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Aerosafety World July 2009 AeroSafety WORLD HEMS FATAL MIDAIR Procedures not followed ADS-B DRAWS NEAR Investment needed for benefits ATR 72 FUEL EXHAUSTION Wrong gauge installed ANAFRONTS Cold, nasty surprises PILOT COGNITION CONSIDERING THE THINKING PROCESS THE JOURNAL OF FLIGHT SAFEty FOUNDATION JULY 2009 “Cessna is committed to providing the latest safety information to our customers, and that’s why we provide each new Citation owner with an FSF Aviation Department Tool Kit.” — Will Dirks, VP Flight Operations, Cessna Aircraft Co. afety tools developed through years of FSF aviation safety audits have been conveniently packaged for your flight crews and operations personnel. These tools should be on your minimum equipment list. The FSF Aviation Department Tool Kit is such a valuable resource that Cessna Aircraft Co. provides each new Citation owner with a copy. One look at the contents tells you why. Templates for flight operations, safety and emergency response manuals formatted for easy adaptation Sto your needs. Safety-management resources, including an SOPs template, CFIT risk assessment checklist and approach-and-landing risk awareness guidelines. Principles and guidelines for duty and rest schedul- ing based on NASA research. Additional bonus CDs include the Approach and Landing Accident Reduction Tool Kit; Waterproof Flight Operations (a guide to survival in water landings); Operator’sMEL Flight Safety Handbook; item Turbofan Engine Malfunction Recognition and Response; and Turboprop Engine Malfunction Recognition and Response. Here’s your all-in-one collection of flight safety tools — unbeatable value for cost. FSF member price: US$750 Nonmember price: US$1,000 Quantity discounts available! For more information, contact: Namratha Apparao, + 1 703 739-6700, ext. 101 e-mail: [email protected] PRESIDENT’sMESSAGE AUTOMATION Expectations o far, 2009 does not look like a great year treat engine failures? I think most of us started for safety. As we hit the halfway mark, the thinking about engine failures at an early stage world already has had as many airline ac- of our aviation consciousness. I remember be- cidents as the recent norm for a whole year. ing 15 years old, dreaming of the day I’d have a SIf things continue at this pace, we could have a handful of throttles and deal brilliantly with an year as bad as 1999, an accident spike. Of course, engine exploding at rotation. Even then I knew recent high-profile crashes of Airbus aircraft have the sequence of events, starting with “dead foot, thrown the debate about automation and envelope dead engine.” This sort of thing is just part of a protection into the spotlight. In the public forum, pilot’s DNA. The “trouble” is, engines just don’t that discussion gets boiled down to some overly quit much anymore. Most of us will retire without basic questions: Is automation good or bad? Is one being a party to an engine failure at any time, much manufacturer’s approach better than the other? less on takeoff. What every pilot will experience, Those are the wrong questions. however, is some sort of confusion regarding the First, it is impossible to turn back the hands of automation. Whether it is due to a system error time on the issue of flight deck automation. Cur- or a human error doesn’t matter. It is a threat that rent aircraft are highly automated, and the next has to be acknowledged and has to be managed generation of aircraft will be more so. I don’t think because it can take down an aircraft. this is bad. But I do think that we all have done a When a pilot flew a DC-6 or a Connie, the big- lousy job — or at least a superficial job — adapting gest worry was an engine failure on takeoff. Now to the reality of automation. Airplanes come with the biggest threat is the possibility of being handed nice checklists to deal with some problems that an aircraft with ambiguous indications, and maybe automation presents, but we generally have fallen a stick shaker in the middle of the night. It is time victim to the unconscious assumption that auto- for young pilots to go to bed thinking about that mation will not fail. Of course it fails. Sometimes threat, and to come up with the equivalent of “dead technicians don’t seat a circuit board properly. foot, dead engine” for that scenario. Just look at the Sometimes a sensor goes bad, like a pitot tube accidents lately; it is time to stop debating the role (maybe the case in the crash of Air France Flight of automation and really start to deal with it. 447) or a radar altimeter fails (certainly the case in the Turkish Airways accident in Amsterdam). Other times, pilots input the wrong weight (e.g., the Emirates tail strike in Melbourne, Australia) or even type in the wrong route. And when automation does fail to protect us, William R. Voss we appear to expect that other automated sys- President and CEO tems will step in to save the day. Is that how we Flight Safety Foundation WWW.FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JULY 2009 | 1 AeroSafetyWORLD contents July2009 Vol 4 Issue 7 features 13 FlightOps | Extreme Weather Makers 16 CoverStory | Thinking Things Through 13 22 SafetyOversight | Dangerous Goods 26 CausalFactors | ATR 72 Ditching 32 HelicopterSafety | Procedural Disregard 37 InfraStructure | Practical Necessity of ADS-B 42 AircraftRescue | In the Drink 16 departments 1 President’sMessage | Automation Expectations 5 EditorialPage | Failed Justice 6 AirMail | Letters From Our Readers 8 SafetyCalendar | Industry Events 22 9 InBrief | Safety News 2 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JULY 2009 ITALY Bari 37 Accident site Palermo SICILY 26 42 AeroSafetyWORLD telephone: +1 703.739.6700 47 DataLink | Route Causes William R. Voss, publisher, FSF president and CEO [email protected] 52 InfoScan | Erring on the Safe Side J.A. Donoghue, editor-in-chief, FSF director of publications 57 OnRecord | Bangs and Flames [email protected], ext. 116 Mark Lacagnina, senior editor [email protected], ext. 114 Wayne Rosenkrans, senior editor [email protected], ext. 115 Linda Werfelman, senior editor [email protected], ext. 122 Rick Darby, associate editor [email protected], ext. 113 Karen K. Ehrlich, web and print production coordinator [email protected], ext. 117 Ann L. Mullikin, art director and designer [email protected], ext. 120 Susan D. Reed, production specialist About the Cover [email protected], ext. 123 Thinking processes in the cockpit. © Chris Sorensen Photography Patricia Setze, librarian [email protected], ext. 103 We Encourage Reprints (For permissions, go to <www.flightsafety.org/asw_home.html>) Editorial Advisory Board Share Your Knowledge David North, EAB chairman, consultant If you have an article proposal, manuscript or technical paper that you believe would make a useful contribution to the ongoing dialogue about aviation safety, we will be glad to consider it. Send it to Director of Publications J.A. Donoghue, 601 Madison St., Suite 300, Alexandria, VA 22314-1756 USA or [email protected]. William R. Voss, president and CEO The publications staff reserves the right to edit all submissions for publication. Copyright must be transferred to the Foundation for a contribution to be published, and Flight Safety Foundation payment is made to the author upon publication. J.A. Donoghue, EAB executive secretary Sales Contacts Flight Safety Foundation Europe, Central USA, Latin America Asia Pacific, Western USA Joan Daly, [email protected], tel. +1.703.983.5907 Pat Walker, [email protected], tel. +1.415.387.7593 Steven J. Brown, senior vice president–operations Northeast USA and Canada Regional Advertising Manager National Business Aviation Association Tony Calamaro, [email protected], tel. +1.610.449.3490 Arlene Braithwaite, [email protected], tel. +1.410.772.0820 Barry Eccleston, president and CEO Subscriptions: Subscribe to AeroSafety World and become an individual member of Flight Safety Foundation. One year subscription for 12 issues Airbus North America includes postage and handling — US$350. Special Introductory Rate — $310. Single issues are available for $30 for members, $50 for nonmembers. For more information, please contact the membership department, Flight Safety Foundation, 601 Madison St., Suite 300, Alexandria, VA 22314-1756 USA, Don Phillips, freelance transportation +1 703.739.6700 or [email protected]. reporter AeroSafety World © Copyright 2009 by Flight Safety Foundation Inc. All rights reserved. ISSN 1934-4015 (print)/ ISSN 1937-0830 (digital). Published 12 times a year. Suggestions and opinions expressed in AeroSafety World are not necessarily endorsed by Flight Safety Foundation. Russell B. Rayman, M.D., executive director Nothing in these pages is intended to supersede operators’ or manufacturers’ policies, practices or requirements, or to supersede government regulations. Aerospace Medical Association WWW.FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JULY 2009 | 3 Serving Aviation Safety Interests for More Than 60 Years OFFICERS AND STAFF light Safety Foundation is an international membership organization dedicated to Chairman, the continuous improvement of aviation safety. Nonprofit and independent, the Board of Governors Amb. Edward W. Stimpson FFoundation was launched officially in 1947 in response to the aviation industry’s need President and CEO William R. Voss for a neutral clearinghouse to disseminate objective safety information, and for a credible General Counsel and knowledgeable body that would identify threats to safety, analyze
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