AeroSafety w o r l d INSPECTOR SCRUTINY ICAO auditors find faults
IMPROVE BRAKING REPORTS Using what’s known
CORPORATE FOQA FSF program moves out
SICK CREWMEMBERS The go/don’t go decision
TECHNICALLY SIMPLE MAINTENANCE ENGLISH MADE EASIER
TheFlight Journal Safety of FFoundationlight Safety Foundation AUGUST 2007 What can you do to improve aviation safety? Join Flight Safety Foundation. Your organization on the FSF membership list and Internet site presents your commitment to safety to the world.
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Send your request to: Flight Safety Foundation 601 Madison Street, Suite 300, Alexandria, VA 22314 USA Telephone: +1 703.739.6700; Fax: +1 703.739.6708 E-mail: [email protected] Visit our Internet site at www.flightsafety.org President’sMessage THE Bell Tolls
ny man’s death diminishes me, be- shortage has hit Indonesia hard, and its body cause I am involved in mankind; count proves it. and therefore never send to know for How does a young democracy with more whom the bell tolls; it tolls for thee.” than 230 million people cope? So far, not very “— JohnA Donne, 1624 well. Structural reforms to deal with this growth Forgive me for resurrecting a famous old quote, are overdue. Inspector pay is a fraction of what but it kept coming to mind last month as I flew it needs to be to retain good people, and yet the back from a difficult trip to Indonesia. Anybody growth continues. The country’s highest-ranking following the aviation industry has been hearing officials know what to do, and they are committed the bells toll for Indonesia, where there have been to doing it. It will be painful, it will take time, and three major crashes in just the first half of 2007. Its it may not happen soon enough to avoid further 10-year accident rate is 3.1 per million departures, disasters, but it must succeed. at least triple the global accident rate. This is just an early battleground; the same Safety there has not been good for some dynamics linger below the surface throughout time, and it’s not getting better. The most recent Asia, Eastern Europe and elsewhere. If those of crash compelled the U.S. Federal Aviation Ad- us who have the answers ignore this problem, we ministration to review Indonesia’s status under are going to have front row seats when the bal- its International Aviation Safety Assessments loon goes up. Program. The agency found that Indonesia fell Our industry must find a better way to manage short of International Civil Aviation Organiza- itself. Investment bankers with wildly optimistic tion standards and downgraded the nation to cash-flow models are going to keep buying air- Category 2. The E.U. followed, blacklisting all planes and starting airlines. The aviation industry Indonesian airlines. needs to reach out to these emerging carriers and Just seven years ago, Indonesia had five airlines help them to see a way to profitability that follows that carried approximately 10 million passengers a path of safely managed growth. Governments in that year. In 2006, 25 airlines carried 30 million that have waited decades for prosperity are not passengers, a 200 percent increase in passenger inclined to say “no” to growth. They need good traffic in six years. The Indonesian government advice and positive reinforcement. Clearly, I see expects passenger traffic to reach 70 million by a role for the Foundation. When I call for help, I 2010. That rate of growth is almost unmanage- hope some of you will answer. able but it is low compared with other countries in the region. It gets worse. The airlines I spoke with in Indonesia have lost about 30 percent of their pilots to other regions of the world. The regula- tor has lost about 30 percent of its inspectors William R. Voss and has about half of the inspectors required President and CEO for today’s needs. The great aviation personnel Flight Safety Foundation www.flightsafety.org | AeroSafetyWorld | August 2007 | AeroSafetyWorld
August2007 Vol 2 Issue 8 11 contents features
11 FlightOps | C-FOQA Takes Root
16 CoverStory | Simplifying the Technicalities
22 CabinSafety | Cabin Fever
27 FlightTech | Heating up in Paris
30 SafetyOversight | Inspector Scrutiny
36 InSight | Improving Braking Action Reports
41 FlightTech | A Moveable View 16 departments 22 1 President’sMessage | The Bell Tolls 5 EditorialPage | Growth and Consequences
6 SafetyCalendar | Industry Events
8 InBrief | Safety News
| flight safety foundation | AeroSafetyWorld | August 2007 30 41 contents 36 AeroSafetyWORLD telephone: +1 703.739.6700 45 FoundationFocus | Members by Region William R. Voss, publisher, FSF president and CEO [email protected], ext. 108 50 DataLink | Cold Comfort in Accident Reports J.A. Donoghue, editor-in-chief, FSF director of publications 53 InfoScan | Decision Management [email protected], ext. 116 Mark Lacagnina, senior editor [email protected], ext. 114 57 OnRecord | In-flight Depressurization Wayne Rosenkrans, senior editor [email protected], ext. 115 Linda Werfelman, senior editor [email protected], ext. 122 Rick Darby, associate editor [email protected], ext. 113 Karen K. Ehrlich, web and print production coordinator [email protected], ext. 117 Ann L. Mullikin, production designer [email protected], ext. 120 Susan D. Reed, production specialist About the Cover [email protected], ext. 123 There are guidelines for making English easier to understand in maintenance documents. Patricia Setze, librarian © Chris Sorensen Photography [email protected], ext. 103
Editorial Advisory Board We Encourage Reprints (For permissions, go to
www.flightsafety.org | AeroSafetyWorld | August 2007 | Serving Aviation Safety Interests for More Than 50 Years Officers and Staff light Safety Foundation is an international membership organization dedicated to Chairman, Board of Governors Amb. Edward W. the continuous improvement of aviation safety. Nonprofit and independent, the Stimpson Foundation was launched officially in 1947 in response to the aviation industry’s need President and CEO William R. Voss F Executive Vice President Robert H. Vandel for a neutral clearinghouse to disseminate objective safety information, and for a credible General Counsel and knowledgeable body that would identify threats to safety, analyze the problems and and Secretary Kenneth P. Quinn, Esq. recommend practical solutions to them. Since its beginning, the Foundation has acted in Treasurer David J. Barger the public interest to produce positive influence on aviation safety. Today, the Foundation Administrative provides leadership to more than 1,000 member organizations in 142 countries. Manager, Support Services Linda Crowley Horger Financial MemberGuide Chief Financial Officer Penny Young Flight Safety Foundation Staff Accountant Maya Barbee 601 Madison Street, Suite 300, Alexandria, VA, 22314-1756 USA tel: +1 703.739.6700 fax: +1 703.739.6708 Membership www.flightsafety.org Director, Membership and Development Ann Hill Membership Services Coordinator Namratha Apparao
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| SINCE 1947 flight safety foundation | AeroSafetyWorld | August 2007 Editorialpage GROWTH AND Consequences
he chief executive for United Air Asia spring up and packed airplanes piece that must be set into place to make Breweries Limited, an Indian quickly turn sleepy terminals into hot it all work: money. company, came to the 2004 Farn- destinations, and there is no turning Nations struggling to provide their borough Air Show to explain why back. The increased travel spreads and people with the bare necessities find it This company was buying A320s and energizes commerce, spurring even difficult to redirect scarce funds to avia- starting Kingfisher Airlines. Among more travel and, sometimes, the birth tion. However, a well-trained and well- India’s one billion-plus people, he said, of carriers of dubious quality. paid inspector force is an essential part is a middle class of more than 200 mil- Thus we arrive at a troubling cross- of any aviation safety system, especially lion able to afford air travel, or about road, reached through the happy success when dealing with a lot of start-up air- the same number of middle class trav- of world development creating a rising lines and flight personnel with minimal elers that live in Europe. These people demand that threatens to push the avia- experience, as is often the case in de- wanted to fly, he said, but they had few tion industry into increasingly dangerous veloping countries. Wayne Rosenkrans opportunities. The capacity just wasn’t territory, the growth straining infrastruc- describes in this issue inspector force available. ture and the abilities of regulators, as Bill problems uncovered by International That, to me, was a stunning bit Voss discusses in his President’s Message Civil Aviation Organization audits (p. of news. Only a few years earlier the (p. 1). 30). We must restate the importance Indian government had opened the Restraining growth either by direct of funding an empowered, trained and door to new airlines; before that, the edict or indirectly, by refusing to expand sustainable inspector force in a way that nation’s incumbent airlines had a fleet airports and related infrastructure, is does not involve payment directly from of fewer than 200 jets. Here were 200 not only politically unpopular, it works the operator. million people who had fought to get against that economic growth and pros- a better life only to discover that the perity thing that everyone believes is so travel available to others was not avail- good. able to them. Manufacturers’ market forecasts This was and remains a politically agree that huge growth in air travel will untenable state of affairs. As the stan- continue. Even if a state here and there J.A. Donoghue dard of living continues to rise around throttles its own traffic, they eventually Editor-in-Chief the world, more and more people have will be swept along with the tide by their AeroSafety World the time and the money to travel, and neighbors’ activity. they demand that their leaders allow Thanks to the Global Aviation Safety more air service, competitively priced. Roadmap, the path to safe, responsible So quality airlines like Jet Airways and growth is clear. But that leaves one final www.flightsafety.org | AeroSafetyWorld | August 2007 | ➤ safetycalendar
FSFSeminars 2007-08 Exhibit and Sponsorship Opportunities Available
Sharing Global Safety Knowledge October 1–4, 2007 Joint meeting of the FSF 60th annual International Air Safety Seminar IASS, IFA 37th International Conference, and IATA Grand Hilton Seoul Hotel, Seoul, Korea
European Aviation Safety Seminar March 10–12, 2008 Flight Safety Foundation and European Regions Airline Association 20th annual European Aviation Safety Seminar EASS JW Marriott Bucharest Grand Hotel, Bucharest, Romania
Corporate Aviation Safety Seminar April 29–May 1, 2008 Flight Safety Foundation and National Business Aviation Association iStockphoto International, Getty Images Inc. 53rd annual Corporate Aviation Safety Seminar CASS
The Innisbrook Resort and Golf Club, Palm Harbor, Florida Inc., © Dreamstime
Send information: EASS CASS IASS (joint meeting: FSF, IFA and IATA) FSF membership information Fax this form to Flight Safety Foundation. For additional information, contact Ann Hill, ext.105; e-mail: [email protected].
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| flight safety foundation | AerosafetyWorld | August 2007 ➤ safetycalendar
AUG. 6–9 ➤ 53rd Annual Air Safety and SEPT. 12–13 ➤ CFIT/Approach and Oct. 1–2 ➤ UKFSC Annual Seminar: Technical Security Week and the Air Safety and Security Landing Action Group ALAR Workshop. Innovation and Human Error Reduction. U.K. Forum. Air Line Pilots Association, International. Flight Safety Foundation and Flight Safety Flight Safety Committee. Heathrow.
www.flightsafety.org | AeroSafetyWorld | August 2007 | inBrief Safety News Hurry-Up Call for Europe’s Single Sky
European Commission task force Community and the Community method the report said. “Require states to apply is calling for acceleration of the as the sole vehicle to set the regulation safety management principles consistently ASingle European Sky (SES) initia- agenda for European aviation by eliminat- and, in particular, facilitate the uniform tive as one means of improving safety ing overlaps between EU [the European application of ‘just culture’ principles. regulation across the region. Union] and other regulatory processes, … Ensure that states’ safety oversight is The High Level Group for the ensuring independent structures for harmonized and that cooperation between Future of European Aviation Regulations regulation and service provision, and national authorities is stimulated to achieve included the accelerated delivery of SES ensuring that safety regulatory activities overall higher levels of performance.” as one of its 10 recommendations for are conducted independently from other The report said that the European enhancing aviation safety and efficiency forms of regulation.” Aviation Safety Agency (EASA) should throughout Europe. The report said that EU member become “the single EU instrument for The High Level Group has endorsed states should be required to systemati- aviation safety regulation” and that the European Commission’s target date cally implement existing commitments, Eurocontrol should play a key role in of 2020 for completing the SES initiative, especially a commitment to end fragmen- delivering SES and a related air traffic as well as other major changes in the avi- tation of the aviation system — a subject management initiative. ation system. However, the Group said in addressed in the SES initiative. its final report that it has identified 2014 “States should address as the year by which its proposals must inconsistent guidelines be implemented to ensure that aviation for [air navigation service in Europe remains “safe, competitive and providers], performance environmentally responsible.” shortfalls in oversight, The final report said that frag- bottlenecks in airport mented regulation is “a major bottleneck capacity and safety in improving the performance of the management, and the new European aviation system” and that the challenges of mitigating problem cannot be dealt with one coun- and adapting to climate try at a time. change,” the report said. “This can only be addressed at The European states the European level,” the report said. also should “deliver con- “Strengthen the role of the European tinuously improving safety,” © Björn Kindler/iStockphoto.com
TCAS Requirements Night Vision
perators of large commercial and collision avoidance systems (TCAS), he Civil Aviation Safety Authority aircraft in Canada have been which indicate when another aircraft of Australia (CASA) is propos- Ogiven two years to comply with presents the risk of a midair collision. Ting to establish standards for the a new requirement to install airborne use of night vision goggles (NVGs) by collision avoidance systems. helicopter pilots in some types of flight Laurence Cannon, minister of operations. transport, infrastructure and commu- Under the proposal, at least initially, nities, said that the action is intended NVGs would be limited to operations as a safety backup to previously exist- involving search and rescue, law enforce- ing ground-based air traffic control ment, aerial fire fighting and support, systems. The new requirement is emergency medical services, marine pilot described in an amendment to the transfer, and training providers who plan Canadian Aviation Regulations that to conduct NVG training. took effect July 1. A final rule will be adopted after The amendment calls for operators a review of public comments on the to install one of two types of traffic-alert proposal, which were due in July. © Honeywell International
| flight safety foundation | AeroSafetyWorld | August 2007 inBrief
NTSB Urges Greater Access to Legal Records
viation medical examiners should The NTSB said that the FAA also Raytheon Bonanza crashed on landing have greater access to legal records should take steps to ensure that applicants at Bullhead City, Arizona, U.S., killing Ainvolving drunken driving arrests be required to provide complete copies of the pilot and one passenger and seriously of individuals applying for medical their arrest records and/or court records injuring a second passenger. The NTSB certificates, the U.S. National Transpor- before their next aeromedical examina- said that the probable cause of the ac- tation Safety Board (NTSB) says. tion. The NTSB also recommended that cident was the pilot’s incorrect judgment In three safety recommendations, the complete medical records, including of distance and speed, which resulted in the NTSB noted that the U.S. Fed- the arrest and/or court records, be made a long landing, and his inadequate recov- eral Aviation Administration (FAA) available to any physician who performs ery from a bounced landing, “all due to already requires applicants for medical an aeromedical examination on these the effects of impairment from alcohol certification to report convictions for applicants and that all pilots who are consumption.” driving while intoxicated, impaired diagnosed with dependence on alcohol or The NTSB said, “The pilot had pre- or under the influence of alcohol or drugs be required to undergo special viously reported a [driving under the drugs. Applicants also must report follow-up examinations as long as they influence] conviction to the FAA, but administrative actions that result in a hold their medical certificates. the FAA did not obtain records of that loss of driving privileges or attendance The NTSB said the recommenda- offense. The [NTSB] subsequently ob- at a required educational or rehabilita- tions resulted from investigations of tained the arrest records, which noted tion program. a number of aircraft accidents — all that the pilot had a blood alcohol level associated of 0.28 percent more than an hour with a pilot’s after his traffic stop. The records also substance detailed that the pilot had been actively dependence controlling his vehicle, was completely — in which conscious and was conversing with the the FAA arresting officer. At a blood alcohol should have level of 0.28, non-tolerant individuals been aware would be unconscious or nearly so.” of the pilot’s The NTSB said that, because of his problem. alcohol tolerance, the pilot would have As an met the FAA definition of substance example, the abuse. If the FAA had considered his NTSB cited a arrest records as part of the process July 23, 2006, of applying for medical certification, accident the pilot would not have been issued a in which a medical certificate, the NTSB said. © Bora Ucak/Dreamstime.com
SMS Expansion
ransport Canada (TC) has proposed safety throughout its organization,” TC taken after a 30-day period for public including airports and air traffic said. “They are based on the operator’s comment. Tservices providers among those in-depth knowledge of its organiza- required to implement a safety manage- tion and integrate safety into policies, ment system (SMS). Airlines have been management and employee practices required to have SMSs since 2005. and procedures. As each organization The proposed regulatory amend- integrates safety into daily operations, ments are intended to “increase ac- management and employees can contin- countability in the aviation sector,” a TC uously work to identify and overcome statement said. potential safety hazards.” “Safety management systems are The proposed amendments were methods a company can use to integrate published July 7; final action will be © iStockphoto.com
www.flightsafety.org | AeroSafetyWorld | August 2007 | inBrief
Confusing Paint Jobs
nconsistency in aircraft paint schemes information, particularly as regards the ensure (preferably by visual observa- is causing confusion among pilots use of conditional clearances,” Eurocon- tion) that the aircraft’s livery is in fact Ireceiving local traffic information trol said. “Therefore, where it is deemed consistent with the livery that would be from air traffic control (ATC), Eurocon- necessary, as a means of providing expected for the aircraft in question.” trol says. additional clarity, “Where the aircraft in question’s liv- to refer [to] an ery is not entirely consistent with a livery aircraft’s operat- which would be expected for a particular ing agency name aircraft operating agency, confusion and or radiotelephony ambiguity can result,” Eurocontrol said designator in in a safety reminder message distributed either local traffic to aviation safety personnel. information or The inconsistencies are a result of during coordi- paint schemes that may reflect an affili- nation between ation with an airline alliance rather than control positions the identity of an individual airline. in the aerodrome “ATC must take particular care, control tower, when describing aircraft in local traffic ATC should © Star Alliance
In Other News … No Thanks
he Civil Aviation Safety Au- unnecessary costs or unnecessarily ustralian pilots and air traffic thority of Australia (CASA) has hinder high levels of participation in controllers are engaging in what adopted new principles intended aviation and its capacity for growth.” Amay be the “inappropriate” use of T pleasantries — such as “thank you” and to prevent unnecessary costs associ- … Less than 10 percent of pilots in ated with new aviation safety regula- China meet international aviation “g’day” — in radio communications, tions. CASA CEO Bruce Byron said English standards, according to news according to a study by the Australian that the principles specify that, among reports. The reports quote officials of Transport Safety Bureau (ATSB). other things, any proposed aviation the General Administration of Civil Researchers reviewed tapes of read- safety regulations “must not impose Aviation of China as complaining that backs on the surface movement control too many pilots are delaying learning (SMC) frequency at the Sydney airport English, despite English proficiency to determine whether there was a rela- standards from the International Civil tionship between verbose readbacks and Aviation Organization. … The African frequency congestion, the report said. Civil Aviation Agency has designated They found no such relationship. Instead, they found that users of the frequency were “well-disciplined in reading back [air traffic control] instructions and clearances,” the report said. The tapes also revealed “a frequent use of pleasantries such as ‘good morn- ing,’ ‘thank you’ and ‘g’day’. “Although these phrases are not endorsed by the [Aeronautical Informa- tion Publication], their use appeared to have little adverse effect on frequency
Civil Aviation Safety Authority Safety of Australia Civil Aviation Windhoek, Namibia, as the home of congestion. But in times of high traffic Byron the new organization. density, it seems inappropriate.”
Compiled and edited by Linda Werfelman.
10 | flight safety foundation | AeroSafetyWorld | August 2007 Foundation introduces apowerfulcorporateaviationsafetytool. pioneered data flight monitoring (FDM) inthe operational efficiencies. of maintenance issues and improvement the of FOQAbenefits, allows identification the also avoid accidents and incidents. early enough to allow timely intervention to tions outside of desired operating procedures operation tounsafe detect practicesor condi tion and analysis of data recorded during flight outside United the States, involves collec the operational quality assurance (FOQA). receive safety the and economic of benefits flight F www.flightsafety.org www.flightsafety.org C-FO BY MARK LACAGNINA MARK BY British and Airways TAP Air Portugal data flight monitoringFOQA, called also to enable corporate aircraft operators to Foundation has implemented aprogram demonstrationful project, Flight Safety ollowing completion the of asuccess |
AeroS a fety W orld orld 1 | Among other
A ugust 2007 ugust Q ‑ ‑ ‑ airlines,” Vandel, said Bob FSF executive vice mostthe safety powerful tools available to the FDM/FOQA programs. Today, more than 100airlines worldwide have programthe by airlines United inthe States. itwhen efforts to led encourage greater of use was coined by Foundation the early inthe 1990s early 1960s.The more descriptive term,FOQA, (CAC) in 2002 began to study the feasibility of are achieved through of use the FOQA.” maintenance and costs, fuel for instance —also had only Tremendous suspected. savings —in to and confirm quantify problems that they dents or incidents, and it helps air the carriers problems to light before can cause they acci president. “FOQA brings previously unknown A “There is no question“There that FOQA is one of The FSF Corporate Advisory Committee takes root ‑ 2
F light O PS |
11 © Ken Babione/iStockphoto.com FlightOPS
using this tool to help improve corporate aviation people to talk to at the safety. With the help of the National Business Avia‑ manufacturers took tion Association (NBAA) Safety Committee, the us a while. We are in CAC launched the corporate FOQA (C‑FOQA) a better position now demonstration project three years ago. The results, because we have some announced at this year’s Corporate Aviation Safety good contacts at the man‑ Seminar (CASS), were a resounding thumbs-up: ufacturers, which will help C‑FOQA works and shows great promise for mak‑ operators get QARs installed in ing corporate aviation even safer. their airplanes.” A QAR — quick access recorder — facilitates Teething Pains data collection and retrieval by tapping into The demonstration project was challenging. the airplane’s digital data stream and recording Operators of 22 airplanes signed up to partici‑ data similar to the parameters gathered by the pate, but most decided not to proceed because digital flight data recorder (DFDR). Total cost of hardware and installation issues, unresolved for the equipment required to participate in the Data are questions about data protection and resistance FSF C‑FOQA program is about US$10,000 to downloaded from by pilots (ASW, 8/06, p. 45). Not coincidentally, $13,000. This includes a QAR with a one-gigabyte a quick access these are among the factors that have impeded storage capacity; an installation kit consisting of a recorder by a direct even greater voluntary use of FOQA by airlines, wiring harness and supplemental type certificate or wireless PC especially in the United States. (STC); and software to convert the QAR data to connection, or The C‑FOQA demonstration project ulti‑ a format suitable for downloading. Installation by removing a mately was launched with the participation of the performed by an outside avionics shop costs storage device. aviation departments at Altria Corporate Services about $2,000. and Merck & Co. “We were disappointed by the Both demonstration project participants number of operators that dropped out,” said Ted found QAR installation and certification to be Mendenhall, CAC vice chairman and C‑FOQA time-consuming. “Installation actually is very program coordinator. “But even with a small simple, requiring only about four man-hours sample, our two operators saw some items of great per airplane, with half of that time dedicated to interest to them, which indicates that they benefit‑ paperwork,” said Jeff Sands, director of flight ted from the opportunity to look at that data.” operations and financial and administrative ser‑ Adapting a basically airline-oriented pro‑ vices for Altria Corporate Services. Altria had gram for use in corporate aviation was difficult. two of its three airplanes, a Gulfstream GIV‑SP “Certainly, we were and a G300, in the demonstration project. new to the game,” Steve Thorpe, assistant chief pilot, airplanes, Mendenhall said. “We and C‑FOQA program manager for Merck & learned a lesson that Co., said, “Our maintenance folks had to work we had been told by closely with the Duncan Aviation avionics the airlines, that it installers to get the QAR installed and running takes longer than you properly.” Merck operates a Dassault Falcon 50EX expect to get things and 900EX, and three Sikorsky S‑76 helicopters. up and running. Just The company equipped the 900EX, which has a due to the multiple DFDR, for the demonstration project. “It did take parties involved, the a while to get things running properly,” Thorpe legal agreements that said. “Our QAR was the first, or at least one of the we had to work out first, installed on a Dassault airframe.” — that took time. Any airplane with a data bus that provides a Finding the right recordable digital data stream theoretically can be © Ted Mendenhall
12 | flight safety foundation | AeroSafetyWorld | August 2007 FlightOPS
depends on the operator’s Internet connection; typi‑ cally, transmission of four months worth of data takes about 20 minutes.
attitude, Spotting Variations engine power, rate Data analysis is highly automated. equipped for C‑FOQA, but of climb/descent, and flight control Basically, the data-processing vendor’s unless the airplane already has a DFDR position. Many other variables can software is programmed to detect installed, the process might be cost- be derived through analysis of these variations from normal parameters and time-prohibitive. U.S.-registered parameters. established by regulation, the airplane multiengine turbine airplanes with 10 or The data map for each DFDR flight manual or industry best practices. © Ken Withers/Jet photos.net photos.net Withers/Jet © Ken more passenger seats built since 1991 are installation is developed by the air‑ In reference to the latter, Mendenhall required to have DFDRs. plane manufacturer and is essential for said that among industry best prac‑ “It would have been preferable FOQA data processing. Some corporate tices of primary concern during the to have both of our airplanes in the airplane manufacturers consider their demonstration project was approach program, but it looked like it would data maps as proprietary information stabilization. have involved a lot of downtime for the and initially were reluctant to provide Figure 1 and Figure 2 (p. 14) are hy‑ Falcon 50EX, which does not have a them to the Foundation. “They thought pothetical examples of what an operator DFDR, and significant cost just to put it was a secret we could not have,” Men‑ might find in a quarterly report pro‑ a QAR in,” Thorpe said. “We decided denhall said. “For the airplanes used in vided by a data-processing vendor. The to put a QAR in the airplane that was the demonstration project, Austin Digi‑ examples were among several in a pre‑ equipped for it and to see how it goes.” tal, the data-processor that we chose for sentation on C‑FOQA by Sands at this Mike DelMastro, director of flight the project, had to sign releases [non‑ year’s CASS. Figure 1 shows hypothetical operations for Merck, said, “We plan disclosure agreements] for the manu‑ deviations from stabilized approach to have any subsequent aircraft we facturers saying that it would not do criteria. Figure 2 shows a hypothetical purchase equipped to participate in the anything with the data maps other than breakdown of deviations from the target FSF C‑FOQA program.” the intended purpose of processing the approach speed. data for C‑FOQA.” Austin Digital is What can be gleaned from C‑FOQA Ones and Zeros among several data-processing vendors data analysis is limited only by the Collecting flight data is one thing; mak‑ that will be available to participants user’s imagination. Data-processing ing sense of the data is quite another. in the FSF C‑FOQA program. Aero‑ vendors can, for example, provide com‑ “All you get from a QAR is a bunch of bytes, Flight Data Services and Sagem puter animations of an event to help the ones and zeros,” Mendenhall said. “To are among other data processors with operator understand what happened make sense of this data, you need what FOQA capability. (photo, p. 15). is called a data map.” The operator periodically down‑ The results of the automated Simply stated, a data map shows loads data from the QAR by removing analyses of flight data must, however, what parameters are recorded on each a storage device or by using a cable or be screened for “false positives.” Sands channel of the DFDR, the sequence wireless connection to a personal com‑ provided an example. One of the in which they are recorded and the puter. Software provided by the data- quarterly reports he received during frequency at which each parameter is processing vendor for the operator’s the demonstration project indicated recorded. Depending on when they were personal computer compresses and that a flight crew might have climbed manufactured, DFDRs record either encrypts the downloaded data and above their assigned altitude. This was 57 or 88 parameters, including time, manages the transmission of the data detected from data showing that the airspeed, altitude, heading, vertical and to the vendor’s secure server. Men‑ indicated altitude overshot the selected longitudinal acceleration, roll and pitch denhall says that transmission time altitude. Looking at other data recorded
www.flightsafety.org | AeroSafetyWorld | August 2007 | 13 FlightOPS
having less than the proper flap setting for take‑ Deviations From Stabilized Approach Criteria off,” he said. “It turned out that the departures were from Toluca, Mexico, where the field eleva‑ Slow approach (CAS < VAPP) tion [8,458 ft] makes that flap setting the normal Below desired glide path on approach Not aligned with runway (localizer deviation) procedure for takeoffs.” High rate of descent on nal approach False positives also can be triggered by faulty Late nal ap extension sensors and other hardware problems in the air‑ Late gear extension plane. During the demonstration project, Men‑
Fast approach (CAS > VAPP) denhall screened all reports for false positives Low power on approach before they were sent to Altria or Merck. “We will 0 5 10 15 20 25 30 continue to have a review process,” he said. “But, Number of unstable approaches quite honestly, the review team could miss some‑ thing that will be picked up by the operator, who CAS = calibrated airspeed VAPP = target approach speed might have a better understanding of the event.” Figure 1 Thus, screening for false positives is also one of the duties of the operator’s gatekeeper. The gatekeeper, typically Distribution of Deviations From Target Approach Speed a pilot with opera‑ tional experience in Target approach speed 16 the airplane(s), has Aircraft 1 Aircraft 2 overall responsibil‑ 14 ity for the aviation 12 department’s C‑FO‑
by aircraft 10 QA program. Because the gatekeeper has
lights 8 f access to non-dei‑ 6 dentified data for a 4 specific period — to
Percentage of enable him or her to 2 talk to the flight crew, 0 –14–13–12–11–10 –9 –8 –7 –6 –5 –4 –3 –2 –1 0 1 2 3 4 5 6 7 8 9 10 11 12 if necessary, to gain Actual approach speed vs. target approach speed (knots) a better understand‑ ing of an event — he must be trusted by his Figure 2 colleagues.
during the event, Sands found that the selected Shutting Out Big Brother altitude was changed at or near the time of the Pilot support is essential for the success of any reported altitude bust. “It was apparent that safety-improvement effort. As administrator of the airplane was proceeding as cleared to the the C‑FOQA program, the Foundation secures assigned altitude when the controller amended legal agreements that specify the data-processing the crew’s climb clearance to a lower altitude; vendor’s responsibilities and prohibit the operator because of the late altitude-clearance revision, from using the data for punitive purposes. what appeared to be an overshoot was, in fact, a A former chairman of the NBAA Safety Com‑ non-event,” he said. mittee, Sands is a longtime advocate of FOQA and Thorpe provided another example of a false began discussing the program with his pilots years positive. “We had a few departures flagged for before the C‑FOQA demonstration project was
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launched. “We were fortunate to have one pilot on staff who previously had © Bill Shull/Airliners.net © Bill Shull/Airliners.net flown for an airline with a FOQA program,” he said. “She was very helpful in describing the safety benefits that such a program offers and its nonpunitive nature.” Said Thorpe, “I am sure there were con‑ Vandel said that as the program matures, the cerns among our pilots at first. I tried to be very Foundation also will examine aggregate data to open about the process; it was so important identify trends affecting specific aircraft types, to convince them that the program is a very airports, air traffic control procedures, phases of important safety tool and not a ‘big brother’ operation — approach and landing, for example enforcement tool or a means to gather informa‑ — and events such as unstabilized approaches. tion to send to the FAA [U.S. Federal Aviation Information on identified trends will be issued Administration].” as advisories or alerts to the industry. ●
Sands and Thorpe said that participation in For more information about the FSF C‑FOQA pro‑ the demonstration project resulted in substan‑ gram, contact Bob Vandel at +1 703.739.6700, ext. 110, tial safety benefits. For example, Sands noted
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Word lists and writing rules take the confusion out of aviation maintenance documents. Simplifying the Technicalities
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nglish is the international language of These and other examples illustrate how aviation — and therefore the language difficult a language English can be, said the most frequently used in technical and Aerospace and Defence Industries Association maintenance documents — but often it of Europe (ASD), which has developed rules Eis not the native language of the maintenance for the use of English in aviation maintenance personnel who use these documents. documents. As a result, complex technical instructions “Many readers [of technical maintenance can be misunderstood, especially by those documents] have a knowledge of English that is without strong English language skills — and limited, and are easily confused by complex sen- occasionally by native-English speakers — and tence structures and by the number of meanings the misunderstandings can lead to accidents. and synonyms which English words can have,” The International Civil Aviation Organization the ASD said. (ICAO) said in a 1996 article in the ICAO Journal that language errors had become more prevalent, Pattern of Errors partly because air carrier airplanes were being A study conducted for the U.S. Federal Aviation manufactured in many different countries, where Administration (FAA) on language errors within many different languages are spoken. the worldwide maintenance repair and overhaul “Sometimes, the technical language of the (MRO) market found that the most common manufacturer does not translate easily into the errors involve both written English and spoken technical language of the customer, and the English.3 The study identified the most frequent result can be maintenance documentation that is language-related errors as involving one of the difficult to understand,” ICAO said.1 following three scenarios, in which a mainte- “Anecdotal evidence suggests a case where a nance employee:3 certain maintenance procedure was ‘proscribed’ (i.e., prohibited) in a service bulletin. The tech- • Was unable to communicate ver- nician reading this concluded that the procedure bally at the level required for adequate was ‘prescribed’ (i.e., defined, laid down) and performance; proceeded to perform the forbidden action.” • Did not realize that a person he or she was The International Federation of Airworthi- speaking with had limited English ability; ness (IFA) cited another example involving a or, Japanese operator’s airplane, in service for five days without batteries for the emergency exit • Did not fully understand written docu- door operation auxiliary system.2 mentation in English, such as a mainte- “During maintenance, the battery cases were nance manual or a work card. replaced,” the IFA report said. “Seven of the “Language errors of many types are pos- eight [replacement] cases did not contain batter- sible, although only a few are frequent, with a ies. Another mechanic who should have checked language-error-prone activity having consis- the existence of the batteries had reportedly tent characteristics: complex task instructions; misread the English manual.” poorly designed document, in English; users
Simplifying the Technicalities BY LINDA WERFELMAN
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with low ability in English and low familiarity The study identified a similar pattern in the with the task to be performed; and time pressure most frequently cited factors that could prevent to complete the task,” said one of several reports language errors: on the study, which included surveys of 941 maintenance personnel in Asia, Europe, Latin • “The mechanic or inspector is familiar America and the United States, along with task- with this particular job; card comprehension tests and group discussions • “The document follows good design of scenarios involving language errors. practice; “When listed in this way, language errors appear to have all of the usual human factors • “The document is translated into the na- ingredients for error, not just language error. … tive language of the mechanic or inspector; The implication is that if the ‘usual’ error-shaping • “The document uses terminology consis- factors are present, then the ‘usual’ interventions tent with other documents; [and,] should be effective (e.g., training, documentation design [and] organization design.)” • “The mechanic or inspector uses the aircraft as a communication device, for
© Chris Sorensen Photography example, to show the area to be inspected.” Although the study found language errors to be a “potential problem,” it also identified two frequent factors in the discovery of an error: the mechanic or inspector either “asked for assistance or clarifi- cation” or “appeared perplexed.” Both factors rely on “feedback from the message recipient to the message sender,” the report said, and both typically occur early in the maintenance process. “Detection of language errors is typically reported well before any maintenance/inspec- tion errors have been committed, or [before] the aircraft is released for service,” the report said. The study found that younger maintenance personnel and those with better reading skills experienced fewer language errors. “Increasing mastery of English will have a significant impact on comprehension and is a vindication of the English language training programs invested in by many of the MROs we visited,” the report said.
‘Strong Case’ for Simplification ICAO said in its 1996 article that the preponder- ance of maintenance information published in English made a strong case for the use of simpli- fied technical English, a “controlled language” — that is, a language specifically adapted to eliminate ambiguity and complexity by using only selected words and applying grammar rules in very specific ways.
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Others in the aviation industry have shared that belief. Efforts to address maintenance prob- Writing to Rule lems associated with misunderstandings of written English began on a large scale in the late 1970s, implified technical English in general — and Specification ASD- when the Association of European Airlines asked STE100, developed by the Aerospace and Defence Industries the European Association of Aerospace Industries SAssociation of Europe, in particular — is intended specifically for people who use English language technical documents in the aero- (AECMA) — as the ASD was then known — to space industry.1,2 develop its first version of simplified technical The primary components of simplified technical English are a set English suitable for use in aviation maintenance of writing rules for style and grammar, and a dictionary containing documentation. AECMA’s first product, AECMA about 1,000 approved words. Also included are a thesaurus and guide- Simplified English, has been revised several times; lines for adding words to the approved technical vocabulary. the current document is ASD Simplified Technical Among the rules: • Write in the active voice (i.e., “The pilot flew the airplane,” rather English, Specification ASD-STE100, which com- than “The airplane was flown by the pilot”); bines writing rules and a dictionary of “controlled • Avoid long compound words and long sentences; and, 4 vocabulary” (see “Writing to Rule”). • Be consistent in your choice of words. “Clear and unambiguous maintenance in- — LW structions are the scope of the specification,” said Notes Orlando Chiarello, chairman of the ASD STE 1. Aerospace and Defence Industries Association of Europe (ASD). Simplified Maintenance Group and product support man- Technical English.
When the technical names and Simplification technical verbs are included, “you have potentially thousands and thousands of STE: “Stop the power supply.” words,” he said, adding that, to some ex- Non-STE: “Turn off the power.” tent, “it’s up to the judgment of the writ- Explanation: “‘Turn’ is approved when you use it to ‘move something around its axis.’ ing establishments within the companies If you do not ‘turn’ something to stop the power supply … do not use the word ‘turn.’” which words they’re going to allow for STE: “Continue the test.” their companies as technical names.” The ASD says that the specification Non-STE: “The test can be continued by the operator.” emphasizes the principle of “one word Explanation: “Use the active voice” — rather than the passive voice in choices of verbs and sentence structure. — one meaning.” Therefore, in situa-
tions in which several English words STE: “Set the rotary switch to INPUT.” mean approximately the same thing, Non-STE: “Rotary switch to INPUT.” the dictionary includes only one and Explanation: “Do not omit verbs [to make sentences shorter]. The reader will not know excludes the synonyms. what the action is.” “For example, ‘start’ was chosen in- stead of ‘begin,’ ‘commence,’ ‘initiate’ or STE: “When the landing gear retracts: ‘originate,’” the ASD says. “When there (1) The door-operating bar on the leg touches and turns the latch. are several possible definitions of a word (2) This causes the roller to move out of the slot. in English, the specification selects one (3) The second roller holds the door-operating bar.” of these definitions to the exclusion of the others. For example, ‘to fall’ has the Non-STE: “During the final movement of the landing gear retraction, the door operating bar located on the leg contacts and turns the latch, withdrawing the roller from definition of ‘to move down by the force the slot and the second roller entraps the door operating bar.” of gravity,’ not ‘decrease’ (Table 1).” Explanation: “The tabular layout of text … with standard punctuation can help to show the Wojcik cited another example: the relationship between two or more complex actions or events. This is clearer than writing word “interference,” which according to long sentences.” the rules may not be used “when it means STE: “Make sure that the oxygen tubes are fully clean. This will help to prevent things knocking together” but is permit- contamination and explosions.” ted in describing electrical interference, Non-STE: “Extreme cleanliness of oxygen tubes is imperative.” which is “not an event but rather an Explanation: “Be specific in a warning or caution. You must tell the users exactly what they environmental condition.” must do and what can happen, to get their attention immediately.” “Many of the rules in simplified technical English are designed just to STE = standard technical English clarify — they’re the same rules that Source: Aerospace and Defence Industries Association of Europe. ASD-STE100, Simplified Technical English. Issue 4. January 2007. any good technical writer would apply,” Table 1 Wojcik said. “In general, it’s a clarify- ing standard. ... It just forces people to take out the double-talk, the unneces- ASD-STE100, including Boeing, Changing Practices sary wording, the circumlocution, all whose Simplified English Checker Philip Shawcross, vice president the things that people will put into a tells writers if they have used unap- of the International Civil Aviation document because they want to sound proved words or violated writing rules. English Association, said that stan- educated or because they just aren’t The program does not automatically dardization of language used by thinking very carefully about how the correct what it identifies as errors, maintenance personnel has become reader is going to understand what however; instead, it provides writers increasingly necessary because of the they’re saying.” with information and allows them to substantial changes in maintenance Several companies produce the determine whether what they have practices over the past 20 years, software typically used to implement written makes sense.5 including:
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• Expansion of the role of computers result, maintenance documents from all Elizabeth Mathews, a specialist in in the maintenance environment; the main manufacturers are much more applied linguistics and leader of the in- uniform and accessible than many were ternational group that developed ICAO’s • Fewer translations of documents 20 years ago.” English language proficiency standards, from English to a native language; Nevertheless, authors of the FAA said that maintenance personnel require • Increased use of manufacturer- language-error study said they were skills in reading, writing and speaking/lis- generated standardized training surprised to find that simplified tening to English. Detailed studies would materials — written in English; technical English “had no consistent be required before the appropriate profi- effect” in limiting language errors ciency levels for maintenance personnel • More alliances among airlines, among non-native speakers of Eng- could be determined, she said. ● many of which are in countries that lish outside the United States. Earlier have no common language; and, findings had shown that simplified Notes technical English was effective for 1. International Civil Aviation Organization • An increasingly mobile, multicul- non-native English speakers in the (ICAO) Secretariat. “Awareness Grows 6 tural work force. United States.7 of Importance of Human Factors Issues “All these trends have something ‘invis- “Perhaps [simplified technical in Aircraft Maintenance and Inspection.” ICAO Journal. January–February 1996. ible’ in common: a much increased English] is less useful when applied in reliance upon language and upon a a setting where the native language is 2. International Federation of Airworthiness single language — English,” said Shaw- other than English,” their report said. (IFA). “Human Factors: New Technology Adds a New Dimension to Documents.” cross, who also is in charge of training “Similarly, neither the interventions of IFA News, 2006. curriculum design for Aviation English a bilingual coach or a glossary pro- Services, which provides training and duced any significant results, despite 3. Drury, C.G.; Ma, J.; Marin, C. “Language Error in Aviation Maintenance: Findings testing in aviation-specific English. their widespread use as interventions at and Recommendations.” Included in “The regulations set by civil aviation MRO sites.” Aviation Maintenance Human Factors authorities represent only one of the The report added that translation of Program Review, Fiscal Year 2005, July pressures exerted on operators to ensure information from English into the na- 2006. The study was conducted for the U.S. that their maintenance staff [attains] a tive language was “the only consistent Federal Aviation Administration, which was given level of proficiency in English,” significant intervention” in preventing especially interested in maintenance, repair and overhaul facilities that were engaged in Shawcross said. “Operational, techni- misunderstanding. Partial translation, contract maintenance for major airlines. cal, safety, financial and commercial with technical terms left in English, was pressures are probably more effective in as effective as full translation. 4. Aerospace and Defence Industries Association of Europe (ASD). Simplified the way they drive for efficient com- As a result of the study’s findings, Technical English.
Accepting a trip while ill would fly in the face of safety principles. By Wayne Rosenkrans Cabin
© Valerie Loiseleux and Joachim Angeltun/iStockphoto Loiseleux Valerie © Fever oncerns about flight attendants and pilots in an aircraft at an 8,000-ft cabin pressure alti- flying while ill deserve attention from avia- tude. Fitness to operate as crewmembers means tion safety professionals and regulators, say that they are deemed to be “physically capable, recent reports to safety reporting systems mentally alert and able to complete all the func- Cfrom crewmembers in the United Kingdom and tions required primarily of their safety duties, the United States. Concepts of illness tend to fall and secondarily of all their service duties,” Giles along separate lines for crewmembers, airline said. “On the airplane, there is no limited duty.” managers and aeromedical specialists, says Heidi Illness, like fatigue, is fraught with com- Giles, vice president of global response services plexity for airlines and crewmembers because for MedAire, a company that provides services it involves self-assessment, social interactions, such as assistance during emergency in-flight labor-management contracts and performance medical events, airline crew support, airline pas- expectations. The airline industry recognizes senger-assistance services, medical evacuations that crewmembers make more errors when they and airport medical fitness assessments. are fatigued, but a direct correlation between ill- Medical fitness to fly means whether people ness and in-flight errors has not been researched can be sustained as healthy, viable human beings as thoroughly. “When people call and say they are ‘just fatigued,’ our nurse case managers will © Dušanzidar/Dreamstime.com ask a lot of questions to make sure that that is all it is,” Giles said. “Most difficult is that when people are fatigued, they are very emotional and not necessarily able to express themselves the way they might were they well rested.” The U.S. Federal Aviation Administration (FAA) Aeronautical Information Manual (AIM) — available at
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distracting symptoms that can impair judgment, Illnesses that are not on this list also can be memory, alertness and the ability to make calcu- serious. “A good example is any gynecological is- lations. Although symptoms from an illness may sue,” Giles said. “Usually something can seem to be be under adequate control with a medication, the fairly minor to crewmembers during layover, but medication itself may decrease pilot performance. they will wait until it becomes bad enough before The safest rule is not to fly while suffering from they call because of heavy bleeding, pain or fever. any illness. If this rule is considered too stringent With minor nausea, they will still fly. But they can- for a particular illness, the pilot should contact an not be actively vomiting and serving meals or fly- Cabin aviation medical examiner for advice.” ing an airplane. They also cannot get up out of the cockpit to go to the lavatory every two minutes.” Common Illnesses Among the in-flight medical advice cases MedAire’s MedLink in-flight medical advice in 2006, 5,955 (34.4 percent) were in the — currently provided to 74 airlines worldwide neurological/neurosurgical illness category, — during the past decade has become known including fainting; 3,289 (19.0 percent) were Fever primarily for assisting passengers. The company gastrointestinal; 1,800 (10.4 percent) were in 2006 had 17,310 in-flight medical advice cases involving all types of aircraft occupants, but cases involving pilots and flight attendants Five Leading Categories of Airline 1 have not been separated from those involving Crewmember Illnesses/Injuries Affecting Flight Duty passengers. Based on 42 months of data from Other its crew-support program, which generated 3,092 (37.0%) 15 cases a day among 10 airlines, MedAire has Total Crew-Support Cases = 8,368 identified in its data the five most common ill- nesses affecting flight attendants and pilots on layovers (Figure 1), and extrapolated its rate to estimate that worldwide, “nearly 1,000 crew- Ear-nose- throat2 members are experiencing a health-related issue 1,625 Gastrointestinal3 1 (19.4%) on duty every day.” 1,364 Among 5,600 crew-support cases handled (16.3%) Orthopedic4 in 2006, 747 (13.3 percent) were in the gastroin- 976 Infectious disease5 (11.7%) Respiratory6 testinal illness category; 648 (11.6 percent) were 696 615 (8.3%) ear-nose-throat, including barotrauma; 471 (8.4 (7.3%) percent) were orthopedic including muscle sprain/ strain; 357 (6.4 percent) were dental care, includ- ing damaged tooth/filling and dental pain; and 281 (5.0 percent) were respiratory, including upper © Dawn Hudson/Fotolia respiratory infections. Generally, the gastrointes- Notes: tinal calls were prompted by diarrhea and inces- Crew-support cases from January 2003 through June 2006 were categorized. 1. Each case involved one or more calls in which MedAire-affiliated physicians and sant vomiting. The ear-nose-throat calls sought nurse case managers assisted pilots and flight attendants employed by 10 airlines, to prevent extreme pain from blocked ears. The typically during a layover period. sprain/strain calls involved concern about ability 2. The typical diagnosis was barotrauma such as ear block. 3. The typical diagnosis was gastroenteritis (inflammation of the stomach and/or intestines). to operate flight controls, to push a cart or operate 4. The typical diagnosis was musculoskeletal injury such as a muscle strain/sprain. a jump seat harness. The dental calls aimed to 5. Diagnoses varied, including illnesses such as influenza. prevent extraordinary pain from an exposed nerve. 6. The typical diagnosis was upper respiratory infection.
And upper respiratory infection calls primarily Source: MedAire involved infections that caused pain in the sinuses because of gas expansion and bubble formation. Figure 1
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respiratory, including upper respiratory infec- called crew scheduling the previous night and tions; 1,298 (7.5 percent) were cardiac; and called in sick. Crew scheduling informed her 692 (4.0 percent) were orthopedic, including that she would have to work the flight to Chi- muscle sprain/strain. cago O’Hare International Airport or it would have to be canceled, and she would be replaced Flight Level Illnesses at O’Hare. She was either ordered or coerced to A U.K. pilot, describing in 2005 the circum- work while ill.”3 stances of a missed approach and diversion, A U.S. A320 captain in 2006 said, “During said, “I had been sick on the previous day, and I the flight, it became readily apparent after we had advised operations that I would be unable departed that the first officer was recovering to fly due to a heavy cold. Despite this, I was from an illness. As he used the radio to com- awakened by a telephone call from the opera- municate with air traffic control, he coughed uncontrollably. It was at this point that I realized that he should have taken some time off via the sick list to recover more fully. It was obvious by our discussion that he was intimidated by the flight office and the chief pilot via the ab- sence-management program, which tracks and punishes pilots for [inappropriately] using sick leave. This policy placed me in an uncomfort- able situation, as I do not have the expertise to diagnose a person’s illness.”4 Another U.S. captain in 2006 said, “When I attempted to brief the flight attendants, it was painfully obvious that [the purser, with laryngitis] had almost no voice at all. … She relayed to me that she really did not want to call in sick because of the sick leave policy. She stated that she did not really feel that bad, but she was also worried about her voice and ability to give commands © Stockxpert during an evacuation if necessary. … The super- visor told her that she should just let someone tions officer who persuaded me to report for else do the communications with the cockpit and duty (in five hours time). … The sixth sector public address system announcements.”5 was back into the home base and the weather had deteriorated significantly. … By this time I Precedents for Pilots was feeling very ill indeed.”2 In the United States, airline pilots and flight In 2005, the U.S. captain of an Airbus A320 attendants are safety-sensitive employees subject said, “Prior to departure, we were informed to FAA drug- and alcohol-testing requirements that we had an ill flight attendant on board, and flight time limitations. To operate, however, and incorrectly assumed that this flight atten- only the pilots must have a first-class or second- dant was a deadheading flight attendant. About class medical certificate that must be renewed one hour into the flight, the purser called up every six or 12 months for an airline transport to inform us that the flight attendant was on pilot or commercial pilot, respectively, by an oxygen and later reported that she spent a FAA-designated aviation medical examiner. significant amount of time vomiting in the The U.S. Federal Aviation Regulations (FARs) [lavatory]. I inquired, and was told that she had concerning medical certification also prohibit
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a pilot from operating with a known medical are not operating the aircraft’ or ‘if push comes deficiency except as authorized by the FAA.6 to shove, a passenger will open those doors if Pilots readily can receive FAA advice on you cannot,’” said Candace Kolander, coordina- prescription and nonprescription medications. tor, Air Safety, Health and Security Department This guidance in part says, “For example, any of the Association of Flight Attendants–Com- airman who is undergoing continuous treatment munications Workers of America. with anticoagulants, antiviral agents, anxiolyt- “I hear those stories more often than stories ics, barbiturates, chemotherapeutic agents, of a manager being supportive and saying ‘You experimental hypoglycemic, investigational, really should not get back on that flight’ — es- mood-ameliorating, motion sickness, narcotic, pecially if the crewmembers are on the fence sedating antihistaminic, sedative, steroid drugs, — they are not bedridden, they don’t have or tranquilizers must be deferred [medical] uncontrollable heaving, but they are also not 100 certification unless the treatment has previously percent — they’ve got an illness that is question- been cleared by FAA medical authority. … Dur- able,” Kolander said. Except for crew resource ing periods in which the foregoing medications management training about pilot in-flight are being used for treatment of acute illnesses, incapacitation, discussions of the safety aspects the airman is under obligation to refrain from of crewmember illness often are absent in recur- exercising the privileges of his/her airman medi- rent training, she said. cal certificate unless cleared by the FAA.”7 Some sickness-absence management pro- In a reminder about fitness to operate, the grams also neglect to mention the links among Air Line Pilots Association, International said illness, fitness to operate and safety. “Very rarely in 2007: “Crewmembers will keep themselves have I seen stand-alone memos that say ‘Do physically and psychologically fit for duty. Flight not fly when you are sick,’” she said. Instead of Nurse case crewmembers will not report for duty when ill, being inserted at the bottom of reminders about managers handle under serious mental stress or while having a investigation procedures for suspected sick airline crew-support known medical deficiency that would render leave abuse, they could say, “Your job as a safety calls at the MedAire them unable to meet the requirements for a cur- professional is really important, and in order to Global Response rent medical certificate.”8 do your job well, you need to be 100 percent,” Center in Tempe, In some countries, fitness to operate for Kolander said. Arizona, U.S. flight attendants is not so explicit, however. Since Dec. 10, 2004, U.S. flight attendants have © MedAire been required to hold a flight attendant certifi- cate of demonstrated proficiency, but this does not require medical certification.
Cabin Crew Perspectives One U.S. cabin safety specialist, with 20 years of experience as a flight attendant, believes that industry perceptions of flight attendants have led some airlines to see this aspect of cabin safety as a malleable commodity. “Although we are required on board the aircraft for safety pur- poses, a manager asking ‘How sick are you?’ or saying ‘If you report sick, we are going to have to cancel a flight, and all these people are going to be stranded’ sometimes conveys to the flight attendants who report sick to ‘take the trip, you www.flightsafety.org | AeroSafetyWorld | August 2007 | 25 26 | © Justin Horrocks/iStockphoto to assess own their ability their illness, though someone may have ability the mayalso tricky. be “Sometimes, even statusillness without expertise medical slacking.” linethe either —of showing up or ill donotThey want that reputation on it take very,says. “They seriously. very of would them not come to work,” Giles might compromise safety, majority the havebers an or illness an injurythat anecdotal vantage points. “If crewmem increasing, except from respective their reporting for has duty been ill while percentagethe of crewmembers ablebeen to gauge accurately whether caretake of this?’” Giles said. to get on airplane, the go home and is going to make me feel better enough counter at apharmacyinFrankfurtthat ask, ‘What“They can Iget over the rising of tide symptoms ifpossible. to MedAirecallers want to stem their one recurrent theme. Essentially, the members on ill layover typically have for adviceCalls from medical crew Feel-Good Solutions CABin For an individual, getting agrip on Neither Kolander nor Giles has safety - - pressuring the crewmember, saying, where the airline station manager was of their illness. “We have had situations have an argument about the seriousness experience third-party input rather than entwined.” get that things those all reputation, work, to opposed as condition, medical personal of context the in illness put would who professional medical a see to willing was she where point a to her get and her with reason to able were they So phone. the over hands hold to how know nurses room emergency or nurses care critical as experience with givers care Neutral them. for good and person’— this with fly to refuse ‘We said, and up stood crew entire the “So well,” as said. she impaired was situation the judge to ability her but situation, emotional some or taking was she that substance a of result a as either state, altered an in was she not, was “She said. Giles well, feeling was she that claimed 2007 July in attendant flight One illness. an edge acknowl to refusal crewmember’s a be professional. care health a by assessed/treated is crewmember the whether on sion deci a and problems, scheduling potential identify to and operate to ability project to airline the for — flight specific a on operate to fitness of probability high or low, of medium scale a on expressed — information preliminary generates manager case ayear. 200times scenario manager involved same the inbasically ofwith perspective the anurse case first time, but that contrasts sharply an happening could illness be for the stances,” Giles said. To acrewmember, to reason circum incertain decreases Complicating some scenarios can can scenarios some Complicating nurse a to call phone initial The Some crewmembers feel relieved to - - - flight safety foundation foundation safety flight 8. 7. 6. 5. 4. 3. 2. proper hand washing techniques, Giles materials for crews such as guidance on prompted development of educational tion at acrew hotel. The datahave also such as environmental contamina epidemiological studies of problems areas or This has illnesses. included out trends involving geographic specific regular report to eachairline, pointing about crewmember to illness produce a can’t fly.’” crewmember could say, ‘MedAire says I said, ‘No, you can’t operate.’ Then the was really torn until we stepped in and last leg,’” Giles said. “The crewmember to leave on time. Come on, this is our ‘Come on, you need to fly, we’ve got 1. N said. otes
Air Pilots Line Association, International. U.K. Confidential Human Factors Reporting org>. Update.” May 14, 2007. AEroS April 25,2007. a f e ty World World | A ugust 2007 ugust - flighttech Heating up in ParisBy J.A. Donoghue | From paris ' While not global warming, the hot pace of orders at the Paris Air Show creates concerns about coping with a rapidly expanding world fleet. aris Air Show 2007 displayed the energetic expansion of nearly every P aspect of the global avia- tion industry, with tens of billions of dollars in sales commitments being announced, a development that was both encouraging and worrisome. While the vigorous economic health of the industry certainly is welcome, the infrastructure and training challenges that will accompany the delivery of the thousands of ordered aircraft must be considered with a degree of concern. Airbus, to a much greater degree than Boeing, targets the show as a stage from which to an- nounce major sales, and this year the European manufacturer outdid itself with 728 orders and options announced during the show’s five days, with additional orders trick- ling in during the following days. Boeing and Airbus together got 545 firm orders during the show. Others announced sales as well, money changing hands so quickly that, by show’s end, the value of sales tallied by just the three major Donoghue J.A. www.flightsafety.org | AeroSafetyWorld | August 2007 | 27 flighttech Europe-based Thales is making simulators for a wide range of new customers, including four full flight simulators for Rudradev Aviation’s new airline training center in Chennai, in southern India; just before the air show, Thales announced orders for additional A320 simulators for Sichuan Airlines’ new training center in Chengdu, China. Avionics news at the show included the announcement by ACSS, the joint venture of engine manufacturers exceeded US$20 billion, L-3 Communications and Thales, that it had with Rolls-Royce alone claiming sales of more concluded development of its SafeRoute system, Dassault displayed than $15 billion. with certification by the U.S. Federal Aviation its newly certificated Continuing a trend several years in the mak- Administration (FAA) expected soon. Using Falcon 7X to the ing, most of the orders came from the develop- automatic dependent surveillance-broadcast crowd. ing world, including the Middle East, Asia and (ADS-B) technology, SafeRoute has two func- Photos: J.A. Donoghue Latin America. With many orders coming from tions: surface area movement management new or rapidly growing airlines, most of these (SAMM) and merging and spacing (M&S). aircraft will be fleet additions, not replacements. In the SAMM function, SafeRoute displays Given today’s shortage of pilots and other skilled the equipped aircraft’s own-ship position on aviation professionals, the source of additional a moving map of the airport surface, plus the crews for these new aircraft seems important to position of any other transponder-equipped figure out. aircraft. The M&S mode allows airborne aircraft Canadian simulator builder CAE Inc., which to line up behind and follow another aircraft at a also has a training arm, estimates that 16,000 precise interval. pilots need to be trained each year for the next Nicholas Sabatini, FAA associate adminis- 20 years to meet the demand in both the airline trator for aviation safety, said at the show that and corporate aviation markets. The company is SafeRoute will enhance pilot “situational aware- expanding the capabilities of its global network ness and allow air crews to separate themselves.” of 24 civil training centers to handle corporate Sabatini also credited the work of UPS and and airline training. Karen Lee, UPS operations director, for working Alteon, Boeing’s training subsidiary, fore- with ACSS to develop the system, “leading edge casts an even greater demand, predicting the stuff, way out there in front,” he said. need for an average of 18,000 new pilots every Lee said the certification testing was “flaw- year, plus 480,000 new mechanics during that less in high density traffic,” and she hoped to get 20-year period. SafeRoute into UPS service this month. 28 | flight safety foundation | AeroSafetyWorld | August 2007 flighttech © Gulfstream ACSS’s SafeRoute simulates how an aircraft approaching an occupied runway would be warned (left). Gulfstream’s PlaneView cockpit would use the primary flight display on the left for the synthetic vision presentation. © ACSS The system will be installed in class 3 providing pilots “a significant increase in situ- electronic flight bags (EFBs) on 107 UPS 757s ational awareness,” Henne said. and 767s for use to control spacing approach- The next generation head-up guidance ing its hub in Louisville, Kentucky, U.S., from system (HGS) Gulfstream will adopt, a Rock- the west. Tests have shown that this ability will well Collins system Henne called HUD2, will increase airport capacity by 10–15 percent, cut integrate the EVS with synthetic vision in the local noise 30 percent and reduce emissions 34 HGS display. percent below 10,000 ft, Lee said. UPS’s plan is Jeffrey A. Standerski, Collins vice president to expand use of the system in Louisville, and it and general manager, air transport systems, said is considering using SafeRoute for its Cologne, the HGS for Gulfstream, which Collins calls the Germany, hub, she added. 5860, will be the first HGS with active matrix The SAMM function, Lee told ASW, not only liquid crystal display, and will have a wide field will increase pilot situational awareness on the of view. Standerski foresees in the very near ground, but, with a glance at the display taking future the combination of EVS, synthetic vision, the place of following “a finger on the [airport] weather radar, traffic information and more on The Antonov An-148, map,” creates a more head-up taxi environment. the HGS plate. Collins also builds the 2200 HGS recently certificated, Use of SAMM on a class 2 EFB seems likely for both pilot positions in the Boeing 787, using flew daily at the show. to get FAA approval, which will dramatically cut the same technology on its Embraer and Das- Photos: J.A. Donoghue the cost of equipping with the system, Lee said, sault installations. but FAA “is still not confident about [approving] Also using synthetic vision is a M&S” on a class 2 EFB. Honeywell PFD-displayed view Gulfstream, which pioneered the use of en- of the world supplemented by hanced vision systems (EVS) in civil aircraft five radar sensors to guide helicopter years ago — 294 EVS-equipped Gulfstreams are pilots during takeoff and landing now in service — plans to certificate a synthetic in “brownout” conditions (ASW, vision system this year. Pres Henne, senior vice 12/06, p. 44). Called Sand- president for programs, engineering and test, blaster, the system currently is said, “We’re looking for things that represent being developed under a U.S. a difference, an advantage for our customers.” Defense Advanced Research The synthetic vision view of what the world in Projects Agency contract. front of the cockpit should look like, taken from While initial use would be by a simplified version of an earth database, will the U.S. military, Honeywell be displayed behind the primary flight display expects civil users would (PFD) graphics, showing terrain, obstacles, benefit from the system’s airport layouts and other significant features, capabilities. ● www.flightsafety.org | AeroSafetyWorld | August 2007 | 29 SAFETYoversight By Wayne Rosenkrans © Aviation-Images.com Inspector Scrutiny viation safety inspectors to proliferation of safety management and post-2004 audits using ICAO’s cur- fielded by some nations have systems (SMSs) — auditors for ICAO rent comprehensive systems approach problems complying with the continue to push for accelerated com- (ASW, 2/07, pp. 39-41). These excerpts standards and recommended pliance through their Universal Safety are incomplete and anecdotal; they Apractices (SARPs) of the International Oversight Audit Program (USOAP). provide general insights about a specific Civil Aviation Organization (ICAO). Compliance deficiencies2 found by time but do not show the extent of any As inspectors face booming aviation the auditors appear in excerpts from deficiency involving inspectors, and system growth and increasing cross- ICAO contracting states’ first-generation many deficiencies are now resolved. By border interdependence1 — with their audits based on the USOAP’s original mid-2007, about half of the 190 ICAO work redefined by forces ranging from auditing approach from 1999 to 2001, states had authorized posting of the globalization of aircraft maintenance follow-up missions from 2001 to 2004, excerpts from their USOAP audit results 30 | flight safety foundation | AeroSafetyWorld | August 2007 SAFETYoversight on a publicly accessible table in the Flight Safety Regarding Bulgaria, a favorable report said, Information Exchange (FSIX) area of the ICAO “Under the current regulations, as reflected in Web site ICAO auditors expect states to commit enough resources for effective oversight. Inspector Scrutiny © Charles Schlumberger/World Bank airworthiness information, such as malfunc- tion reports, to manufacturers and other states. Authoritative Credentials The enforcement power represented by an aviation safety inspector’s badge and/or other credentials played a critical role in effective safety oversight, according to some of the reports. Inspectors in some states had neither a badge nor other credentials, however. When provided, some credentials were inconsistent in their purpose. www.flightsafety.org | AeroSafetyWorld | August 2007 | 31 SAFETYoversight instead of a government credential, only an air- deficiencies. The main issues were insufficient port identification card granting access to airport random checks of certificate candidates and property. Some civil aviation authorities, such as insufficient quality control of testing procedures, in Sweden, initially objected to these findings, leading to entirely “self-monitoring by the air however, arguing that such amendments were operators.” unnecessary because no inspector in the past had been denied access. Competitive Salaries Exercising authority also implies clear Low inspector salaries is one theme echoing definition of inspectors’ privileges and ready through a number of reports. Auditors focused on access by inspectors to domestic aircraft, foreign the safety-related consequences, such as chroni- aircraft, operator buildings/installations, air cally unfilled positions, high turnover of inspec- traffic organizations, airports, maintenance and tors, oversight delays or backlogs caused by the repair organizations, training institutions, paper shortage of inspectors, difficulty attracting highly documents and digital data. Auditors’ follow- qualified professionals from industry, insufficient up comments were favorable when Bulgaria travel funds for inspection/training missions and not only spelled out how inspectors can initi- inability to schedule inspector training, especially ate statements for administrative violations but recurrent training on the aircraft types operated formally documented the authority of inspectors under the state’s air operator certificates (AOCs). to issue written guidelines for corrective actions Related issues were the civil aviation by operators or other organizations. authority’s ability to provide stable long-term At the civil aviation authority in Moldova, employment and whether the ministry of auditors found that monetary penalties and transportation arbitrarily established inspectors’ imprisonment could be imposed by law for vio- salaries. “[Senior operations and airworthiness lation of aviation regulations. Records showed inspectors] are on a yearly renewable contract Government- only that aircraft had been grounded and cer- due to government policy, and no provision is issued vehicles tificates had been suspended temporarily. Yet no available to reinforce the technical capacity of and credentials enforcement methods less severe than these four the [civil aviation authority] by offering them that confer rights sanctions were in place for situations in which long-term contracts,” said a report on Lesotho. of access are inspectors routinely identified a safety discrep- A report on the Czech Republic noted, “[In- considered essential ancy and simply wanted a timely correction. spectors’ classification under civil servant law] for all aviation safety Inspectors’ oversight of designated examiners, means that their salary can reach, on average, a inspectors. line check pilots and contractors also involved maximum of one-third of the salary of qualified line pilots [of an] air company.” Poland’s civil aviation authority said that recent operations inspector vacancies had been filled by pilots retired from the state airline industry. Hiring was difficult due to “low inspector salaries which remain approximately one-tenth of those provided to similarly quali- fied people in industry.” Sometimes, the civil aviation authority’s response was to deny that low salary was a safety concern. The civil aviation authority in the Netherlands told ICAO, “This has no direct impact on the recruitment of flight operations inspectors [or] on existing competency and experience among the team of inspectors for the 32 | flight safety foundation | AeroSafetyWorld | August 2007 © Charles Schlumberger/World Bank SAFETYoversight present level of activity of the [civil aviation au- thority]. The government has already launched a study which will allow additional compensa- tion for the entire organization.” In some cases, however, the ICAO follow-up mission found that as soon as the civil aviation authority in- creased salaries, inspector turnover ceased to be a problem. The solution in Poland was for the minister of transport to index the inspector salary scale to a maximum of 80 percent of the salary re- ceived in comparable positions in the industry, and to amend a law to “require maintenance of European Civil Aviation Conference and Joint Aviation Authorities SAFA Program SAFA Authorities and Joint Aviation Conference Civil Aviation European inspector salaries at that level.” Sufficient Staffing Low salary sometimes led to insufficient inspec- tor staffing, which some auditors simply called “too much workload.” In response to this finding, the civil aviation authority of Ireland held on to its belief that it employed a satisfactory number of inspectors but agreed to add inspectors to reduce dependence on external contractors. In Switzerland, the safety consequence of an acute shortage of operations inspectors was that “subsequent to the issue of an [AOC], only a few operations inspections on some commercial air “indicated that most of the scheduled audits Acute shortages of transport operators are conducted.” Some civil have not been performed due to a shortage of inspectors in some aviation authorities — such as in Singapore — re- flight operations [inspectors] and airworthiness/ countries have limited sponded to such findings by refining the workload maintenance inspectors.” inspections of parameters and formulas they use to calculate the Civil aviation authorities of various sizes re- air carriers. required number of flight operations inspectors. ported difficulty enabling operations inspectors, Other auditors identified failures by civil as a group, to stay current as pilots on all aircraft aviation authorities to meet their own sched- types flown by the state’s AOC holders. A report ules of en route flight deck/cabin inspections about the civil aviation authority in Finland said, and station inspections for scheduled air “Although the [civil aviation authority] tries operators. “Neither the state regulations nor the to have all the aircraft expertise within its own [inspector’s] handbook [specifies] the minimum staff, it also has to use the expertise of [desig- number of inspections that should be performed nated] company check pilots to complement its for each operator during the year,” said a report capabilities and to conduct type-specific inspec- on Poland. “Inspections are planned according tions not covered by its inspector work force. to the manpower presently available. Due to this … [The civil aviation authority’s] inspectors lack of regulations and the shortage of opera- perform all operations system inspections, route tions inspectors, the division is accomplishing checks covering non-type-specific elements, less than the minimum number of inspections [operators’ crew] training and ramp inspections. recommended by ICAO guidance material.” In They also review the work done by the desig- Oman, the civil aviation authority’s audit plan nated check pilots.” www.flightsafety.org | AeroSafetyWorld | August 2007 | 33 SAFETYoversight The civil aviation authority in inspectors to be absent from their in- and a government vehicle for surveillance Denmark said, addressing a related audit spection duties for long periods of time. and on-site inspections. In other states, finding, that “it would not be physically The operations inspectors in Switzerland the inspectors lacked long-distance tele- possible for the relatively few inspec- were authorized to maintain currency in phone service, Internet access, facsimile tors employed by a small unit … to be their pilot ratings within the industry by equipment, slope and distance measuring qualified and current in each aircraft type flying 20 percent of their working hours. equipment and photo/video cameras. used by the … operators.” The solution ICAO auditors also found, however, was a commitment by the civil aviation Procedures, Checklists and Training that a civil aviation authority’s acquisi- authority to adhere to SARPs and Joint Deficiencies in establishing proper tion of computer hardware, software Aviation Authorities procedures “as far as procedures for inspectors were promi- and Internet access by itself did not possible” and to “use adequately qualified nent in reports about some states. translate into adequate access to, or and authorized line check commanders, Auditors’ concerns about checklists also control of, essential technical materi- generated findings, such as: inspector als. They favored a dedicated techni- checklists that were not comprehen- cal library — digital, paper or both sive; inspectors conducting inspections — to quickly access material such as without any checklists; and use of mandatory continuing airworthiness unapproved checklists or job aids. information, master minimum equip- Some of the most comprehensive ment lists and manufacturers’ technical inspector training programs found by publications. auditors comprised initial indoctrina- The civil aviation authority of tion, on-the-job training, recurrent Iceland told ICAO that it “does not training, a pilot currency system, require nor have the necessary means advanced courses and detailed files of or resources to obtain, store and main- inspector training. Absence of such files tain current, technical documentation was noted for a number of civil aviation as detailed in the [audit] recommen- authorities, however. dation, except when design organiza- ICAO auditors also questioned tions can provide that data in digital the appropriateness of civil aviation format.” Instead, its practice was for authorities taking cues from operators inspectors to obtain information from © Chris Sorensen Photography© Chris on when to conduct inspections. “In an external organization — such as practice, inspections are conducted on an aircraft operator or maintenance an irregular basis or when requested by and repair organization — that is the industry,” said a report about Bah- required by law to maintain updated rain. “Any deficiencies identified during documentation. an inspection are handled informally.” The traditional method of airwor- This civil aviation authority could not thiness surveillance, sometimes called acceptable to [the civil aviation author- produce acceptable evidence of the “100 percent checking,” is being aban- ity], for specific type-related checks. … inspections, deficiencies or follow-up doned by some civil aviation authorities The minimum experience requirements, actions under this system. — with the endorsement of ICAO and which are identical for [civil aviation au- other international safety specialists — thority] inspectors and designated check Tools of the Trade in favor of SMSs. For example, noting pilots, are mandated by regulation.” Deficiencies in office facilities and the current environment of inspectors, In Hungary, agreements with airlines equipment also affected inspectors. For a USOAP audit report for Bulgaria said, enabled operations inspectors to fly a example, findings in the Marshall Islands “The regulatory staff rely extensively on minimum of 200 hours per year as line were addressed by purchasing a photo- prescriptive checklist methodology and pilots. But ICAO auditors also found copier, microfiche and microfilm reader, have not yet embraced and introduced that this arrangement required the mobile telephones, a laptop computer the broader regulatory audit regime, 34 | flight safety foundation | AeroSafetyWorld | August 2007 SAFETYoversight and concepts such as SMS, including risk assessment.” Top-Flight Practices USOAP audits also furnish insights about best practices and innovations. For example, the civil aviation authority’s inspection-activity database in Bulgaria consolidated “all the data, checklists and photographs collected by the inspectors during their audits and inspections, all aircraft and maintenance records, status © Chris Sorensen Photography of life-limited parts, checklists relating to renewals of certificates of airworthiness, The civil aviation authority in the of air operators, during which the ef- and records of certificates issued.” United Kingdom committed to a fully fectiveness of their reliability programs is The civil aviation authority in digital solution for its own documents, monitored. Consequently, the inspectors Finland based its inspector training plan introducing an Internet-based format are not informed of any degraded levels on one-year, three-year and five-year for its inspector’s manual with acces- of safety to justify any decision taken, [or] forecasts and factored in regionwide sibility to all staff. “No hard [printed] to initiate or impose special operational inspector training requirements. The copies (except for a master copy) have restrictions.” ● authority in the Czech Republic applied been published,” the report said. software to automate its process of The civil aviation authority in Austra- Notes requesting a corrective action plan from lia described to auditors how its con- 1. Scovel, Calvin L. III. “Aviation Safety: FAA an operator, monitoring implementation ventional inspection processes had been Oversight of Foreign Repair Stations.” and prompting inspectors to ensure that superseded by a “system safety analysis Testimony of the inspector general of the every corrective action item is cleared. approach” backed by comprehensive U.S. Department of Transportation before In Canada, the civil aviation author- training for flight operations inspectors. the Committee on Commerce, Science and Transportation; Subcommittee on ity built incentives for commercial “The [civil aviation authority cur- Aviation Operations, Safety and Security; aircraft operators into continuous rently] relies on a system where the prime U.S. Senate. June 20, 2007. This document airworthiness surveillance through a responsibility for airworthy aircraft re- describes changes occurring worldwide national program. “The certificate of mains with the owner-operator,” a report in the role of aviation safety inspectors, airworthiness remains valid as long about Sweden said. “Aircraft certificates of including the effects of conducting main- as all airworthiness requirements are airworthiness are renewed based on dec- tenance of large commercial jets outside their country of registry and the introduc- fulfilled and an annual airworthiness larations from maintenance organizations tion of safety management systems within information report is completed and in conjunction with random inspections, civil aviation authorities. signed by the owner or an authorized including spot-checking of [airworthiness delegated person and submitted,” the directives].” 2. When auditors from the Universal Safety Oversight Audit Program of the report said. “The audit is conducted As such shifts of responsibility to op- International Civil Aviation Organization within intervals of six to 36 months, erators occur under SMSs, the traditional identified inspector-related deficiencies covering all large commercial air trans- inspector role in some cases can expand within civil aviation authorities, they port operators and maintenance orga- to include on-site participation in risk typically referred to standards and recom- nizations and manufacturers as well analysis conducted by the operator. As a mended practices cited in Document as any approval holder … targeted as result, a new type of audit finding under 8335, Manual of Procedures for Operations Inspection, Certification and Continued high risk. The [program] also includes ICAO’s comprehensive systems approach Surveillance, and Document 9734, a follow-up of the findings identified has emerged. Auditors who assessed Bul- Safety Oversight Manual, Part A — The during the audit, which are required to garia, for example, said, “[Inspectors] are Establishment and Management of a State’s be [cleared] in the following two years.” not participating in the periodic meetings Safety Oversight System. www.flightsafety.org | AeroSafetyWorld | August 2007 | 35 in sight BY ODDVARD JOHNSEN Using performance data from landing aircraft Improving would eliminate current inaccuracies. Reports he accuracy of braking action there were no injuries. To the pilots, In December 2005, a Southwest reports can be improved substan‑ the landing had appeared to be normal Airlines Boeing 737 with 103 people tially by basing them on flight during the initial phase. It was not until aboard overran the runway at Chicago data derived from landing aircraft, just before they prepared to turn off the Midway Airport and struck two auto‑ researchT in Norway has shown. This runway — at a groundspeed of about 50 mobiles when it came to a stop on an technique could eliminate discrepancies kt — that they were caught by surprise off-airport road. Preliminary informa‑ between the braking action measured and by braking action that was described by tion indicates that the aircraft touched reported by airport personnel and the the captain as “nil.” The runway friction down fast and long, and that the thrust braking action actually experienced by measurement that had been provided to reversers were deployed only seconds flight crews, as in the following examples: the pilots on approach was five hours old before the aircraft left the runway. Al‑ In December 1999, a Premiair and had indicated that braking action though braking action had been report‑ McDonnell Douglas DC‑10‑10 with 399 was good. Special friction measurements ed as good, based on a runway friction people aboard was traveling at about 30 taken about 20, 30 and 40 minutes after measurement taken 30 minutes before kt when it overran the 2,950-m (9,679- the accident also indicated that brak‑ the accident, the pilots had used either ft) runway at Oslo International Airport ing action was good. The investigation a medium or maximum autobrake in Gardermoen, Norway. The airplane determined that these reports were setting. Less than 10 minutes after the came to a halt about 305 m (1,000 ft) “unrealistic.” The temperature was at accident, another friction measurement beyond the end of the runway. The freezing, and visibility was down to 800 was taken, and it too indicated that DC‑10 was moderately damaged, but m (1/2 mi) in drizzle and fog.1 braking action was good.2 36 | flight safety foundation | AeroSafetyWorld | August 2007 flightsafety.org flightsafety.org www Deceleration Factors Table 1 Source: Oddvard Johnsen,from Boeing (approximate) Airplane Mu braking report action Braking Relationship Between Braking Coefficients andReports Figure 1 Source: Oddvard Johnsen 2 . Deceleration (ft/second ) 10 12 14 0 2 4 6 8 11 51 92 32 72 13 537 35 33 31 29 27 25 23 21 19 17 15 13 11 9 7 5 3 1 | eroS A Brakes Thrust Reverse Drag a fety World World .802 .00.05 0.10 0.20 0.38 r odMdu/arPoor/Nil Medium/Fair Good Dry | A ugust 2007 ugust Seconds © D. Satyajit enough force to prevent the accident. and functioning properly, would have provided sued is whether the 737’s thrust reversers, if used until the final report on the Midway overrun is is‑ tance. A question that might remain unanswered a reverse thrust credit in calculating landing dis‑ performance computations ( ( manual (AFM) and the quick reference handbook in advisory material such as the airplane flight distances published by aircraft manufacturers to understand the fundamentals for the landing runway friction and braking action, it is important Before discussing the various methods of assessing Deceleration Factors n 2 illustrates dynamic the nature of The this. and airplane braking Mu. inFigure The curve braking between actionreports byoped Boeing Figure 2(p. 38)show relationships the devel‑ and reverse are thrust factored out. Table 1and level of deceleration, aerodynamic when drag ways an expression of an average sustainable measurement. Airplane braking Mu is inmany Aviation Organization (ICAO) for friction by samethe termused International the Civil braking Mu must, which not with confused be the factor that really counts. 60 to 50 kt; at these lower speeds, wheel braking is reverse thrust may be disregarded at speeds below run, for practical purposes, aerodynamic drag and influence performance throughout the landing thrust diminishes quickly. Although these factors Deceleration from aerodynamic drag and reverse landing run. These relationships are not constant. and relationship among these factors throughout a reverse and thrust braking. factors over that vary aerodynamic time: drag, stops. Deceleration comprises three major (deceleration) at any given until time aircraft the of maximum the available negative acceleration because itbecause differentiates airplane braking Mu QRH). AFM data are the foundation for on on-linearity of relationships the is important, Recent discussions have focused on the use of Aircraft manufacturers termairplane the use Figure 1 shows the approximate distribution Landing distance theoretically is afunction ASW , 2/07, p. 22). in ght s - board i | 37 insight from the commonly used ICAO terminology for Relationship Between Braking Coefficients and Reports mechanical braking-action testing devices. 0.40 Reference landing distances found in the QRH incorporate non-runway items such as aerody‑ namic drag and reverse thrust. The QRH does 0.30 not indicate how much each factor contributes to deceleration and, thus, landing distance; however, there are ways to estimate their contributions. 0.20 Table 2, for example, shows reference data for medium/fair braking action for the 737-700. After factoring out the air distance included Airplane braking Mu Airplane 0.10 in QRH landing distance values and a 15 percent safety margin, the net landing distance is 1,132 m (3,714 ft). By using the landing reference speed, Vref, and a full-stop configuration, we can derive Dry Good Medium Poor an estimated average deceleration for the landing Braking action report © D. Satyajit © D. run of about 0.19 g. By comparing this to cor‑ Source: Oddvard Johnsen, from Boeing responding airplane braking Mu for medium/fair, which is 0.10, we see that approximately 0.09 g Figure 2 is attributed to factors that are not dependent on the runway. The challenge is to extract the air‑ Reference Landing Distance, Boeing 737-700* plane braking Mu portion from a landing run. Landing distance per QRH 1,690 m Current Methods Air distance 305 m Current methodologies for assessing braking Safety margin 15% 253 m action can be broken down to the following Net landing distance 1,132 m major groups: visual/qualitative, subjective and Average deceleration for landing run 1.89 m/s2 mechanical. Average g force for landing run 0.19 g Table 3 is from Safety Alert for Operators Airplane, medium braking action 0.10 g (SAFO) 06012, Landing Performance Assessments Deceleration attributed to aerodynamic drag, 0.09 g at Time of Arrival (Turbojets), issued by the U.S. reverse thrust, etc. Federal Aviation Administration (FAA) on Aug. QRH = quick reference handbook 31, 2006. It illustrates how qualitative braking *Medium/Fair braking action action reports are related to runway contami‑ Source: Oddvard Johnsen nants. Today, we know that simple descriptions of Table 2 contaminants do not easily convert into braking action. There are a Relationship Between Braking Action Reports and Runway Contaminants multitude of factors influencing braking ac‑ Dry (not Braking Action reported) Good Fair/Medium Poor Nil tion, such as the status of the runway micro Contaminant None Wet Packed or Wet snow Wet ice Dry snow (< 20 compacted Slush texture and the weather snow mm) Standing water history, to mention a Ice few examples. Source: U.S. Federal Aviation Administration The subjective method is simply pilot Table 3 reports. The pilot’s 38 | flight safety foundation | AeroSafetyWorld | August 2007 insight assessment of braking action is a personal judg‑ Relationship Between Runway Friction Measurements ment that is influenced by a number of factors; and Braking Action Reports given the same conditions and aircraft, two pilots likely will judge the conditions differently. Vari‑ Measured Coefficient Estimated Braking Action Code ous factors affect the pilot’s perception. Braking 0.40 and above Good 5 action on a long runway, for example, might 0.39 to 0.36 Medium to good 4 be perceived as better than braking action on a 0.35 to 0.30 Medium 3 shorter, marginal runway where the end seems to 0.29 to 0.26 Medium to poor 2 approach substantially faster. A pilot with experi‑ 0.25 and below Poor 1 ence in harsh winter conditions will most likely Source: Oddvard Johnsen, from International Civil Aviation Organization judge braking action to be better than a pilot with Table 4 little experience in such conditions. Particularly in Northern Europe and North substantially different effects on a light turboprop America, airports use various types of mechani‑ airplane compared with a heavier and faster jet. cal devices to measure runway friction. Although We also know that snow contaminants can the devices produced by different manufacturers produce considerably different degrees of “slip‑ vary somewhat in design, they all follow the basic periness” in one geographic region, compared principle of braking a wheel against the pavement with another. One factor is the salt content of the at a constant ratio and at a constant speed. The environment; qualitatively, the same contaminant friction scale begins at 0 and goes to 1. ICAO produces a different slipperiness in a coastal envi‑ has assigned measured coefficients to braking ronment than in an inland environment. action estimates (Table 4). Although there is no correlation to airplane braking action — and Little Progress aircraft manufacturers state that the coefficients Because of the complex interactions among should not be confused with airplane braking Mu ambient factors, as well as their interactions — these numbers are still applied as a foundation with various elements of aircraft dynamics, a for in-flight performance analysis. definitive determination of braking action is In particular, the visual/qualitative and impossible. The current methods of assessing mechanical methods are applied in a uniform braking action are indirect. With the exception manner, regardless of aircraft type. However, we of subjective pilot reports, none of the methods know that the same ambient conditions can have actually uses the aircraft as a reference. © Morten Nelson A Braathens 737-700, like the one shown here, was used in braking performance information tests in Tromsoe, Norway. 39 | www.flightsafety.org | AeroSafetyWorld | August 2007 | 39 insight Furthermore, there has been little derived than the methods used today. systems harmonized to a set of prede‑ or no progress in the development of Furthermore, it uses the dynamic scale termined aircraft groups. effective measures to improve the quality of airplane braking Mu, which is the Commercial aviation safety no longer of information associated with operat‑ foundation for aircraft performance depends on pilots’ local knowledge, ing on contaminated runways. Although advisory information found in the experience and intuition; we are now in effort and resources have been devoted QRH/AFM. a digital world with “boxes” to be filled. to national and international programs Using aircraft data to calculate The result is that inaccuracies are ampli‑ to improve the understanding of braking braking action is a more objective and fied when runway conditions are critical. action, practical results have been few. consistent method. Today, data can be There is no quick fix, but by using the ap‑ The work that has been done has transmitted more easily from aircraft propriate tools and making use of today’s failed for several reasons, primarily after landing — for example, via a ability to acquire, compute and transfer because it has been stuck to “old tracks” data link or wireless ground link. The data worldwide in an instant, it is possible without renewed thinking. The approach frequency at which braking action in‑ to counter the trend of increased runway has been too academic, with little under‑ formation is collected — a function of excursions. ● standing of actual airline operations. the number of aircraft landing — also A retired airline captain, Oddvard Johnsen has is much greater than the intermittent served for the past 35 years as an advisor to the Tromsoe Experience methods currently used. Norwegian AAIB on runway conditions and In 1999, I was assigned by the Norwe‑ installations. He is a former vice chairman of gian Aircraft Accident Investigation Grouping Data the International Federation of Air Line Pilots’ Associations (IFALPA) Airworthiness Study Board (AAIB) to serve on the team The tests at Tromsoe pertained only to Group and participated in the Halla Banor formed during the investigation of the the 737‑700, and the results were devel‑ (Slippery Runways) Program, conducted by Premiair DC‑10 accident to examine oped with reference to Boeing advisory IFALPA and the Aeronautical Research Institute the ability of modern aircraft to provide material, including the definitions of Sweden in the 1970s. Johnsen also par- essential braking action information. of airplane braking Mu and braking ticipated in the Joint Winter Runway Friction The test program involved the collec‑ action. Similar reference material has Measurement Program, conducted by the FAA and Transport Canada in the 1990s. tion of flight data from 2000 through not been analyzed for other types of 2005. The tests were conducted with a aircraft. Notes Braathens 737‑700, and the bulk of the The founding principle for cur‑ information was collected at the Trom‑ rent braking action reports is that 1. Norwegian Aircraft Accident Investigation Board report no. 5/2001, Report of Aircraft soe airport in northern Norway, where they should apply to all aircraft types. Accident at Oslo International Airport, winter conditions are common. Flight data calculations, however, must Gardermoen Runway 19L, December 6, Among the results of the tests and conform to the basic data in the AFM/ 1999. Pertinent portions of the report subsequent analyses was a method to QRH. We know that the same ambi‑ were translated into English by Oddvard derive airplane braking Mu from flight ent conditions can provide different Johnsen for ASW. data after a landing run. This method braking action for two different aircraft. 2. U.S. National Transportation Safety Board uses the aircraft as a reference and essen‑ However, it would be impractical and preliminary report no. DCA06MA009; tially factors out the aerodynamic drag cumbersome to develop a reference sys‑ Aviation Safety Network 40 | flight safety foundation | AeroSafetyWorld | August 2007 © Basslinefx/Dreamstime.com and Mateusz Skalski/iStockphoto.com BY SHARON D. MANNING AND CLARENCE E. RASH E. CLARENCE AND MANNING D. SHARON BY designed toprovide informationandflightguidance. Head-up displaysare pavingthewayforhead-worn A MoveableView additional and cues flight indicators. guidanceflight systems by providing ment displays but play also role the of duplicate information the on instru — are like HUDs inthat not they only as helmet-mounted displays (HMDs) military,in the whereare they known head-worn displays (HWDs). developments in flight deck technology: what many believe will be one of the next A www. HWDs since 1980s the —inuse flight researchers are looking toward in commercial jets worldwide, ually become standard equipment s head-up displays (HUDs) grad sa f e t y.or g | AeroS a fety W or l d d | | A u g us - t 2007 2007 - the HUD design is moved from the conditions. during low visibility takeoff and landing pilots with greater situational awareness — advanced vision systems that provide (EVS) and synthetic vision systems (SVS) increased use of enhanced vision systems look-around capability opens the way for information that HWDs provide. This without losing sight of the head-up flight of vision, enabling them to look anywhere lots an almost unlimited see-through field The most significant is that they give pi But HWDs have unique advantages. In HWDs, the reflective surface of 1 - components: binocular applications. of the eyes, with both monocular and visor or a beam-splitter located in front and imagery are projected onto either a military HMDs, the flight information attached to some form of headgear. In also enabling see-through vision — is optical device that reflects imagery while accomplish this, the beam-splitter — an eyes — or often in front of one eye. To splitter” located in front of a pilot’s ed inside the windshield to a “beam- transparent glass or plastic plate mount An HWDhas four basic the aircraft. while lookingoutside information insight to keepflight will enablepilots displays Head-worn FLIGHT tech - | 41 © Airbus FLIGHTtech Helmet-mounted displays — military precursors of head- worn displays — have been used for years by pilots in the armed forces. © U.S. Air Force © U.S. • A mounting platform, which can be as in the same direction or to select SVS data simple as a headband or as sophisticated as that correlates with the pilot’s line of sight. a full flight helmet. In addition to serving Presentation of FLIR or synthetic imag- as an attachment point, it must provide the ery requires a preflight procedure called stability to maintain the critical alignment boresighting, which aligns the sensor’s line between a pilot’s eyes and the HWD view- of sight with the pilot’s line of sight. ing optics; As with standard HUDs, HWDs can present vir- tually any type of informational format: numeri- • An image source for the information cal data, such as altitude and airspeed values; imagery that is optically presented to the pictorial or color symbols; maps; and video in- pilot’s eyes. Advances in miniature displays formation.2 The first three formats currently are have produced a wide selection of small, more common, but the video format is expected lightweight and low-power choices at to become popular because of the increasing moderate cost, while meeting the demands availability of EVS and SVS imagery. of high luminance and resolution; Advantages of HWDs • Relay optics, which relay to the eyes the HWDs offer all of the advantages of HUDs, information produced by the image source. including — most importantly — increased situ- Relay optics typically consist of multiple ele- ational awareness. By centralizing critical flight ments, usually lenses. The last element is the information within a pilot’s line of sight, operation- beam-splitter. Initial designs for commercial al safety is enhanced. Transitioning from heads- aviation are expected to be monocular with down instrument flight to visual flight can be the beam-splitter in front of one eye; and, problematic. As with all HUDs, however, HWDs offer pilots the advantage of monitoring critical • A head-tracker, which is optional if the aircraft status data without having to repeatedly HWD is used only to present informa- look down to scan flight instrument displays. tion with symbols but required if EVS and Another proven benefit of HUDs, and also SVS imagery is to be presented. With this of HWDs, is that, with the ability to keep their equipment, the pilot’s directional line of eyes fixed to the outside world, pilots are more sight must be recalculated continuously likely to detect important changes within the and used to point the sensor in the EVS field-of-view3 — an advantage important in © Maxim Pimenov/iStockphoto.com forward-looking infrared (FLIR) camera identifying runway incursions. 42 | flight safety foundation | AeroSafetyWorld | August 2007 FLIGHTtech © U.S. National Aeronautics and Space Administration National Aeronautics © U.S. Potential Problems lem can be reduced by keeping the number of Head-worn displays Most of the disadvantages of HWDs are well symbols presented to a minimum and within are likely to make it known because they are common to all HUDs. the recommended size. Reducing the clutter easier to make use First is the phenomenon of “attention capture” caused by too many symbols also can decrease of advanced vision — or tunneling — which is the unwanted the potential for attention capture. systems that enhance tendency for pilots to pay too much attention to In addition to these general HUD-related pilots’ situational the HUD and not enough attention to events in disadvantages, other concerns are unique to awareness during their field of vision outside the airplane.4,5 HWDs — and unique to the concept of mount- takeoffs and landings Attention capture with HUDs mounted just ing the display to the head. The first of these in low visibility.. inside a windshield has been blamed for unde- is user acceptability, which is important when tected runway incursions — one of the types any new technology is introduced; without user of events that HUDs are intended to prevent. acceptance, the technology will not be used. The Numerous studies have attempted to understand primary factors affecting acceptance are the head- attention capture and how it can be mitigated. supported weight, center-of-mass offset, required Most disturbing is a developing consensus that modification in head movement and display lag. HUDs limit a pilot’s ability to simultaneously Many pilots are not accustomed to wearing process information derived from HUDs and more than a headset on their heads. Current from the real world.6 headsets are generally lightweight, typically 12 Most HUD symbols are not “conformal” to 18 oz (340 to 510 g).9 HWDs will increase — that is, they are not overlaid in a one-to-one head-supported weight by at least 16 oz (454 g). relationship to match shapes and features in the Because the HWD’s display source and optics real world. Therefore, the HUD symbols are must be placed in front of the eye, the HWD’s perceived as different from the scene outside an added weight will be above and forward of the hu- aircraft’s windows. This causes pilots to delib- man head’s natural center of mass — a factor that, erately shift their attention to view either the as a flight progresses, may result in muscle fatigue. symbols or the outside scene. The transition to For HWDs to present FLIR and synthetic conformal symbology may mitigate the atten- imagery that represent what a pilot is seeing, tion capture problem.7 This conformity must be the HWD must incorporate head-tracking. The required for video imagery presented in HWDs. need for head-tracking increases the cost and A second disadvantage is the possibility that the complexity of HWDs. HUD symbols or other imagery could obscure The head-tracking process of determining critical objects in the outside scene.8 This prob- the pilot’s head position, relaying this position VanDetta/iStockphoto.com © Dylan www.flightsafety.org | AeroSafetyWorld | August 2007 | 43 FLIGHTtech to the sensor, the sensor’s movement Symptoms typically arose during the 3. Harris, D.; Muir, H. (Editors) to the correct line of sight, the sensor’s first HWD trial and worsened over time. Contemporary Issues in Human Factors acquisition of the scene, and transmitting and Aviation Safety. Burlington, Vermont, and presenting the final imagery on the The Future U.S.: Ashgate Publishing. 2005. 10 HWD takes time. This time is called HWDs will be required if pilots are to 4. Foyle, D.C.; McCann, R.S.; Sanford, B.D.; system latency. Latency times are typically take full advantage of EVS and SVS Schwirzke, F.J. “Attentional Effects With hundreds of milliseconds. The largest advanced vision systems. However, Superimposed Symbology: Implications for contributor is the “slew rate” of the sensor, HWDs are not problem-free and will Head-Up Displays.” In Proceedings of the or the time for the sensor to move to the face pilot acceptance issues. Their Human Factors and Ergonomics Society 37th Annual Meeting. Santa Monica, California, new head position. Studies have shown implementation ultimately may be U.S., Volume 2, pp. 1350–1354. 1993. that total system-latency times approach- determined by whether they make ing one-third of a second or longer (300 flight tasks easier and safer by reducing 5. McCann, R.S.; Foyle, D.C.; Johnson, J.C. “Attentional Limitations With Head- or more milliseconds) are unacceptable workload and improving safety. Up Displays.” In Jenson, R.S. (Editor), from a performance standpoint. The debut of HWDs into commer- Proceedings of the 7th International These latency times have been cial jet aviation will be easier than the Symposium on Aviation Psychology. blamed for motion sickness. The onset introductions of many previous technolo- Columbus, Ohio, U.S.: Ohio State and severity of motion sickness symp- gies. The military has been using HMDs University, pp. 70–75. 1993. toms are difficult to predict, and such oc- for almost three decades and already has 6. Ibid. currences in commercial aviation would resolved most of the technical, ergonomic 7. Wickens, C.D.; Long, J.L. “Conformal be unacceptable. Studies by the U.S. Na- and human factors issues associated with Symbology, Attention Shifts, and the tional Aeronautics and Space Administra- their design, manufacture and use. ● Head-Up Display.” In Proceedings of the Human Factors and Ergonomics Society tion (NASA) have documented the need Sharon D. Manning is a safety and occupational 38th Annual Meeting, Human Factors for improvement in image alignment, health specialist at the Aviation Branch Safety and Ergonomics Society. Santa Monica, accuracy and bore-sighting of HMDs to Office at Fort Rucker, Alabama, U.S., and has California, U.S.: Human Factors Society, 11 more than 15 years experience in aviation safe- help mitigate this problem. Volume 2, pp. 1350–1354. 1994. ty. Clarence E. Rash is a research physicist at the Taxiing Tests U.S. Army Aeromedical Research Laboratory at 8. Foyle; McCann; Sanford; Schwirzke. Fort Rucker with more than 25 years of experi- 9. Rash, C.E. “Shutting Out the Noise.” Under NASA’s Aviation Safety Program ence in aviation safety, operational performance AviationSafetyWorld Volume 1 (November (AvSAFE), various HUD types and data and human factors issues. 2006): pp. 42–45. formats are being evaluated for improve- Notes ment of commercial aircraft taxi opera- 10. Rash, C.E. (Editor) Helmet-Mounted Displays: Design Issues for Rotary-Wing tions.12 In a recent study, experienced 1. An enhanced vision system (EVS) is a sen- Aircraft. Bellingham, Washington, U.S.: sor system that extends the visual range commercial flight crews evaluated two SPIE Press. 2001. of pilots — for example, in darkness, fog, HWD concepts and a baseline head- smoke or haze. The U.S. Federal Aviation 11. Bailey, R.; Arthur III, J.; Prinzel III, L.; down display for acceptance and us- Administration (FAA) uses the term Kramer, L. “Evaluation of Head-Worn ability. In the study, pilots compared the enhanced flight vision system (EFVS) to Display Concepts for Commercial three configurations while performing a describe a sensor system used in combina- Aircraft.”Proceedings of SPIE, Volume series of taxi scenarios at O’Hare Inter- tion with a head-up display to enable an 6557, pp. 65570Y-1 to 16. 2007. aircraft to be landed in situations involving national Airport in Chicago. All of the 12. Ibid. low visibility. A synthetic vision system taxiing tasks involved exiting the runway (SVS) uses databases containing terrain, and taxiing to the airport terminal area. obstacle-clearance and runway informa- Further Reading From FSF Publications Participating pilots described the tion to provide pilots with a computerized Donoghue, J.A. “A Clear View at HWDs as easy to use. They found no three-dimensional view of the area sur- Farnborough.” AviationSafety World Volume 1 difference in workload between head- rounding their airplane. (September 2006). down designs and HWD designs. 2. Sanders, M.; McCormick, E. Human FSF Editorial Staff. “Head-Up Displays in Civil However, motion sickness was reported Factors in Engineering and Design. New Aviation: A Status Report.” Flight Safety Digest by 25 percent of the participating crews. York: McGraw-Hill. 1993. 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Consulting (Transport System El Al Israel Airlines Corporate Netherlands Blue Panorama Airlines Advisory Services) Emirates Aerobytes NAVIAIR Blue1 Saferflight Etihad Airways DaimlerChrysler Aviation National Aerospace Laboratory–The Superstructure Group Cimber Air Netherlands Gulf Air Dasnair Cirrus Airlines Netherlands Civil Aviation Authority Individuals Iran Air Dunell Aviation International CityJet Iraqi Airways Norway Civil Aviation Authority Nuno Aghdassi BinterCanarias Matton, Inc., Images © Getty Eurojet Holdings Corsair Poland Civil Aviation Office Angel Arroyo Kuwait Airways Jetflite Eastern Airways Bart Bakker Libyan Arab Airlines NATS RAF Centre of Aviation Medicine–UK easyJet John Barrass Middle East Airlines–AirLiban Netjets Transportes Aereos Royal Norwegian Air Force Eurowings Luftverkehrs Michael Chamberlain Midwest Airlines PrivatAir–Switzerland STK Skandinavisk Tilsynskontor Falcon Air Nicolas Charlemagne NetJets Middle East Rabbit-Air Statens Haverikommission First Choice Airways Swedish Civil Aviation Authority Gennadily Cosí Oman Air Helios Airways Charter U.K. Civil Aviation Authority Tom Curran Pakistan International Airlines Hellas Jet Mediterranean Aviation Co. VERVOER-BEDRIJFSERKENNING– Katia DeFrancq Palestinian Airlines Hemus Air Zimex Aviation Belgium J. de Lange Qatar Airways 48 | flight safety foundation | AeroSafetyWorld | august 2007 FoundationFocus Royal Flight of Oman Individuals James Attoh Asia & Pacific Singapore Airlines Cargo Royal Jordanian Airlines Shabnam Kinkhabwala Raymond Barske Airlines TransAsia Airways Saudi Arabian Airlines Jacobus H. de Jager Xiamen Airlines P.K. Misra Air China International Corp. Sri Lankan Airlines Capt. Ananthakrishnan Ranganathan Air Koryo Helicopter Syrianair Australia & Air Macau Aero Asahi Corp. Tunisair Africa New Zealand Air Marshall Islands Yemenia, Yemen Airways Airlines Airlines Airports Air Niugini PT(Persero) Angkasa Pura II Aero Zambia Air New Zealand Regional Airlines Air Pacific AfriJet Airlines BHP Billiton Manufacturers C.A.L. Cargo Airlines Air Tahiti Nui Iran Aseman Airlines érie Qantas Airways Ishikawajima-Harima Heavy Air Vanuatu Industries Co. Israir Airline and Tourism Air Botswana Low Cost Carriers AirAsia Kish Air Air Gabon Corporate Virgin Blue Airlines Airfast Indonesia, PT Mahan Airlines Services Co. Air Madagascar Samsung Techwin Co. All Nippon Airways Trans Mediterranean Airways Air Malawi Regional Airlines Asiana Airlines Academia Air Mauritius Air Nelson Helicopter Biman Bangladesh Airlines Air Force Academy, Education & Air Namibia Cobham Flight Operations & Services Training Center for Aviation Safety Petroleum Air Services (Australia) Cathay Pacific Airways Air Senegal International Aletheia University China Airlines Manufacturers Air Seychelles Helicopter Hanseo University China Cargo Airlines Israel Aircraft Industries Air Tanzania Co. Telstra Childflight Institute of Transportation, MOTC Sirocco Aerospace International Air Zimbabwe China Eastern Academia China Southern Airlines Government/CAAs Corporate Cameroon Airlines Raaf College Library Dragonair Brunei Department of Civil Aviation Saudi Aramco Commercial Airways Civil Aviation Authority of Singapore Ethiopian Airlines RMIT Carlton (TAFE) Library EVA Airways Corp. Charter General Administration of Civil Inter Air Trace University Far Eastern Air Transport Corp. Jordan Aviation Airlines Aviation of China, Center of Aviation Kenya Airways University of New South Wales Garuda Indonesia Safety & Technology National Air Services Liñhas Aeréas de Moçambique Government/CAAs Hainan Airlines Co. Hong Kong Civil Aviation Department Royal Jet JAL Express Precision Air Services Airservices Australia Republic of Korea Air Force Academia JALways Co. Royal Swazi Australia Civil Aviation Safety Republic of Singapore Air Force Egyptian Aviation Academy– EAA Rwandair Express Authority Japan Airlines International Taiwan Civil Aeronautics M&M Aviation Consultancy Safair Australian Directorate Defence Japan Asia Airways Administration Government/CAAs Sierra National Airlines Aviation & Air Force Safety Korean Air Aviation Associations Australian Transport Safety Bureau Air Force Academy–Dundigal, India Solomon Airlines MIAT Mongolian Airlines Air Line Pilots Association–Singapore Defence Library Service–Albatross Amiri Flight–Abu Dhabi Sudan Airways Malaysia Airlines Association of Asia Pacific Airlines Defence Library Service–Canberra DGCA–Director General of Civil South African Airways Mandarin Airlines Association of Air Transport Aviation, India TAAG–Linhas Aereas de Angola Defence Library Service–Oakey Nippon Cargo Airlines Engineering & Research–Japan Egyptian Meteorological Authority Tassili Airlines Defence Library Service –Williams Philippine Airlines Aviation Safety Council International Airport Projects–Saudi Virgin Nigeria Airways Department of Transport & Regional Polynesian Airlines Flight Safety Foundation–Taiwan Arabia Services–Australia Royal Brunei Airlines Japan Aeronautical Engineers’ Kuwait Directorate General of Civil Regional Airlines New Zealand Civil Aviation Authority Association Shanghai Airlines Aviation Air Gemini New Zealand Civil Aviation Authority Japan Aircraft Pilots Association Shenzhen Airlines Individuals Bellview Airlines –Librarian Information Services Polyspring Enterprises Co. Simrik Air Dr. Montaser Fayek El-khaldy Nationwide Airlines New Zealand House of Representatives Singapore Airlines Individuals Mustafa Fetouri SA Airlink New Zealand Transport Accident Thai Airways International Lo Sheng-Chiang Shabnam Kinkhabwala Zambian Airways Investigation Commission Turkmenistan Airlines Yea Fuh Hwang Kamal C. Mututantri Corporate Aviation Associations Vietnam Airlines Lee Chi Lien Narinder Pal Yadav Anglo Operations Australian Federation of Air Pilots Robin Low Charter Regional Airlines India Aviation Safety Foundation–Australia Tashi Phuntsho Solenta Aviation (Pty) Air Caledonie Airlines Flight Attendants’ Association Hiroshi Sogame Sonair Air Japan Co. Air India Minseok Song Individuals Air Nippon Co. Indian Airlines Government/CAAs Jun Sato Richard Bucknell Air Tahiti Kingfisher Airlines Ghana Civil Aviation Authority John Trevett Robert Courtenay Bangkok Airways Sahara Airlines South African Civil Aviation Authority Steven Khoo Hock Yew James Harris Japan TransOcean Air Wang Yi-Fen Regional Airlines Aviation Associations Richard Hodge Phuket Airlines Jet Airways Air Traffic Navigation Services David McBrien Shandong Airlines Aviation Associations Individuals David Platten Sichuan Airlines © Elena Korenbaum/iStockphoto, NATS, Getty Images Inc. NATS, Korenbaum/iStockphoto, © Elena Skycare Aviation Safety Society Olumide Aiyegbusi David George Prior SilkAir www.flightsafety.org | AeroSafetyWorld | august 2007 | 49 DataLink Cold Comfort in Accident Reports Antihistamines used by pilots for relief from colds or allergies were associated with 338 fatal U.S. civil aviation accidents in a 16-year period. By Rick Darby here was an increasing trend in the use of — hereafter called, for simplicity, antihistamines a certain class of antihistamines — which — in the remains of pilots in fatal accidents.2 The Tcan cause sedation and impair cognitive researchers examined the U.S. Federal Aviation function — among U.S. civil aviation pilots Administration Civil Aerospace Medical Institute killed in accidents during the 1990–2005 period, (CAMI) Toxicology Database for reports indicat- according to a new study.1 Ninety percent of the ing the association of antihistamines, sometimes accidents occurred in general aviation opera- combined with other drugs or alcohol, with pilot tions, and the analysis suggests that pilots have fatalities during the 16-year study period. Only disregarded warnings. the records for pilots-in-command — no copilots Antihistamines, usually consumed in the or first officers — were studied. form of tablets or capsules, are drugs used to Of 5,281 fatal accidents from which results alleviate symptoms of allergy and the common of a post-mortem examination were recorded cold. They are typically sold “over the counter” in the database, there were 338 accidents in as nonprescription medicines, but some for- which the pilots’ remains indicated the pres- mulations are marketed as prescription drugs. ence of antihistamines. Of the 338 accidents, “The first-generation antihistamines have 304 (90 percent) were general aviation acci- been reported to be associated with signifi- dents.3 Table 1 shows the breakdown according cant sleepiness and impaired performance on to operational type. flight tasks, resulting in slowed reaction times, Of those 338 pilots who tested positive for memory difficulties and impaired vigilance,” antihistamines, the certificates held included 175 the report says. private pilot, 88 commercial, 48 airline transport The study considered the presence of 13 pilot, 20 student, and one non-U.S. type; six of the most commonly used first-generation were non-certificated. Among the 88 commer- antihistamines known as H1 receptor antagonists cial pilots, 72 were conducting general aviation 50 | flight safety foundation | AeroSafetyWorld | August 2007 DataLink Operational Category Distribution Fatal U.S. Civil Aviation Accidents Reported in CAMI Toxicology Database, 1990–2005 Antihistamine-Related Operational Category Aviation Accidents Pilot Fatalities Pilot Fatalities General aviation (FARs Part 91) 4,734 4,655 304 Air taxi and commuter (FARs Part 135) 271 265 15 Air carrier (FARs Part 121) 27 20 1 Agricultural (FARs Part 137) 157 157 8 Rotorcraft (FARs Part 133) 30 29 2 Ultralight vehicle (FARs Part 103) 47 47 4 Public use 69 66 2 Other categories 48 42 2 Total 5,383 5,281 338 CAMI = U.S. Federal Aviation Administration Civil Aerospace Medical Institute FARs = U.S. Federal Aviation Regulations Notes: Includes fatal accidents of registered and unregistered aircraft from which post-mortem biological samples were submitted for toxicological evaluation. Because only toxicological results of the pilot-in-command were considered in each accident, the number of antihistamine- related pilot fatalities equals the number of accidents. Source: U.S. Federal Aviation Administration Table 1 operations, five air taxi and commuter opera- which the use of antihistamine(s) was deter- tions, seven agricultural operations, one helicop- mined to be the cause of the accidents. In one ter operation, two public use operations, and one pilot fatality [among the 63], only one antihista- was classified “other.” Among the 48 airline trans- mine was found. However, other drugs and/or port pilots, 35 were conducting general aviation ethanol [alcohol] were also present in 12 fatali- operations, 10 air taxi and commuter operations, ties. Of these, five had two antihistamines and one air carrier operation, one agricultural opera- one had three antihistamines. tion, and one helicopter operation. “In 50 accidents, the use of antihistamine(s) Thirty-five of the 338 pilots held first-class was determined to be a contributing factor. This medical certificates, 107 second-class medical group of accidents entailed seven fatalities in certificates and 182 third-class medical certifi- which only one antihistamine was found.” cates. The other pilots did not have medical The antihistamine-involved pilot fatalities certificates. as a percentage of total pilot fatalities during Of the 338 pilots, 94 had consumed only one the 16-year period “clearly suggested a steady “The use of the antihistamine, but 244 tested positive for at least increase in the number of fatalities with antihistamine(s) two types of antihistamine, other drugs, alcohol these medications,” the report says (Figure 1, or a combination of those substances (Table 2, page 52). “For example, the antihistamine- by pilots was page 52). Other drugs identified by the toxicol- associated fatalities/aviation accidents were ogy reports included amphetamines, analgesics approximately 4 [percent] and 11 percent in determined to be (narcotic and non-narcotic), antidepressants, 1990 and 2004, respectively.” The difference barbiturates, benzodiazepines, cardiovascular in the percentages of antihistamine-associated the probable cause medicines, cocaine and several others. accidents by years was statistically significant or a contributing “The use of the antihistamine(s) by pilots (p < 0.001). was determined to be the probable cause or a “Pilots are not only cautioned for the medical factor in 63 of the 338 contributing factor in 63 of the 338 accidents,” conditions that might interfere with flight safety, the report says. “There were 13 accidents in but also against the potential impact of some accidents.” www.flightsafety.org | AeroSafetyWorld | August 2007 | 51 DataLink Double Trouble warning users against activities involving motor Antihistamines and Other Substances Involved in 338 Fatal skills, such as operating a vehicle or machinery. U.S. Civil Aviation Accidents, CAMI Toxicology Database, 1990–2005 However, patients — including aviators — do not appear to take these warnings seriously.” ● Substance(s) Pilot Fatalities One antihistamine 94 Notes Two antihistamines 9 1. U.S. Federal Aviation Administration Office of One antihistamine plus drugs and/or alcohol 209 Aerospace Medicine, Civil Aerospace Medical Two antihistamines plus drugs and/or alcohol 25 Institute. “First-Generation H1 Antihistamines Three antihistamines plus drugs and/or alcohol 1 Found in Pilot Fatalities of Civil Aviation Accidents, Total 338 1990–2005.” DOT/FAA/AM-07/12. May 2007. CAMI = U.S Federal Aviation Administration Civil Aerospace Medical Institute 2. Another class of antihistamines, known as second- Note: Includes only pilots-in-command, tested post-mortem. generation H1 antagonists, is considered to cause no Source: U.S. Federal Aviation Administration sedative effect or cognitive impairment. Some of the second-generation drugs are approved by aeromed- Table 2 ical authorities. 3. Because the data were accident-dependent, no drugs, even when pilots feel better by taking conclusions can be drawn about how frequently an- them,” the report says. “Among these drugs, the tihistamines were used by pilots in general aviation most important are the ones that alter CNS [cen- compared with pilots in other types of operations. tral nervous system] functions. Although [anti- histamines] are not CNS-specific drugs, as such, Further Reading From FSF Publications they have major side effects on the CNS. Because Mohler, Stanley R. “Allergy Symptoms May Interfere of this very reason, the package labeling of these With Pilot Performance.” Human Factors & Aviation medications contains precautionary statements, Medicine Volume 48 (September–October 2001). Trending Higher Percentage of Fatal U.S. Civil Aviation Accidents Involving Antihistamine, CAMI Toxicology Database, 1990–2005 12 10 8 6 4 Antihistamine-involved Antihistamine-involved 2 fatal accidents/pilot fatalities (%) fatalities accidents/pilot fatal 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Year CAMI = U.S. Federal Aviation Administration Civil Aerospace Medical Institute Source: U.S. Federal Aviation Administration Figure 1 52 | flight safety foundation | AeroSafetyWorld | August 2007 InfoScan Decision Management The vast amount of information available to today’s decision makers is being studied to find out how it can be optimally used. BOOKS book considers its application in several fields. A number of them by various contributors are Decision Making in Complex Environments relevant to aviation. Examples of those chapters Cook, Malcolm; Noyes, Jan; Masakowski, Yvonne (editors). include the following, with brief samples of Ashgate: Aldershot, England, and Burlington, Vermont, U.S., 2007. observations made in them: 458 pp. Figures, tables, references, index. • “Human Information Processing Aspects of ecision making is not what it used to be. It’s a Effective Emergency Incident Management great deal more complicated. In our globalized, Decision Making”: “Effective incident com- technologically linked world, information is D manders functioned as if they had a good constantly changing and increasing almost faster practical understanding of the limitations than anyone can keep up with it. Decisions tend to of their information processing system. … affect more people in a larger sphere of influence. They had developed a rich network of deci- “Today, we are inundated with a plethora of sion rules organized in schemas [tentative information, e-mails and ever-changing software,” internal representations of the outer world] Masakowski says. “It is imperative that we master which enabled them to use, mostly, fast, the critical components of knowledge manage- rule-based, robust recognitional decision ment and decision making that will enhance and processes rather than slow, vulnerable, empower the individual and/or nation.” knowledge-based analytical problem solv- Automation, as usual, has both helped and ing processes, which involve heavy demand created its own concerns. “There has been [on] working memory capacity.” significant progress made in the development of technologies that serve to modify data, reduce • “Air Traffic Controller Strategies in Hold- the clutter and present information/knowledge ing Scenarios”: “The difference in pattern in a manner in keeping with human information matching [of two randomly selected control- processing,” Masakowski says. “However, there is ler groups in an experiment] highlighted still a need to be aware of the trade-offs involved one of the main differences between the between the human decision maker and those au- sequencing of simple or complex traffic tomated technologies that support their decision flows. The controllers sequencing the simple maker. Currently, we are faced with an abundance traffic flow mainly ordered the traffic ac- of information that challenges our attention and cording to patterns of traffic in a plan view. cognitive capacities, as well as placing increased The controllers viewing the complex traffic demands on time management.” flow considered the flight level of the aircraft Besides several chapters on general char- more important and sequenced traffic ac- acteristics of complex decision making, the cording to the vertical view of the aircraft.” www.flightsafety.org | AEROSafetyWorld | August 2007 | 53 InfoScan • “The Flight Deck of the Future: Field Stud- issues,” the report says. “Several of the analysts ies in Data Link and Free Flight”: “Data were involved in clustering these into a set of link has the potential to offer the ‘perma- comprehensive safety culture elements.” nence’ of information in a way that buffers Safety culture elements, which were also the vulnerability of working memory. This categorized into sub-elements, comprised would allow air traffic control officers to “safety management commitment,” “trust in devote their cognitive resources to other organizational safety competence,” “involvement demanding cognitive tasks, for example, in safety,” “ATCO [air traffic controller] safety solving conflicts and so on.” competence” and “a just, reporting and learning culture.” Analyzing statements extracted from • “The Flight Deck of the Future: Perceived the interviews, the researchers found examples Urgency of Speech and Text”: “From the of practices that “enable” or “disable” safety findings it is clear that both speech and culture in each sub-element. text commands in expected or unexpected For example, in the sub-category of “com- situations have their relative merits. It munication about changes,” disabler examples in- is likely that in routine, low-workload clude “new procedures are issued by staff notice”; communications, such as a request for a “there is only one accessible computer with the change in [altitude] as stated on the flight information and no verification that controllers plan, the use of data link could avoid er- understand”; and “people sometimes forget to do rors that may occur due to mishearing, the computer-based briefing before [a] shift.” low radio quality or perceptual confusion In the same sub-category, enabler examples between two similar flight numbers. How- include “safety briefing by station manager with ever, for non-routine situations, such as team outlines new staff notices, new activities, a pilot running low on fuel, the potential restrictions, etc.”; “for big changes, controllers impact of data link could be more critical.” are given training in simulations”; and “mainte- REPORTS nance engineers communicate with controllers before touching a system.” Understanding Safety Culture in Air Traffic Management Birdstrike Risk Management for Aerodromes Eurocontrol Experimental Centre. EEC Note 11/06. September 2006. 50 pp. U.K. Civil Aviation Authority, Safety Regulation Group. CAP 772. Figures, tables, annexes. Available via the Internet at 54 | flight safety foundation | AEROSafetyWorld | August 2007 InfoScan measurement, it is hard to gauge the effective- Ornithology,” offers guidance in identification, ness of risk reduction techniques. biology and behavior by species. The assessment process typically involves, among other things, identifying bird species and ELECTRONIC MEDIA habitats in the area; the probability of a strike Archives of the Aerospace with each species, considering current mitiga- Medical Association Journals tion procedures and seasonal factors; the size and numbers of each species, including whether his DVD contains 73 years (1930–2002) the birds are solitary or in flocks; and the of full-text articles from three magazines frequency of serious strikes involving multiple T— Aviation, Space, and Environmental birds. Taking all factors into account, the ac- Medicine and its two preceding titles, Aerospace ceptability of the level of risk can be plotted on Medicine and The Journal of Aviation Medicine. a matrix with scales for severity and probability, All have been published by the Aerospace Medi- both ranging from very low to very high. cal Association. The chapter on risk reduction includes sec- Special features help researchers quickly tions on habitat management, bird dispersal and access the 16,691 titles: an index for browsing by safeguarding — keeping an eye on new or pro- publication date, article title, author and maga- posed land-use development outside the airport zine, plus basic and advanced search capability. perimeter that could attract birds to the area. Articles may be printed, saved or read on the Managing the habitat that offers birds food computer monitor. Articles include tables, fig- or security can in some cases be as important ures and references as they appeared in print. as dispersion. The report calls management of The DVD is priced separately for members, grass areas “the most effective habitat control nonmembers and institutions. Order informa- measure,” with both short and tall grass attract- tion is available at the association’s Web site, ing birds, and recommends maintaining grass at field of medicine are several aviation products free and online. available to members Current and archived full-text issues of CAT: and nonmembers in The Journal for Civil Aviation Training are available “This Is Aerospace in digital format and can be read online or printed. Medicine,” a 63-slide Halldale says that CAT has a regional and interna- presentation, posted tional focus in its reporting on “training challenges on the Web site. and solutions” for commercial aviation. The publications The World and Regional Aviation Train- section of the Web site ing Conference and Tradeshow (simultaneous contains other items programs focusing on airline pilot, cabin crew free to nonmembers. and maintenance training, referred to within the Some are written for industry as WATS/RATS) “brings together lead- travelers; some, such ing aviation training companies to discuss the as Medical Guidelines for Airline Travel (second evolution of training equipment, regulations and edition, May 2003, 22 pp.) are directed to medical processes,” according to the Web site. In addi- professionals. AsMA says the document was writ- tion to providing information about upcoming ten for “physicians [who] need to understand the events, the site provides complete presentations world of commercial flight, environmental and from the previous conference. Two examples physiological stresses, and vaccination require- of agenda items from the 2007 event are “Pilot ments in order to properly advise patients.” The Technology-Driven Training: The New Aircraft guidelines address specific medical conditions and System Challenges” and “WATS/RATS Pilot that may be pre-existing or manifest in flight. Air Carrier Training Insights.” Portions of AsMA’s peer-reviewed journal, Presentations from the same conference Aviation, Space, and Environmental Medicine, addressing cabin crew subjects such as “Safety, are available free to nonmembers — tables of Egress/Emergency Evacuation Training” are contents and abstracts of monthly issues, plus offered online to be read or downloaded. Some selected full-text articles. Medical News, a sec- presentations contain audio and video clips. tion of the journal that informs readers about Proceedings from the 2007 maintenance confer- organizational and medical news, is also online ence are also available. at no charge. Likewise, there are full-text presentations Links to constituent and affiliated organiza- from the 2006 European Aviation Training Sym- tions with purposes and objectives similar to posium, which focused on suppliers of training those of AsMA, such as the Aviation Medical products to the European air transport market. Society of Australia and New Zealand, and re- “Safety and Unexpected In-Flight Events” and lated professional and commercial organizations “Advances in Flight Training Technology” were are included at the Web site. Its multi-media on- two of several session topics discussed. line bookstore sells items of interest to members Free international directories and guides and nonmembers. to providers of simulation equipment, training (Editorial note: Dr. Russell B. Rayman, products and services are provided through executive director of the Aerospace Medical As- the 56 | flight safety foundation | AEROSafetyWorld | August 2007 OnRecord In-flight Depressurization Cargo door seal was installed incorrectly. BY MARK LACAGNINA The following information provides an aware- pressurization systems were checked by engi- ness of problems in the hope that they can be neers, the aircraft was released for service. “The avoided in the future. The information is based engine bleed and pressurization systems were on final reports by official investigative authori- again checked by the flight crew, and all indica- ties on aircraft accidents and incidents. tions were normal, with the aircraft pressurizing normally,” the report said. JETS The aircraft then departed from Shannon, at an unspecified time, with 237 occupants for a Crew Conducts Emergency Descent scheduled flight to New York. While climbing to Airbus A330-300. No damage. No injuries. cruise altitude, the crew observed cabin altitude oon after departing from Dublin, Ireland, at increasing through 7,500 ft and reduced the rate 1241 local time on Aug. 18, 2005, for a flight to of climb. As the aircraft was being leveled at Flight SShannon International Airport, the flight crew Level (FL) 350 (approximately 35,000 ft) over the observed an “ENG 1 BLEED LOW TEMP” warn- Atlantic Ocean, cabin altitude increased through ing on the electronic centralized aircraft monitor 8,500 ft. The crew changed the pressurization (ECAM). “The ECAM actions were carried out, mode from automatic to manual but were unable but the indication remained,” said the report by the to control cabin altitude. At about 1515, they Irish Air Accident Investigation Unit (AAIU). requested and received clearance from air traffic As the aircraft climbed through 10,000 ft, control (ATC) to descend and return to Shannon. the captain noticed that cabin altitude was an Cabin pressure then increased to nearly unusually high 4,900 ft. He decided to continue 10,000 ft, and an ECAM warning was generated. the flight at 10,000 ft rather than climb to 16,000 The crew donned their oxygen masks, declared ft, as planned. The aircraft was landed without PAN and conducted an emergency descent to further incident at 1317. 10,000 ft. “On completion of the checklists, the A postflight report (PFR) generated by the flight crew conducted a full [analysis] of the aircraft maintenance computer indicated a situation and, having considered all options, no. 1 engine bleed problem and a cross-bleed including burning off fuel, etc., decided to pre- problem. “There was no reference on the PFR pare for an overweight landing at Shannon and to a pressurization problem,” the AAIU report to land as soon as possible,” the report said. said. A test of the bleed management computer The crew requested and received vectors for the no. 1 engine revealed a fault that sub- from ATC for a long final approach to Runway sequently had been cleared. Nevertheless, the 24, and landed the aircraft uneventfully at 1623. bleed management computer was replaced. “Neither the passengers nor the crew reported After the engine bleed, cross-bleed and any ill effects,” the report said. www.flightsafety.org | AEROSafetyWorld | August 2007 | 57 OnRecord Engineers visually inspected the cabin pres- Catering Vehicle Struck During Pushback sure outflow valve and found no abnormalities. Boeing 737-700. Substantial damage. No injuries. Then they inspected the aft cargo door seal, he aircraft was being prepared for departure The door seal had which had been replaced two days before the from Chicago for a scheduled flight with incident flight by the airline’s maintenance con- 105 passengers to Tampa, Florida, U.S., the been installed T tractor in Dublin. The report said they found morning of July 8, 2005. The driver of a cater- “inside out and that the door seal had been installed “inside ing vehicle that had serviced the 737’s aft galley out and upside down,” preventing inflation of was awaiting marshalling assistance to back the upside down.” the seal by pressurized air in the cargo hold. vehicle away from the aircraft, the NTSB report Pressurized air normally enters through 2-mm said. (0.1-in) holes in one side of the seal; because of The driver of another catering vehicle the incorrect installation of the seal in the inci- parked behind the aircraft and exited the vehicle dent aircraft, the holes faced the outside of the to assist the driver who had serviced the 737. aircraft. This resulted in a pressurization leak He then returned to the vehicle and prepared to through the unsealed cargo door. drive it away from the aircraft. Meanwhile, however, the operator of the Windshield Emits Smoke and Flames pushback vehicle, who was not aware of the Bombardier CRJ200. Minor damage. No injuries. catering vehicle behind the aircraft and who had he aircraft was climbing through 17,000 ft not received the “clear for pushback” signal from after departing from Asheville, North Caro- the aircraft marshaller (wing walker), began the Tlina, U.S., for a scheduled flight with 30 pas- pushback. The marshaller, who was in sight of sengers to Covington, Kentucky, on March 19, the pushback vehicle operator, gave the hand 2006, when the captain smelled smoke. “A few signal to stop the pushback. “I put up the stop seconds later, flames and smoke started shooting signal and yelled ‘stop,’ but the plane kept on be- out of the lower left [side of the] windshield,” ing pushed,” he said. said the U.S. National Transportation Safety The section of the aircraft near the auxil- Board (NTSB) report. iary power unit (APU) door struck the cater- The captain told the first officer to turn off ing vehicle and tipped it over onto its side; the the windshield heating system. This eliminated driver was not injured. The flight crew said that the flames, but the smoke persisted. The crew they “did not feel any jolts or unusual aircraft declared an emergency and returned to Ashe- movement” when the impact occurred. How- ville Regional Airport, where the aircraft was ever, after noticing that the APU had stopped landed without further incident. operating, they discontinued the engine-start Postflight examination of the aircraft re- procedure and halted the pushback. vealed overheat damage to the windshield near NTSB said that the probable cause of the a terminal block for the windshield heating accident was “the pushback tow driver not system. “The overheat damage was the result of maintaining visual lookout for the wing walker’s an improperly installed fastener that resulted visual signal.” in arcing between the terminal block lug, the aircraft wiring eyelet, and the fastener and lock No Explanation for Cockpit Blackout washer that secure the two components to- British Aerospace BAe 146-300. No damage. No injuries. gether,” the report said. “The arcing progressed he aircraft was en route from London to over time, degrading the solder junction Inverness, Scotland, with 71 passengers between the terminal block and the windshield Taboard on the night of Nov. 8, 2006. Soon heating system braid wire [and resulting] in after the APU was started during descent, there heat damage to the sealant and the subsequent was a loss of electrical power to the primary flame.” flight displays, navigation displays and cockpit 58 | flight safety foundation | AEROSafetyWorld | August 2007 OnRecord lighting, said the U.K. Air Accidents Investiga- started to clear very rapidly.” The crew returned tion Branch (AAIB) report. to Birmingham and landed without further The flight crew declared an emergency and re- incident. ported the situation to ATC. They flew the aircraft “It was concluded that, on the first occasion, in visual meteorological conditions (VMC) above a bearing failure led to seal damage and con- the clouds while troubleshooting the problem. tamination of the air conditioning system,” the “The commander ‘worked backwards’ and report said. “It appeared that residual oil in the switched the APU off,” the report said. “Genera- system, resulting from the initial failure, had not tor 1 (GEN 1) and Generator 4 (GEN 4) were been eliminated during the rectification and was then reset, and electrical power to all the flight responsible for the second event.” deck displays returned to normal.” The cabin crew reported that galley power had been lost Aluminum Plate Strikes Tail During Taxi momentarily but the cabin lights had remained Boeing 737-300. Substantial damage. No injuries. illuminated. “At no stage were any circuit break- he airplane was being taxied for departure ers found to be tripped,” the report said. from La Guardia Airport in New York on The flight crew conducted an instrument TJune 8, 2006, when the right horizontal landing system (ILS) approach and landed stabilizer was struck by an aluminum plate. The without further incident at Inverness. “On the NTSB report said that the plate, which measured ground, the only fault which could be identified 25 in by 60 in (64 cm by 152 cm) had been left was a possible problem on the ground service on the taxiway by workers performing taxiway bus,” the report said. Replacement of the no. 1 maintenance. generator control unit eliminated the problem. “The plate was supposed to have been a “The aircraft was returned to service, from thicker and, hence, heavier steel plate to prevent which time it has continued to operate without it from being affected by the jet blast from taxi- any recurrence,” the report said. The AAIB ing airplanes,” the report said. “Guidance to the and the aircraft manufacturer were unable to construction company regarding the use of such determine conclusively what caused the loss of plates was provided by the FAA [U.S. Fed- electrical power. eral Aviation Administration] and the airport authority.” Smoke Enters Flight Deck — Twice Avro 146 RJ100. Substantial damage. No injuries. Controller Error Blamed for Incursion he aircraft was descending to land at Edin- Airbus A330-300, Boeing 737-300. No damage. No injuries. burgh, Scotland, the night of Sept. 20, 2006, perations on intersecting runways were being Twhen smoke began to fill the flight deck. conducted in VMC at Boston Logan Interna- The crew observed low oil pressure in the no. Otional Airport the afternoon of June 9, 2005. 2 engine and shut down the engine, the AAIB The local east controller (LCE) was responsible for report said. operations on Runway 04R and Runway 09, and After the Avro was landed and the 51 pas- the local west controller (LCW) was responsible “As the APU air sengers were deplaned, the aircraft was ferried for operations on Runway 04L and Runway 15R, entered the aircraft, to the airline’s maintenance base in Birming- the NTSB report said. Runways 04L and 04R were ham, England, where the no. 2 engine was being used for landings, and Runways 09 and 15R the smoke started to replaced. During departure, smoke again filled were being used for departures. the flight deck after the flight crew shut down Because Runway 15R intersects the other clear very rapidly.” the APU and selected engine air. “Engine air was three runways, the LCW was required to quickly turned off and APU air selected,” the receive a release from the LCE before clearing report said. “The APU was then restarted, and, an aircraft to take off on Runway 15R. After as the APU air entered the aircraft, the smoke providing a release, the LCE was required to www.flightsafety.org | AEROSafetyWorld | August 2007 | 59 OnRecord cease operations on the other runways until the angle.” The right main landing gear collapsed, aircraft departed from Runway 15R. and the right wing-tip tank struck the ground The LCW received a release from the LCE before the Learjet was stopped. before clearing the Airbus, which had 340 people NTSB said that surging of the left engine aboard, for takeoff on Runway 15R. Five seconds during takeoff and the flight crew’s subsequent later, the LCE cleared the Boeing, which had 108 loss of control of the airplane resulted from the people aboard, for takeoff on Runway 09. The 737 operator’s inadequate maintenance of the engine’s first officer said that he had just called “V1” when fuel computer harness. Company maintenance he saw the A330 rotating near the intersection. records indicated that the harness had been “He told the captain to ‘keep it down’ and pushed checked six days before the accident. However, the control column forward,” the report said. investigators found several discrepancies, includ- “He further stated: ‘The Airbus passed overhead ing deteriorated and missing shielding, corrosion, our aircraft with very little separation, and once a worn ground wire and a broken connector pin. clear of the intersection, the captain rotated, and we lifted off towards the end of the runway. I TURBOPROPS reported to departure control that we had a near miss, at which time [a flight crewmember aboard Barrel Roll During Missed Approach the A330] reported, ‘We concur.’” Beech King Air A90. Destroyed. No injuries. The LCE told investigators that he had been aytime instrument meteorological condi- very busy and had forgotten that he had given tions prevailed on Aug. 22, 2006, when the LCW a release for the A330’s departure. Dthe pilot flew his King Air from Weston, NTSB said that the probable cause of the runway Ireland, to Knock to practice instrument incursion was the LCE’s failure to follow stan- approaches and gain familiarity with an inte- dard operating procedures. grated avionics system that had been installed in the airplane. The pilot had 743 flight hours, Engine Surges Involved in Control Loss including 95 flight hours in type. His passenger Gates Learjet 35. Substantial damage. No injuries. had about 2,000 flight hours in multiengine ighttime VMC prevailed on March 22, 2006, airplanes, had previously owned a King Air and when the flight crew began a “standing-start” was familiar with the avionics system. Ntakeoff from Runway 27L at Philadelphia The AAIU report said that weather condi- International Airport for a cargo flight. The pilot tions worsened as the airplane neared Knock. held the wheel brakes until the engines spooled up Visibility was 4,400 m (2 3/4 mi) with light rain, to 70 percent N2, high-pressure rotor speed, then and ceilings were broken at 100 ft and overcast released the brakes and increased power. at 500 ft. ATC cleared the pilot to conduct an The NTSB report said that the pilot disen- ILS approach to Runway 27. The pilot told the gaged the nosewheel steering system when the controller that he would discontinue the ap- copilot called out “airspeed alive” at about 60 proach 600 to 700 ft above the airport and go kt. Airspeed was about 95 kt when the airplane around for another approach. The controller began to turn right. “The copilot noticed fluc- told the pilot to initiate the missed approach tuations with the engine indications and called with a right turn and climb to 3,000 ft while for an abort,” the report said. “The pilot reduced navigating directly to the initial approach fix. the power to idle and corrected back to the left The pilot hand-flew the ILS approach to using left rudder pedal and light braking. The 1,400 ft, about 735 ft above the airport, and airplane then turned to the right again, and began the missed approach. He said that he the pilot corrected once again to the left. The retracted the landing gear, partially retracted airplane continued to turn left and departed the the flaps and was climbing straight out at about left side of the runway, tail-first, at a 45-degree 140 kt when he felt a sudden jolt and the aircraft 60 | flight safety foundation | AEROSafetyWorld | August 2007 OnRecord rolled right, beyond 90 degrees of bank, and and 2 mi (3,200 m) visibility, and that aircraft did not respond to aileron input. “He said that were landing at Jacksonville International he did not believe he had become distracted Airport, which had a runway visual range and that he was very conscious of what he was (RVR) greater than 6,000 ft (1,800 m). The pilot doing,” the report said. “The [passenger] joined told ATC that he would “take a look at Craig” [the pilot] on the controls during the upset, and and that he had the current automatic termi- he let him take control, as [the passenger] was a nal information service information, which much more experienced pilot.” included a vertical visibility of 100 ft and 1/4 mi The passenger said that he had been examin- (400 m) horizontal visibility. He requested and ing a chart when he glanced up and noticed the received vectors for the ILS approach to Runway excessive bank angle; he did not feel a jolt or any 32, which had a decision height of 241 ft and a significant turbulence. He said that application minimum visibility of 1/2 mi (800 m). of left aileron had little effect, and he decided to Recorded ATC radar data indicated that continue the right roll. “Due to his position in the Merlin descended below the ILS glideslope the cockpit, he was unable to reach the throttles, during final approach. The airplane struck trees, which were at a high power setting,” the report rolled right and struck the ground 1.8 nm (3.3 said. “As the aircraft rolled inverted … he could km) from the airport at 0752 local time. The see the roof of the canopy getting darker as they pilot was killed; the passengers received minor neared the ground. He continued the roll until injuries. brightness showed in the canopy again, applying full back pressure to the controls.” The passen- Power Loss Traced to Gearbox Malfunction ger said that during recovery, airspeed increased British Aerospace Jetstream 32. Substantial damage. No injuries. to between 280 and 300 kt, and aerodynamic he aircraft was on a scheduled passenger loading reached about 5 g. flight from Mount Gambier, South Australia, The King Air was flown back to Weston and Tto Adelaide the afternoon of Dec. 23, 2005. landed without further incident. The pilot said During a shallow turn at FL 120, about 93 km that he did not see anything wrong with the (50 nm) east of Adelaide, the right engine surged aircraft and was surprised when his mechanic twice and then stopped, said the report by the later told him about the damage, which included Australian Transport Safety Bureau (ATSB). buckled skin on the wings and empennage. The The flight crew secured the engine and re- report said that the underlying structural dam- quested and received clearance from ATC to fly age likely was beyond economic repair. directly to Adelaide and to descend to 10,000 ft. Before beginning the descent, the crew attempt- Weather Below Approach Minimums ed an automatic and a manual restart. “During Swearingen Merlin. Destroyed. One fatality, four minor injuries. these attempts, the engine would rotate and the he pilot was conducting a private flight from propeller would unfeather, but the engine would Beaumont, Texas, U.S., to Craig Airport not start,” the report said. The crew conducted a “The engine in Jacksonville, Florida, the morning of single-engine landing without further incident. T would rotate and Nov. 27, 2003. His four children were aboard Examination of the engine revealed two as passengers. The pilot knew before departure damaged gears in the propeller reduction the propeller would that weather conditions were below the ap- gearbox. A tooth on one gear was fractured, and proach minimums at Craig Airport and, nearing several others were worn; all the teeth on the unfeather, but the Florida, was told by an air traffic controller that gear to which it mated were missing. the fog at the airport was not expected to lift for The report said that the operator had pur- engine would at least an hour and a half, the NTSB report said. chased the engine from the manufacturer and not start.” The pilot also learned that the airport in installed it on the Jetstream on Dec. 20, 2005. The nearby St. Augustine was reporting clear skies gear with the lesser damage had been installed www.flightsafety.org | AEROSafetyWorld | August 2007 | 61 OnRecord new by the manufacturer during a continuing Cannabis Consumption Noted in CFIT Probe airworthiness maintenance inspection in October Piper Seneca II. Destroyed. Three fatalities. 2005; the gear with the stripped teeth had been in he airplane was chartered for a sightsee- the gearbox since the engine was manufactured. ing flight from Ardmore to Kerikeri to The engine had accumulated 6,258 operating TTaupo, on New Zealand’s North Island, the hours since manufacture, including 16 operating morning of Feb. 2, 2005. Although the operator hours since its installation on the Jetstream. told the two passengers that weather conditions ATSB said that accelerated tooth wear on the were not good, they elected to take the flight as more extensively damaged gear likely resulted planned, said the report by the New Zealand from “the mating of new and worn compo- Transport Accident Investigation Commission. nents,” but it could have been initiated by a The pilot conducted two instrument ap- foreign object in the gearbox. proaches to Kerikeri but was unable to land because of the weather conditions. He requested PISTON AIRPLANES and received clearance from ATC to proceed to Taupo, which was reporting 50 km (31 mi) Hypoxia Likely Caused Control Loss visibility and a broken ceiling at 4,000 ft. Before Cessna 404. No damage. No injuries. the pilot began the descent, the controller he unpressurized aircraft departed from asked which instrument approach procedure San Pedro Airport, Cape Verde Islands, at he intended to fly. The pilot said that he would T1855 local time for a private flight to Dakar, conduct the NDB/DME (nondirectional beacon/ Senegal, on Dec. 16, 2006. The U.K. AAIB distance measuring equipment) approach. report said that the pilot did not continuously Before beginning the approach, the pilot use supplemental oxygen above 10,000 ft during was told by an airport Unicom operator that the the climb to, and initial cruise at, FL 210. The weather was “closing in a bit.” Visibility was 7,000 passenger said that the pilot took off his oxygen m (4 mi), and there were a few clouds at 1,000 ft mask several times. The pilot told investigators and a broken ceiling at 2,000 ft. The minimum that he took off his oxygen mask to respond to a descent altitude for the circling approach was 1,940 perceived engine problem at about 1930. ft, and minimum visibility was 2,800 m (1 3/4 mi). “He was probably suffering from hypoxia After turning inbound, the aircraft’s ground when he attempted to adjust his engine controls, track deviated increasingly left of the intermedi- and this resulted in vibration and an uncon- ate and final approach tracks. When the pilot trolled descent,” the report said. The passenger reported crossing the final approach fix — his said that he heard a change in engine noise and last radio transmission — the Seneca was about felt the vibration before the aircraft began to de- 6 km (3 nm) left of the fix. The aircraft was at scend at high speed and in a spiral. He called the 2,600 ft about 30 seconds later when it struck a pilot twice on the intercom system. The aircraft mountain 8 km (4 nm) from the airport. was descending through 5,000 ft when the pilot Investigators found no anomalies with the responded to the passenger’s second call. navigation aids, and no likely sources of signal After regaining control of the airplane, the interference were identified. “No obvious cause pilot requested and received clearance from for the accident could be determined,” the ATC to divert to Amilcar Cabral Airport, Cape report said. “Autopsy reports showed the pilot Verde Islands. He landed there without further had consumed cannabis [marijuana], probably incident at 2005. The pilot said that he likely be- between 12 and 24 hours before the accident. gan experiencing hypoxia during the climb and While cannabis can adversely affect a person’s that the perceived engine problem probably had ability to operate an aircraft, its effects can vary resulted from the engine controls being improp- greatly; so, this could not be conclusively identi- erly set for cruise flight. fied as a cause of this accident.” 62 | flight safety foundation | AEROSafetyWorld | August 2007 OnRecord Icing Triggers Stall on Departure 7, 2005, the helicopter was returning to the ship Cessna T310R. Destroyed. One fatality. with less than 40 kg (88 lb) of gear in the bonnet oderate icing conditions prevailed on (sling). The bonnet, which was attached to the the pilot’s normally scheduled cargo helicopter by a 33-m (108-ft) external line, had Mroute in Arizona, U.S., on Dec. 7, 2004. been lashed closed with a polypropylene rope, The pilot landed in Flagstaff, which had 1 1/2 said the report by the Transportation Safety mi (2,400 m) visibility and a 300-ft overcast, Board of Canada. at 1826 local time and requested that the The helicopter was being flown at about airplane be deiced. The line service techni- 60 kt when the rope apparently slid up the ex- cian who deiced the 310 said that there was a ternal line and the bonnet opened. The report substantial amount of ice on the airplane and said that the bonnet then flew forward, into that light snow continued to fall at the airport the helicopter’s flight path, and the external until the airplane departed more than an hour line struck and disabled the tail rotor. The pilot later. was unable to deploy the emergency flotation Witnesses said that the airplane rotated system before the helicopter struck the water about 5,000 ft (1,524 m) down the 7,000-ft and sank. (2,134-m) runway and that one or both of the The report noted that the pilot was engines sounded very rough. The airplane was wearing his lap belt but not the upper-body descending in a wings-level and slightly nose- restraints; his helmet, which was fractured high attitude when it struck a highway embank- during the impact, protected his head from ment 2 nm (4 km) from the airport. Elevation severe injury. “The pilot was able to exit the of the accident site was 6,798 ft — 200 ft lower sunken helicopter but remained face down in than airport elevation. the water,” the report said. “He was wear- The NTSB report said that the operator kept ing an uninflated lifejacket. The pilot was a truck on standby at the airport to transport the rescued within three minutes and revived, cargo if it could not be flown because of weather but remained in critical condition for several conditions or a mechanical problem. However, days.” entries in the pilot’s journal indicated that he perceived considerable pressure to operate the Unattended Helicopter Rolls Over 310, which did not have deicing boots, in icing Bell 206B. Substantial damage. No injuries. conditions. “There was insufficient information hile preparing the helicopter to pick up from which to determine whether the company passengers for a sightseeing flight in culture condoned or encouraged this behavior,” WBoulder City, Nevada, U.S., the morning the report said. of Nov. 11, 2006, the pilot started the engine and NTSB said that the probable cause of the completed the preflight checks. After checking accident was the pilot’s decision to attempt generator load, he left the engine running at 100 flight in known adverse weather conditions and percent rpm to charge the battery, the NTSB with ice and snow that had accumulated on the report said. airplane while it was on the ground. “The pilot exited the helicopter with the engine running and the rotors turning to HELICOPTERS disconnect the APU and to move it away from the helicopter,” the report said. “While mov- External Line Strikes Tail Rotor ing the APU, the pilot heard the engine sound Messerschmitt-Bolkow-Blohm BO 105. Destroyed. One serious injury. change, turned around and saw the front fter completing 27 cargo flights from a skids lifting off the ground.” The helicopter coast guard vessel to a lighthouse in Bella then moved backward and rolled down an ABella, British Columbia, Canada, on May embankment. ● www.flightsafety.org | AEROSafetyWorld | August 2007 | 63 OnRecord Preliminary Reports Date Location Aircraft Type Aircraft Damage Injuries June 1, 2007 Zurich, Switzerland Gulfstream G-V minor 9 none The nose landing gear did not extend on approach, and the flight crew conducted a go-around. Attempts to extend the nose gear were unsuccessful, and the crew landed the G-V with the nose gear retracted. June 3, 2007 Kashira, Russia Robinson R44 substantial 1 fatal, 2 serious The helicopter crashed under unknown circumstances during a local flight from Moscow. The pilot was killed. June 4, 2007 Milwaukee Cessna Citation II destroyed 6 fatal Soon after departing on an air ambulance flight, the flight crew declared an emergency, reporting a runaway trim condition. The crew was attempting to return to Milwaukee when the airplane struck Lake Michigan. June 5, 2007 Simiti, Bolivar, Colombia Bell 206L-3 substantial 2 fatal, 4 serious Instrument meteorological conditions (IMC) prevailed when the helicopter struck mountainous terrain at 1,000 ft. The pilot and copilot were killed. June 10, 2007 Santa Barbara, California, U.S. Dassault Falcon 900 substantial 15 none The captain said that although he eventually pulled the control column back to his chest, the airplane did not rotate. The crew rejected the takeoff, but the Falcon overran the runway. June 13, 2007 Guipuzcoa, Spain Bell 212 destroyed 2 fatal IMC prevailed when the helicopter struck terrain during a positioning flight from Santander to Alicante. June 16, 2007 Chelinda, Malawi Cessna U206F destroyed 6 fatal The airplane was on a sightseeing flight when it struck high terrain in visual meteorological conditions (VMC). June 26, 2007 Placitas, New Mexico, U.S. Beech 58 Baron destroyed 1 fatal VMC prevailed when the Baron struck a mountain at about 10,000 ft during a business flight from Torrance, California, to Clinton, Oklahoma. June 18, 2007 Blenheim, New Zealand Beech 1900D substantial 17 none The crew reported an unsafe landing gear indication on approach to Wellington. They diverted to Blenheim and conducted an intentional wheels-up landing. June 20, 2007 Boston Embraer 135 minor 41 none The crew observed a “landing gear lever disagree” warning during the flare and rejected the landing at Logan International Airport. The flaps were damaged when the airplane contacted the runway, gear-up, during the go-around. The crew manually extended the gear and landed at Logan without further incident. June 21, 2007 Kamina, Democratic Republic of Congo LET 410 substantial 1 fatal, 24 NA The airplane struck terrain on takeoff and came to a stop upside down in a swamp. June 23, 2007 Naryn, Kyrgyzstan Yakovlev 40 destroyed 13 NA Engine problems occurred after takeoff from Ysykkul Airport. The crew shut down two of the three engines and conducted an emergency landing in a field. There were no fatalities. June 25, 2007 Sihanoukville, Cambodia Antonov An-24RV destroyed 22 fatal The airplane struck a mountain at 1,640 ft during approach. June 25, 2007 Treviso, Italy Boeing 737-800 NA 181 none The crew heard a loud bang during the landing. The nose landing gear axle had fractured, and the left nosewheel had separated. June 28, 2007 M’banza Congo, Angola Boeing 737-200 destroyed 6 fatal, 73 NA The 737 touched down about halfway down the 1,800-m (5,906-ft) runway, overran the runway and struck vehicles and buildings. The fatalities included one person on the ground. June 30, 2007 Saltillo, Mexico North American Sabreliner 40 substantial 4 NA The airplane landed long and overran the runway onto rocky soil. There were no fatalities. June 30, 2007 Conway, Arkansas, U.S. Cessna Citation destroyed 1 fatal, 1 NA The Citation landed long on the 4,875-ft (1,486-m) runway, and the pilot attempted to go around. The airplane overran the runway and struck a building, killing the pilot. 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. 64 | flight safety foundation | AEROSafetyWorld | August 2007 Let us give you the world. AeroSafety WORLD AeroSafety World is Flight Safety Foundation’s monthly magazine that keeps pace with the most important safety issues and developments in aviation. Until recently, only FSF members could receive it. Now anyone can … FREE. AeroSafety World is available for downloading via a link from the FSF Web site. We’ve been amazed at the number of downloads the online version has received. We’re delighted at the interest that readers have shown. So we’re doing still more to accommodate you. No longer do you need to remember to check the Web site each month. You can literally subscribe to the online AeroSafety World. Just fill out a brief subscription form and every month you will receive an e-mail with a link to the latest issue — which appears even before many people get their printed copy. AeroSafety World. The information is solid, thoroughly researched by a knowledgeable editorial staff and industry aviation safety experts. The design is dazzling. You can talk back to us via letters to the editor. What are you waiting for? Go to After all, it isn’t every day you get a FREE offer for the world. International Federation International Air Transport of Airworthiness Association Joint meeting of the FSF 60th annual International Air Safety Seminar IASS, IFA 37th International Conference, and IATA Sharing Global Safety Knowledge October 1–4, 2007 Seoul,Grand Hilton Seoul HotelKorea Hosted by © Juergen Sack/iStockphoto © Juergen