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1,500 HOURS Are you really experienced? FIRST RESPONDERS Flight attendants and safety SKY’S THE LIMIT Single European Sky lags FIGHTING FOR ATTENTION SENSORY OVERLOAD
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his is a bit of a confession. I had a seat better centralization of data and analysis, but the at the table when the international com- underlying assumptions behind SMS and state munity debated how safety management safety programs no longer make sense. systems (SMS) would fit into the interna- Just imagine you are an accountable executive tionalT regulatory framework. My colleagues and I at a subsidiary airline. Much of the safety oversight missed something really big. We all assumed that is done by the parent airline’s safety department, the industry would stay the same, that airlines which has access to data from all of its subsidiaries would retain their nationalities like they had for and has access to the board of directors. But you the previous 60 years. Everything was built on report to a regulator in your country that expects the assumption that each country would have a you to run your own SMS, based on agreements regulator that would oversee multiple airlines, each between your airline and the regulatory agency. holding a single air operator certificate (AOC) So what happens? Perhaps your regulator says you and each with its own SMS. Each SMS would be have to change a process or a target in your SMS. run by an accountable executive who would set You coordinate with people in the group safety safety targets and proactively manage risk. The ac- office a thousand miles away and they disagree. countable executive would report to the regulator, You are stuck. Or the group safety office decides who would make sure the executive was doing a to do business in a new way, and your regulator responsible job and ensure that the efforts of the disagrees. You have a choice between getting in a airlines would achieve a target level of safety for fight with the guy who holds your certificate or that country that would satisfy the flying public. the guy who signs your check. It is a system that These all seemed like reasonable assumptions at is “spring-loaded to the screw-up position.” the time, but they were wrong. So what do we do about this mess? The Foun- Let’s look at reality. Airlines have found a dation is trying to start a new conversation within work-around to the restrictive notion that they airlines and the international regulatory bodies. It must have nationalities. Instead, they’re forming is essential that we figure out the proper relation- airline groups that span borders. When an airline ship between the corporate governance of multi- wants to expand its market, it needs traffic rights. national airline companies and the operational It gets those traffic rights by buying or creating application of SMS. The vision we had at the end subsidiary airlines in other countries. A significant of the last century is not going to fit the industry percentage of the world traffic is now managed by that is emerging today. It is time to deal with it. international airline groups that oversee a dozen or more AOCs in eight or 10 different countries. Just consider Qantas, Air Asia, Singapore (Tiger), Hainan Group, LAN/TAM, Copa and Air France/ KLM, to name a few. This is a great way to circumvent ownership William R. Voss and trade regulations that have crippled the President and CEO industry. Safety could actually benefit through Flight Safety Foundation
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 | 1 AeroSafetyWORLD
December 2012–January 2013 contents Vol 7 Issue 11 features
8 SeminarsIASS | Safety Information Protection
16 CoverStory | Flight Deck Sensory Overload
16 21 SafetyRegulation | Reshaping Pilot Experience 21 26 SafetyRegulation | Single European Sky Delay 30 CausalFactors | Falcon 10 Veer-Off Analysis
33 AccidentInvestigation | AF 447 Behind the Scenes
38 CabinSafety | First Responders Aboard
42 FlightOps | Performance-Based Navigation 26 departments 1 President’sMessage | Mistaken Assumptions
5 EditorialPage | Look Back, Move Forward
6 SafetyCalendar | Industry Events
7 Executive’sMessage | Looking Forward to 2013
12 InBrief | Safety News
2 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 30 42
33
AeroSafetyWORLD telephone: +1 703.739.6700 | 48 DataLink Commercial Jet Evacuations William R. Voss, publisher, FSF president and CEO 52 InfoScan | UAS Introduction Issues [email protected] Frank Jackman, editor-in-chief, FSF director of publications 56 OnRecord | Close Call Over the Atlantic [email protected], ext. 116
Wayne Rosenkrans, senior editor [email protected], ext. 115
Linda Werfelman, senior editor [email protected], ext. 122
Rick Darby, associate editor [email protected], ext. 113
Jennifer Moore, art director [email protected]
Susan D. Reed, production specialist [email protected], ext. 123
About the Cover Sensory overload could be a problem in emergencies. Editorial Advisory Board © Udo Kroener/istockphoto Photo illustration Jennifer Moore David North, EAB chairman, consultant
William R. Voss, president and CEO Flight Safety Foundation
Frank Jackman, EAB executive secretary We Encourage Reprints (For permissions, go to
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 | 3 Serving Aviation Safety Interests for More Than 60 Years
OFFICERS AND STAFF light Safety Foundation is an international membership organization dedicated to Chairman, Board of Governors David McMillan the continuous improvement of aviation safety. Nonprofit and independent, the Foundation was launched officially in 1947 in response to the aviation industry’s need President and CEO William R. Voss F for a neutral clearinghouse to disseminate objective safety information, and for a credible Chief Operating Officer Capt. Kevin L. Hiatt and knowledgeable body that would identify threats to safety, analyze the problems and General Counsel and Secretary Kenneth P. Quinn, Esq. recommend practical solutions to them. Since its beginning, the Foundation has acted in the public interest to produce positive influence on aviation safety. Today, the Foundation provides Treasurer David J. Barger leadership to more than 1,075 individuals and member organizations in 130 countries. ADMINISTRATIVE
Manager, Support Services and Executive Assistant Stephanie Mack MemberGuide FINANCIAL Flight Safety Foundation 801 N. Fairfax St., Suite 400, Alexandria VA 22314-1774 USA Financial Operations tel +1 703.739.6700 fax +1 703.739.6708 flightsafety.org Manager Jaime Northington Member enrollment ext. 102 MEMBERSHIP AND BUSINESS DEVELOPMENT Ahlam Wahdan, membership services coordinator [email protected] Seminar registration ext. 101 Senior Director of Namratha Apparao, seminar and exhibit coordinator [email protected] Membership and Business Development Susan M. Lausch Seminar sponsorships/Exhibitor opportunities ext. 105 Kelcey Mitchell, director of events and seminars [email protected] Director of Events and Seminars Kelcey Mitchell Donations/Endowments ext. 112 Susan M. Lausch, senior director of membership and development [email protected] Seminar and Exhibit Coordinator Namratha Apparao FSF awards programs ext. 105 Kelcey Mitchell, director of events and seminars [email protected] Membership Services Coordinator Ahlam Wahdan Technical product orders ext. 101 Namratha Apparao, seminar and exhibit coordinator [email protected] COMMUNICATIONS Seminar proceedings ext. 101 Director of Namratha Apparao, seminar and exhibit coordinator [email protected] Communications Emily McGee Website ext. 126 Emily McGee, director of communications [email protected] TECHNICAL Basic Aviation Risk Standard Director of Greg Marshall, BARS program director [email protected] Technical Programs James M. Burin BARS Program Office: Level 6, 278 Collins Street, Melbourne, Victoria 3000 Australia Deputy Director of tel +61 1300.557.162 fax +61 1300.557.182 Technical Programs Rudy Quevedo
BASIC AVIATION RISK STANDARD
BARS Program Director Greg Marshall Manager of Program Development Larry Swantner facebook.com/flightsafetyfoundation
@flightsafety Past President Stuart Matthews Founder Jerome Lederer www.linkedin.com/groups?gid=1804478 1902–2004
FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 EDITORIALPAGE
LOOK BACK, Move Forward
ditorials written at this time of the to the most current issues of the magazine members and the cause of aviation safety. year often are dedicated either to will be limited to Foundation members For example, if you haven’t already taken looking back at the year past or for three months following publication. a look, please check out the redesigned ahead at what’s to come. I am writ- For example, once the February issue is ASW landing page on the Foundation’s Eing this early in the final month of 2012, published, it will be posted to the Founda- website. The changes made several weeks but most of you won’t see it until early in tion website, but most of the issue’s content ago make the articles and information 2013, so I am going to grant myself the will be accessible only by members or the more accessible and easier to read. liberty of doing both. employees of member organizations until On a personal note, I joined Flight Looking ahead, AeroSafety World will early May, when it will be made available Safety Foundation in April to succeed the strive to continue to deliver the in-depth on a publicly accessible area on our website. retiring J.A. Donoghue and, as expected, safety information, data and analysis for Print distribution of the magazine, which Jay has proved to be a tough act to follow. which it is known. Some of the subjects already is limited to individual mem- The learning curve has been steep, but we will tackle in 2013 include helicopter bers and member organizations, will not the subject matter is fascinating and my safety, unstable approaches and go-around change, although you likely will see each education has been hastened by numer- decision-making, voluntary reporting sys- issue of the magazine earlier in the month ous people within the Foundation and tems, the integration of remotely piloted (see below). Archived issues of the maga- across the industry. Please accept my vehicles into civilian airspace, multi-crew zine will continue to be publicly available. heartfelt thanks. Of course, I have had a pilot licensing, operations in remote re- In 2013, we again will publish 11 issues great deal of help from the talented and gions and the safety implications of Next- of ASW, with a combined December 2013– patient AeroSafety World editorial and Gen. Revisions to the International Civil January 2014 issue. You should, however, production staff, and for that, I want Aviation Organization’s Global Air Navi- see the magazine earlier each month than to say thank you. In addition, I want to gation Plan, further developments in the in years past. Beginning with the February thank the writers and photographers on industry’s efforts to protect safety informa- 2013 issue, we are changing the ASW publi- whose talent and effort much of ASW’s tion from misuse, and Foundation-aided cation cycle. Copies of the magazine will be reputation is built. With your help, we can safety efforts in developing countries also mailed within the first few days of the issue continue to make a difference. will be covered. As always, we welcome month. So, your February issue should be Happy New Year. your comments and ideas for articles. on its way to you early in the month. Flight Safety Foundation COO Kev- Looking back, 2012 has been a busy in Hiatt has details on p. 7 about some year. In addition to our usual array of Foundation-specific developments you successful seminars and safety projects, can expect in 2013, but there is one I par- we have made some changes internally to Frank Jackman ticularly want to highlight. Beginning with make ASW and the Foundation run more Editor-in-Chief the February issue of ASW, website access efficiently and to better serve you, our AeroSafety World
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 | 5 ➤ SAFETYCALENDAR
JAN. 8–17 ➤ SMS Training Certificate Course. FEB. 4–5 ➤ Human Factors in Aviation/ APRIL 29–MAY 3 ➤ Aircraft Accident U.S. Transportation Safety Institute. Oklahoma CRM. Vortex Training Seminars. Denver. Investigation. Embry-Riddle Aeronautical City, Oklahoma, U.S. D. Smith,
JAN. 9–11 ➤ Risk Management Conference. FEB. 4–6 ➤ Safety Management Systems MARCH 12–13 ➤ Safety Across High- Airports Council International–North America. and Flight Data Monitoring. Vortex Training Consequence Industries Conference. Parks Las Vegas, Nevada, U.S.
6 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 EXECUTIVE’SMESSAGE
Looking Forward to 2013
t a meeting I attended recently, one of the our website, and that effort will continue in the speakers said, in essence, that while we new year. Also, in addition to the launch of the cannot predict the future, how we conduct members-only e-newsletter, we are rolling out ourselves today will play a big part in how members-only access to select information on Athings turn out. With that in mind, I thought I our website. Beginning in February, new issues of would share some insight into our planning and AeroSafety World will be available digitally only work scope for 2013. to members for the first three months following The Foundation has six principal operating publication. After three months, digital access will areas: membership, seminars, technical programs, be opened up to everyone. Data and information communications, BARS (Basic Aviation Risk Stan- that currently reside on the website will continue dard) and government/political affairs. In each to be available to all. area, we set priorities for projects and the funding The BARS program, which primarily con- that goes into them. The leadership team, working ducts audits for operators associated with the in conjunction with the Foundation’s officers and mineral and mining industry, has matured and Board of Governors, produces a work plan that will focus on current customers’ needs while fits the Foundation’s mission. working strategically to add more BARS member In the membership program, we are opening organizations. more lines of communication with a monthly In November, we signed a memorandum of e-newsletter to keep you up to date on what is cooperation with the International Civil Aviation happening at the Foundation. In addition, we Organization that will enable us to expand our will further develop our student membership and work with countries around the world on issues student chapter programs, and will continue to such as the protection and sharing of safety data. hone our dues structure. There will be more interaction with governments Our seminar team is planning two major safety that may need our facilitation with safety issues events: our Business Aviation Safety Seminar, concerning airports, air traffic control and gath- scheduled for April 10–11 in Montreal, and the ering of data. International Air Safety Summit, Oct. 29–31 in These are the primary areas that we will be Washington. Also in the planning stages are two, focusing on. However, if there is an issue that or possibly three, smaller regional seminars. Keep pops up where we think we can make a difference checking our website for updated information. for aviation and aerospace safety, we will jump in. In technical programs, information sharing After all, that is what our members expect. and safety management system evaluations will be a focus. The Foundation also will continue to facilitate and participate in committee work, and we are looking at forming more partnerships to keep on top of all that is going on in the industry. We have been working to enhance communi- Capt. Kevin L. Hiatt cation with our membership, and the broader avia- Chief Operating Officer tion/aerospace industry, through improvements to Flight Safety Foundation
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 | 7 8 | Force on Safety Information Protection. AviationCivil Organization (ICAO) Task dation, and chair vice of International the counsel and secretary, Flight Safety Foun- laws, says Kenneth P. general Quinn, forbe countries/regions to specific enact threaten hard-won risk mitigations may to be sensitized toto judicial the system. be protection nor should we. …We need said. “We’re not going to have absolute to have immunity nor should we,” he reporting programs. “We’re not going industry’sthe voluntary occurrence tigations under ICAO Annex 13or in not interfere either inaccident inves- thatfully judicial authorities should has possible it to argue been success- said,Quinn and only inrecent years mune to application the of law, criminal mendations to ICAO inJanuary 2013. and finalization its of expected recom- task forcethe has for reviewed two years Santiago, summarized Chile, key issues tional Air Safety in inOctober Seminar His presentation during FSF the Interna- T SEMINARSIASS The aviation is not industry im- court-ordered disclosures that aviation safety information against world’s vast store of confidential he most way effective to protect the 1 by safety investigators, said. Quinn authoritiescial or inappropriate actions tion without undue interference by judi - that encourages flowof free the informa - safety an culture ideal scribe for states all mendations for ICAO the Secretariat. Navigation Bureau, containing recom - to Nancy Graham, director of Air the to deliveruled areport inJanuary 2013 in December, task force the is- sched meetings followed by stakeholder input recommendations. on four Based prior of safety information using task force ofCouncil ICAO to enhance protection previous the struction for October the and ICAO the Assembly’s General in- Safety Conference previous the April CEO, during ICAO the High Level by William Voss, R. FSF president and in response to recommendation the task forceplinary 2010 in December mission established multidisci the - aviationbenefit safety, he said. priate administration of justice can also or of evidence gross negligence, appro- misconduct, ofreveals evidence willful example, ifan accident investigation sensitized to to us.” need be They For The task force to de- has struggled The ICAO Air Navigation- Com FLIGHT FOUNDATION SAFETY takes freely,”takes he said. enable aviation workers to “admit mis - airline operations. Such programs to riskcritical mitigation throughout aviation safety information today are administration of justice.” information for is proper the necessary release of confidential aviation safety appropriate authority determines that such as “except where by areview an ambiguous exception to protection, the language” that often includes ahighly what bothers me and alot of people is existing the protection,had been and today. We’re focusing alot on what realize, howfully little protection exists you probably [don’t realize], or don’t ever-greater of pool information but sequences, and you’re an collecting grams built on confidentiality, he said. said. “And there risk” liesthe to pro- normal administration of justice, Quinn comply with laws privacy and the permit mation, aviation the has to also industry ing and protecting aviation safety infor An important issue is that instandardiz- Task Force Context | Yet and collection the sharing of Disclosures have “serious con-
WORLD AEROSAFETY | DECEMBER 2012–JANUARY 2013 -
© DNY59/iStockphoto hosted a very largehosted avery summit … and their seminar with judiciary. their They developed an education and training nance technicians, he said, but “have homicide charge against two mainte- notties only have dropped negligent the recorder (CVR). Now, Spanish authori- audio recording from cockpit the voice public Internet —of postings final the Spanish —and media news ultimately flaps and slats, that included to aleak inadvertently to failed correctly select lowing crew flight the inwhich atakeoff Spanair MD-82accident, fol Boeing - guidance ignore material, will they it.” ignore it. Particularly ifit’s international law that judges the must follow, will they guidance material, but unless there is a to do[judicial] training, it’s great to have tive exceptions,” said. Quinn “So it’s great material that contain ambiguous, subjec- non-binding attachments or guidance ecutors and lawyers are likely to ignore or manslaughter charge. “Courts, pros- itbecause sounds relevant to ahomicide of confidential safety information simply towilling require release to prosecutors safety issues often have ready been and an ICAOtaskforce seekingtoprotect confidentialaviationsafetyinformation. The urgentneedforjudicial‘advancearrangements’challenges SAFEGUARDS SHAPING FLIGHTSAFETY.ORG He cited aftermath the of 2008 the Judges without education on the |
WORLD AEROSAFETY | DECEMBER 2012–JANUARY 2013 Articles 12andArticles 14 inEuropeanties Regulation 996/2010 miliar with guidance to judicial authori- and safety information.” sensitivity now of aviation information …aboutpolice, with judiciary the the with national the police, with local the aviationcivil authority is inadialogue some judges to seriously consider legal an ominousseen unwillingness among andwide, Quinn Foundation the have In light of other court decisions world- Releases Court-Ordered for any future interaction, he said. investigation authorities inpreparation prosecutors these between and accident among prosecutors as well as adialogue specialization inaviation accidents pore, chief the prosecutor has facilitated Convictions Rejected,” p. 12).In Singa- “Concorde appeal successful in their (see manufacturer and amechanic but also convictionnal of two airlines, aircraft the authority not was used only- crimi inthe Frenchthe aviation accident investigation tion. In other examples, of expertise the reports to lawyers pursuing litiga civil - accessdenied to draft aircraft accident A Spanish judge fa- became —who 1 — also recently —also BY WAYNE ROSENKRANS
recommendations for or new enhanced The task force developing has been Task Force Objective in court, he said. database information from used being Congress to prohibit an airline’s ASAP statuteor specific by enacted U.S. the there was no common law privilege cockpit,”in the said. Quinn ona chilling pilot effect communications disclosure of CVRscontents would have basis for suggestion the tiary that the thatjudge there ruled - was “[no] eviden In another recent Canadian the case, civil aviation safety action programs (ASAPs). formation from aprogram similar to U.S. confidential in- as otherwise evidence, lawyers,to plaintiff’s the for potential use safety required act airline the to release successfully that national the and health a terminated attendant flight argued In one Canadian lawyers case, civil for outweighed safety-related all arguments. aviation community risk mitigations — mation —despite on chilling the effect national laws allowing of discovery infor practices. One that judge existing ruled arguments about safety-related industry A U.S. magistrate similarly said SEMINARSIASS - |
9 © draco77/iStockphoto SEMINARSIASS
ICAO standards and recommended The scope of anticipated recom- seeking in court to establish negligence practices to protect aviation safety mendations likely will comprise accident routinely file FOIA-type requests for information. A concurrent project is investigation; legal enforcement or ad- information from aviation occurrence drafting a new Annex 19 in conjunc- ministrative actions (such as suspension reporting sources, Quinn said. tion with the ICAO Safety Management or revocation of an airman certificate/ New judicial education includes Panel, he said. This annex — cover- license or issuance of a letter of correc- the aviation industry perspective that ing occurrence reporting and safety tion or letter of warning); responses to courtroom use of confidential aviation management systems — will assure subpoenas and requests under the U.S. safety information should be prohibited; protection of occurrence reporting Freedom of Information Act (FOIA) “unless this safety information can only information in addition to protect- and its non-U.S. equivalents from news be obtained by going after this source — ing accident investigation information media, lawyers and the public; and com- and unless it is necessary to ensure a fair under Annex 13. pany discipline of employees. Lawyers trial or [prevent] a miscarriage of justice
Conflicts in Administration of Justice and Uses of Aviation Safety Information
Event Leading to Court Action Affected Aviation Professionals Concerns About Chilling Effect1 Brazil — September 2006 One military air traffic controller was convicted The consensus of aviation safety specialists in October 2010 on a criminal charge but the is that “information given voluntarily by A business jet and a large commercial jet military court acquitted four other controllers. persons interviewed during the course of collided in flight, and the airliner crashed The convicted controller was sentenced in May safety investigations is valuable, and … such with 154 fatalities (ASW, 2/09, p. 11, and 2011 to more than three years of imprisonment information, if used by criminal investigators or 3/08, p. 12). but was eligible for community service, and prosecutors for the purpose of assessing guilt another controller was acquitted on charges of and punishment, could discourage persons harming national air transport safety. Two U.S. from providing accident information, thereby business jet pilots were convicted in May 2011 adversely affecting flight safety.”2 on criminal charges and sentenced to more than four years in prison. The judge recently commuted their sentences to community service, which has not been enforced. Indonesia — March 2007 The captain of the accident flight was charged in The exception within aviation safety specialists’ February 2008 with six counts of manslaughter. argument against the criminal prosecution of A large commercial jet was destroyed in In April 2009, the captain was found guilty individuals is evidence of an intent to cause a runway overrun with 21 fatalities (ASW, of criminal negligence and sentenced to two damage or conduct with knowledge that 1/08, p. 42). The non-judicial accident years in jail. In September 2009, the high court damage would probably result, equivalent to investigation concluded in part that the overturned the captain’s sentence. reckless conduct, gross negligence or willful landing airspeed was twice the correct misconduct. A chilling effect on other aviation value and that the captain (pilot flying) professionals has not been not a concern in ignored 15 warning alarms and the first these rare circumstances. officer’s repeated requests to go around. Cyprus and Greece — December 2008 Authorities in Cyprus charged the airline and four The Greek court used a draft accident report individuals (former chief pilot, chairman, CEO and final accident report by the national A large commercial jet crashed after and operations manager) with 120 counts of accident investigation authority, along with decompression and occupants’ loss of manslaughter. A Cyprus court in December 2011 testimony from an accident investigator, as consciousness during cruise, with 120 acquitted the individuals; the attorney general has evidence in the criminal case — contrary to fatalities (ASW, 1/07, p. 18). appealed. A Greek court in April 2012 sentenced prevailing international practices. three executives and an engineer to 123 years in jail, reduced to 10 years for manslaughter and negligence; appeal is expected.
Notes: 1. The term chilling effect in this context refers to potential unwillingness by aviation personnel to voluntarily disclose information needed to correctly determine accident causation, or to routinely report safety-related events, threats and errors in their everyday work. 2. From the Joint Resolution Regarding Criminalization of Aviation Accidents, signed in October 2006 by leaders of the Académie Nationale de l’Air et de l’Espace, Civil Air Navigation Services Organisation, European Regions Airline Association, Flight Safety Foundation, International Society of Air Safety Investigators, International Federation of Air Traffic Controllers’ Associations, Professional Aviation Maintenance Association and Royal Aeronautical Society.
Sources: Kenneth P. Quinn and AeroSafety World
Table 1
10 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 SEMINARSIASS
— it does not come in, it is protected,” went through the judiciary [training] Quinn said. Moreover, even if allowed in was asked to force an aerospace com- such circumstances, suitable safeguards pany to turn over safety-related informa- must be in place such as de-identifying tion and — on the basis of that training the information, issuing a protective — turned down the request.” order or providing an opportunity to In the United States, protections seal the proceedings so the information of aviation safety information against is not made public except perhaps to the these types of court-ordered disclosures plaintiff’s lawyers. “Otherwise, it will remain relatively weak after recent ef- have a tremendous chilling effect that forts to strengthen them under the FAA will negate [airline risk mitigation] pro- Reauthorization Act of 2012. grams, will stop the programs; then we’ll Despite some solid FOIA protec- go back to learning about safety through tion, Quinn said, “Be aware that all of Quinn accident analysis,” he said (Table 1). that information can still be subject Very liberal rules of discovery — or statements, … CVR [audio record- to a subpoena and civil litigation in a that is, requiring defendants to turn ings or] transcripts, and communica- wrongful death case. Be aware that a over everything that may be relevant tions between persons involved in the grand jury can subpoena all that infor- — prevail in trials worldwide. A better aircraft’s operations.” mation, and local law enforcement can approach would be for courts to follow This regulation allows disclosure of get all that information.” the standard of first considering the confidential aviation safety informa- Typically, under FOIA-type leg- high-level consequences of releasing tion if the benefits of the disclosure islation, voluntarily supplied safety confidential aviation safety informa- outweigh the adverse domestic and information has been given greater tion, then deciding what can be used international impact on future air safety protection than mandatorily supplied before a jury or a judge, Quinn said. investigations. In a related favorable safety information, he said. “Europe is The European Union already has set note, the Eurocontrol Just Culture Task moving additionally to protect man- a positive example with Regulation 996, Force recently demonstrated the value datorily supplied safety information. in his opinion. “They are quickly com- of creating a model prosecution policy … That’s going too far, and we have to ing up to speed on appropriate systems and conducted a dialogue with pros- recognize that the public has a right to to have a dialogue of advance arrange- ecutors and law enforcement officials, know, the media have a right to know. ments with the judiciary, with prosecu- discussing in part the prohibition of If there’s an accident, they ought to be tors, with law-enforcement,” he said, criminal prosecution absent evidence of able to pull up failures and malfunc- urging all states and regions to promote willful misconduct or gross negligence. tions and defects. They ought to be able this type of dialogue regardless of task In the years since the 2006 midair to pull up service difficulty reports. … force recommendations, ICAO deci- collision of a Gol Transportes Aéreos There’s really no chilling effect because sions or gaps in legislation and policies Boeing 737-800 and an ExcelAire Servic- people have to file [these reports].” of local jurisdictions. es Embraer Legacy 600, positive changes Note: “If you can, formalize that dialogue have occurred in Brazil’s standards for in terms of a memorandum of under- criminal prosecution in aviation ac- 1. Kenneth P. Quinn is an attorney and part- standing in an advance arrangement,” cidents, Quinn said. The Chamber of ner, Pillsbury Winthrop Shaw Pittman. Quinn said. “Europe is providing a path Deputies in the Brazilian Congress “has The IASS presentation reflected his views and those of Flight Safety Foundation, and forward. … [Regulation 996 Article passed recently legislation that would was not made on behalf of the task force. 14] is prohibiting making the following protect safety information and prevent kinds of safety information available: its use in a criminal prosecution,” he 2. The title isRegulation (EU) No 996/2010 of the European Parliament and of the statements from safety investigation said. As in Spain, Brazilian authorities Council of 20 October 2010 on the inves- authorities, sensitive and personal are “reaching out and doing training of tigation and prevention of accidents and information, information provided by their judiciary, and they’ve had a suc- incidents in civil aviation and repealing
Wayne Rosenkrans Wayne third-party countries … draft reports cess,” he said. “One of the judges that Directive 94/56/EC.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 | 11 INBRIEF Safety News Rudder Control Concorde Convictions Rejected
leven years after the fatal crash of an American Airlines French appeals court has thrown out the criminal Airbus A300-600 that was traced to excessive rudder- convictions of Continental Airlines and one of its Econtrol inputs, the U.S. Federal Aviation Administration Amechanics in connection with the July 25, 2000, crash (FAA) has ordered action to prevent excessive loads on the of an Air France Concorde during takeoff from Charles de vertical stabilizers of several models of A300s and A310s. Gaulle Airport in Paris. The FAA issued an airworthiness directive (AD) in No- vember requiring either a design change to the rudder control system on all A300-600s and A310s or the installation in those airplanes of a stop-rudder-inputs warning modification. The AD was intended to “prevent loads on the vertical stabilizer that exceed ultimate design loads, which could cause failure of the vertical stabilizer and consequent reduced con- trollability of the airplane,” the FAA said. The FAA said its action was prompted by “events of exces- sive rudder pedal inputs and consequent high loads on the vertical stabilizer on several airplanes.” Among those events was the Nov. 12, 2001, crash of the American Airlines A300 after takeoff from John F. Kennedy Alexander Jonsson/Wikimedia International Airport in New York. All 260 people in the air- All 109 people in the airplane and four people on the plane were killed, along with five on the ground. ground were killed when the Concorde burst into flames The airplane’s vertical stabilizer and rudder, and then its and crashed into a hotel. engines, separated in flight. The U.S. National Transportation The French Bureau d’Enquêtes et d’Analyses (BEA) iden- Safety Board (NTSB) said the probable cause of the accident tified the probable causes of the crash as the passage of one was the separation of the vertical stabilizer “as a result of the of the Concorde’s tires over a part lost by another airplane, loads beyond ultimate design that were created by the first offi- the “ripping out” of a piece of the fuel tank and the ignition cer’s unnecessary and excessive rudder pedal inputs. Contrib- of leaking fuel. Accident investigators said the lost part was a uting to these rudder pedal inputs were characteristics of the metal strip that had fallen from a Continental DC-10. Airbus A300-600 rudder system design and elements of the Published reports said that, although criminal charges American Airlines Advanced Aircraft Maneuvering Program.” were dismissed, the appeals court upheld a lower court order requiring Continental — which has since merged with United Airlines — to pay the equivalent of more than Upgrade for Israel $1 million in civil damages to Air France. Flight Safety Foundation praised the appeals court’s srael’s civil aviation authority has been found in compliance rejection of the criminal convictions. with the International Civil Aviation Organization’s (ICAO’s) “We’re very pleased that courts are recognizing that Isafety standards, according to an October review by the U.S. professional human error does not amount to criminal Federal Aviation Administration (FAA). conduct, even where it can lead to catastrophic conse- The FAA upgraded Israel to Category 1 status from the quences,” said FSF General Counsel Kenneth Quinn, also Category 2 rating it had received in a 2008 review by the FAA. the vice chair of the International Civil Aviation Organi- A Category 2 rating means that a country’s civil aviation zation Task Force on Safety Information Protection (see authority is deficient in at least one of several areas, including “Shaping Safeguards,” p. 8). technical expertise, trained personnel, record keeping and in- “The tragedy of this accident and others is only spections procedures. A Category 1 rating indicates compliance. compounded by decades-long efforts to find someone to If a country is assigned a Category 2 rating, its air carriers blame, rather than focus on human factors, training and may not establish new service to and from U.S. airports; exist- technology to make sure that the tragedy does not reoc- ing service is unaffected, however. cur,” he said. “Undue prosecutorial and judicial interfer- Under its International Aviation Safety Assessment pro- ence can not only create further victims of accidents but, gram, the FAA conducts safety reviews of all countries with air more importantly, [can] harm the integrity and timeliness carriers that operate to the United States or that have applied of the accident investigation process, with an adverse effect for such operations. on aviation safety.”
12 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 INBRIEF
Infrastructure Upgrade Accident Fatalities Decline
he Latin American and Caribbean Air Transport Associa- atalities from aircraft accidents worldwide declined tion (ALTA) and other aviation organizations have signed a 41 percent from 2010 to 2011, the International Civil Tdeclaration urging governments in the region to “facilitate FAviation Organization (ICAO) said in its annual the timely development of air transport infrastructure.” Safety Report. Others to sign the declaration during the 9th ALTA Airline A total of 414 fatalities were recorded in 2011, down Leaders Forum in Panama City, Panama, in November, included from 707 in 2010, according to the report, which said the the Civil Air Navigation Services Organisation, Airports Coun- decline resulted in one of the safest years on record in cil International (ACI), ACI-Latin America and Caribbean, and terms of loss of life. the International Air Transport Association (IATA). The report, published in November, also said that IATA Director General and CEO Tony Tyler told the fo- no fatalities were recorded in 2011 in runway-related rum that the region’s top aviation priorities are improvements accidents involving scheduled commercial operations. In in safety and infrastructure. 2010, 165 people were killed in runway-related accidents — an Airport and air navigation infrastructure “has not kept accident category that has been designated as a safety priority pace with rising demand for air connectivity in Latin Ameri- by ICAO and other aviation organizations. ca,” he said. Overall, there were 126 accidents involving scheduled He noted the 32 percent improvement in the hull loss rate commercial flights in 2011, up from 121 in 2010. The for Western-built jets in the region in 2011, compared with report said the increase was “consistent with the related 2010, but noted that the region lags behind the global hull loss [3.5 percent] increase in traffic and therefore did not rate. In 2011, the global rate was one hull loss of a Western-built significantly affect the global accident rate.” jet for every 2.7 million flights; the rate in Latin America was The 2011 rate of 4.2 accidents per million departures one accident for every 780,000 flights. was unchanged from 2010.
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For details, visit our Web site at flightsafety.org/BASS2013. To advertise in AeroSafety World Magazine, contact Emerald Media. To register or exhibit at the seminar, contact Namratha Apparao, Cheryl Goldsby Kelly Murphy tel.: +1.703.739.6700, ext. 101, [email protected]. [email protected] [email protected] To sponsor an event, contact Kelcey Mitchell, ext. 105, [email protected]. tel: +1 703 737 6753 tel: +1 703 716 0503 FLIGHTSAFETY.ORG | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 | 13 To receive membership information, contact Susan Lausch, ext. 112, [email protected]. INBRIEF
Information Sharing
light Safety Foundation (FSF) and the International Civil Aviation Organization (ICAO) have begun a new Fcooperative effort to promote and share aviation safety information and metrics. The new worldwide initiative is designed to support ICAO guidance for safety management systems, which calls for increased monitoring, analysis and reporting of safety data. “The establishment of this framework for enhanced co- © Ulf Wallin operation with FSF is an important step in helping us achieve NTSB’s Most Wanted the highest levels of aviation safety worldwide,” said Roberto mproving safety in airport surface operations is among the Kobe González, president of the ICAO Council. “Aviation U.S. National Transportation Safety Board’s (NTSB’s) top safety knows no borders, and these types of collaborative 10 safety challenges for 2013. data sharing and risk mitigation efforts are essential to help I states and industry address safety risks before they lead to a Surface operations and general aviation safety are the only aviation-specific items on the agency’s list, announced serious incident or accident.” in November, but several others — preserving the integrity of The memorandum of cooperation calls for ICAO and transportation infrastructure, eliminating distraction and im- the Foundation to work together to encourage compliance proving fire safety — touch on aviation, as well as other modes with ICAO standards and recommended practices and of transportation. related guidance material. “Transportation is safer than ever, but with 35,000 annual The memorandum also “promotes joint activities fatalities and hundreds of thousands of injuries, we can and between the organizations in the areas of data sharing and must do better,” NTSB Chairman Deborah A.P. Hersman said. analysis, training and technical assistance,” according to The NTSB called for more and better ground movement the announcement of the agreement. “The joint analyses safety systems, such as cockpit moving maps and runway status developed will facilitate the harmonization of proactive and lights, and for pilot training that includes simulator sessions predictive safety metrics and the promotion of a just safety involving gusty crosswinds and other realistic conditions. culture globally.” “The problem … requires all parties involved in airport Foundation President and CEO William R. Voss, noting operations to work together to create a safer, more vigilant that some U.S. air carriers and the U.S. Federal Aviation Ad- environment,” the NTSB said. “Ground movement safety ministration already operate under cooperative data-sharing systems, such as cockpit moving map displays that provide agreements, said the new cooperative agreement would help a timely warning to flight crews to prevent runway incur- other countries “establish models that are suited to their sions, are just one potential solution. Another is a system of unique needs and constraints.” cross-checking the airplane’s location at the assigned runway Regional forums will be convened soon to aid in estab- before preparing for takeoff. lishing information-sharing goals. “New technology — such as runway status lights and enhanced final approach runway occupancy signals — can provide a direct warning capability to the cockpit, thereby In Other News … eliminating the delay in warning the pilots by relaying it through an air traffic controller.” he U.S. National Transportation Safety Board has issued For general aviation, the NTSB recommended improved recommendations calling for the installation of active pilot education, including training on the use of electronic Tfire suppression systems in all cargo containers or flight displays, and screening for risky behavior. compartments of cargo aircraft. … All 191 member states Other specific recommendations called for increased invest- of the International Civil Aviation Organization have begun ment in aviation infrastructure, including engineered materials using a new aircraft flight plan designed to aid in managing arresting systems to mitigate injury and damage from runway the increasing volume of air traffic. … The U.S. Federal Avia- overruns, and improved weather information for pilots; the in- tion Administration, the U.S. National Transportation Safety stallation of fire suppression systems and fire retardant materials Board, airlines and aviation labor unions have agreed to a in airplane cargo compartments; and enhanced efforts to elimi- new information-sharing program designed to identify nate distraction in aviation and other modes of transportation. systemic risks and help prevent related accidents.
Compiled and edited by Linda Werfelman.
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Date: 04/13/12 Client: Teledyne Job #: 04242012 File Name: 0424_TEL_WGL_adRevs_ASW_May12_r2 Page 1 of 1 Account Director: Henry Artime Editor: Designer: ha Revised By: ov Production: Color: 4C/Process Trim: 8.5"× 11" Bleed: 8.75"× 11.25" Safety: 7.035"× 9.125" Fold: none Publication(s): AeroSafety World Magazine Run Date(s): May 2012 Special Instructions: Approved By: COVERSTORY
As flight deck displays become more numerous and more sophisticated, pilots grapple with sensory overload.
AttentionBY CLARENCE on E. RASH Deck
16 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 COVERSTORY
© Chris Sorensen Photography
pilot from the pioneering days of aviation, have both visual and auditory modalities; this who flew with little more than a compass is especially true of displays presenting caution for flight information, would no doubt be and warning information. delighted — and overwhelmed — by the Visual displays primarily present informa- Aarray of instruments on today’s flight decks. More tion using intensity (brightness), size and color displays mean that pilots have more information characteristics. Auditory displays use intensity — and that leads to improved decision making (loudness) and frequency (tone). Both visual and enhanced flight safety. and auditory displays often incorporate a pulsat- However, cognitive scientists warn that ing characteristic, such as a flashing light or a providing more and more information has its beeping tone. limitations, increases workload and actually can Displays can be considered as having two negatively influence the amount of information functional modes. The first, and most obvi- pilots can absorb and act upon. This concern ous, is to present current status information for may be most important in emergency situations various aircraft performance parameters such when multiple, simultaneous warning displays as airspeed and angle of climb, and to have this activate, overwhelming pilots with information. information always available. This is espe- This warning has not gone unheeded, as cially true for visual displays. An example is an many cockpits have a declutter mode, allowing altitude indicator. There is no need for pilots to pilots to greatly reduce the number of instru- continuously monitor this parameter, but the ment displays vying for their attention. When information is always there, for example, for a declutter mode is not available, pilots often timely awareness of deviation from clearances. simply turn off the instruments they consider In a second functional mode, a display may unnecessary or distracting. serve as a caution or warning indicator. In this mode, the display moves from a passive to an Cockpit Information active function. Based on certain predeter- The first step in avoiding the potential problem mined criteria, the display alerts pilots that the of information overload is understanding the current status of some flight parameter requires balance between information requirements monitoring or immediate action. Communica- (how much information is needed) and avail- tions systems, which are a type of auditory dis- ability (how much information is being pre- play, fall within this mode, as air traffic control sented or is quickly accessible).1 How much communications regarding altitude changes or information is required is ever-changing and the presence of nearby aircraft require acknowl- depends on flight task, aircraft type and phase edgement and possible action. Stall warning of flight. Information availability also depends indicators are another example. on the cockpit instrument panel design — that is, the number and location of instruments, the Using Displays types of displays and the modes of information While all flight displays should be monitored at presentation. appropriate intervals, pilots generally interface Equally important is the human at the most with the displays used during takeoff and controls. Pilots use multiple senses — especially landing and during emergency situations. Dur- sight and hearing — to gather information ing the en route phase of flight, the use of auto- about their aircraft and its relationship to the pilot is customary, with the interface adapted for outside world (i.e., situational awareness). monitoring. Although the first aviation displays were During takeoffs and landings, pilots use
entirely visual in nature, many modern displays scanning techniques to systematically and Moore Jennifer
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 | 17 COVERSTORY
purposefully direct their attention to the is limited, and attention is selective. However, important and relevant task-defined displays. details beyond these general statements remain During these flight phases, pilots must monitor in contention. hundreds of sources of information within the The principle that attention is limited leads cockpit, as well as attend to additional inputs to an appealing, but not fully accepted, idea that from outside the aircraft. In general, pilots can humans have a finite pool of attention resources select when and where to direct attention during that can be distributed across one or more sen- most, if not all, phases of flight. sory inputs (divided attention). This portrayal is In an emergency scenario, multiple caution useful in a first attempt to understand attention, and warning displays generate new visual or audi- but it fails to point out its complicated nature. tory stimuli, such as red flashing lights or sirens, The concept of a finite pool of attention which are intended to capture pilots’ attention. resources implies that tasks may be performed In such situations, there is a sudden shift in how in parallel by dividing these resources. How- pilots interact with the displays, which compete ever, there is not total agreement as to whether to capture pilots’ urgent and full attention. truly simultaneous parallel attention is occur- ring when we divide attention between two or Attention more tasks at the same time, or if attention is In today’s fast-paced world, multi-tasking is just rapidly being switched between individual considered the norm, and motor, visual and sensory inputs. auditory tasks apparently are being attended to Some psychologists believe that there simultaneously. However, studies consistently is not one pool of attention resources but show that overall performance suffers when several. Even if multiple resource pools exist, attention is divided among multiple tasks.2 The some studies have suggested that resources ability to absorb visual and auditory informa- used for visual and auditory stimuli may not tion from multiple sources is thought of as be- be completely separate; this is more apparent ing second-nature, but the concept of attention when the stimuli are in different locations.4 In is actually complex. the cockpit, this may translate into pilots not Attention is formally defined as the mecha- being able to effectively attend to both visual Multi-tasking is nism that takes place in the brain to ensure that and auditory warnings from opposite sides of a preferred sensory input receives immediate the cockpit. considered the cognitive processing over all other inputs.3 Aviation psychologist Chris Wickens5,6 This definition presumes some preliminary has suggested a multiple resource theory for norm, and motor, cognitive processing, with or without atten- attention that says each task has three dimen- tion. Attention may be better understood if it sions that determine how attention is allocated. visual and auditory is thought of as a process that ensures contin- These dimensions are: tasks apparently ued cognitive processing of a chosen sensory input. You must actively and continuously • Which cognitive processing stage does the are being attended maintain attention in order to maintain a high task involve — for example, perceiving a level of cognitive processing of a desired input. light or selecting a switch to turn on? to simultaneously. An obvious implication is that if attention is • Does the task involve the verbal or spatial shifted from one input to another, intentionally mode of processing — listening to a com- or inadvertently, cognitive processing of the munication or searching for a specific first input is greatly reduced, if not terminated instrument readout? altogether. While a complete understanding of how • What are the types of input and output in- attention works still eludes cognitive scientists, volved — auditory or visual inputs; verbal two basic tenets have been identified: Attention or motor outputs?
18 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 COVERSTORY
Wickens’ theory argues that there may Task Types likely leads to the second tenet — that be a separate pool of attention resourc- Task type is another factor affecting di- attention is selective. It seems reason- es for each combination of the three vided attention when performing mul- able that if an asset is limited, then the task dimensions and that performance tiple tasks. For tasks largely related to user of the asset would have the ability deteriorates when there is a shortage of attending to cockpit instruments, task to determine where it should be used. these different resources. type can be defined by the information Selective attention is the process of input method and can be categorized choosing what to attend to. This may Difficult Tasks as either visual, such as searching for involve directing attention to a specific Regardless of whether multi-tasking a specific switch or reading a display object or event, or in a general direc- occurs simultaneously or with rapid value, or auditory, such as monitoring tion. Though the brain continues to switching, the ability to divide atten- communications for your call sign or receive information from the entire tion seems to depend on a number attending to an auditory display warn- environment, most of this information of factors.7 A primary factor is the ing. Like attention in general, theories is largely ignored. Selective attention difficulty of the attention task. It is of how two or more different types of enables a person to concentrate on the obvious that the more difficult a task, tasks compete for attention are complex input of interest while disregarding the greater concentration (attention) and not fully understood. other inputs from the environment is required. It is possible for a task to An example of this complexity is in such as engine noise, cabin conversa- be so difficult that divided attention the size of the environment from which tion or changing display readouts.10 is impossible. Not as obvious is that competition for attention can arise. Selective attention is called “top- the attention resources required for a Because humans have two ears on op- down” processing, which is goal-driven; specific task do not remain constant. posite sides of the head, we are sensitive the individual determines which Training and experience can reduce to sounds generated anywhere around stimulus receives the selective atten- the requirements. us. In contrast, the human instanta- tion. This also is referred to as executive When a task is first learned, the atten- neous visual field — what can be seen attention. This does not imply that all tion resources required can be so great when the head is in a fixed position — attention resources have been focused that the task may be all-encompassing. is limited to mostly the frontal hemi- on the selected single object or the event With practice, the attention demand sphere. Foveal vision, which provides of interest. The brain continues to use a decreases dramatically, and the task fine detail, is further restricted to only “bottom-up” approach in which atten- becomes automatic. This reduction in at- about two degrees of the visual field. tion is stimulus-driven. This means that tention demand is called automaticity and In studies that have looked at the there are certain aspects — for example, is the major goal of training. The mecha- problem of simultaneous visual and color, brightness increase or loudness — nisms that allow for automaticity are not auditory inputs, such as an indicator of an input stimulus that can override a clearly understood. One theory suggests light flashing at the same time a tone person’s selective (focused) attention. that with training, some of the processes is emitted, it was found that the tone is involved in an attention task eventually frequently not detected. This may imply Attention Tunneling are eliminated.8 Another proposed expla- that attention seems to favor visual in- Sometimes selective attention can go nation is that with well-practiced tasks, put when both the visual input and the too far, resulting in attention tunneling. the increased role of memory reduces the source of the auditory input are located Colloquially called tunnel vision, this attention demand.9 within the visual field. However, in condition occurs when a pilot fixates As might be expected, if a specific natural environments, sounds not col- on a specific input while becoming task is not performed routinely, or if a located with a visual input can be used oblivious to all other incoming infor- long delay occurs in the practice or per- to draw attention to a visual target or mation. All attention resources become formance of a task, the task’s attention event not in the visual field. dedicated to a single input from one demand will return to previous higher information source. This could be a levels. This inevitable regression is what Selective Attention specific location or specific readout on is behind requirements for maintaining The first generally accepted tenet of a display, or it could be some object flight proficiency. attention — that it is limited — very outside the aircraft. In many cases,
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 | 19 COVERSTORY
stress, workload and fatigue can in- indicated that in most tasks, cognitive 5. Wickens, C.D. “Processing Resources in crease the likelihood of tunnel vision.11 processing seems to favor visual inputs Attention, Dual Task Performance, and The classic experiment conducted over auditory inputs.16 Workload Assessment.” In R. Parasuraman and R. Davies (editors), Varieties of by Fischer, Haines and Price12 revealed Solving the Problem Attention. New York: Academic Press. that pilots flying with a head-up display 1984. (HUD) were less likely to detect unex- Reviews of the U.S. National Transpor- 6. Willingham. pected runway incursions than those tation Safety Board (NTSB) aviation flying with conventional head down accident database have concluded that 7. Goldstein, E.B. Cognitive Psychology: instruments, despite the fact that the nearly half of the reported accidents Connecting Mind, Research, and Everyday Experience. Belmont, California, U.S.: HUD allowed direct runway viewing could be attributed to crew error in- Thompson Wadsworth. 2005. so that the incursion could be seen. The volving lapses of attention.17,18 Human study concluded that pilots were focus- factors experts continue to study the 8. Anderson, J.R. Rules of the Mind. Hillsdale, New Jersey, U.S.: Erlbaum. 1993. ing their full attention on the HUD attention issues involving pilots and symbology at the expense of all other instrument displays, and to develop 9. Logan, G.D. “An Instance Theory of visual information. better guidelines for information pre- Attention and Memory.” Psychological Review Volume 109, 376–400. 2002. sentation. Better guidelines, coupled Sensory Overload with the flexibility of glass cockpits that 10. Lee, S. (editor). Encyclopedia of School In today’s instrument-rich cockpits, are no longer constrained in the type Psychology. Thousand Oaks, California, U.S.: Sage Publications, Inc. 2005. pilots typically encounter more infor- and location of the information they mation (sensory inputs) than can be present, may help reduce the potentially 11. Baddeley, A.D. “Selective Attention and processed at any one time, especially disastrous consequences of sensory Performance in Dangerous Environments.” British Journal of Psychology Volume 63, during emergency situations when overload and attention tunneling. 537–546. 1972. multiple warnings may be flashing and Clarence E. Rash is a research physicist with 35 13 12. Fischer, E.; Haines, R.F.; Price, T.A. chiming. This can lead to a condition years of experience in military aviation research Cognitive Issues in Head-Up Displays, known as sensory overload. and development and the author of more NASA Technical Paper 1711. Moffett Field, Sensory overload causes an over- than 200 papers on aviation display, human California, U.S.: NASA Ames Research factors and protection topics. He also teaches demand of cognitive resources. The Center. 1980. theory of multiple pools of attention a course in sensory, perceptive and cognitive human factors engineering principles through 13. Johnston. W.A.; Dark, V.J. “Selective resources explains sensory overload as the University of Tennessee Space Institute in Attention.” Annual Review of Psychology a supply-and-demand problem that oc- Tullahoma, Tennessee, U.S. Volume 37, 43–75. 1986. curs when an individual must perform 14. Drinkwater, B.L. “Performance of Civil two or more tasks that require the same Notes Aviation Pilots Under Conditions of resource. Conversely, overload will Sensory Input Overload.” Aerospace 1. Deveans, T.; Kewley, R. Overcoming not occur if the multiple tasks do not Medicine Volume 38, 164. 1967. Information Overload in the Cockpit. make demands on the same resources. West Point, New York, U.S.: Operations 15. Harris, D. (editor). Human Factors for Sensory overload has long been known Research Center, Military Academy. 2009. Civil Flight Deck Design. Hampshire, U.K.: to cause pilot error in simulator stud- Ashgate Publishing. 2004. 2. Wang, Z.; Tchernev, J. “The Myth of Media ies14 and is believed to be a contributing Multitasking.” Journal of Communication 16. Roberts, D. (editor). Signals and factor in a number of aviation accidents Volume 62 (3): 493–513. 2012. Perception. Hampshire, U.K.: The Open attributed to pilot error. Situations of University. 2002. 3. Willingham, D.T. Cognition: The Thinking sensory overload can cause disorienta- Animal. Upper Saddle River, New Jersey, 17. Dismukes, K.; Young, G.; Sumwalt, C.R. tion, degrade decision-making ability, U.S.: Pearson Prentice Hall. 2004. “Cockpit Interruptions and Distractions.” and delay or even prevent the correct ASRS Directline Issue 10. December 1998. 4. Driver, J.; Spense, C.J. “Spatial Synergies response.15 Between Auditory and Visual Attention.” 18. Strayer, D.L.; Drews, F.A. “Attention.” In This raises the question of whether In C.M.M. Umilta (editor), Attention and Handbook of Applied Cognition. Druso, one attention resource dominates Performance. Cambridge, Massachusetts, F.T. (editor). West Sussex, U.K.: John the others. A number of studies have U.S.: MIT Press. 1994. Wiley and Sons. 2007.
20 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 MORE MORE REQUIRED EXPERIENCE
© Editorial/Dreamstime.com I FLIGHTSAFETY.ORG difficult operationaldifficult conditions, before are they hired by U.S. passenger and cargo airlines. tration (FAA) Extension Act of 2010,aims to ensure that pilots have more in especially experience, pilot (ATP) aresult certificate. The rulemaking, of Airline the Safety and Federal Aviation Adminis - eligibility and qualification requirements requirements the and modifies for an airline transport Requirements published to be expected Federal inthe rule, Registeron May 17,2013,amends pilot increase and time in flight requirements. certification The and Pilot Qualification Certification n August 2013,pilots inair to operations seeking fly carrier United inthe States asharp see will |
WORLD AEROSAFETY | DECEMBER 2012–JANUARY 2013 BY HEATHER BALDWIN accidents causedbypilotinexperience. New pilotqualificationruleseekstoreduce REGULATIONSAFETY |
21 SAFETYREGULATION
The rule is now in executive clearance fol- flight hours [that] a full ATP certificate would lowing closure of the public comment period on require.” April 30, 2012. If published on schedule, it will Gilligan explained the reasoning behind the go into effect Aug. 1. exception, saying, “In the 2010 act, Congress Known colloquially as the “1,500-hour clearly acknowledged that the measurement of rule,” the proposal primarily affects first officers experience in determining when an individual (FOs), who will be required to hold an ATP cer- may be ready to serve is not limited solely to the tificate, which requires at least 1,500 hours of number of hours flown. Rather, education and flight time, and a type rating for the aircraft other commercial flying experience must also be to be flown. Currently for U.S. Federal Avia- considered.” tion Regulations (FARs) Part 121 and Part The requirements for captain will change, 135 operations, FOs are required to have too, but less dramatically than for FOs. Under only a commercial pilot certificate, which the new rule, pilots will need at least 1,000 flight requires 250 hours of flight time, and appropri- hours in air carrier operations to serve as a ate category and class ratings. pilot-in-command in Part 121 operations. Requirements for the ATP will change as well. An ATP certificate with an airplane catego- Background ry multi-engine class rating or type rating will The rule aims to reduce the number of accidents require 50 hours of multi-engine flight experi- and incidents caused by pilot inexperience. ence and completion of a new FAA-approved In a notice of proposed rulemaking (NPRM) ATP certification training program that would published on Feb. 29, 2012, the FAA said it had include academic training and training in a identified 31 accidents in Part 121 air carrier op- flight simulation training device. The training erations and 30 accidents in Part 135 air carrier will prepare a pilot to function in multipilot and operations between fiscal year 2001 and fiscal air carrier environments, in adverse weather year 2010 that “could have been mitigated if the conditions such as icing and in high altitude proposed enhanced ATP qualification standards operations, and adhere to the highest profes- and Part 121 requirements had been in effect sional standards. at the time of those accidents. The analysis The rule makes two exceptions to the 1,500- indicated the accidents were a result of various hour requirement. Military pilots with 750 flight issues, including improper aircraft handling, hours and graduates of an accredited four-year poor CRM [crew resource management], poor university program with 1,000 flight hours1 will situational awareness and inadequate training. be able to obtain a “restricted privileges” ATP These accidents resulted in 107 fatalities, 28 certificate. serious injuries, and 44 minor injuries.” “Pilots with this restricted certificate would Despite this trend pointing toward the need only be able to serve as first officers for U.S. for increased pilot training and qualification airlines. They could not use it to serve as a standards, it wasn’t until the Feb. 12, 2009, crash captain in any commercial flying operation that of Continental Airlines Flight 3407, operated requires an ATP, nor use it to teach other pilots,” by Colgan Air, that the issue really came into Peggy Gilligan, FAA associate administrator for the public spotlight. On approach into Buf- aviation safety, told the House Committee on falo Niagara International Airport, in wintry Transportation and Infrastructure’s subcom- weather conditions, the Bombardier Dash 8-400 mittee on aviation on April 25, 2012. “Pilots turboprop slowed to dangerously low speeds seeking a restricted ATP would be tested to the and stalled. The captain failed to follow estab- same standard required for full ATP certificates, lished stall recovery procedures, pulled back on and they would be required to have the equiva- the yoke and overrode the stick pusher, crashing
U.S. Federal Aviation Administration, top; Susan Reed top; Administration, Aviation Federal U.S. lent minimum instrument time and nighttime into a private home.
22 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 SAFETYREGULATION
The accident killed 45 passengers, two flight Reliability Methods, has been a longtime advo- attendants, both pilots and an individual on the cate of this rule. “Not only have I tried to make ground. The U.S. National Transportation Safety sure this rule was implemented, but my FO on Board’s (NTSB’s) final accident report cited the Hudson River was also very active,” said flight crew qualifications, failure to adhere to the Sullenberger, who is widely known for success- sterile cockpit rule and improper handling of the fully landing US Airways Flight 1549 on New aircraft as causal factors in the accident. York’s Hudson River in January 2009 after the Shortly after the accident, family members of Airbus A320 struck a flock of birds. “There’s the passengers formed Families of Continental a constant tension between economics and Flight 3407 and began pushing lawmakers for safety. I’m of the point of view that we must reforms they said would bring regional airline make these improvements for three reasons: hiring and pilot qualification standards to a higher level. “Our goal is one level of safety,” said Scott New Rule Will Severely Impact Maurer, father of Flight 3407 passenger Lorin Pilot Hiring Pool Maurer and one of the family group leaders who has been instrumental in pushing for the &A with Louis Smith, president, Future and Active Pilot Advisors passage of the legislation. “We advocate very (FAPA) strongly for: let’s get the right pilots in the QASW: What has been the response of your members to the new cockpit and let’s set them up for success. Pilot pilot qualification rule? qualification is only one provision of [the law] Smith: The low-time pilots are wondering how they will be able to and there’s no one brick in this structure that accumulate hours. There aren’t enough pilots with 1,500 hours to take gets the job done. You need them all.” the regional jobs. We are already seeing the impact: I just got an email Some argue that the new pilot qualification from a large regional carrier who said they were out of pilots and can’t fill their November class. rule would not have prevented the Flight 3407 ASW: What is FAPA’s position on the rule? disaster as both pilots had more than 1,500 hours at the time of the accident (the captain Smith: We don’t think the mandate will work at the regional airline level, given the current pay and benefit structure. The only way the had logged 3,379 hours and the first officer had regional airlines can attract high-time pilots at their current pay and 2,244 total hours). Maurer strongly disagreed. benefits is to tie the offer to a major airline seniority number — not He pointed out that Colgan had hired the just a guaranteed interview, but a contingent seniority number with captain with just 618 hours; the new rule would little restrictions and no further impediments to the offer. have prevented him from being hired until ASW: How will the rule change the hiring landscape? he had much more experience. Moreover, the Smith: Establishing a reliable source of competent pilots will be a chal- new ATP requirements would have given both lenge for even the major airlines. Some of the majors are now recruit- pilots specific training on operating in adverse ing pilots from the regional airlines, which triggers instructor attrition weather conditions. at the flight schools and aviation universities, and the domino effect ripples through the industry. The 1,500-hour rule will reduce the pool Maurer said the rule has positives and nega- of qualified pilots and will require radical changes in the current offer tives. “It’s got all the stakeholders, and we can made to pilots entering at the regional level. certainly agree with and support the exception ASW: Will there be enough pilots to fill the needs of airlines? for military pilots,” he said. “But we are con- Smith: We don’t expect a shortage at the major and global airlines but cerned about the university exception. We don’t without significant pay and benefit changes, the regional airlines will want to see simulators as a substitute for flying experience serious shortages. One recruiter, briefing top management in the clouds and cold weather and ice.” recently, said, “Be prepared to park airplanes next year because we don’t have enough people to fly them.” Industry Reactions FAPA is a career and financial advisory service for professional and aspir- Chesley Sullenberger, a retired US Airways ing pilots.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 | 23 SAFETYREGULATION
Passengers deserve it, colleagues expect it, and on him to know when to shift his priorities,” the profession demands it. These improve- Sullenberger recalled. “When we were ap- ments are long overdue.” proaching the water, I had to judge to a fraction In fact, Sullenberger, who had 20,000 of a second when to pull the nose. Jeff [Skiles, flight hours at the time of the Hudson event the FO] knew that. Without me telling him, he and has studied safety his entire professional immediately stopped trying to get more thrust life, argued that 1,500 hours is not enough. from the engine and began calling out airspeed “Two hundred and fifty hours is ludicrously, and altitude. He knew intuitively that he had to insanely, stupidly low. Going to 1,500 is a step shift to a higher priority. in the right direction, but we are not all the “Had I had someone with much less ex- way there.” He pointed to his experience on perience, we would not have had as good an the Hudson as an example, saying that had his outcome and people would have perished,” Sul- first officer, who also had 20,000 hours, been a lenberger said. “You can be surprised when you less experienced pilot, the outcome would have least expect it and suddenly you have only 208 been very different. seconds to solve it. So I really get the importance “On our flight, the crisis was so extreme, the of having the proper experience in the cockpit.” workload so high, the pressure beyond belief, Some have stressed that the training — not we didn’t even have time to have a conversation. the hours — is the key piece of this proposed I had to rely on his experience to intuitively rule. “There’s not a direct correlation between understand what was happening by what I was hours and safety. A pilot’s experience will cer- telling ATC [air traffic control]. I had to rely tainly increase with more hours but it depends
24 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 ©Boeing Commercial Airplanes Summary of Commercial Jet Airplane He pointed to Boeing’s 2011 Statistical upset recovery program inairplanes. tant, he said, there should aformal be majority of accidents. Most impor address problems the that cause the wanted evenmore to see training to polish.” Specifically, Cox said he airplanes.”jet pilotsperienced coming into complex of 250hoursrule had relatively inex - entering decksThe is flights good. old creasing level of experience the pilots with more than 14,000hours. “In- Systems and aretired airline captain John Cox, founder of Safety Operating “Parts of are this good,” weighedin Targeted TrainingCrucial law. new safer be as aresult will industry of the elements required” that be will and the and leadership training and teamwork against more the structured mentoring up situational awareness. Overlay that “When you build up hours, you build result of bringing up hours. baseline the safety improvements see will try as a passengers.” He that added indus the - a commercial license isn’t enough to fly nicely with our position that just having goals we’vethe and identified lines up to operate alarge It jet. alot meets of are now and you experience the need “strikes where abalancebetween we is important.”experience approach to building more quality and on line? the Having amore structured are working they with acheck airman just building hours on own? their Or captain at Alaska Airlines. “Are they national (ALPA) 737 and aBoeing Air Pilots Line Association, Inter Cassidy,said Sean president, first vice on how accumulate they hours,” those FLIGHTSAFETY.ORG But “needs that he added rule the Cassidy said forthcoming the rule |
WORLD AEROSAFETY | DECEMBER 2012–JANUARY 2013 - - technology and restructuringtechnology industry ing standards new because was needed told panel the that achange intrain- operations, safety and security. Voss tation’s subcommittee on aviation Commerce, and Science Transpor before U.S. the Senate Committee on President and CEOWilliam Voss R. testimony of Flight Safety Foundation 800 and 1,000hours. level would betweenexperience be Cox second-in-command said, agood of careers.” their With training, this spendmostment will they inwhich provide pilots training environ inthe - addressed,”to be he said. “We to need thingslower need These speeds. stall ent meteorological conditions and a different environment with differ are [at] cruising altitude, are they in altitudein high “When flight. jets you can’t doinasimulator.” lots must recognize Gforces, the which of recovery asuccessful is reduced. “Pi- airplanethe is stalling,” likelihood the and recognize it as akey indicator that er. Until you kindof this instability see rolled steeply from one sideto oth the - and Air France Flight 447, animationthe of Colgan [Flight 3407] imitate and stalls upsets. “If you at look ing past the decade. leaders as causes the of accidents dur for 18of 79accidents the —were clear rain accidents accounted also —which andin flight controlled into flight ter ofother type accident. of Loss control moretalities, than were caused by any onboard fatalities and fa- 80external accidentsThose resulted in1,493 were caused by loss of control inflight. duringcommercial 2002–2011 fleet jet fatal accidents (22.7percent) inthe Accidents said, which that 18of 79 the His points echo March the 20 Cox said more training is needed Simulators, he said, don’t effectively 2 the wings the - - - - Notes ing operations.” knowledge of cold weather and deic- respectively, lacked yet critical still ago had 8,300hours and 3,500hours ington National more than 20years Florida pilots crashed who at Wash- to avert atragedy,” Air he said. “The knowledge lackedwho critical the pilots with many thousands of hours, are“There countless examples of prompted first place. inthe rule the toed avert kinds the of tragedies that and not enough on training the - need putsrule much too on focus hours consequences.” dated, and we are some seeing tragic past “to become dangerously out- has caused requirements the of the world, rather than simply increasing trainingcal that targets real risk inthe more be will aresult of mandating criti- realthe effectiveness of rule new the less to chance. The Foundation believes program would reduce risk by leaving reduced,to be since that training ing program can allow requirement this notion the ports that astructured train- Flight Safety Foundation strongly sup- of a1,500hour is understood,pose rule 2. 1. numberthe of hours.”
inputs to led astall. information,speed and excessive control pitotthe tubes, producing unreliable air d’Analyses had blocked said icecrystals by French the Bureau d’Enquêtes et people aboard. The accident final report onOcean June 228 all 1,2009,killing A330-200 that crashed into Atlantic the affiliated the universitywith or college. ment flight ratingfrom a schoolpilot commercial pilot certificate and- instru an aviation obtained also degree a ifthey Air France Flight 447was an Airbus This provision applies graduatesto with However, that he added new the Voss stated, further “While pur the REGULATIONSAFETY
- - |
25 SAFETYREGULATION
he Single European Sky (SES) fragmentation. Promised improve- national supervisory authorities and air project is “not delivering” on its ments have not materialized.” navigation service providers. promise of a seamless and efficient The impetus for SES, according The second, begun in 2009, is the air traffic management system to an EC timeline, came with the five-part SES-II, which deals not only Tthroughout Europe, Siim Kallas, Europe- liberalization of the European Union’s with regulating performance, providing an Commission (EC) vice president for aviation market in the 1990s and the technological solutions through the SES transport, says. resulting expansion of air services. Air Traffic Management Joint Undertak- To address shortcomings in creation Between 1993 and 2012, air traffic in ing (SESAR JU), maximizing airport of the single European airspace, Kallas Europe increased 54 percent, the capacity and incorporating human factors plans to introduce a series of legisla- EC said. concerns, but also with uniformly ad- tive proposals early in 2013 to speed The increase in air traffic and the dressing safety concerns, in part through implementation of the program and accompanying constraints on airspace the European Aviation Safety Agency. strengthen its legal framework. capacity caused flight delays, attribut- After SES is fully implemented, Kal- Industry groups echoed Kallas’ able in large part to what the EC called las said, safety will improve “by a factor remarks and endorsed his legislative “fragmented and inefficient” air traffic of 10,” airspace capacity will triple and plans as a top priority in European control in Europe (see “European Air- costs will be halved. aviation. space,” p. 28). Without SES, “chaos will reign,” he “The Single European Sky is … too “Airspace is currently structured added. important to be allowed to fail,” Kallas around national boundaries, and so The EC sees progress in implement- told an October 2012 meeting of top flights are often unable to take direct ing some elements of SES, especially European aviation officials. “We have routes,” the EC added. “To make a com- in the separation of service providers fallen seriously behind in our original parison, in an airspace which is roughly and the bodies that regulate them, the ambitions. After more than 10 years, the same size, Europe has more than 30 creation of national supervisory au- the core problems remain the same: too en route air navigation service provid- thorities and the harmonization of some little capacity generating the potential ers, and the USA has just one. The USA technical systems. Service providers for a negative impact on safety at too serves twice as many flights as Europe have achieved prescribed standards in high a price. There are some signs of with the same costs.” their safety management systems, and change, but overall, progress is too SES is based on two legislative pack- some airspace classifications have been slow and too limited. We need to think ages. The first, begun in 2004, is SES-I, harmonized, the EC says. In addition, of other solutions and apply them which separates regulatory authority airspace use has become more flexible quickly. There is too much national from service through the creation of and is operated as “a single continuum
FALLINGEuropean nations aren’t keeping up with the schedule for BEHIND advancing the Single European Sky, EC officials say.
26 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 SAFETYREGULATION © Chris Photography Sorensen FALLING BEHINDBY LINDA WERFELMAN
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 | 27 SAFETYREGULATION
… to satisfy the needs of all users at the needed to establish FABs. In early more centralized route planning and time they need it,” the EC says. 2013, it will seek additional enforce- to strengthen the separation of service The EC considered 2012 a key year ment powers. providers from national regulators. for implementation of SES, with one “The commission will present element of the program calling for the proposals to make sure these regional Parliamentary Resolution establishment by Dec. 4, 2012, of nine air traffic management blocks deliver The European Parliament passed a Functional Airspace Blocks (FABs) real operational improvements,” the resolution in October calling for the — designed not according to national EC said. “They will be required to de- merger of national air traffic control boundaries but instead according to velop strategic and operational plans at airspace across Europe to enhance traffic flow patterns — as an interme- FAB level. It is not enough to exist on safety and reduce air traffic congestion, diate step toward SES. However, only paper; FABs must deliver real opera- flight times and flight delays. two FABs are in place — one for the tional results swiftly.” Jacqueline Foster, a member of the airspace over Scandinavia and a second Other proposals will be aimed at European Parliament from the United for airspace over Ireland and the United strengthening the SES legal framework Kingdom and sponsor of the resolu- Kingdom. in general and in several specific areas, tion, said SES is needed if Europe is to including performance targets for have “proper, efficient use of airspace Enforcement Action increased airspace capacity and lower and 21st century technology for traffic The EC said that, “to ensure the neces- costs. In addition, proposals will address management.” sary progress,” it would use its existing EC authority to require member nations She added, “Airspace across much enforcement authority against coun- and the FABs to “deliver the agreed of the EU is so congested that it faces tries that fail to take the steps required targets,” to reinforce powers assigned the prospect of massive gridlock in a to implement SES, including the steps to the network manager for Europe for matter of years. We need more efficient and integrated handling of air traffic, which would be delivered by the Single European Airspace European Sky.”1
uropean airspace is controlled by 27 national air traffic control systems, ‘Back on Track’ which operate 60 air traffic control centers and provide services to aircraft in Tony Tyler, CEO and director general of Emore than 650 sectors.1 Airspace is structured around national boundaries, making direct routes from the International Air Transport Associa- one country to another often impossible. The European Commission says that the tion, said his organization fully supports fragmented airspace adds an average of 42 km (26 nm) to every flight. Extra costs Kallas in his efforts to “put the long- associated with the resulting inefficiencies total about 5 billion euros annually. delayed SES project back on track.” European Union data show that about 1.4 billion passengers fly from Citing delays in the establishment Europe’s 440 airports every year and that 27,000 controlled flights occur every day — about 10 million flights a year. of FABs, Tyler said that the airspace Air traffic is expected to increase about 5 percent every year, with about 17 blocks are crucial steppingstones to “a million flights by 2030. fully functional SES.” By comparison, the EC says that U.S. air traffic management is twice as effi- He added, “If states are not deliv- cient as the EU’s, with twice the number of flights “for a similar cost, from a third ering, then top-down action from the as many control centers.” Commission is critical, and we would The EC estimates that establishment of SES will result in a tenfold increase in aviation safety, a tripling of airspace capacity, a 50 percent reduction in air traffic fully support infringement [enforce- management costs and a 10 percent reduction in harmful environmental effects ment] procedures by the Commission attributed to air traffic. to force states to comply with their — LW obligations.” Note The European Business Aviation 1. EC. “Single European Sky: 10 Years on and Still Not Delivering.”
28 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 SAFETYREGULATION
over the lack of decisive action taken The EU’s functional by member states and for having airspace blocks (FABs) are arranged according unequivocally condemned them for NEFAB failing to make the changes needed to traffic flow, not to deliver the benefits of the Single national boundaries. DK-SE European Sky initiative.” FAB UK-Ireland EBAA CEO Fabio Gamba said his FAB Baltic organization “firmly stands behind the FAB
commission to do whatever is neces- FABEC FAB CE Danube sary, including enforcing infringe- FAB ment procedures, to put this crucial South West FAB Blue Med programme back on track as soon as FAB possible.” The Civil Air Navigation Services Moore Jennifer Organisation (CANSO) said that its Maurice Georges, chairman of needs full common understanding of July 2011 members “fully acknowledge that air the CANSO European CEO Com- the issues and close cooperation of all navigation service provision needs to mittee, added, “The complexity of involved partners.” change and urge the Commission to realising the SES, together with a more take full account of the need for [provid- business-oriented approach to Euro- Note ers] to make investments to realise both pean air traffic management, should 1. CANSO. “Comment: Time to Deliver the the infrastructure and the social aspects not be underestimated. Any transition, Single Sky.” Airspace Issue 19 (Quarter 4 of this transformation.” and specifically one such as the SES, 2012): 16–17.
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FLIGHTSAFETY.ORG | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 | 29 CAUSALFACTORS
he flight crew of a Skycharter “the lack of adherence to company groundspeed of 290 kt, and the crew Dassault Falcon 10 flew a fast, standard operating procedures and tried repeatedly to read back the unstabilized approach to Toro nto/ crew resource management, as well as clearance, at one point switching radio Buttonville Municipal Airport the non-completion of checklist items frequencies to reach a controller who T(CYKZ) after a six-minute flight from by the flight crew” among the accident’s could receive the transmission. a nearby airport, overshooting the causes and contributing factors. At 1503:25, the Toronto area control runway centerline before the airplane The flight began with takeoff at center controller cleared the Falcon for touched down and veered off the pave- 1500 local time from Toronto’s Lester a contact approach to Runway 33 at ment, accident investigators said. B. Pearson International Airport. The Buttonville. The report said the control- Neither of the two pilots — the only crew completed the “After Takeoff” ler included instructions to “begin the people in the airplane — were injured checklist and began a climb to 5,000 ft descent and to keep the approach tight, in the June 17, 2011, accident, which above sea level (ASL); at 1501, air traf- as there was traffic to follow. damaged the airplane’s nose, right wing, fic control (ATC) altered the clearance “At that point, the aircraft was slats and engines. to 4,000 ft. approximately 3.0 nm [5.6 km] from The Transportation Safety Board Less than one minute later, ATC the airport, descending through 2,600 of Canada (TSB), in its final report cleared the pilots to descend to ft ASL with a groundspeed of 230 kt on the crash, cited the “unstabilized 3,000 ft. Over the next 30 seconds, and heading towards the threshold of approach with excessive airspeed” and the airplane descended, reaching a Runway 33 on a tight left base.”
BY LINDA WERFELMAN
The Falcon 10 touched down too fast and veered off the landing runway at a Toronto airport.
© Transportation Safety Board of Canada Board Safety Transportation © Unstable 30 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 engines and exited through main the cabin door. stopped. About pilots 1506,the shut down the beforesign it crossed ataxiway intersection and Falcon arunway/taxiway struck identification of because minimal grass the surface, and the airplane’sthe goundspeed at less than 110kt. tosurface right,” the report the said, estimating titude, immediately then runway the departed on main the landing gear at inanose-high - to right the on short final. for flaps andtain called entered full asteep bank responded but continued approach.” the approach,missed captain report the said. “The and …non-standard phraseology,” a called and first officer, the using “a low tone of voice ground-proximitythe warning system (GPWS), ly 0.3nm.” runway the overflew centreline by approximate- exceedingleft, 30degrees of The bank. aircraft regain runway the centreline, aircraft the banked proximately In final. 1nm[2km] an attempt to at atransverse angle of about 120degrees at ap- report said. “It through inbound the flew track and was heading inan eastward direction,” the from[0.6 km] inbound the track to runway. the through atdescended 1,400ft 210kt, about 0.3nm pilots base. turned right left awider to fly through at 1,900ft agroundspeed of 220kt, the fromkm] runway the threshold and descending FLIGHTSAFETY.ORG before occurrence. the accidentthe and 28hours 90-day inthe period had 10hours flown They 30 days inthe before crew, only accident the and flew airplane. they 2011.The two wereary always paired as aflight management training, Falcon inthe 10inJanu- gone recurrent training, including crew resource transport pilot licenses, and had under both captain the Both and held first officer airline the Pilot Experience Braking and steering responses were At Falcon 1504:49,the “touched down hard Another “pull up” followed, alert as cap the - At 1504:20,a“pull up” was sounded by alert aircraft“The out leveled from right the turn The pilots were cleared to land as airplane the At Falcon the 1503:40,while was 1.6nm[3.0 | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 - degrees, report the said. glideslope, and angle ifthe of exceeds bank 30 airspeed, altitude,from or specified the localizer standard callouts required ifthere are deviations pre-descent,cruise, approach and landing. until after phase takeoff of the but flight not for accident pilots the flight, checklist the used compromised,”be report the said. the During captain determines that safety the of may flight deviation from procedures these …unless the Falconthe 10checklist for with “no flights, all cedure for (SOP) called its crews flight to use maintenance program. cording to current regulations and an approved 12,697 hours total and time was maintained ac- with operator the service for about 20years, had short report the flights, added. well-rested, report the said. 60 hours before accident the and had been both Falcon offthe duty had been for 10.Both about hours,had 7,100 flight including 475hours in ing 4,000hours Falcon inthe first officer 10;the In addition, crew the didnot make the The company’s standard operating pro- The accident airplane, in had which been didnotThey route this typically fly or other The captain hours, had 12,000flight includ- T Dassault Falcon 10 Source: Jane’s AlltheWorld’s Aircraft and a45-minute of1,918nm/3,555km. fuelreserve) a maximumcruisingspeedof494ktandrange (withfour passengers passengers andhadamaximumtakeoffweight of8,500kg/18,740lb, of theMystère 20/Falcon was designed to 20.It seat upto seven business jetfirstproduced version in1973,was ascaled-down he DassaultFalcon twin-turbofan 10, anexecutive-transport, CAUSALFACTORS |
31 CambridgeBayWeather/Wikimedia 32 | Susan Reed CAUSALFACTORS V of circuit, the 140kt onlegand base the should 160kt be on downwind the leg (VFR)patternfor rules flight avisual tion, except for flaps. full airplanethe inlanding be configura- andof and glideslope; localizer the that airplane within aone-dot be deflection landingflaps or selected flaps); that the landing with full speed as stall 1.3 times erence landing usually defined speed, authorizes airspeed. ahigher ofkm) acontrolled unless ATC airport, above ground level or within 10nm (19 ASL or more than 200kt below 3,000ft of more than 250kt below 10,000ft hibit operation of aircraft at airspeeds aircraft’s calibrated airspeed was 186kt.” circuitthe At on leg. base point, this the cleared directly to to CYKZand fly joined weight of 17,000lb. The aircraft was V crew currence the that determined flight, report said. “Prior to on- takeoff oc the speed and notspeed lower than V plusbe or minus 10kt of approach the criteria included that indicated airspeed touchdown,” report the said. Those window criteria above within 500ft if aircraft didnot “meet approach the crews to conduct approach amissed REF REF The TSBsaidtheFalconveered off therunwayimmediatelyafterittoucheddown. “According to SOP, the airspeed the Canadian Aviation Regulations pro- Skycharter’s SOP required its flight
was 117kt for landing calculated the plus 10kt approach,” on final the the
runway excursion 33 of Start REF (the ref (the - from 1984to 1997. and-landing accidents that occurred factors in66percent of 76approach- unstabilized approaches were causal Safety Foundation study found that tions and Skycharter’s SOP.” inexcessflown of current the regula - cated airspeed values, aircraft the was that, evenafter conversions the to indi- groundspeed values, it was determined Although radar indications provided attained speeds the during flight. the ASL,ft there at was to no need fly minutes induration and below 4,000 entire was approximately flight six The report said that, “considering the Was‘There No Need’ eventin the that awarning is received.” “may place crews and passengers at risk that operators without such procedures lowed of incase aGPWS and added alert SOP didnot include procedures fol to be - runwaythe threshold.” tion heights, and deviation down to crossingwhen minimum the stabiliza- excessive flight-parameter deviations of GPWS, the late extension of flaps, cluded excessive angle, bank activation an unstabilized approach. in- These said, “there were indicators several of The report noted that a1999Flight The report noted that Skycharter the “In occurrence,” this report the runway excursion Bravo-Alpha Taxiway End of 1 Not to scale FLIGHT SAFETY FOUNDATION insufficient to deter captain the from for[in his call approach] amissed were ing and tone by used first officer the ficer” and that “the non-standard word- approachmissed from call first of the - follow aural the GPWS and the alerts likely decision the influenced not to degree of instability of path flight the landing or lack of understanding of the tors that “the captain’s commitment to accident’s causes and contributing fac- more aggressive and non-standard.” vres to regain runway heading became tinued to reduce quickly, and manoeu- distance to runway the threshold con- Atbank. that point, report the said, “the turn witha left more than 30degrees of course and that at one point it entered approachit through final passed the Falcon’s airspeed was about 140kt as tight,” report the said, noting that the with ATC’s request to “keep circuit the track as crew the attempted to comply airplane overshot approach final the crew an flying unstabilized approach.” approach briefing. This resulted inthe requiredthe checklist items and the tasks dictatedthe by company the SOP, amount of available time to performall route or other short routes, reduced the that crew the didnot routinely this fly 1. Note aviation/2011/a11o0098/a11O0098.asp>. available at January–February 1999). 17–18 (November–December 1998/ Aviation.” Flight Safety Digest Volume Flight Safety Foundation. “Killers in The noted report also among the of excessive the Because the speed, excessive and“The speed, fact the | AEROSAFETYWORLD | DECEMBER2012–JANUARY 2013 ACCIDENTINVESTIGATION The BEA’s arduous path to its final report on Air France Flight 447 yields insights for the world’s investigators and pilots. Time to Reflect BY WAYNE ROSENKRANS ooking back, a few of the key people respon- sunken wreckage of the Airbus A330-200 in the sible for investigating the June 1, 2009, crash South Atlantic (ASW, 8/12, p. 14), they say. of Air France Flight 447 see the event itself “An exceptional mystery … surrounded the and the resulting professional demands as exact circumstances of the accident, as the aircraft Lextraordinary on many levels. For 23 months, had disappeared without any message from the uncertainty pervaded their expectation of find- crew and beyond radar coverage,” said Jean-Paul Bureau d’Enquêtes et d’Analyses d’Enquêtes Bureau ing, much less extracting critical data from the Troadec, director, Bureau d’Enquêtes et d’Analyses FLIGHTSAFETY.ORG | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 | 33 ACCIDENTINVESTIGATION answered questions during the ISASI 2012 Forum in Baltimore, Maryland, U.S., presented by the International Society of Air Safety Investigators. Paul-Louis Arslanian, BEA director when the accident occurred, had made the recov- ery of the crash recorders the highest priority. “Without the readout, the investigation could not be conclusive — even if the examination of the parts recovered at the surface of the sea and the data collected from the aircraft message [containing maintenance data transmitted via the aircraft communications addressing and re- porting system (ACARS)] gave some indication on the accident,” Troadec said. “It was only on 2 April 2011, during the fourth phase of under- water searches, that the wreckage was [located]. The recorders, quickly recovered, could be read out in their entirety after spending two years at a depth of 3,900 m [12,795 ft] under water. … We then needed to understand the reason of the pilots’ action, and how the loss of airspeed indi- cation alone could have led to such a disaster.” The AF 447 investigation “sadly …was also exceptional in the number of violations [by third parties] of the ethics of safety investigation, which require respect for the confidentiality of working documents that are not published by the investigating authorities,” Troadec said. “Finally, there was an exceptional level of con- troversy and unjust accusation against the BEA Bureau d’Enquêtes et d’Analyses d’Enquêtes Bureau investigators, whose professional integrity and impartiality were called into question.” Behind the scenes, (BEA), the civil aviation accident investigation au- Another major difficulty proved to be the undersea recovery thority of France. “These circumstances were only public’s misunderstanding of the scope of BEA’s of the A330’s clarified thanks to the readout of the recorders in mission and how France divides judicial and non- DFDR (previous May 2011. … This accident had its origins in the judicial responsibilities (see “Shaping Safeguards,” page and above) obstruction of the pitot probes by ice crystals and, p. 8). A safety investigation “does not seek to and CVR on May as a consequence, the temporary loss of airspeed determine responsibilities, that being the role of 1–2, 2011, yielded indication. But above all, however, it resulted from the judicial investigation that takes place in paral- information requiring the airplane exiting its flight envelope through the lel and independently from ours as laid down a new human factors crew losing situation awareness.” under French law,” Troadec said. “Unfortunately, working group. Troadec joined two investigators and a media in the mind of the public, it is not always easy to representative from BEA — and conveyed the understand the difference. Many people expected views of Alain Brouillard, investigator-in-charge — from the BEA investigation that it would point during presentations in August 2012 of their inside out responsibilities and even culpabilities.” perspective of the bureau’s AF 447 challenges After three interim reports, the final report on and related thought processes. They spoke and the accident was published July 5, 2012, at 34 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 ACCIDENTINVESTIGATION bea.aero/en/enquetes/flight.af.447/rapport.final. contains] almost no salt,” he said. “It is very en.php>. At the forum, two BEA investigators cold, like 0–1–2 degrees C [about 32 degrees focused on the readouts of the digital flight data F]. … From the time the flight recorders would recorder (DFDR), cockpit voice recorder (CVR) be recovered, we knew we would have 10 days and memory chips in other devices; and analy- more or less before we would get the recorders sis of human factors pertaining to flight crew [into] the BEA.” actions. (This article omits a fourth presentation The reason was that BEA did not have cus- on BEA interactions with the news media and tody of the recorders; rather, the French Minis- families of the 228 crash victims.) try of Justice transported the recorders to BEA, allowed BEA to work on them and then stored Recorders Fulfill Hopes them away from BEA to ensure legal traceability, Léopold Sartorius, an investigator who served Sartorius said. as head of the systems and equipment working “We tried to be as prepared as possible to group, described exhaustive preparations for deal with any type of damage,” Sartorius said of the imagined scenarios if the DFDR and CVR the advance procedural visualization. In reality, were recovered, and for performing readouts of when technicians opened the DFDR, there was data — including readiness to replace any com- huge relief. “We expected a little corrosion or ponents on circuit boards or even to cut open completely corroded [circuit boards] … but memory chips, if necessary, to directly read data nobody was expecting something perfect like bit-by-bit under a microscope. “Everyone was that,” Sartorius said. “The CVR, well, it was a expecting the flight recorders to help; at least we bit different.” CVR memory chips were in good were hoping they would help,” he said. Then a condition, and the damage was confined to development in a parallel investigation raised a readily repairable resistors, capacitors, memory On May 13–14, 2011, worst-case specter.1 address devices and similar parts. after visual inspection “The accident in Comoros … was puzzling BEA investigators were anxious to analyze revealed no damage us somehow because the flight recorders were re- the DFDR and CVR data in light of pre-crash to the DFDR memory covered after 60 days at a bit more than 1,000 m maintenance message data captured via ACARS. board, the protective [3,281 ft] deep,” Sartorius said. “There was a very The delays in receiving the recorders were used coating was removed, high level of corrosion. The memory boards … productively to formulate hypotheses about the followed by 36-hour were quite badly damaged, and there was physi- ACARS message, pre-identify a parameter sub- oven drying, testing cal damage [not only] to some small components set of immediate interest, validate preliminary and data extraction. but also to some memory chips. So … even after weeks of extensive work on the chips themselves, with help from the [U.S. National Transportation Safety Board], by the way, we could not recover all the data, from the CVR especially.” The sea floor in areas of the AF 447 search was about four times deeper, and the elapsed time was 10 times longer. “We had no idea whether we would spend two days or two years trying to read out those memory chips — they were the very same type of recorders,” he said. Theoretically, unlike in Comoros, where the water salinity and temperature are relatively high, the location of AF 447 recorders provided a good chance for preservation. “Specialists say that at this depth, the water is almost clear [and d’Enquêtes et d’Analyses Bureau FLIGHTSAFETY.ORG | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 | 35 ACCIDENTINVESTIGATION findings and settle on other working hypotheses the pilots. Showing an animation of the instru- among other tasks. ments, he said, “And from this moment, what’s Just minutes after obtaining the DFDR data quite interesting is if you look at the thrust and in May 2011, the first 30 plots of the first param- pitch parameters, it’s not so easy to understand eter subset were generated. “In a few hours, we what’s going on — especially that you are stalling. got hundreds of parameters [of a total of 1,300 Because as you can see [in] this type of attitude, nominally available] and everyone was just the pitch is, let’s say, between 0 and 10 degrees overwhelmed at that,” he said. Among needed- nose up and the thrust is fine. It’s just fine. The BEA investigators’ but-missing data were parameters from the thing is, the airplane is stable in a position it will final report showed right-side primary flight display — where the not get out of by itself, and the pilots will never the change over pilot flying (PF) was seated — and those for the finally do what could have been necessary to time in the three position of flight director command bars. retrieve [recover] the control of the airplane.” recorded angles- Data recovered from computers helped of-attack and a investigators pinpoint the start and end — about Human Factors Prioritized calculated theoretical 30 to 40 seconds apart — of the pitot probe The wealth of data generated so quickly prompt- threshold at which blockage–unreliable airspeed–autopilot discon- ed BEA to change the original organization of the stall warning nect sequence, which was not a causal factor in four working groups after launching the AF 447 was triggered. the final report. “The autopilot disconnection investigation, BEA investigator Sébastien David told the forum. In July 2011, BEA’s third interim report added descriptive factors about the event. “A lot of questions were raised with the analysis of the data from the flight recorders, but right after the release of the [third] interim report, it was decided to open a human factors working group,” said David, who was selected to be its head. The first phase of the human factors inves- tigation sought to identify why human actions could lead to a breakdown in the safety defenses. The second phase sought to determine how these safety defenses affected the expected behaviors and skills of the crew in the situation they encoun- tered. “This involved identifying the failures that occurred during the flight in relation to the ex- plicit and implicit safety expectations,” David said. Analyzing Crew Performance This working group first analyzed the behavior and performance of the flight crew during the 50-second interval from autopilot disconnection Bureau d’Enquêtes et d’Analyses d’Enquêtes Bureau to triggering of the stall warning. This analysis and the reversion to alternate [control] law and included the pilots’ detection of the problem, some other consequences were due to at least control of the flight, identification of the situ- two of the three pitot [probes] getting blocked ation, attempt to control the flight path, and by ice crystals,” Sartorius said. resumption of handling the airspeed anomaly. Success in recovering the flight data helped Among other tasks, the working group BEA recreate what instruments had presented to looked at what occurred in the time elapsed 36 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 ACCIDENTINVESTIGATION from the triggering of the continuous were dependent on invalid indicated airplane will stay in the flight envelope. stall warning to a selected point sev- airspeed — was his persistent nose-up That’s how it’s designed. Now in that spe- eral seconds after the resting captain’s input. “We gave four or five possible cific [AF 447] case, the blockage of pitot return to the flight deck. He provided explanations for the persistence of the [probes] made the flight control system an example of comparing working nose-up input by the pilot flying. … switch from normal to alternate law, and group expectations with what actually Those nose-up inputs contributed to the main consequence of this change had occurred. destabilize the flight path, which had a was basically that there were no envelope “Human operators notice [anoma- major impact for the identification and protections anymore. … We don’t really lies] and act according to their mental the awareness of the situation,” he said. know how far [the AF 447 pilots] un- representation of the situation and not “The startle effect due to the auto- derstood the consequences of the switch to the real situation,” David said. “The pilot disconnection, associated with the to alternate law. … What we analyzed is probability and the speed of detection destabilization of the flight path, led that, effectively, it may make a difference of anomalous signals [are] connected to … a degradation of the CRM [crew in … that people today may not be as … to the salience of these signals. And resource management], a degradation trained as they could be — or maybe as depending on the frequency of the hu- of the communication … between the they should be — in laws different from man operator’s exposure to the anomaly two pilots. … So they were unaware of normal law because, in [cruise] opera- during his training or his real operation, the situation, and they totally lost the tion, it never happens,” David said. his response may be automatic, apply- control of the situation.” He said one of the accident’s most ing rules or … on the basis of in-depth important lessons was proper response to knowledge. … We also expect, when Lingering Questions disconnection of the autopilot in cruise there is a sudden anomaly, that the crew The investigators pointed forum at- at Flight Level 350 [approximately 35,000 will react in an expected time frame.” tendees to the final report to read all ft], not this airplane’s reversion from nor- Regarding airspeed display anoma- the possible explanations of the AF 447 mal control law to alternate control law. lies, the accident crew first would be ex- flight crew’s non–situational awareness Ultimately, the AF 447 crash left pected to control the flight path, then to of the stall, including the possibility these investigators with indelible impres- identify loss of consistency in the indi- that while “very stressed with a high sions and commitments to possible ways cated airspeed, and then to manage this emotional factor,” they had not per- the worldwide industry will be able to anomaly with the procedure provided by ceived the aural stall warning. mitigate the risk of recurrence. Troadec Airbus to Air France, David said. In response to questions about today’s said, “Clearly, we can still increase the In writing the final report, BEA practical understanding among pilots level of automatic systems, improve the investigators could not be sure that the of built-in protections against flight- reliability and present protections. But in accident crew was aware of anomalies envelope deviations when the airplane is the end, safety will still depend — above in airspeed displays before the autopilot operating under normal control law ver- all — on getting the right adequacy disconnection, however. “But since the sus alternate control law or direct control between the cognitive capacities of pilots salience of the speed anomaly was very law — and the salience of instrument in- and the signals that are provided to them low compared to the autopilot discon- dications when a reversion of control law to understand and act on. This accident nection, signaled by a visual and aural occurs — David said that the final report has also taught us that hypotheses used warning, the crew detected the problem recommends training improvements in for safety analysis are not always rel- with this disconnection and not the air- this area of knowledge and practice. evant, [that] procedures are not always speed indicator,” David said. “The crew “I think it’s a key question, an excel- applied by the crew, and that warnings was very surprised, which was analyzed lent question for the accident because are not always perceived.” by the human factors group as normal” what we need to make clear is, effectively, Note: for the cruise phase. when the airplane is in normal law — 1. The June 30, 2009, fatal crash of a Yemenia In light of the flight data analysis, when all the functions of the airplane Airways Airbus A310 in the Indian Ocean one of the most perplexing aspects of the are working well, for sure you can do off the coast of Moroney in Comoros subsequent responses of the PF — after whatever you like and especially, pull on heavily involved the BEA in leading an initial nose-up flight control inputs that the stick as strong as you want — and the undersea search campaign, Sartorius said. FLIGHTSAFETY.ORG | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 | 37 CABINSAFETY The International Cabin Safety Conference looked at ways to improve flight attendant and passenger survivability. Cabin Fever BY RICK DARBY | FROM AMSTERDAM flight attendant can become, with little Conference, held in Amsterdam in October, he or no prior notice, the first responder at outlined safety issues concerning cabin crew- an accident scene. “That requires him or members, many of which were discussed by her not only to know what to do when other speakers.1 Anotified of an impending emergency, but also “Flight attendants are trained for emergency when to take action without being notified,” said evacuations, and all the evidence shows they Gary Morphew, senior advisor and instructor at do their job well in such difficult conditions,” (L/D)max Aviation Safety Group. As the key- Morphew said. “But it’s important that they Morphew note speaker at the International Cabin Safety be encouraged to talk about their experiences afterward. Management often isn’t very encour- aging about this, but should be. “When the evacuation works well, everyone wants to know. And when things don’t go as well, everyone wants to learn from the cabin crewmembers’ experience.” Morphew outlined what he sees as today’s most important challenges in cabin safety. Besides sharing of cabin crewmembers’ nar- ratives of emergency events, he listed training for runway overruns, survivability investiga- tions, mitigating turbulence injuries and fatigue management. “Runway overruns are one of the more com- mon accident types, and result in more fatalities and injuries than the more dramatic and better publicized runway incursions,” Morphew said. 38 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 | 38 CABINSAFETY “The flight crews are well trained in dealing “Fortunately, today fatigue risk management with these events. But once the flight attendants systems [FRMS] are taken seriously by regulators are strapped in their seats for takeoff or landing, and operators,” he said. “Technology is lending a they don’t actually have to do anything except hand, too. Jeppesen Systems offers the CrewAlert be alert. I’m sure they try to be, but takeoffs and iPhone application for fatigue data collection. landings are such a routine experience for them Continued on p. 41 that it would be surprising if the attention didn’t wander sometimes.” Learning From a Cabin Pressure Loss More research into survivability factors in accidents is needed, he continued. ris Hutchings is manager, Inflight Safety, “Any cabin injuries should be thoroughly in- for Canada’s WestJet Airlines. He led the vestigated, not just recorded and tallied,” he said. Kinvestigation of a loss of cabin pressure in a Boeing 737-600 at 41,000 ft. The pilots donned “We might be surprised at what we learn about their oxygen masks, and because the loss of factors involved. And cabin configurations have cabin pressure was not explosive they were able Hutchings many variables. Operators can revise them fairly to warn the flight attendants and passengers quickly. Business class equipment is constantly with a public address system announcement prior to commencing the being upgraded to lure these all-important emergency descent. customers. The seats and amenities are designed ASW: What action did you and WestJet take immediately follow- ing the incident? for comfort, but has anyone thought about their KH: The crew was immediately pulled from duty and contacted safety implications in an accident? by our leadership team to ensure their well-being. They were then “At the other end of the economic scale — deadheaded home and had a safety debriefing with our Inflight Safety and the other end of the plane, the back end — team the following day. you have another consideration if seat spacing ASW: Who was included in the safety review team (SRT) that you has been reduced. Think of 29-in [74-cm] seat convened? KH: An SRT is composed of a lead investigator; leaders responsible pitch. Yes, civil aviation authorities conduct for corrective action plans [CAP]; required stakeholders, as identified evacuation demonstrations with different seat- by the lead investigator and/or the leader responsible for CAP; and a ing configurations, but even the most ‘realistic’ Safety Services representative. evacuation test cannot match the conditions in ASW: What did they find specifically relating to the cabin crew- an actual emergency — if only for psychological members and cabin procedures? reasons. A participant always knows in the back KH: The cause of the depressurization was not attributed to the cabin crew. However, the execution of their decompression procedures of his or her mind, the worst that can happen in a allowed us to identify opportunities for improvement with our current simulated evacuation might be a sprained ankle.” procedures. Specifically, we identified the operation and differences Although he believes any cabin safety– of the fixed oxygen masks located in the galley compared to those related event should be thoroughly investigated, located in the cabin; the effects that chemical oxygen generators have Morphew acknowledged that commercial on the cabin environment (heat, smell and smoke); the stowage of fixed motivations play a role: “They want to get that oxygen masks for landing after deployment, specifically the masks in the galley that hang over the aircraft doors; and procedural differences aircraft back into service as soon as possible.” between a rapid decompression and a gradual loss of cabin pressure. Turbulence is the most common source of ASW: How were these findings communicated to WestJet flight attendant injuries, he said, adding, “Better management? procedures to reduce the threat have evolved. KH: Inflight Management is a member of the SRT and was respon- Still, we need to make further progress. When sible for developing corrective actions for these findings. any flight attendant becomes incapacitated, it isn’t ASW: What corrective actions were taken? KH: Changes were made to our training programs — initial and just a problem for the individual. It means that recurrent — and to our flight attendant manual to address the four flight attendant may no longer be an effective first findings just mentioned. We also sent out safety communications to all responder in a survivable accident.” our flight attendants to make them aware of the incident. Probably every airline flight attendant in — RD the world has experienced fatigue on the job. FLIGHTSAFETY.ORG | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 | 39 CABINSAFETY Cabin Crew Checklists: A Safety Innovation? effrey Hendren is supervisor–train- have a protocol for adverse events. contributing to ing, Cabin Safety & Crew Perfor- Hospitals using checklists have the team? Flight Jmance, at Canadian North Airlines. measured reductions in rates of post- attendants are His work includes responsibilities re- surgical infection, medication error and just as fallible as lated to flight attendant training, evalu- patient mortality. any other human ation, the flight attendant manual, first ASW: Can aviation, particularly being, and air Hendren aid and regulatory compliance. in cabin safety, learn from medical operators and the ASW: We have heard that the practices? regulators should consider that when practice of medicine has incorporated JH: That is the really exciting part for developing standard operating proce- some SOPs from aviation. What have us in the cabin safety world. Medicine is dures and the inclusion of checklists “they” learned from “us”? generating fresh ideas with compelling into normal, abnormal and emergency Jeffrey Hendren: Pilots research- evidence-based research. The way that situations. Take something like arming ing human factors, as well as external some hospitals have adopted checklists doors; though uncommon, there are experts — in some cases consulting is unusual. You might think that the incidents of blown slides [ASW, 7/07, with medicine and social psychol- surgeon would be the one conducting p. 22]. Could a checklist help prevent ogy — helped drive the momentum of the checklist, but what they have found or reduce the occurrence? what we have learned in aviation about in some cases is that it can be more ASW: You conducted a survey of human factors and the importance of effective if the circulating nurse runs the flight attendants at Canadian North breaking barriers. Through incidents checklist. We can take our CRM [crew about their views on including more such as the Kegworth disaster involving resource management] skills to the checklist items. What did you find out? British Midlands Flight BD 92 in England next level by challenging the hierarchy JH: We were not shocked to dis- in 1989,1 we have learned about tangi- in the cabin in a similar way. Instead of cover that 80 percent of flight atten- ble (e.g., flight deck door) and intangible the captain always running the preflight dants polled do not use the optional (e.g., cabin crew hierarchy) factors that briefing, we can increase engagement preflight equipment checklist. We were create fatal communication barriers. and demonstrate how communication impressed to see that 85 percent of It’s natural that medicine would is everyone’s responsibility by rotating flight attendants polled would view relate what we have learned about the source of the briefing. positively a mandatory formal checklist these barriers to the hospital operat- ASW: Your presentation con- system. We learned that 92 percent of ing room. Doctors are the “pilots,” and cerned checklists for cabin crewmem- respondents believe a checklist will nurses and other medical professionals bers. Why are they needed? Are all help to trap errors. When it comes to are analogous to the flight attendants; cabin crewmember actions currently communication, 85 percent of respon- we face the same type of barriers and memory items only? dents feel that they would be far more stereotypes. In many surgical suites, JH: I can’t speak for all airlines, but comfortable raising a concern or chal- we are starting to see a “preflight” my research has revealed the majority of lenging a fellow crewmember when an operating team briefing between the airlines provide very little in the way of error is made if they had a checklist to surgeons, anesthetists, nurses and as- checklists for cabin crew. You will almost back it up. sistants; much like our safety demon- always find an emergency landing ASW: What is the next step? strations, the patient is also included in checklist in the flight attendant manual. JH: We will test several checklists. the briefing. You may find a preflight equipment in- This phase will use sample checklists of What medicine has really started spection checklist, but the vast majority various designs and content to deter- to embrace is the checklist. There are are not mandatory, and often leave a lot mine what works best for flight atten- simply too many steps, too many things of room for interpretation. dants. There are always two pilots, but in to remember, so the checklist helps to When we look at pilot duties, they the cabin, we can have anywhere from ensure the medical professionals have have almost no memory action items. one to five flight attendants, and that reviewed each of their responsibilities All duties, including those that one creates a challenge on how the checklist and contributions to the team, assessed might consider normal or routine, are can be completed. There is also a concern hazards for both the patient and the backed up with a checklist. So why about becoming too dependent on professional (e.g., needle sticks), have not extend the same strategies to checklists, so we still need to encourage reinforced the protection of the sterile other in-flight operations that include the out-of-box thinking adaptable to zone around the surgical patient, and multiple steps and many individuals different situations in the cabin. 40 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 CABINSAFETY After proving the checklists’ design Canadian North, we have a strong Kegworth, Leicestershire, England. and usage, we will have to decide which safety culture, and our flight atten- The aircraft struck the embankment procedures require a checklist, and dants are engaged and passionate of the M1 motorway short of the airport, with 39 passengers killed how to capture that in our manuals and about what they do. immediately and eight more later training programs. Checklist discipline It is not on regulators’ radar at the dying from their injuries. The U.K. is something that plays a large role in moment. Transport Canada is currently Air Accidents Investigation Branch pilot training, and currently there is no occupied with the implantation of SMS accident report said that the cause direction from the regulator on checklist [safety management systems]. But cabin was “the incorrect response of the flight crew” to a fan blade fracture of discipline for flight attendants. checklists are very much in line with the the no. 1 engine, mistakenly throttling ASW: How do you expect the indus- spirit of an SMS. We need to ensure that back the no. 2 engine. try and regulators to react to the idea? any initiatives include performance met- JH: Implementing a checklist rics that will help back up our hypoth- The report said, “Although the cabin crew immediately became aware of program is far less costly than other eses and prove our outcomes. heavy vibration at the onset of the innovations that are currently being emergency, and three aft cabin crew discussed. Ultimately, the safety culture Note saw flames emanating from the no. 1 engine, this information was not of the operator will determine whether 1. The accident occurred on final communicated to the pilots.” the crewmembers buy in or not. At approach to East Midlands Airport, — RD “Moreover, the Jeppesen Crew Fatigue Assess- “The chances are, CFAS will be widely ment Service (CFAS), which is Web-based, makes used for flight crews. For cabin crews? We’ll it practical to perform a systemwide assessment of s e e .” planned and actual crew pairing or rostering, using the Boeing Alertness Model to measure fatigue. Note You can efficiently survey a route, a fleet or your 1. The proceedings of the conference have been entire operation — and it’s now available to all published by its sponsor, (L/D)max Aviation Safety airlines, large or small. It integrates into an SMS Group. Phone +1 805.285.3629; in the United [safety management system] or FRMS. States and Canada, toll-free, 877.455.3629. The Cabin Scene in an Emergency Landing teve Hull is aviation director for RTI based in London. He has more than 41 years of airline experience, including 38 years with British Airways. His career has included more than 8,500 flight hours as a flight engineer on the Boeing 747 and SConcorde. In his presentation, “Do We Heed Lessons Learned From Accidents?” he cited the U.K. Air Accidents Investigation Branch report’s description of what it looked and felt like in the cabin of British Airways Flight 38, a Boeing 777, as it landed short at London Heathrow Airport, an accident ascribed to dual-engine rollback from flow restrictions caused by ice that detached within the fuel system (ASW, 2/10, p. 20). • “There was no time for the flight crew to brief the cabin crew or issue a ‘brace, brace’ command; • “The cabin crew initiated the evacuation; • “The captain initially gave the instruction to ‘evacuate’ over the VHF [very high frequency] radio, but ATC [air traffic control] informed him of this, [and] he then repeated it over the cabin PA [public address] system; • “Some passengers attempted to retrieve personal items during the evacuation; • “The evacuation alarm was perceived by the cabin crew as sounding ‘faint’ in the cabin; • “The evacuation alarm was later found to operate OK, except at [door 1 left], which was silenced due to a stuck reset switch; [and,] • “Nine of the 32 premium economy video monitors detached from the seat backs during the impact.” © U.K. Air Accidents Investigation Branch Investigation Air Accidents © U.K. FLIGHTSAFETY.ORG | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 | 41 FLIGHTOPS Perfect PerformanceBY MARIO PIEROBON Global safety implications of Europe’s first PBN 0.1 implementation quickly became obvious. n March 2012, Atlantic Airways, the flag carrier The equipment aided a perfect landing and of the Faroe Islands, became the first European since has enabled the airline to improve airport airline to use required navigation performance access and service reliability at its operationally with authorization required (RNP AR) 0.1 demanding Faroe Islands base. The RNP naviga- Iprocedures on a commercial flight.1 tion system installed on the Atlantic Airways “At the time of landing — around 4 p.m. — A319 uses sophisticated positioning equipment the western Atlantic winds had spread a mass of to enable pilots to conduct approaches and take- low-level clouds above the channels and fjords offs in challenging weather conditions that are of the Faroe Islands. We could only see the typical in the Faroe Islands, an archipelago un- spines of the mountains,” said Andrea Artoni, an der Danish rule situated between the Norwegian aeronautical journalist, aviation consultant and Sea and the North Atlantic Ocean. The system a former air traffic controller who was aboard also guides pilots along the non-linear approach the delivery flight of the Atlantic Airways Air- path to Vágar Airport, necessitated by the high bus A319. The new aircraft was equipped with terrain at either end of the runway.2 the RNP navigation system. “The pilots consulted the approach chart. Efficient Navigation Tension was palpable. The weather conditions RNP is a category of procedures under perfor- forced the pilots to use, starting from the very mance-based navigation (PBN), an overarching first flight, the special instrument approach concept comprising different levels of precision procedure which determined the decision of in navigation procedures without specifying the the airline to purchase exactly that aircraft with technology used to achieve them. Also included © Kenny Janssens/Planepictures.net © Kenny exactly that equipage,” said Artoni. under PBN is area navigation (RNAV), the Photos.com Frederiksen/Faroe © Ólavur 42 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 FLIGHTOPS broadest category of PBN procedures. The main greenhouse gas emissions and relief of con- difference between RNAV and RNP is that RNP gested airspace. A relatively large proportion of equipment includes alerting and monitoring the global airline fleet already is equipped with systems allowing pilots to constantly monitor, PBN navigation systems. According to Marcel- on the flight management system display, the lo Astorri, an air navigation systems consultant RNP precision value in nautical miles. Further- and former airline pilot, “The world’s 10 largest more, RNP instrument approach procedures are airlines have 97 percent of their fleets equipped flown with the autopilot selected and using only with RNAV capability, while 47 percent of their satellite signals. PBN allows aircraft to fly flight fleets are equipped with RNP systems.” The paths more precisely than previous standards, problem, however, is that the operational ap- and without the necessity of having a direct link provals to actually navigate in accordance with between a ground-based navigation aid (NA- PBN are still relatively few. “Only 23 percent VAID) and an aircraft navigation system, thus of the world’s 10 largest airlines’ fleets have allowing improved operational efficiency and operational approvals to fly RNP approach better utilization of available airspace. procedures in accordance with ICAO’s [Inter- PBN can be considered a framework for national Civil Aviation Organization’s] PBN “defining a navigation performance specifica- Manual,” Astorri said during a technical semi- tion along a route, during a procedure, or in nar in Rimini, Italy, in September. The seminar airspace within which an aircraft must com- was organized by Artoni as part of AIRET, a An Atlantic Airways ply with specified operational performance technology trade fair. Airbus A319 flew Europe’s requirements. It provides a simple basis for first RNP 0.1 approach the design and implementation of automated Safety Implications in March. The flight flight paths and for airspace design, aircraft The enthusiasm of airlines to use PBN pro- was into Vágar Airport separation and obstacle clearance. It also of- cedures, the legislative activity of regulators in the Faroe Islands. fers a straightforward means to communicate with regard to PBN and the consequent need the performance and operational capabilities of air navigation service providers (ANSPs) necessary for the utilization of such paths and and airports to adapt to a new operational and airspace. Once the performance level (i.e., the regulatory environment should be managed accuracy value) is established on the basis of with a focus on the safety implications of such a operational needs, the aircraft’s own capabil- technological, operational and cultural shift in ity determines whether the aircraft can safely air navigation. “While it is true that technologi- achieve the specified performance and thus cal innovation, both at hardware and software qualify for the operation.”3 levels, on the ground and airborne, offers a real Under PBN, generic requirements are de- help for the increase of safety within all aspects fined on the basis of operational requirements. of air navigation, it is also true that the introduc- “Operators then evaluate options in respect [to] tion of new systems and procedures can create available technology and navigation services, a situation of confusion and work overload to which could allow the requirements to be met. users, which can endanger the level of safety. An operator thereby has the opportunity to Especially in cases of operational disruption, select a more cost-effective option, rather than when the failure of automatic systems can create a solution being imposed as part of the opera- a situation of uncertainty, and operators can tional requirements. Technology can evolve over find it difficult to carry on their tasks, it can be time without requiring the operation itself to be complicated to understand what is happening revisited as long as the requisite performance is and what to do once the disruption is over,” said provided by the RNAV system.”4 Mauro Barduani, an air traffic control (ATC) of- The expected benefits of widespread PBN ficer and an air traffic management (ATM) and usage include reduced fuel consumption and safety scholar. FLIGHTSAFETY.ORG | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 | 43 FLIGHTOPS There is a range of possible threats An FTS is a more sophisticated flexibility the controller has in provid- in the transition to PBN, and they are assessment than airspace modeling, ing vectors close in to the airport,” of concern to all stakeholders involved, and it “returns more precise and realis- according to a GE Aviation white paper namely air operators, ANSPs, airports tic results, while still not requiring published in July.5 and regulators. the active participation of controllers “From an airline perspective, flight The primary consequence of PBN or pilots; however, in terms of data crews must be provided with training implementation is a change in the collection and input, preparation can and policies to ensure that they are airspace concept under which such be demanding and time-consuming,” aware of conditions where the PBN navigation procedures are performed. ICAO said. path places the aircraft within range to “Validation of an airspace concept RTSs realistically replicate ATM unintentionally capture the final seg- involves completing a safety assess- operations and require the active ment,” stated GE Aviation. ment. From this assessment, additional participation of proficient controllers The redesign of standard operating safety requirements may be identified and simulated or “pseudo” pilots. “In procedures (SOPs) will ensure com- which need to be incorporated into the some cases, sophisticated RTS can be pliance with the new PBN regulatory airspace concept prior to implemen- linked to multi-cockpit simulators requirements — whichever these will tation,” said ICAO. “Four validation so that realistic flight performance is be — as well as navigation within the means are traditionally used to validate used during the simulation. One of required safety levels. “However, there an airspace concept: airspace modeling, the difficulties that can be encoun- may still be terrain-challenged airports fast-time simulations (FTS), real-time tered with real-time simulation is that where placing the PBN path within simulations (RTSs), and live ATC tri- the navigation performance of the range of final segment guidance may be als.” If the changes in the airspace con- aircraft is too perfect. Aircraft in RTS necessary,” the white paper said. cept are consistent, then a combination may operate with a navigation preci- of the four means may be necessary. sion that is unrealistic, given realities Regulatory Coordination Airspace modeling is a beneficial of weather, individual aircraft perfor- Regulatory adaptation and the defini- first step because it provides some mance, etc. In such cases, error rates tion of international standards is a long understanding of how the proposed from live operations are analyzed, and and delicate process, but it is necessary implementation will work while not these can be scripted into the RTS,” to ensure minimum levels of safety all requiring the participation of control- reported ICAO. around the world. The problem is not lers or pilots. “Airspace models are Live ATC trials are used to verify specifically that there could be dif- computer-based, so it is possible to operating practices or procedures ferences in PBN regulation between make changes quickly and effectively to when subtleties of the operation are different regions of the world. The issue ATS [air traffic service] routes, holding such that FTS and RTS do not satisfy is rather that in politically integrated patterns, airspace structures or sector- validation requirements. regions like the European Union, where ization to identify the most beneficial The initial safety assessment for the there are 27 national aviation authori- scenarios (i.e., those that are worth airspace concept validation should be ties (NAAs), regulatory inconsisten- carrying forward to more sophisticated performed in parallel with the iden- cies may be generated because it is a types of validation). Using a computer- tification by all stakeholders of more competence of the NAAs to implement based airspace model can make it specific issues associated with transi- legislation promulgated at Community easier to identify non-viable operating tion to PBN. level, including the PBN-related imple- scenarios so that unnecessary expense menting rules under development. “So and effort [are] not wasted on more SOP Redesign far, even if there exist some standards of advanced validation phases. The main PBN procedures “improve the predict- reference, namely ICAO’s PBN Manual, role of the airspace model is to elimi- ability and efficiency of the flight paths several operators and countries con- nate non-viable airspace scenarios and but require additional coordination tinue to utilize their own ‘parameters,’ to support the qualitative assessment of and planning. ... The increased pre- in particular with regard to mainte- further concept development,” accord- dictability and consistency of the PBN nance regulations and minimum levels ing to ICAO. transitions can in some cases limit the of service,” said Barduani. 44 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 their PBNtheir procedures are implemented. by organization’s the leaders with regard to how quantitythe and quality of observations made The basis of such asystem of incentives may be adaptation to technologies new and practices. at individual workers demonstrating proactive a carefully weighed system of incentives targeted sponse supported can be and complemented by workforce’sthe reluctance to change. Such are- competitiveness inaddressing useful —can be change and —operational market efficiency become completely automated,” said Barduani. for of types assignments, certain could which increased workloads and reduced personnel changes,cal ifsuch changes especially to lead alwaysbe available and open to technologi- concerns natural the human not tendency to workforce [during] evolution the towards PBN “A reluctant behaviour on sideof the the Workforce Resistance operations are most frequent. amonglar those countries the where PBN the existing among different countries,- inparticu date with PBN-related the regulatory differences itwhich is subjected, but that also it keeps up to requirements of competent the authority to ANSP not only complies with regulatory the fly-ability of procedures the and increased the attention from pilot the with regard to the approach procedures, require which higher we consider intricacies the of RNP new the training inair navigation,” said Astorri. “If cant evolution from tradition the of didactic domain inthe ties of PBN represents- asignifi regulation and economics in light of PBN. personnel and inair transport safety experts to retool crews, flight dispatchers, operational transition. As amatter of there fact, is aneed requiredthe knowledge technical to manage the transition to PBN, an organization may not have It is likely that before and at of beginning the the Knowledge Gap FLIGHTSAFETY.ORG Clarifying to workforce the Clarifying reasons the for It becomes necessary, therefore, that each “The increased emphasis“The on training- activi | WORLD AEROSAFETY | DECEMBER 2012–JANUARY 2013 sonnel, necessary. when personnel, operators airport per and military personnel, aeronautical information services havetraining will also provided to be to ANSP of satelliteracy signals,” said Astorri. iswhich ensured by autopilot the and- accu the precisionthe of on-board the navigation system, ture and only to need concentrate on maintaining inputs from traditional the navigation- infrastruc as pilots no longer actively and use search the arisk of is indeed “There increased complacency command and decision making for crews. flight management, crew resource management, and for more targeted training inthreat and error element that should is need recognized the be organizationalthe certifications.” high-performance simulation environment and for RNP-rated crews conducted flight to be ina approach inPBN fundamentals, syllabus anew on combiningfocused together across-cultural responsethe of operators the have will to be ofneed qualifications released by NAAs, the Beyond the flying community, flying the Beyond PBN-specific In addition training, to afurther PBN-specific RNP services RNP Ground-based navigation - dimensional precision thrust whilereducing profile descentsand facilitates optimized continuous descent aerodynamic noise. of RNPflightpaths arrivals withidle FLIGHTOPS The three- | 45 © GE Aviation FLIGHTOPS Traffic Increase: Airspace platform can help the ATM network Among the systemic interdependencies The forecast increase of traffic in ATM to plan in advance a strategic flow which could give rise to safety issues, systems represents a significant threat management and give precise timing he listed a lack of cooperation among even if, as expected, PBN makes airspace to airports for the utilization of their key stakeholders, a poorly defined and management run more smoothly. Dur- infrastructure and services. “The managed interface, a deficit of compe- ing the transition to PBN, safety can be concept is difficult to implement but tences, a deficit in the visualization of enhanced by the sharing of relevant infor- allows for higher predictability and the new system and an unsuccessful mation among key stakeholders. “Under punctuality, permitting airports to be identification of the peculiarities, such SESAR [Single European Sky ATM Re- more flexible, use their infrastructure as aircraft and approach design. search], there are provisions for a SWIM efficiently and on time according to “An increased systemic complexity (system-wide information management) the demand, reduce delays and taxi results in stronger interdependencies ATM information model. SWIM has times, switch slots among flights, and an increasing amount of issues been designed to allow communication, [and] plan in advance recovery ac- which cannot be solved on a stand- develop programs, and transfer and share tions in case of disruption,” said alone basis. What changes with PBN information in a simple way, in order to Barduani. with regard to safety planning is an permit users to acquire data without the increased awareness of the implications necessity of specific and deep knowledge Safety Planning of one’s decisions and actions in the of the system’s features. The concept is to Initial identification and assessment context of an even more complex and create a ‘system of systems,’ and to reach of risks, followed by their mitigation, interactive system. With the transition this goal, it is necessary that all opera- should be the basis of further safety to PBN, there will be an even stronger tors have access to a shared information planning by all PBN stakeholders. Activ- need to make well-thought decisions and data system. From the perspective ities and time schedules to be used and coordinated among all players and of ATM, widespread cooperation is es- respected should be identified; respon- stakeholders,” said Grüninger. sential to define optimal aircraft flight sibilities among the members of safety paths, thus allowing [ATM] to [transi- teams should also be split. Objectives Notes tion] towards trajectory-based operations and targets of the safety action should be 1. As explained in “Preparing for PBN,” by (TBO),” said Barduani. defined and reference safety indicators Frances Fiorino in Avionics Magazine, listed and outlined. February 2011, RNP AR “requires the Traffic Increase: Airports In the field of ATM, the safety highest level of navigation performance. Airports also will face traffic increases indicators can be considered as the … A value of ‘RNP 0.3’ means the aircraft is capable of remaining within 0.3 nautical because PBN allows more reliable opera- workload, the situational awareness, the miles to the right or left of center line 95 tions to and from a given airport and losses of separation, the usability (the percent of the time within a defined con- thus more movements to and from the measure of the ergonomics and fitness tainment area; RNP 0.1 means an aircraft same airport. “According to a forecast for use of any work tool), the errors, the must remain within 0.1 nm.” [by] Eurocontrol, approximately 20 teamwork, the level of trust, the accept- 2. Shepherd, Lesley. “Atlantic Airways Airbus percent of the future air traffic demand ability (level of trust in the effectiveness A319 First in Europe to Use RNP.” representing a real bottleneck for the issues associated [with] the systemic 4. ICAO. Performance-based Navigation whole system,” said Barduani. interdependencies which character- (PBN) Manual (Doc 9613 AN/937), Third In addition to the necessary in- ize transition to PBN” said Michael Edition, 2008. frastructural investments to increase Grüninger, an aviation safety consultant 5. GE Aviation. PBN to xLS: Implementation capacity at airports, an airport col- and formerly a flight inspector at the Today. GE white paper prepared by laborative decision making (CDM) Swiss Federal Office of Civil Aviation. Naverus, Inc., 9 July 2012. 46 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 The Foundation would like to give special recognition to our BARS Benefactors, Benefactor and Patron members. We value your membership and your high levels of commitment to the world of safety. Without your support, the Foundation’s mission of the continuous improvement of global aviation safety would not be possible. bars benefactors benefactors Snecma patrons FLIGHTSAFETY.ORG | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 | 47 DATALINK BY RICK DARBY Not all emergency exits are equal at evacuation time. This Way Out n 90 commercial jet evacuations from Nine Evacuation Scenarios 1961–2011, on average about half the available exits were used, and in only Threat/ Fire When did Scenario one case were all the available exits Condition scenario source? re start? number Iused. Those were among the findings presented by Fons Schaefers of SGI External 1 Aviation at the 2nd International Cabin On Fire ground 2 Safety Conference in Amsterdam, Internal Netherlands, in October.1 Intact In ight 3 “All these accidents were survivable Water 4 but life-threatening because of fire or submersion in water,” Schaefers said. Fire 5 “In situations requiring urgent evacua- Breaks? Accident Water 6 tion, exits can make the difference be- Intact or tween life and death. But how often are breaks Fire 7 exits used in such critical situations?” Ground 8 Surprisingly few attempts have been collision made to analyze exit usage in relevant Inverted 9 accidents, he said. The Amsterdam presentation was an update of a similar Source: Fons Schaefers presentation given in 1994, adding data from 1993–2011. Figure 1 48 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 DATALINK Accidents meeting the criteria for inclu- Numbering of Exits, Wing-Mounted Engine Aircraft sion in his latest study database totaled 150.2 Of those, the reports for about 90 accidents included Exit locations Examples enough information to draw useful conclusions Locations 1, 2, 4 and 5 1, 2, 3, 4, 5 Boeing 747, DC-8-60 concerning exit usage. In 51 of the 90 accidents, consist of oor-level exits. 1, 2, 4, 5 Airbus A300, A330, A340 the number of evacuees for each exit was known; Location 3 consists of 1, 2, 3, 5 McDonnell Douglas DC-10, oor-level exits or Type III exits MD-11 in 39, data showed only which exits were used (typically two pairs). 1, 3, 5 Airbus A310, A320, and not how many evacuees they served. Boeing 707 (most), Boeing 737, Convair 880, Various criteria can be present or absent in Douglas DC-8 (short) accidents in which evacuation is required. To 1, 3, 4, 5 Boeing 707 (some) 1, 5 BAe146 (high wing) clarify exit usage under different conditions, the accidents were grouped into nine scenarios (Figure 1). In addition, exits were numbered R according to location, both for aircraft with wing-mounted engines (Figure 2) and those with fuselage-mounted engines (Figure 3). L 1 2 3 4 5 The number of evacuees per exit was known in only some of the accidents in each scenario. Because the known-to-unknown ratio varied among scenarios, the numbers of evacuees per exit may suggest differences but are not directly comparable. By the same token, not all aircraft have the same number of exits, so differences in Source: Fons Schaefers usage do not necessarily indicate the efficiency of an exit position. Figure 2 Scenario 1: Land — Intact — External Fire Numbering of Exits, Fuselage-Mounted Engine Aircraft This was the most common scenario, represent- ing 42 of the 150 accidents in the database. In Exit locations Examples this type of accident, the aircraft came to rest Locations 1, 2 and 4 1, 3, 4, Tail Boeing 727-200 consist of oor-level exits. 1, 3, 4L, Tail McDonnell Douglas on its landing gear, fuselage or a combination. Location 3 consists of Type III MD-80/90 “Intact” refers to the condition of the fuselage. exits (typically two pairs). 1L, 2R, 3, Tail Boeing 727-100 Location Tail consists of 1, 3, Tail Douglas DC-9, The overall exit usage rate was about 50 per- a ventral exit or a tail cone exit. Aerospatiale Caravelle cent. Location 1, the farthest forward, was most 1, 3, 4 Vickers Super VC-10 used for evacuation in this type of accident. 1, 3 Fokker F.28/100, Canadair CRJ Scenario 2: Land — Intact — Internal Fire Started on the Ground R Tail This scenario led to seven evacuations. The L 1 2 3 4 overall exit usage rate was about 70 percent, with location 1 most commonly used, followed in frequency by location 3. Scenario 3: Land — Intact — Internal Fire Started in Flight Source: Fons Schaefers Only four accidents in the database met the criteria for this scenario. These accidents had Figure 3 FLIGHTSAFETY.ORG | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 | 49 DATALINK a “high fatality rate,” Schaefers said. “Only 3 — had a high percentage of use. Position forward [location 1] and overwing [location 3] 2 was also used often. The other positions exits were used.” scored low. Scenario 4: Water — Intact Scenario 7: Land — Intact or Breaks Unknown Ten of the accidents were included in this catego- — External Fire ry, and the exit usage rate was relatively high at 70 This scenario accounted for the third high- to 100 percent for all exits other than the tail. est number of accidents, 32. In 29 of those, however, the exit usage was unknown, thereby Scenario 5: Land — Breaks — External Fire limiting analysis. This is the first scenario in which the fuselage Two other scenarios included 8, “Ground broke into two or more sections, provid- Collision — External Fire” and 9, “[Fuselage] ing additional exit possibilities beyond the Inverted,” both rare enough to preclude signifi- standard exits — in some cases occupants cant findings about exit usage. were ejected or extricated by rescue personnel Besides the overall finding that an average through the breaks. of half the available exits were used, Schae- It was a relatively common scenario, com- fers reported that in six cases where exits prising 40 accidents of the 150 in the database. were usable, no evacuation took place or only “In absolute numbers, position three scored fuselage breaks were used for escape. In the highest in scenario 5,” Schaefers said. “However, greatest number of accidents, more than one although not that many aircraft have exits in but fewer than half the available exits were positions 2 and 5, position 2 actually had the used (Figure 4). highest ‘usage rate’ of about 65 percent, posi- Tail exits are only used on older aircraft tion 5 had a rate of about 45 percent and the rest types. Of 27 evacuations of aircraft equipped were lower.” with a tail exit, that exit was only once used suc- cessfully. “In most cases, it was not used, but in Scenario 6: Water — Breaks two cases, passengers and crew became trapped In this scenario, also one in which the fuse- and had to be extricated by rescue personnel,” lage breaks up, the overwing exits — position Schaefers said. “This was not always successful and people have died as a result.” Number of Exits Used in Evacuations Subdividing the entire 1961–2010 period into decades, it was found that the numbers of 25 evacuation accidents rose in 1971 through 1980, 20 but then decreased and were lowest in the most 15 recent decade — in spite of considerable traffic growth over the whole stretch. 10 In the survival ratio, or percentage of oc- 5 cupants who survived the accidents, there was Number of evacuations 0 little change from decade to decade, more than 10 >1; Source: Fons Schaefers which they had boarded? It would appear so. In the 51 cases where the data for evacuees per exit Figure 4 were known, 1,847 were directed to or chose 50 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 DATALINK exits on the left, compared with 1,555 who used Evacuations, by Exit Positions exits on the right. The presence of fire might have influenced the side chosen for evacuation in some cases. However, in 63 cases involving external fire, there were 13 — 21 percent — in which exits on 1 2 3 4 5 0 only one side were used. In only three cases were all the exits on one side used to the exclusion of 20 the other side. 40 Positions 2, 3 and 5 had high evacuee rates 60 per used exit (Figure 5). Position 1 had a high usage rate when the fuselage remained intact, 80 but it was rarely used in break-up cases. Posi- 100 Exits installed tions 4 and the tail were virtually unused. 120 Exits used “Tail exits have become deathtraps,” Schaefers 140 Evacuees (x10) said, recommending that they not be included in designs. Note: Data refer to evacuations (N = 51) in which the number of evacuees per exit was known, and include aircraft with wing-mounted and fuselage-mounted engines. Schaefers’s analysis included reasons for Source: Fons Schaefers particular exits not being used. In approxi- mate order of frequency, he said, they includ- Figure 5 ed these: supplemented by breaks. In water scenarios, • There was a fire outside. overwing exits are most used.” • The exit was in a destroyed section of the His recommendations included the aircraft. following: • The door was jammed. • “Exits should be installed in opposite pairs; • The exit was obstructed, inside or outside • “Exits should be designed so that they can the aircraft. quickly be closed again after opening; [and,] • The aircraft’s position on the ground or • “Do not assume exits are not usable on water made the exit unusable. one side because a fire is reported on that side.” • Passengers did not understand the use of exits, particularly overwing and tail exits. Notes Less frequent factors included exits that were 1. Schaefers, Fons. “Exit Usage in Survivable Accidents out of reach because of a fuselage break, the Under Life-Threatening Conditions.” Proceedings difficulty or impossibility of opening and then of the International Cabin Safety Conference, 23–25 closing an exit, inward door movement impeded October 2012.” Portland, Oregon, U.S.: (L/D)max by crowding, slide malfunctions and submersion Aviation Safety Group. in water. 2. Criteria for inclusion of accidents in the study To sum up, Schaefers said that generally, exit included the following: jet air transport aircraft; use depends on the accident scenario. “In light Western-designed; passengers aboard; at least one usable exit; evacuation vital (in hindsight) for life impact cases with external fire and all cases of saving; not caused by hostile action. “Evacuations internal fire, forward exits are most ‘popular,’” that were precautionary or could be determined he said. “Where there has been a heavy im- retrospectively to have involved no threat to life were pact, rear exits are most often used, sometimes excluded,” Schaefers said. FLIGHTSAFETY.ORG | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 | 51 INFOSCAN UAS Introduction: Ready … or Not? FAA addresses complex issues to integrate unmanned aircraft into the national airspace system. BY RICK DARBY REPORTS efforts and issuing a final rule for small UAS. … While FAA has taken steps to meet them, it United States Government Accountability Office Report to Congressional Requesters GAO Rulemaking Under Pressure is uncertain when the national airspace system will be prepared to accommodate UAS, given September 2012 Unmanned Aircraft Systems: Measuring Progress and UNMANNED AIRCRAFT SYSTEMS Addressing Potential Privacy Concerns Would Facilitate that these efforts are occurring simultaneously Measuring Progress and Addressing Integration Into the National Airspace System Potential Privacy and without monitoring to assess the quality Concerns Would U.S. Government Accountability Office (GAO), Report to Facilitate Integration of progress over time toward the deadlines into the National Congressional Requesters. GAO-12-981. Sept. 18, 2012. Congress established.” On September 18, 2012 we updated this report to reflect an additional addressee. gov/products/GAO-12-981>. Although the U.S. market for UAS is cur- n 2012, the U.S. Congress enacted require- rently dominated by the military and govern- GAO-12-981 ments and deadlines for the U.S. Federal Avia- ment agencies, the report says that an industry Ition Administration (FAA) to safely accelerate forecast predicts the emergence of extensive the routine operation of unmanned aircraft sys- civilian and commercial uses. These include tems (UAS) with existing air traffic in national “pipeline, utility and farm fence inspections; airspace. Most of the requirements are to be met vehicular traffic monitoring; real-estate and by the end of 2015. construction-site photography; relaying tele- The GAO is watching FAA’s progress, but communication signals; fishery protection and according to this study report, FAA is not moni- monitoring; and crop dusting. FAA’s goal is to toring its own progress well enough. eventually permit, to the greatest extent possible, “FAA, in coordination with stakeholders, routine UAS operations in the national airspace has begun making progress toward complet- system while ensuring safety,” the report says. ing those requirements, but has missed one “As the list of potential uses for UAS grows, so deadline and could miss others,” the report do the concerns about how they might affect ex- says. “Many of the requirements entail sig- isting military and non-military aviation, as well nificant work, including completing planning as concerns about how they might be used.” 52 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 INFOSCAN Currently, FAA authorizes use of UAS on air traffic capacity of the NAS, and reduce a case-by-case basis, mainly to government the impact of aviation on the environment, organizations through a process called granting FAA says. a certificate of waiver or authorization (COA), FAA has undertaken several initiatives for safely and to some private sector operators for folding UAS into the NAS. They fall into four experimental purposes via special airworthi- broad categories. ness certificates. As the UAS fleet and number The first is a comprehensive plan and road of operators grows, FAA will be faced with map. This includes a phased-in approach to, and merging the unmanned aircraft into airspace timeline for, the integration and the establish- that averages 100,000 flights a day, including ment of a process to develop certification, flight commercial air carriers, general aviation and standards and air traffic requirements at UAS military aircraft. test ranges. “In 2008, we reported that UAS could not “To date, FAA has not developed measures meet the aviation safety requirements developed for assessing the various efforts to achieve safe for manned aircraft and that UAS posed several integration by September 2015,” the report says. obstacles to operating safely and routinely in “The 2012 act [detailing FAA’s requirements for the national airspace system,” the report says. UAS integration] specifies content for a more “FAA and others have continued their efforts to comprehensive plan than what was laid out in address these obstacles, but many still remain, the two-page road map, but it does not set forth including: any expectation for monitoring to assess the quality of progress over time toward meeting the • “The inability for UAS to detect, sense and range of activities to be outlined in the plan. avoid other aircraft and airborne objects “Our [GAO’s] Standards for Internal Control in a manner similar to ‘see and avoid’ by in the Federal Government provide the overall a pilot in a manned aircraft [for recent framework for establishing and maintaining in- developments concerning this issue, see ternal control and for identifying and addressing ‘Pressure Gradient,’ ASW, 10/12, p. 16]; major performance and management challenges • “Vulnerabilities in the command and and areas at greatest risk of fraud, waste, abuse control of UAS operations; and mismanagement. One of those standards • “The limited human factors engineering is monitoring, which is an internal control incorporated into UAS technologies; designed to assess the quality of performance over time. This internal control should generally FAA will be faced • “Unreliable UAS performance; be designed to assure that ongoing monitoring with merging the • “The lack of technological and operational occurs in the course of normal operations and that it is performed continually and is ingrained standards needed to guide the safe and unmanned aircraft consistent performance of UAS; in the agency’s operations. In light of the time frames and complicated tasks ahead, the absence into airspace that • “The lack of final regulations to guide the of regular monitoring precludes the agency safe integration of UAS into the national and Congress from assessing progress toward averages 100,000 airspace system; [and,] completion of the 2012 act requirements.” flights a day. • “The transition to NextGen [the Next The second category involves the COA Generation Air Transportation System].” process. The report says, “FAA has changed the NextGen is a comprehensive overhaul of existing COA process … including taking steps the U.S. National Airspace System (NAS) to expedite COAs for public safety entities and to add capabilities that make air transpor- finalizing agreements with government agen- tation safer and more reliable, increase the cies to expedite the COA or waiver process.” FLIGHTSAFETY.ORG | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 | 53 INFOSCAN Among other types of streamlining, the length has not yet been fully implemented, it remains of UAS authorization has been extended from unclear whether it will provide the support 12 months to 24 months, so users do not have to needed to complete the work. reapply as frequently. “FAA’s UAS efforts rely on expertise and Third, “FAA has taken steps to develop, but resources from several offices within FAA, such has not yet established, a program to integrate as the Aviation Safety Organization, the Air UAS at six test ranges, as required by the 2012 Traffic Organization, the Research and Develop- act. … FAA expects data obtained from these ment Integration Office, the NextGen Office test ranges will contribute to the continued de- and the federal multi-agency Joint Planning and velopment of standards for the safe and routine Development Office. FAA has reorganized its integration of UAS.” office that oversees UAS activities several times FAA’s request for comments about test over the past few years but had not previously ranges, published in the Federal Register, drew assigned a single and visible leader to this effort. The agency now 227 responses from Congress, state and local We have previously reported the need for stable governments, industry, academia and individu- leadership at FAA for major aviation efforts. finds itself with a als. The agency now finds itself with a collec- More recently, FAA has taken steps to provide tion of varied, if not conflicting, suggestions. the organizational leadership needed to facilitate collection of varied, “The comments addressed questions such progress to safely accelerate UAS integration if not conflicting, as what certification requirements should be into the national airspace system. set for aircraft as part of the test ranges, who “In March 2012, FAA assigned an executive suggestions. should manage the airspace and what restric- manager for its newly created UAS Integration tions should be placed on those using the test Office, which is expected to combine UAS- ranges, and where test ranges should be lo- related activities from the agency’s Air Traffic cated,” the report says. “For example, FAA has Organization and Aviation Safety Organiza- proposed outsourcing the management of the tion. However, as of July 2012, the UAS Inte- test ranges; however, some commenters pre- gration Office had not yet been finalized within ferred FAA or another public entity to main- FAA and no employees had been officially tain oversight responsibility. Some commenters assigned to the UAS Integration Office. FAA also said that test ranges should be selected officials told us that they expect approximately based on locations with existing facilities and 50 federal employees and contractors eventu- infrastructure, given the absence of any fund- ally will be assigned to the office; however, ing available for the set-up, management or the officials are still evaluating the number of oversight of the test ranges.” personnel needed.” The fourth category falls under the head The report discusses other privacy and of rulemaking. “While FAA has efforts under security issues that might further delay the ac- way supporting a rulemaking for small UAS, as ceptance of UAS in FAA’s domain. required by the 2012 act, it is uncertain whether UAS are potentially capable of providing FAA will be able to meet the established dead- some kinds of surveillance data at far less cost line,” the report says. than “spy” satellites. “Recently, members of The report says that, although FAA has Congress, a civil liberties organization and made progress toward meeting the requirements others expressed concern that the potential of the 2012 act, “those requirements that remain increased use of small UAS for surveillance and will require significant work from the agency to other purposes in the national airspace system meet the established deadlines. FAA has reorga- has potential privacy implications,” the report nized to provide more focus on its UAS integra- says. “Many stakeholders we interviewed tion efforts; however, because the reorganization projected how past Supreme Court cases that 54 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 INFOSCAN address privacy issues related to government the UAS that is not reliant on GPS, which is the surveillance might apply to UAS. While the Su- case with larger UAS typically operated by [the preme Court has not addressed privacy issues Department of Defense] and [the Department of related to governmental UAS surveillance, the Homeland Security].” court has, however, upheld several instances In its conclusions, the report says, “FAA involving government aerial surveillance from faces the daunting task of ensuring that all of manned aircraft.” the various efforts within its own agency, as well The U.S. Transportation Security Adminis- as across agencies and other entities, will align tration (TSA) is charged with addressing risks, and converge in a timely fashion. The pace of threats and vulnerabilities in transportation — progress toward UAS integration that occurred including non-military UAS. “According to a prior to the 2012 act and questions about the TSA official, it recently reviewed its UAS-related agency’s ability to meet deadline requirements advisories and determined that they are still raise concerns about when UAS integration in applicable,” the report says. “However, TSA has the national airspace system will be achieved. not provided information on specific steps it Incorporating regular monitoring will help to has taken to mitigate the potential threats but assess progress toward goals identified in the believes its current practices are sufficient to ad- comprehensive plan and five-year road map dress UAS security. … that can help FAA understand what has been “Security remains a significant issue that could achieved and what remains to be done.” be exacerbated with an increase in the number of UAS. TSA’s practices might be sufficient in the WEBSITES current UAS environment of limited operations taking place under closely controlled conditions, New Online Safety Support but these controlled conditions will change as Global Aerospace SM4, FLIGHTSAFETY.ORG | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 | 55 ONRECORD Close Call Over the Atlantic An air traffic control breakdown placed an airliner and a military transport on a collision course. BY MARK LACAGNINA The following information provides an aware- The lead C-17 was about 4,000 ft (1,219 m) ness of problems that might be avoided in the ahead of the other transport and about 500 ft future. The information is based on final reports (152 m) left. by official investigative authorities on aircraft The airplanes were in the same sector of accidents and incidents. airspace governed by the New York Air Route Traffic Control Center but were being handled by two different radar controllers. One control- JETS ler had cleared the 777 flight crew to climb to Message Misunderstood Flight Level (FL) 230 (approximately 23,000 ft); the other controller had cleared the lead C-17 Boeing 777-200, Boeing C-17 Globemaster. No damage. No injuries. flight crew to descend from FL 250 to 10,000 ft. ncomplete and incorrect coordination among The controller handling the 777 was engaged air traffic controllers was cited by the U.S. in clarifying a route clearance with the crew of INational Transportation Safety Board (NTSB) another airplane in the sector when he received as the probable cause of a near midair collision a landline call from the center’s air traffic data between the 777 and the C-17 over the North controller, who was coordinating the activities Atlantic the night of Jan. 20, 2011. of both the 777 controller and the C-17 control- In its final report on the incident, the NTSB ler. The 777 controller, focusing on a lengthy said that noncompliance with established com- clearance readback by the other crew, told the munications phraseology and incorrect data coordinator that he would call back, but the co- block displays were contributing factors when the ordinator proceeded to instruct the controller to airliner and the lead airplane in the flight of two stop the 777’s climb at FL 210. The 777 control- U.S. Air Force C-17 transports came within 0.38 ler apparently did not hear that instruction. nm (0.70 km) of each other at the same altitude “While still on an open line with that con- about 80 nm (148 km) southeast of New York. troller, the data controller [coordinator] leaned The incident occurred at 2235 local time toward the controller working the two C-17s in visual meteorological conditions (VMC) on and told him to stop his flight at FL 220,” the what was described as a dark night. The 777 report said. “The controller working the 777 was southeast-bound, en route from New York’s overheard the portion of the communication John F. Kennedy International Airport on a where the [coordinator] said to stop at FL 220 scheduled passenger flight to São Paulo, Brazil. and believed that the instruction was meant for The C-17s were west-bound, returning to Joint the 777. Therefore, the controller instructed the Base McGuire-Dix-Lakehurst in Wrightstown, 777 to climb to FL 220, while at the same time New Jersey, after completing an aerial-refueling the [other] controller instructed the C-17s to operation with a McDonnell Douglas KC-10. descend to FL 220.” 56 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 ONRECORD New York Center’s radar data processing cleared to descend to 10,000 ft,” the report said. system generated a conflict alert about the same “Both of these were incorrect.” time the 777 crew received a traffic-alert and collision avoidance system (TCAS) resolution Tail Strike During Go-Around advisory to descend. The airplanes were about 7 Airbus A321-211. Minor damage. No injuries. nm (13 km) apart when the 777 crew reported he A321 was en route the evening of Dec. 23, that they were following a TCAS “descend” 2011, from Austria with 182 passengers and instruction. The report noted that the initial Tsix crewmembers to Manchester, England, TCAS resolution advisory to descend was soon which was reporting surface winds from 320 de- followed by an advisory to increase the descent grees at 16 to 27 kt, scattered clouds and light rain rate and then by an advisory to climb, but the showers. The aircraft encountered turbulence as report did not provide details about the reversal it descended through 1,500 ft above ground level or the crew’s response to the TCAS resolution (AGL) during the instrument landing system advisories. (ILS) approach to Manchester’s Runway 23R. The C-17s also were equipped with TCAS, “The copilot [the pilot flying] disengaged the but the systems were configured to provide only autothrust system as briefed, and, with turbulence traffic advisories. increasing as the aircraft descended, the com- “When the controllers noticed the conflict, mander increased the approach speed target by 5 they instructed both [the 777] and [the C-17s] kt,” said the report by the U.K. Air Accidents In- to turn, in an unsuccessful attempt to maintain vestigation Branch (AAIB). “Slightly below 1,000 separation,” the report said. The 777 crew was ft, the copilot disengaged the autopilot.” instructed to turn left, and the C-17 crews were Aircraft control became increasingly dif- told to turn right. ficult as the A321 descended below 400 ft, and The data blocks The 777 crew also was advised that they had the copilot had to make nearly continuous roll “traffic now one o’clock, four miles southwest, inputs, occasionally with full sidestick deflection. on the controllers’ heavy C-17, Flight Level 220.” A few seconds “By about 100 ft, the situation had become worse, later, the controller asked the 777 crew if they and shortly afterwards, he initiated a go-around,” radar displays did had the traffic in sight. The response was: “No, the report said, noting that recorded flight data we do not.” showed a wind shear from a 4-kt tailwind compo- not show the actual The crew of the lead C-17 was advised that nent to an 8-kt headwind component. altitude assignments. the “traffic right below you is a Boeing triple- The crew set TOGA (takeoff/go-around) seven that should be leveling at Flight Level thrust, and the copilot rotated the aircraft to a 210.” The C-17 crew replied, “Yeah, [we] just 10-degree nose-up pitch attitude. “Almost simul- came within approximately 2,000 feet of that taneously, the crew sensed a severe downdraft traffic.” which caused the aircraft to sink and the main The 777 crew then radioed, “That guy gear to make contact with the runway,” the report passed us now, and that was not good.” The con- said. Flight data showed that the 8-kt headwind troller replied, “I understand that, and I apolo- component had sheared to an 8-kt tailwind com- gize. I am not working that other airplane.” ponent as the go-around was initiated. Investigators found that when the near colli- The crew completed the go-around and then sion occurred, the data blocks on the controllers’ added 10 kt to the target airspeed for the second radar displays did not show the actual altitude approach. The aircraft again encountered wind assignments — that is, that the 777 and the shear, which caused a 10- to 15-kt airspeed loss C-17s had been cleared to FL 220. Instead, “the close to the runway, but the copilot landed the data block for the 777 indicated that the airplane Airbus without further incident. was cleared to climb to FL 230, and the data “During the commander’s external inspec- block for the C-17s indicated that [they] were tion after arriving on stand, he discovered FLIGHTSAFETY.ORG | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 | 57 ONRECORD damage to the lower rear fuselage skin and Incursion Prompts High-Speed RTO suspected that the aircraft had suffered a tail Airbus A321-231, Boeing 737-800. No damage. No injuries. strike during the go-around manoeuvre,” unway 16 was in use at Dublin (Ireland) the report said. “An engineering inspection Airport the afternoon of May 21, 2011, but confirmed that the aircraft would be unable Rthe A321 flight crew requested, and re- to operate the return sector pending further ceived, clearance to use the longer runway, Run- maintenance action.” way 28, for departure. The Airbus was bound for Tenerife, Spain, with 152 passengers and six Asleep at the Wheel crewmembers. Boeing 737-700. Substantial damage. No injuries. As the A321 was taxied from the stand, the snowplow operator was clearing snow from ground traffic controller instructed the crew the ramp at Denver International Airport to proceed via Taxiway E1 and hold short of Athe afternoon of Dec. 22, 2011. He had Runway 28. Taxiway E1 leads to an intersection been on duty for 6.5 hours after a six-hour rest common to the approach end of Runway 28 and break, during which he attempted to sleep in a the departure end of Runway 16. Although a left vehicle following a previous shift from 1730 to turn and a right turn were required to reach the 0200 local time. Investigators were unable to taxiway, the crew mistakenly continued taxiing determine why he spent the rest period in the straight ahead, onto Taxiway A, which is north- As the 737 accelerated vehicle, rather than in the snow-removal com- west of Taxiway E1. pany’s bunkhouse. Meanwhile, the ground controller had through 80 kt, the “Since the vehicle was being operated, he instructed the A321 crew to switch to the tower probably did not get uninterrupted sleep and, frequency and had diverted her attention to other commander saw most likely, got less than six hours of sleep,” the aircraft. She did not see the A321 enter Taxiway A. the A321 taxiing NTSB report said. “The company did not have, “As they approached the edge of Runway and was not required to have, guidance or a 16, the first officer, or pilot not flying (PNF) toward the end policy addressing fatigue management.” questioned their position, so [the commander] The snowplow operator told investigators stopped the aircraft,” said the report by the Irish of the runway. that he fell asleep while driving behind the 737, Air Accident Investigation Unit. The A321 came which was being prepared for pushback from to a stop on the runway. the gate. “The snowplow passed the airplane and By this time, the tower controller had cleared then initiated a gradual turn to the right,” the the flight crew of the 737 to take off on Runway report said. “The snowplow continued around 16. The 737 was bound for Vilnius, Russia, with 180 degrees and hit the airplane on the left side, 145 passengers and six crewmembers. The crew near the empennage.” initiated the takeoff as the A321 was taxied onto The impact buckled the auxiliary power Taxiway A. unit access door, pierced three 4-in (10-cm) As the 737 accelerated through 80 kt, the holes in the fuselage skin and broke a stringer. commander saw the A321 taxiing toward the The snowplow cabin also was damaged, but the end of the runway, and she asked the first of- operator was not hurt. ficer, “Where’s that guy going?” The first officer The report said that the snow-removal replied, “He’s taxiing out in front of us.” The company’s “lack of a policy regarding employee commander called “stop” and initiated a high- fatigue” was a factor in the accident. The com- speed rejected takeoff (RTO) just before the pany told investigators that its snowplow op- tower controller instructed the crew to discon- erators typically worked 12- to 14-hour shifts tinue the takeoff. and that “the responsibility for fatigue and Indicated airspeed was 123 kt, or about 4 fatigue management comes down to personal kt below V1, and the 737 was 820 m (2,690 ft) responsibility.” from the approach end of Runway 16, when the 58 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 ONRECORD 737 commander applied the wheel brakes and The airplane was about 10 minutes from the reduced power to initiate the RTO. The Boeing destination when air traffic control (ATC) told came to a stop about 360 m (1,181 ft) from the the crew that the reported MU values on the Airbus, or about 1,455 m (4,774 ft) from the beginning, middle and end of Runway 19 were approach threshold of Runway 16. The 737 crew 40, 42 and 40, respectively, with patchy thin then taxied the aircraft back to the stand, where snow over patchy thin packed snow and ice on maintenance technicians examined the wheel the runway surface. brakes and released the aircraft for departure. The crew conducted the ILS approach to “When asked by investigators if she had car- Runway 19 in weather conditions that included ried out an actual RTO before, the [737] com- surface winds from 180 degrees at 11 kt, 1/2 mi mander said she had not and added that ‘all the (800 m) visibility in light blowing snow, a bro- simulator training works,’” the report said. ken ceiling at 500 ft and an overcast at 2,500 ft. The A321 pilots told investigators that the “The landing was made at a time when the taxi route from the stand to the runway was runway conditions were deteriorating and the short but complicated, and that bright sunlight braking performance was becoming less effec- reflecting off the wet taxiways had made the yel- tive,” the report said. “During the landing roll, low markings difficult to see. thrust reversers were deployed, and the crew The report noted that a red stop bar on noted that all of the ground and air slat indica- Taxiway A was used only during low-visibility tion lights were green and that the anti-skid sys- conditions and, thus, was not illuminated when tem began to pulse. … Despite the application of the incident occurred. Dublin Airport Author- maximum thrust reverse, there was no effect on ity made several changes as the result of the slowing the airplane, and it exited the departure incident, including mandating 24-hour use end of the 6,300-ft [1,920-m] runway and came of the stop bar, installing additional taxiway to rest just beyond the blast pad.” directional markings and publishing “hot-spot” The report noted that MU values were information on the airport chart. reported as 34, 33 and 23 about seven minutes after the G200’s overrun. Braking Action Deteriorates Gulfstream G200. No damage. No injuries. he airplane’s departure from Bozeman, TURBOPROPS Montana, U.S., for a positioning flight to Jammed Door Blocks Gear Jackson, Wyoming, the morning of Nov. 22, T Fairchild Dornier SA 227-DC. Minor damage. No injuries. 2010, was delayed because of adverse weather conditions and reported runway surface friction ight VMC prevailed on Jan. 19, 2010, when (MU) values in the 20s at Jackson Hole Airport. the Metroliner, inbound from Brno, Czech “MU values range from 0 [to] 100, where NRepublic, with just the two pilots aboard, 0 is the lowest friction value and 100 is the was established on final approach to Runway 07 maximum friction value,” the NTSB report said. at Stuttgart (Germany) Airport. When the crew “A MU value of 40 or less is the level at which attempted to extend the landing gear, they re- aircraft braking performance starts to deterio- ceived an indication that the right main landing rate and directional control begins to be less gear was not down and locked. responsive.” After cycling the landing gear and receiv- About an hour after the originally planned ing the same indication, the crew initiated a departure time, a company dispatcher released go-around and tried several times to extend the the G200 for the flight, telling the flight crew landing gear using the emergency procedure. that the weather at Jackson had improved and “All attempts were futile,” said the report by the that MU values were in the 40s. German Federal Bureau of Aircraft Accident FLIGHTSAFETY.ORG | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 | 59 ONRECORD Investigation (BFU). “The indications for the The report said that the probable cause of right main landing gear remained red.” the accident was “the pilot’s improper preflight The crew flew the Metroliner past the planning, which resulted in a loss of engine airport traffic control tower for a visual check power due to fuel exhaustion.” by the controllers, who confirmed that the right main landing gear was not extended. The crew Asymmetric Reverse Thrust then was vectored to an area where they induced Dornier 328-100. Minor damage. No injuries. positive and negative loads on the aircraft in an wo pilots and three technical crewmembers attempt to unlock the right main gear. “After were dispatched from Cairns, Queensland, nine minutes, the attempts were aborted because TAustralia, to participate in a search-and- they had been in vain,” the report said. “The rescue mission at Horn Island the afternoon of crew declared an emergency and decided to land Jan. 10, 2012. While conducting an NDB (non- with the one remaining main landing gear and directional beacon) approach, the crew noted the nose landing gear.” that they would have an 8-kt left crosswind on Both engines were shut down, the propellers landing. were feathered, and the electrical system was dis- Shortly after touching down on the run- The first officer engaged before the aircraft touched down. “After way centerline, the first officer, the pilot flying, the landing, as speed had been reduced and the moved the power levers into ground idle, then transferred control right wing could no longer be kept in the air, into reverse. “The flight data recorder indicated the aircraft was steered toward the right and off that the reverse thrust was initially applied to the captain shortly the runway into the grass, so that the right wing evenly,” said the report by the Australian Trans- could be rested on soft ground,” the report said. port Safety Bureau. before the aircraft “After the aircraft had come to a complete stop, However, when the first officer released the crew left it by way of the passenger door.” back pressure on the power levers as the aircraft veered off the left Investigators found that the outer clamshell decelerated through 48 kt, the reduction of in- door on the right main landing gear had jammed ternal spring pressure moved the right lever into side of the runway. against the edge of the wheel well and had ground idle, but the left power lever remained in prevented the gear from extending. Pre-existing the reverse position. The resulting asymmetric dents and rippling of the door skin were found, thrust caused the Dornier to veer left, despite but the cause of this damage was not determined. the first officer’s application of full right rudder. “At the same time, the nosewheel weight-on- Fuel Planning Falls Short wheels sensor showed the nosewheel alternating Cessna 208 Caravan. Substantial damage. One minor injury. between ground and air modes, resulting in the he Caravan was refueled with 16 gal (61 L) nosewheel steering not being operational,” the of jet fuel, which the pilot deemed sufficient report said. Tfor two skydiving flights near Mesquite, Ne- The first officer transferred control to the vada, U.S., on Dec. 17, 2011. “During the second captain shortly before the aircraft veered off the skydiving flight, he delayed releasing the skydiv- left side of the runway. “The captain brought ers due to traffic in the area,” the NTSB report both power levers back into reverse thrust and said. “As he turned the airplane back toward the recovered the aircraft back onto the runway,” drop zone, the airplane’s engine experienced a the report said. “Following the incident, an total loss of power.” engineering inspection found that the left power The pilot signaled the skydivers to jump lever appeared not to spring as far forward as and attempted to land the powerless airplane on the right power lever when released from the the runway. The Caravan touched down long, reverse thrust position. overran the runway and crossed a road before “Power lever split had been noted on other coming to a stop on a golf course. aircraft within the fleet; however, the operator 60 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 ONRECORD did not consider that these presented a ser- The report said that the pilots might have viceability issue as the approved technique for thought they were clear of high terrain north bringing the power levers out of reverse thrust of the airport when they began a wide left base back to ground idle required a controlled input and inadvertently descended into clouds. The and not reliance on the release of spring ten- Navajo struck the tops of trees and crashed in a sion alone.” field on the upper slope of a mountain about 2 nm (4 km) northeast of the airport. Loose Bolt Causes Gear Collapse Mitsubishi MU-2B-20. Minor damage. No injuries. Takeoff on an Empty Tank he pilot heard a “pop” when he extended the Cessna U206G. Substantial damage. One serious injury, three minor injuries. landing gear on approach to Walterboro, TSouth Carolina, U.S., the afternoon of Jan. he single-engine airplane was departing 16, 2011. “During the landing roll, the nose gear from Matinicus Island, Maine, U.S., for a collapsed, resulting in minor damage to the nose Tcharter flight to Rockland the afternoon of gear doors and the skin behind the nose gear July 17, 2011, when the engine began to lose area,” the NTSB report said. The pilot and his power about 200 ft above the ocean. The pilot passenger were not hurt. “immediately advanced the throttle and turned Examination of the MU-2 revealed that the on the auxiliary fuel pump, with no results,” the bolt holding the downlock drag brace joint link NTSB report said. to the airframe was loose and had fractured The airplane sank after it was ditched, but when the nose gear was extended. The report the pilot and his three passengers, one of whom said that the nose gear rigging had not been was seriously injured on impact, clung to the adequately checked, as required, during the last separated cargo pod for about one hour until maintenance inspection of the airplane. they were rescued by the crew of a fishing boat. The passengers had not received a preflight briefing. “If a piece of wreckage had not been PISTON AIRPLANES available for the passengers to hold on to, the failure of the pilot to notify the passengers of the Mountain Shrouded by Clouds availability of life vests could have increased the Piper Navajo. Destroyed. Two fatalities. severity of the accident,” the report said. aving recently retired from airline opera- Examination of the recovered wreckage tions, the pilot departed from Welshpool showed that the fuel selector was positioned to H(Wales, U.K.) Airport the morning of Jan. the right tank, which held about 1 pint (1/4 L) of 18, 2012, to refamiliarize himself with the Na- fuel and 25 gal (95 L) of seawater. The left tank vajo in preparation to fly part-time in business held about 27 gal (102 L) of fuel and 2 gal (8 L) operations. VMC prevailed at the airport, but of seawater. The report said that the probable low broken clouds shrouded the tops of local cause of the accident was “the pilot’s improper mountains. fuel management, which resulted in a total loss Another pilot familiar with the aircraft and of engine power due to fuel starvation.” the area accompanied the pilot. They initially flew south for some distance and then returned Pressing Ahead in IMC to land. The pilot flew over the runway, estab- Piper Twin Comanche. Destroyed. Two fatalities. lished the aircraft on upwind, crosswind and he pilot had filed a composite visual/instru- then left downwind for Runway 22. He flew ment flight rules flight plan from Lucques, a wider-than-normal downwind leg, likely to TItaly, to Troyes, France, but, en route at provide clearance from a helicopter ahead on 2,000 ft the morning of June 17, 2011, he asked downwind, said the AAIB report. a controller at Nice Flight Information Service FLIGHTSAFETY.ORG | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 | 61 ONRECORD if he could transition to instrument flight rules pilots were seriously injured and the passenger earlier than planned. “The controller responded sustained minor injuries when the MD-600 that it was not possible to comply with this descended rapidly to the street. request,” said the report by the French Bureau The report concluded that “the accident d’Enquêtes et d’Analyses (BEA). occurred due to a sudden engine failure shortly The controller then asked the pilot to after takeoff caused by the ingestion of ice at navigate via two waypoints that took the Twin a height and with a speed not sufficient for Comanche north of the flight-planned route. autorotation.” The pilot complied with the request while con- tinuing under visual flight rules (VFR). Wire Strike Over Highway The aircraft was registered in England, and Hughes 369D. Substantial damage. No injuries. U.K. representatives who participated in the efore departing on a positioning flight from investigation commented that the controller’s Knoxville, Tennessee, U.S., the afternoon request did not comply with standard ATC Bof Dec. 21, 2011, the pilot determined that phraseology and might have been interpreted by VMC prevailed at Knoxville and at the destina- the pilot as an instrument flight rules clearance. tion, Blountville, also in Tennessee. About eight minutes after making the “However, while the pilot was following a request, the controller told the pilot that he had highway in cruise flight at 400 ft AGL, the ceiling lost radar contact with the aircraft. The pilot rapidly became lower, and the pilot encountered acknowledged the advisory about two minutes IMC,” the NTSB report said. “Moments later, before the Twin Comanche struck rising terrain while cruising at an airspeed of 65 kt, the pilot at 2,700 ft, killing the pilot and his passenger. saw marker balls, which indicated that power The BEA report concluded that “the accident lines were directly in front of the helicopter.” was due to the pilot’s decision to continue the The pilot began a right, diving turn in an flight under VFR in instrument meteorological attempt to avoid the power lines, but a main conditions [IMC] and at an altitude that was rotor blade struck a wire. “The rotor speed lower than the high ground in the region.” remained within limits, but the helicopter began to vibrate, so the pilot decided to land in a nearby field,” the report said. Examination of the HELICOPTERS helicopter revealed substantial damage to the rotor blade. Ice Ingestion Causes Flameout MD Helicopters MD-600N. Destroyed. Two serious injuries, Settling With Power one minor injury. Robinson R44. Destroyed. Two fatalities. he flight crew was inspecting the roofs of he pilot was circling at low altitude and wav- buildings in central Germany for snow dam- ing at people on the ground when the R44 Tage and landed the helicopter on a street in Tdescended and struck terrain near Center- Jena to board an employee of a building-supplies ville, Louisiana, U.S., the morning of Jan. 19, store the afternoon of Dec. 28, 2010. “Witnesses 2012. The pilot and his passenger were killed. observed a big snow cloud being raised by the “Examination of the airframe and engine re- helicopter and it hovering for a long period vealed no evidence of mechanical malfunctions of time above the snow cloud before it finally or failures that would have precluded normal landed,” said the BFU report. operation,” the NTSB report said. “Impact signa- During the subsequent lift-off, the helicop- tures were consistent with the engine develop- ter again raised a large amount of snow and ing power at impact, and it is likely that … the was transitioning to forward flight at about helicopter was in a steep descent consistent with 100 ft AGL when the engine flamed out. Both settling with power.” 62 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 ONRECORD Preliminary Reports, October–November 2012 Date Location Aircraft Type Aircraft Damage Injuries Oct. 7 St. John’s, Antigua and Barbuda Britten-Norman 2A-26 destroyed 3 fatal, 1 serious Thunderstorms were reported in the area when the Islander crashed on takeoff. Oct. 7 Khartoum, Sudan Antonov 12BP destroyed 13 fatal, 9 serious The An-12 crashed after two engines lost power on departure. Oct. 7 Medford, Oregon, U.S. Garlick UH-1H substantial 1 minor The helicopter crashed in a valley after the tail rotor gearbox separated during a firefighting mission. Oct. 9 Mount Pocono, Pennsylvania, U.S. Bell 407 destroyed 2 fatal, 1 serious The helicopter struck terrain in instrument meteorological conditions (IMC) during a business flight from Elmira to White Plains, New York. Oct. 14 Antalya, Turkey Boeing 737-800 substantial 2 serious, 25 minor, 162 none The captain ordered an emergency evacuation after a fire erupted on the flight deck during pushback. Oct. 19 Nifty Copper Mine, Western Australia Fokker 100 substantial The aircraft landed hard after encountering wind shear on approach. Oct. 19 Pontianak, Indonesia Boeing 737-400 substantial 160 none The nose landing gear collapsed when the 737 overran the runway while landing in heavy rain. Oct. 25 Yola, Nigeria Cessna 208B destroyed 6 NA Night IMC prevailed when the Caravan struck trees on approach. All six occupants were injured. Oct. 28 Bir Kalait, Chad Beech 1900D destroyed 17 NA The aircraft struck terrain short of the runway on approach. No fatalities were reported. Oct. 31 Boyne City, Michigan, U.S. Piaggio P180 substantial 1 none The Avanti veered off the runway after touchdown and struck the airport perimeter fence. Nov. 1 San Marcos, Texas, U.S. Cessna 320E destroyed 1 fatal Visibility was 1/2 mi (800 m) in fog when the airplane crashed on takeoff. Nov. 3 Atlanta, Georgia, U.S. Hughes OH-6A destroyed 2 fatal The police helicopter struck a power line and crashed on a road during a night search mission. Nov. 6 Curitiba, Brazil Piper Cheyenne IIXL destroyed 4 fatal The Cheyenne crashed in a field after control was lost on approach. Nov. 6 Wichita, Kansas, U.S. Cessna 208B substantial 1 fatal The Caravan crashed in a field on departure after the pilot reported that the windshield was covered with oil. Nov. 10 Shaver Lake, California, U.S. Cessna 421C destroyed 2 fatal The airplane was at 27,000 ft when it entered a rapid descent and broke up in flight. Nov. 11 São Paulo, Brazil Cessna 525B CJ3 destroyed 1 serious, 2 minor The airplane overran the runway, traveled down a slope and crashed into a stone wall. Nov. 15 Aweil, South Sudan Fokker 50 substantial 57 NA The left main landing gear collapsed and the left wing separated when the Fokker overran the runway. Nov. 17 Greenwood, South Carolina, U.S. Cessna 550 Citation II destroyed 2 none Collision with a deer on landing ruptured the left wing fuel tank. The pilots were able to exit the Citation before it was consumed by fire. Nov. 18 Snow Lake, Manitoba, Canada Cessna 208B destroyed 1 fatal, 7 serious The pilot was killed when the Caravan struck terrain while departing in adverse weather conditions. Nov. 21 San’a, Yemen Antonov 26 destroyed 10 fatal The An-26 crashed out of control in an abandoned marketplace shortly after the flight crew reported technical problems on departure. Nov. 21 Deputatskiy, Russia Antonov 26B-100 substantial 26 NA The An-26 veered off the runway on landing and struck a snowbank. Nov. 27 Moroni, Comoros Embraer 120ER destroyed 29 NA The flight crew ditched the Brasilia after reporting a fuel leak on departure. All the occupants were rescued. Nov. 30 Brazzaville, Congo Ilyushin 76T destroyed 32 fatal The six crewmembers and 26 people on the ground were killed when the cargo aircraft overran a wet runway, struck several dwellings and crashed in a ravine. 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. FLIGHTSAFETY.ORG | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 | 63 SMOKEFIREFUMES Selected Smoke, Fire and Fumes Events, August–September 2012 Date Flight Phase Airport Classification Subclassification Aircraft Operator Aug. 1 Descent — Air distribution system Smoke Embraer EMB-135LR American Eagle Airlines While the aircraft was on final approach, a flight attendant reported an odor of smoke in the galley. The circuit breakers in the galley were pulled. The flight crew declared an emergency and landed the aircraft without incident. The odor source was located in the galley trash can bin, but maintenance technicians could not determine what had caused the smoke odor. Aug. 3 Cruise New York (JFK) Air distribution fan Smoke Embraer ERJ-190 JetBlue Airways The flight from Washington Dulles to Boston Logan was diverted to JFK because of in-flight electrical smoke. Maintenance technicians found the odor emerging from recirculating fan vents in the cockpit. They removed and replaced the recirculating fan. Aug. 8 Climb — Cabin cooling system Smoke Embraer EMB-145LR Atlantic Southeast Airlines After takeoff, the crew reported smoke in the cabin and elected to return to the departure airport, where the aircraft was landed without incident. Upon inspection, maintenance found the source of the smoke to be a seized no. 1 air cycle machine. Maintenance replaced the air cycle machine. Aug. 11 Cruise Boston (BOS) Air distribution fan Smoke Boeing 767 US Airways The crew reported two occasions of smoke and fumes: a sweet, burning smell throughout the cabin shortly after takeoff, then strong electrical smoke about one hour into flight. The crew declared an emergency and diverted into BOS. The aircraft was landed without further incident. Maintenance replaced the right recirculation fan. The vendor’s repair shop findings included moderate contamination, bearings separated, bearings seized in the endbell, the rotor grooved and the endbell distorted. Aug. 18 Climb — Attitude gyro and Smoke Boeing 767 United Parcel Service indicating systerm The flight was turned back due to the captain’s attitude director indicator (ADI) becoming inoperative, with a popping and crackling heard, accompanied briefly by an electrical odor. Maintenance found the captain’s ADI circuit breaker tripped and replaced the ADI. Aug. 21 Climb — Cabin cooling system Smoke Airbus A319 Frontier Airlines The electronic centralized aircraft monitor (ECAM) indicated a no. 2 pack overheat during the climb through 11,000 ft on departure. A flight attendant reported smoke in the aft cabin, along with an odor that was notable but dissipating. The crew declared an emergency and turned back. During the landing rollout, the ECAM message reappeared, and the crew completed the indicated actions. Aug. 23 Cruise — Air distribution system Smoke Boeing 737 Southwest Airlines Smoke was detected in the passenger cabin and the aircraft was returned to the departure airport. Maintenance technicians removed and replaced the recirculation high efficiency particulate air (HEPA) filter. Aug. 25 Cruise — Air distribution system Smoke Embraer EMB-145LR Atlantic Southeast Airlines The crew reported an electrical smoke odor in flight. Maintenance inspected the aircraft and found the left avionics exhaust fan inoperative, with no other defects detected after ground runs. Sept. 3 Climb Philadelphia Air distribution fan Smoke, warning Boeing 757 US Airways (PHL) indication Fumes were detected in the cockpit as the aircraft was climbing through approximately 9,000 ft after takeoff. Five minutes later, the crew received an emergency engine-indicating and crew-alerting system (EICAS) message. The crew donned their oxygen masks and declared an emergency. The flight was returned to PHL and landed without further incident. Maintenance technicians replaced the equipment cooling fan. Sept. 5 Cruise Santa Cruz, Navigation system Smoke Boeing 757 American Airlines Bolivia (VVI) The crew reported smoke and odor in the cockpit and a high-altitude switch shorted. The flight was diverted to VVI and was landed without incident. The aircraft was removed from service. Maintenance technicians placarded the high-altitude switch according to the minimum equipment list. Sept. 8 Cruise — Cabin cooling system Smoke Embraer EMB-135KL American Eagle Airlines The crew reported a faint but persistent unusual odor in the cockpit and cabin. They declared an emergency and landed the aircraft without incident. The aircraft was removed from service. Maintenance technicians determined the odor in the cockpit and cabin to be rubber lubricant used on the sleeves of the no. 1 dual temperature control valve, which was removed and replaced. Sept. 16 Cruise Amarillo, Texas, Air traffic control Smoke Boeing 737 American Airlines U.S. (AMA) transponder system During flight, the crew reported smoke in the cockpit. An emergency was declared and the flight diverted to AMA, where it was landed without incident. The aircraft was removed from service. Maintenance technicians opened the air traffic control/traffic-alert and collision avoidance system panel and found a burned connection to the light panel. The panel was replaced. Sept. 17 Cruise — Air distribution fan Smoke Boeing 737 Continental Airlines The cabin crew reported visible smoke and a strong burning odor in the cabin. The odor spread from the aft galley to the cockpit but dissipated after the crew completed the procedures in the quick reference handbook. Maintenance technicians inspected the aircraft while performing engine runs and found the left recirculation fan circuit breaker popped and could not reset it. The fan was removed and replaced. Sept. 21 Cruise — Water/waste Smoke Bombardier Charter system wiring Canadair CL-600 While en route, a cabin attendant detected odor and saw smoke coming from the galley area. The captain asked the first officer to verify and help locate the source of the smoke. Once the location was determined, the captain had the cabin attendant pull all circuit breakers to the galley. The captain shut off all galley and cabin power, declared an emergency and landed the aircraft. Maintenance technicians found that the galley hot water heater had shorted, causing smoke. They disconnected the water heater, pulled and collared the hot water heater and galley power circuit breakers, inspected all surrounding wiring and determined that the aircraft was safe for a ferry flight. Source: Safety Operating Systems and Inflight Warning Systems 64 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | DECEMBER 2012–JANUARY 2013 © Chris Sorensen Photography contact us ightsafety.org Fax: +1703.739.6708 Tel.: +1703.739.6700 Alexandria, Virginia U.S. 22314-1774 801 N.Fairfax Street, Suite 400 Headquarters: FoundationFlight Safety CONVERSATION LEADING THE — astrong, e culture. globalsafety ective Membership intheFlight Foundation Safety isyour visiblecommitment to theaviation community’s core value each member. work Our isexempli ed inthefollowing areas: The Foundation that achieves challengingprojects make itsgoalsby undertaking aviation safer, thereby bene tting Individual membersrange from pilotsto accident investigators to regulators andbeyond. manufacturers, educational institutions, airports, non-pro t andgovernment companies. service organizations andsupport The Foundation membershipcomprises organizations from around theworld —aircarriers, businessaviation operators, umt n eiashl rudtewrd BARS– The Aviation Basic Standard Risk Globaltraining initiatives andseminarsheldaroundSummits theworld Humanitarianefforts Approach (ALAR) andLandingAccident Reduction for safetydata confidentiality Support Media outreach membership@ ightsafety.org Tel.: ext. 102 coordinatormembership services Ahlam Wahdan Member Enrollment for more than65years. 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