’ (NTSB). “The pilot then remained clear of checklist,” said the report by the Irish Air Acci- clouds and executed a no-flap circling approach dent Investigation Unit (AAIU). “This check- to the opposite-direction runway.” list is completed from memory and included Investigators determined that the approach booster pump and flap-to-zero selections.” airspeed was excessive and that the tire on the The captain was applying wheel braking and right main landing gear burst during the hard the indicated airspeed was below 90 kt when the touchdown. The airplane then bounced and nose landing gear suddenly collapsed. Both pro- veered off the runway after the left main gear pellers struck the runway, and the aircraft came collapsed. Four passengers sustained minor to an abrupt stop resting on its nose. Neither injuries; the pilot and two other passengers pilot was injured. were not hurt. The AAIU determined that the first officer likely had inadvertently retracted the landing ‘Complacency’ Cited in CFIT gear, rather than the flaps, during the landing Rockwell 690A. Destroyed. Six fatalities. roll. “Whilst it is not possible to be definitive as ight VMC prevailed when the Commander to why the landing gear selector was moved to departed from Falcon Field in Mesa, Arizo- the ‘UP’ position, the [first officer] described Nna, U.S., for a visual flight rules (VFR) flight feelings of tension and stress associated with the to Safford, Arizona, on Nov. 23, 2011. “There was limits approach he flew into [Dublin] due to the no moon, and the direction of flight was toward poor weather conditions,” the report said. sparsely lit terrain,” the NTSB report said. “The “It is possible that following the success- pilot did not request VFR flight-following or ful landing, and the associated relief of tension minimum safe altitude warning (MSAW) ser- and stress, the [first officer] may have relaxed, vices” for the 110-nm (204-km) flight. leading to a reduced level of task attention as Due to inbound traffic, the tower control- he went through his checks prior to leaving the ler kept the airplane on the northeasterly runway. This reduced level of task attention runway heading for about two minutes before probably facilitated the lapse whereby the land- clearing the pilot for his requested right turn- ing gear selector was incorrectly moved to the out. There was no further radio communica- ‘UP’ position.” tion with the Commander.
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Radar data showed that the airplane turned of Phoenix Class B airspace. The direct track directly toward Safford and climbed to 4,500 between the Mesa and Safford airports passed ft. About four minutes later, it struck a 5,057-ft about 3 nm (6 km) south of the mountain, but mountain about 15 nm (28 km) southeast of the “the delayed right turn from [Mesa] put the air- airport, killing all six occupants. plane on a track that intersected the mountain,” “This controlled flight into terrain (CFIT) the report said. “The pilot did not adjust his accident was likely due to the pilot’s complacency flight track to compensate for the delayed right (because of his familiarity with the flight route and turn to ensure clearance from the mountain.” because he selected a direct route, as he had previ- The report noted that six years before the ously done, even though he turned toward the crash, passenger seating had been reduced from six destination later than he normally did) and lack of to five by removing a seat belt from the aft divan; situational awareness,” the report said. the modification rendered the Commander ex- The cruise altitude likely had been chosen empt from the requirement to be equipped with a to keep the airplane below the 5,000-ft floor terrain awareness and warning system (TAWS).
PISTON AIRPLANES
Engine Fire on Takeoff in an area where fire-suppression bottles Convair 340. Substantial damage. No injuries. could not reach.” he captain suspected that the spark plugs The crew turned back to Saint Thomas. The were fouled when the left engine backfired fire had damaged the left brake line, and after Tduring the run-up for a cargo flight from touching down, the airplane veered off the right San Juan, Puerto Rico, to Saint Thomas, Virgin side of the runway, crossed a taxiway and a pe- Islands, the morning of Jan. 17, 2011. “An addi- rimeter road, went through the perimeter fence tional engine run resulted in no further back- and came to a stop with the nose section over a firing, and the captain decided to depart,” the public road. NTSB report said. Examination of the left engine revealed Nearing the destination, the left engine that two of the 18 pistons did not move in their backfired again, but the freighter was landed cylinders when the propeller was rotated. “This without further incident. No maintenance was discrepancy could result in unburned fuel or oil requested or performed before the subsequent entering the exhaust system and igniting in the departure for the return flight to San Juan. exhaust or augmentor tubes,” the report said. “During the takeoff, the local controller noted black smoke trailing the left engine and Inadvertent Gear Retraction advised the flight crew,” the report said. “How- Beech Duchess. Substantial damage. No injuries. ever, the captain attributed the smoke to normal he Duchess was taking off from Bour- operation for the airplane type and decided to nemouth (England) Airport for an instru- continue the flight.” Tment instructional flight the afternoon of After the flight crew switched radio Feb. 6, 2013, when the landing gear partially frequencies to San Juan Approach, the local retracted. “The aircraft was brought to a rest on controller at Saint Thomas saw bright orange the runway with a collapsed nose gear and par- and red flames emerge from the Convair’s left tially collapsed main gear,” the AAIB report said. engine. The information was relayed by the The pilot, the flight instructor and the passenger approach controller to the crew. “They im- were not injured. mediately executed the fire checklist and shut Investigators determined that while making down the left engine,” the report said. “How- rudder inputs to maintain directional control in a ever, the fire continued because it was located brisk crosswind, the pilot’s knee likely had struck
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and dislodged the gear selector knob, which is at the pilot saw smoke emerge from the nacelle the bottom right side of the panel. “A detent sys- and from below the panel. He shut down both tem designed to prevent inadvertent operation of engines and exited the airplane. the gear lever was not effective,” the report said. “Local personnel responded and extin- guished the fire,” the NTSB report said. Subse- Fuel Leak Causes Fire quent examination of the left engine revealed Cessna 310K. Substantial damage. No injuries. that the fire likely was caused by the ignition hortly after starting the left engine in prepa- of fuel that had leaked from the fuel strainer ration for a flight from Olive Branch, Missis- onto electrical connections for the battery and Ssippi, U.S., the morning of March 7, 2012, starter solenoid. HELICOPTERS
‘Fast-Changing Weather’ Unapproved Fuel Eurocopter AS350-B3. Destroyed. Four fatalities. Hughes 500D. Substantial damage. No injuries. he pilot had conducted three charter flights he pilot was conducting a positioning flight in Papua, New Guinea, the morning of to Aiken, South Carolina, U.S., the after- TMarch 16, 2012, and was en route with three Tnoon of March 20, 2012, when the tailwind passengers from Wanagon to the company’s base changed to a headwind. The pilot realized that in Timika when he received a radio call from the reduced groundspeed would prevent him the company asking him to pick up another pas- from reaching the destination, so he diverted to senger in West Gully. McCormick, South Carolina. “The pilot flew to West Gully and at- Finding that no fuel was available at the tempted to land twice but was unsuccessful airport, the pilot repositioned to a nearby auto- due to poor visibility,” said the report by the mobile station, where the helicopter was refueled Indonesian National Transportation Safety with 25 gal (95 L) of 87-octane gasoline. “The pi- Committee (NTSC). lot did not know what the approved alternate fuel The pilot resumed the flight to Timika but was for the turbine engine,” the NTSB report said. found that the weather conditions there also “According to the engine manufacturer, automo- precluded a landing. He radioed the company tive fuel is not an approved fuel on the list.” that he was diverting to Landville. The report Shortly after departing from the station, the noted that the remote, mountainous area is helicopter was about 200 ft above the ground and subject to fast-changing weather and that at 70 kt when the engine lost power. “The pilot Landville was an oft-used alternate because it lowered the collective pitch as much as possible to generally has better visibility than the heliports clear a power line and reach an open field,” the re- at higher elevations. port said. “Once clear of the power line, he lowered There was no further radio communication the collective pitch to the full-down position.” with the pilot. An emergency locator transmit- The helicopter touched down hard in a tail- ter (ELT) signal was detected, but the search low attitude. The tail boom separated, and the was delayed by a false report that the helicopter helicopter rolled over on its right side. had landed at Landville and was subsequently The 500D flight manual lists several types hampered by adverse weather conditions. of jet fuels as “primary” fuels for the helicopter The wreckage of the helicopter was found and notes that aviation gasoline can be used in the next morning at 8,000 ft. The NTSC deter- an emergency. The report said that the probable mined that the helicopter was in level cruise cause of the accident was “the pilot’s decision flight when it struck the steep mountain slope. to use automotive fuel instead of [an] approved The accident was categorized as CFIT. alternate fuel.”
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Preliminary Reports, December 2013
Date Location Aircraft Type Aircraft Damage Injuries Dec. 2 La Alianza, Puerto Rico Fairchild Metro III destroyed 2 fatal The Metro was nearing San Juan International Airport on a cargo flight in night visual meteorological conditions (VMC) when it made a steep right turn, entered a descent that ranged from 12,000 to 21,000 fpm and crashed in a pasture. Dec. 2 Walton, Indiana, U.S. Cessna Citation 560 substantial 3 none The Citation was descending through 17,000 ft on approach to Chicago Midway Airport when the right engine cowling separated and struck the horizontal stabilizer. The airplane subsequently was landed without further incident. Dec. 3 London, England Airbus A320-214 substantial 64 none A tail strike occurred when the A320 touched down hard at London Heathrow Airport and bounced into a nose-high attitude. Dec. 4 Novo Progresso, Brazil Britten-Norman Islander destroyed 5 fatal The Islander struck wooded terrain shortly after taking off for a medevac flight. Dec. 4 Abuja, Nigeria Boeing 747-200 substantial 6 NA No fatalities were reported when the 747 freighter veered off the runway on landing and struck construction equipment and several vehicles. Dec. 5 Madrid, Spain Boeing 767-300ER substantial 203 none The right rear wheel and tire on the right main landing gear burst on takeoff, and debris punctured the left wing. A hydraulic system failure prevented the flight crew from retracting the landing gear. They declared an emergency and returned to the airport for a landing. Dec. 8 Jacksonville, Florida, U.S. Cessna 310R substantial 3 fatal Night instrument meteorological conditions (IMC) prevailed when the Cessna struck terrain during a missed instrument landing system approach. Visibility was 2.5 mi (4,000 m) in mist and the ceiling was overcast at 200 ft. Dec. 10 Guayaramerín, Bolivia Fokker F-27 substantial 25 none A bird strike shortly after takeoff damaged the right engine and wing. The flight crew returned to the airport for a landing. Dec. 10 London, England Gulfstream G550 NA NA The Gulfstream struck an antenna when it touched down short of Runway 04 at London Stansted Airport. Dec. 11 Kalaupapa, Hawaii, U.S. Cessna 208B substantial 1 fatal, 3 serious, 5 minor The engine lost power shortly after the Caravan took off for an air taxi flight. One passenger was killed, and the pilot and two passengers were seriously injured during the subsequent ditching. The survivors donned life vests and were rescued 80 minutes later. The Caravan floated for about 25 minutes before sinking. Dec. 11 Eau Claire, Wisconsin, U.S. Beech King Air E90 minor 1 none The King Air was on a positioning flight at 19,000 ft when the inner ply of the right windshield cracked. Windshield heat was not being used at the time. The pilot diverted to Eau Claire for a precautionary landing. Dec. 14 Vargas Island, British Columbia, Canada Cessna 421B destroyed 2 fatal The 421 struck terrain under unknown circumstances during approach to Tofino Airport on Vancouver Island. Dec. 17 Atlanta, Georgia, U.S. Raytheon Premier I destroyed 2 fatal Shortly after departing from Fulton County Airport in VMC, the pilot radioed that he had a problem and was returning to the airport. The airplane struck trees and terrain while turning onto final approach to Runway 26. Dec. 19 Viña del Mar, Chile Beech King Air 90 substantial 2 none Shortly after taking off for a night positioning flight, the flight crew encountered a technical problem and turned back to the airport. The King Air touched down short of the runway and slid to a stop against a fence. Dec. 26 Irkutsk, Russia Antonov 12 substantial 9 fatal Night IMC prevailed with 1,700 ft (about 500 m) visibility in smoke and mist, and a 200-ft overcast, when the cargo airplane crashed into a military storage facility during approach.
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.
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