FACING THE ISSUES BARS Audits Pinpoint Weaknesses ADVANCING AWARENESS Updating AOA Displays GOING ROGUE The Intentional Crash Phenomenon
UNHEEDED WARNINGS ICE-INDUCED STALL DOWNS PHENOM
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FLIGHTSAFETY.ORG | AEROSAFETYWORLD | SEPTEMBER 2016 | 1 AeroSafetyWORLD
contents September 2016 Vol 11 Issue 7 features
12 CoverStory | Ice-Induced Stall Ends in Crash
18 RegionalSafety | Lessons From European Collaboration
24 AuditReview | BARS Pinpoints Operator Weaknesses
29 FlightTech | High Hopes for AOA Awareness
12 35 HumanFactors | No Pattern for Pilot Suicides 18 41 HumanFactors | Rogue Pilot–Intentional Crash departments
1 President’sMessage | Coming Soon
5 EditorialPage | Clamp Down
7 AirMail | Letters from Our Readers
8 SafetyCalendar | Industry Events
2 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | SEPTEMBER 2016 H
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P A 24 29 35
9 InBrief | Safety News
47 DataLink | Accidents, Fatalities Down in 2015
51 OnRecord | ‘In the Same Boat’ 41
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About the Cover The wreckage of an Embraer Phenom Frank Jackman, editor-in-chief, lies near a house that it struck in FSF vice president, communications Gaithersburg, Maryland, U.S. [email protected], ext. 116 © Jose Luis Magana | Associated Press Wayne Rosenkrans, senior editor [email protected], ext. 115
Linda Werfelman, senior editor We Encourage Reprints (For permissions, go to
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isk mitigation is necessarily a cooperative rogue producers and exporters. And flagrant activity. It takes stakeholders from across abuses of dangerous goods shipping regulations, the aviation industry doing their parts indi- which place aircraft and passenger safety at risk, vidually and in coordination with others to must be criminalized,” Tyler said. Rcreate the effective layers of mitigations that keep Other interested parties should take a cue from crews and passengers safe flight after flight, year IATA and the battery supply chain and pressure after year. Organizations outside of aviation have governments to take action against rogue battery an important role to play, too, and sometimes that manufacturers and shippers. According to IATA, role is to enforce standards and regulations that lack of enforcement is increasing pressure on air- already are on the books. lines and regulators to unilaterally ban all forms of Recently, the International Air Transport Asso- lithium battery shipments from aircraft, which, in ciation (IATA) and trade associations representing turn, could drive rogue manufacturers and ship- leaders of the lithium battery supply chain released pers to increasingly mislabel battery shipments. a joint statement demanding stricter enforcement The safe shipment of lithium batteries and of international regulations regarding the transport other dangerous goods requires transparency and of lithium batteries (see “Safety News,”4 p. 9). The adherence to the rules by manufacturers, shippers call for stricter enforcement of regulations was and all other involved stakeholders. Anything less aimed at ministers of trade, industry and trans- could jeopardize safety. port and directors of civil aviation in the world’s largest lithium battery manufacturing and export countries. According to IATA Director General and CEO Tony Tyler, the rules that airlines, shippers and manufacturers have worked to establish to ensure that lithium batteries can be carried safely are only effective if they are enforced and backed up Frank Jackman by significant penalties. “Government authorities Editor-in-Chief, ASW must step up and take responsibility for regulating Flight Safety Foundation
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | SEPTEMBER 2016 | 5 Serving Aviation Safety Interests for Nearly 70 Years OFFICERS AND STAFF Chairman ince 1947, Flight Safety Foundation has helped save lives around the world. The Board of Governors Kenneth J. Hylander Foundation is an international nonprofit organization whose sole purpose is to President and CEO Jon L. Beatty Sprovide impartial, independent, expert safety guidance and resources for the aviation General Counsel and aerospace industry. The Foundation is in a unique position to identify global safety and Secretary Kenneth P. Quinn, Esq. issues, set priorities and serve as a catalyst to address the issues through data collection Treasurer David J. Barger and information sharing, education, advocacy and communications. The Foundation’s effectiveness in bridging cultural and political differences in the common cause of safety FINANCE has earned worldwide respect. Today, membership includes more than 1,000 organizations Vice President, Finance Brett S. Eastham and individuals in 150 countries. Controller, GSIP Grants Administrator Ron Meyers
MEMBERSHIP AND BUSINESS DEVELOPMENT Vice President, Business Operations Susan M. Lausch MemberGuide Senior Manager of Flight Safety Foundation Events and Marketing Christopher Rochette 701 N. Fairfax St., Suite 250, Alexandria VA 22314-2058 USA Manager, Conferences tel +1 703.739.6700 fax +1 703.739.6708 flightsafety.org and Exhibits Namratha Apparao Member enrollment ext. 102 Membership Ahlam Wahdan, membership services coordinator [email protected] Services Coordinator Ahlam Wahdan Seminar registration ext. 101 Consultant, Caren Waddell Special Projects Namratha Apparao, manager, conferences and exhibits [email protected] Donations/Endowments ext. 112 Susan M. Lausch, vice president, business operations [email protected] COMMUNICATIONS Technical product orders ext. 101 Vice President, Communications Frank Jackman Namratha Apparao, manager, conferences and exhibits [email protected] Seminar proceedings ext. 101 Namratha Apparao, manager, conferences and exhibits [email protected] TECHNICAL Website ext. 116 Vice President, Frank Jackman, vice president, communications [email protected] Technical Mark Millam Basic Aviation Risk Standard David Anderson, BARS managing director [email protected] GLOBAL PROGRAMS BARS Program Office: 16/356 Collins Street, Melbourne, Victoria 3000 Australia Vice President, tel +61 1300.557.162 fax +61 1300.557.182 [email protected] Global Programs Greg Marshall
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facebook.com/flightsafetyfoundation Past President Capt. Kevin L. Hiatt @flightsafety Founder Jerome Lederer 1902–2004 www.linkedin.com/groups?gid=1804478
FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | SEPTEMBER 2016 AIRMAIL
Flight Simulation Training Devices [Manual of Criteria for the Qualification operators now to Responding to questions from AeroSafety World of Flight Simulation Training Devices, train their trainers. during editorial research and to the article Edition 3 and Edition 4] should not be The draft ICATEE “Brave New World” (ASW, 7-8/16, p. 29) about used as an indicator of implementation of Research and Technology Report flight simulation training devices, the U.S. UPRT, as its focus is simulator evalua- [by the International Committee for Federal Aviation Administration (FAA) sent the tion standards, not training standards. Aviation Training in Extended Enve- following statement. The FAA is pleased to see so many U.S. lopes] served as a useful foundation fter years of research and collabora- airlines that are both developing their for the development of FAA rules and tion with aviation industry experts, training programs and updating their full guidance. This draft was approved by Athe FAA published these new rules flight simulators before they are required the Royal Aeronautical Society for pub- and guidance. The FAA is further em- to do so. That is the best indicator. Before lication in 2014. Then, on reflection, phasizing the expectations of the regula- the required 2019 start of UPRT in the it was decided that it would be best to tions through the training of inspectors United States, the FAA has witnessed take advantage of what was learned and working directly with stakeholders wholesale changes in stall prevention with respect to UPRT in the creation as they develop their programs. Imple- training, which is important, as stall is of both Edition 4 of ICAO Doc 9625 mentation will be progressive from now the No. 1 cause of loss of control fatalities. and [U.S. Federal Aviation Regulations] until 2019, as the FAA has begun to eval- Those changes include better Part 60 [Flight Simulation Training uate simulators and training programs prevention strategies, recoveries from Device Qualification Standards for Ex- put forth by early adopters. FAA guid- stall warnings at cruise altitudes, and tended Envelope and Adverse Weather ance in the form of Advisory Circular the new focus on reducing the angle-of- Event Training Tasks]. Legally, it was (AC) 120-109A [“Stall Prevention and attack to recover from a stall warning. not possible to do that until the March Recovery Training”] and AC 120-111 Many U.S. airlines also perform upset 2016 publication of Part 60. Now it is [“Upset Prevention and Recovery Train- recovery training now from non-stalled possible to make those refinements to ing”] describe in detail the requirements conditions and are paying closer atten- the ICATEE document for consistency that are set forth in the FAA regulations tion to the challenges of delivering that prior to its publication. and the expectations for delivery of training. These are a couple of key ex- As research is ongoing on airplane stall and upset prevention and recovery amples of how the training is changing. state awareness and related technologi- training (UPRT). The regulations for The FAA will begin measuring mastery cal advances, it is too early to tell what 2019 require that instructors must be of the issues involved in loss of control value the results may have. The FAA satisfactorily trained to teach UPRT, and when the required training begins in is hopeful that the results can tangibly FAA guidance is explicit on what must 2019. As far as concern about sufficient reduce the loss of control accident rate be covered in that training. qualified UPRT instructors, the FAA even further beyond the full stall and Adoption of International Civil will remain vigilant, but it is encouraged upset training it is requiring in 2019. Aviation Organization [ICAO] Doc 9625 by the steps being taken by many of the U.S. Federal Aviation Administration
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | SEPTEMBER 2016 | 7 ➤ SAFETYCALENDAR
SEPTEMBER 7–8 ➤ Asia Pacific Aviation OCTOBER 11–13 ➤ Helitech International NOVEMBER 24–25 ➤ 5th annual Safety in Safety Seminar. Association of Asia Pacific Helicopter Expo and Conference. European African Aviation (SiAA) Conference. AviAssist. Airlines (AAPA). Tokyo. Helicopter Association. Amsterdam. Livingston, Zambia. <2gether4safety.org>.
8 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | SEPTEMBER 2016 Safety News INBRIEF Worker Shortage Presents Risks he “safe, secure and orderly expansion of international air She noted that ICAO’s Next Generation of Aviation Profes- transport” will be threatened over the next few years by sionals program is intended to bolster the number of skilled Tglobal shortages of skilled human resources and training aviation personnel. The program was begun after ICAO began capacity, Fang Liu, secretary general of the International Civil to emphasize its projections of pilot, controller and mainte- Aviation Organization (ICAO), says. nance staff shortages in 2009. In remarks before students at the Incheon Aviation Acad- “The aviation community needs to analyse future growth, emy in Seoul, South Korea, in mid-August, Liu said the need determine its specific needs and collaborate on identifying, for human resources development action is especially crucial in educating and retaining the next generation of skilled profes- the Asia-Pacific region. sionals who will help citizens and businesses benefit from the “The more than 100,000 daily flights now managed by air truly global connectivity which aviation provides,” Liu said. transport’s global network will surpass 200,000 in just the next “Determined collaboration amongst governments, industry, 14 years,” Liu said. “It is … critical that everyone in aviation, labour and educational organizations in the years ahead will from organizations like ICAO to airlines, airports and oth- be critical to ensuring that there will be enough qualified ers do everything possible to attract more young and talented candidates to keep our network running safely, securely and candidates.” efficiently.”
© Simon Hartshorne | iStockPhoto
Reporting Runway Conditions
ew standards are set to take effect Oct. 1 in the United States to reduce risks of runway overrun accidents and Nincidents associated with runway contamination. The U.S. Federal Aviation Administration (FAA) says the takeoff and landing performance assessment (TALPA) standards were developed by an aviation rulemaking committee formed in the aftermath of the Dec. 8, 2005, accident in which a Southwest Airlines Boeing 737 overran a snow-contaminated runway at Midway International Airport in Chicago and skidded into motor vehicle traffic on an off-airport street. A 6-year-old boy — a passenger in a car hit by the 737 — was killed.
The committee’s work resulted in a new method of commu- © Eurocontrol Gabriel Widyna | Wikimedia CC BY 2.0 nicating actual runway conditions to pilots of arriving aircraft “in terms that directly relate to the way a particular aircraft is what stopping performance to expect from their aircraft, the expected to perform,” the FAA said. “TALPA improves the way FAA said. the aviation community assesses runway conditions, based on The agency added that pilot reports of braking action contaminant type and depth, which provides an aircraft opera- will continue to be provided to flight crews. However, brak- tor with the effective information to anticipate airplane braking ing action currently characterized as “fair” will be described performance.” as “medium,” and reports of no braking action (NIL) will no The system calls for use of a standardized analysis longer be acceptable, the FAA said, noting that a NIL descrip- format to categorize runway conditions instead of the tion of braking action on a runway or other surface will result subjective judgments that have been used in the past. After in closure of that surface. After that surface is closed, it will not receiving the runway conditions report, flight crews or be reopened until the airport operator “is satisfied that the NIL dispatchers would consult manufacturer data to determine braking condition no longer exists,” the FAA said.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | SEPTEMBER 2016 | 9 INBRIEF
Cautions on Cataracts
ilots and aviation medical examiners should be more aware of the risks that cataracts may present to night vision, especially to night flight op- Perations, the U.S. National Transportation Safety Board (NTSB) says. In safety recommendations addressed to the U.S. Federal Aviation Ad- ministration (FAA) and the Aircraft Owners and Pilots Association (AOPA), the NTSB said that both the regulator and the pilots group should “develop and disseminate educational information” for pilots about a Dec. 26, 2013, general aviation accident in Fresno, California, U.S., and about “the risks cataracts may pose to flight safety.” The FAA should provide similar information for examiners, the NTSB recommended. © barabasa | Shutterstock The recommendations said that pilots diagnosed with cataracts should consult eye care professionals for further diagnosis and treatment options. The 2013 accident involved a Cessna 172K that struck a 62-ft (19-m) tall tree with its left wingtip and then crashed during a third attempt to land on a hazy, dark night in visual flight rules conditions, the NTSB said. The pilot and his passenger were killed. The NTSB’s final report on the accident said the pilot had been diagnosed with cataracts four years before the crash and cited as a causal factor the pilot’s “continued operation of the airplane at night with a diagnosed medical condition that degraded his night vision.”
Penalties Urged for Rogue Battery Shippers
rganizations representing airlines and lithium battery In letters to ministers of trade, industry and transport in suppliers are calling on governments around the world the world’s major lithium-battery–producing countries, the Oto crack down on shippers that violate regulations gov- signers said that lithium battery safety regulations must be erning air shipment of the batteries. enforced at the point of origin. The International Air Transport Association said that it “Safety is aviation’s top priority,” IATA Director General had been joined by The Global Shippers Forum, the Inter- and CEO Tony Tyler said. “Airlines, shippers and manufactur- national Air Cargo Association and lithium battery associa- ers have worked hard to establish rules that ensure lithium tions in drafting letters calling for stricter enforcement of batteries can be carried safely. But the rules are only effective international regulations on the transport of the batteries. The if they are enforced and backed up by significant penalties. associations included PRBA – The Rechargeable Battery As- Government authorities must step up and take responsibility sociation and RECHARGE, the Advanced Rechargeable and for regulating rogue producers and exporters.” Lithium Batteries Association. The letter called for cooperative enforcement initiatives among jurisdictions “to address situations where lithium batteries manufactured in one state are driven over a border to be flown from another state,” IATA said, adding that such actions should be penalized by “significant fines and custodial sentences.” IATA said that governments have repeatedly been asked to address risks associated with “the willful disregard of the in- ternational regulations by rogue manufacturers and shippers and to close existing legal loopholes that prevent prosecutions of serial offenders.” Weak enforcement of international regulations has led to increased pressure on airlines and regulators to ban all forms of lithium battery shipments by aircraft, the organizations said. “The actions of a minority threaten to undermine confi- dence in legitimate battery and product manufacturers,” said PRBA Executive Director George Kerchner. Peter D. Blair | U.S. Navy © OstapenkoOlena | Vectorstock
10 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | SEPTEMBER 2016 murat sarica
INBRIEF
Upgraded Rating for Indonesia
ndonesia has been granted a Category 1 safety standards rating by the U.S. Federal IAviation Administration (FAA), signify- ing that the country is in compliance with safety standards set by the International Civil Aviation Organization (ICAO). Indonesia previously held a Category 2 rating, which indicates either that a country lacks “laws or regulations neces- sary to oversee air carriers in accordance with minimum international standards, or [that] its civil aviation authority … [is] deficient in one or more areas, such as technical expertise, trained personnel, © Lightspring | Shutterstock record keeping or inspection procedures.” Indonesia was first assigned the Cate- New Rules on Fitness gory 2 rating in 2007; previously, from 1997 until 2007, it had a Category 1 rating. he European Aviation Safety Agency (EASA) has proposed new rules on The FAA said that the new Category pilot medical fitness, including provisions to include drug and alcohol 1 rating, issued under the FAA’s Interna- Tscreening and mental health assessments in initial and recurrent aero- tional Aviation Safety Assessment (IASA) medical examinations. program, was based on a March 2016 EASA published the proposed rules in August as part of its response to assessment of safety oversight provided by the crash in March 2015 of Germanwings Flight 9525 (see “No Clear Pat- the Indonesian Directorate General of Civil tern,” p. 35, and “The Rogue Pilot Phenomenon,” p. 41). Aviation. Other provisions call for improving the training and oversight of aero- The IASA program evaluates the civil medical examiners, and for all incomplete aeromedical assessments to be aviation authorities of countries whose air reported to authorities. carriers operate in the United States, have The proposals will be the basis of legislation to be presented later this applied to operate in the United States or year to the European Commission. participate in code-sharing arrangements Issuance of the proposals nearly coincided with EASA’s move to modify with U.S. airlines. The purpose is to ensure its recommendation, issued after the Germanwings crash, to have two that they comply with ICAO safety stan- crewmembers in the cockpit at all times. EASA Safety Information Bulletin dards, not FAA regulations. (SIB) 2016-09 now recommends that “first, a risk assessment is performed, With a Category 1 rating, and authori- and then, based on the results of the assessment, the operator may decide to zation from the FAA and the U.S. Depart- maintain the ‘two-persons-in-the-cockpit’ procedure as one possible mitigat- ment of Transportation, a country’s air ing measure.” carriers may fly to and from U.S. airports; The SIB says that when conducting the risk assessments, operators without it, their operations in the United should consider the psychological and security screening of the flight crew, States are limited. among other factors.
In Other News …
The U.S. Federal Aviation Administration says it is opening a new Air Transportation Center of Excellence for Technical Training and Human Performance to conduct research and development on technical training for air traffic controllers, aviation safety inspectors, engineers, pilots and technicians. Teams from the University of Oklahoma and Embry-Riddle Aeronautical University will lead the effort. … Transport Canada says it has begun a series of safety-related improvements at 13 regional airports across the country. Projects include rehabilitation of runways, taxiways and aprons; improvements in lighting and electrical systems; and purchase of aircraft rescue and fire fighting vehicles.
Compiled and edited by Linda Werfelman.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | SEPTEMBER 2016 | 11 COVERSTORY
BY MARK LACAGNINA
An ice-induced stall sent a Phenom hurtling into houses near the approach end of the runway.
ccording to the investigators, the warning Embraer EMB-500 Phenom 100 descended out of signs were there. Airframe icing was control and struck three houses near the ap- imminent, and the airplane needed to be proach end of the runway at Montgomery Coun- protected. But the warning signs were not ty Airpark in Gaithersburg, Maryland, U.S. Three Aheeded, and the protection was not provided. people in one of the houses were killed, as were Moreover, the airspeeds used by the pilot during the pilot and his two passengers. The airplane was the final stages of the nonprecision approach destroyed by the impact and post-impact fire. were too slow for the existing conditions. The accident occurred the morning of Dec. The subsequent ice-induced stall occurred 8, 2014. The investigation by the U.S. National at an altitude too low to permit recovery. The Transportation Safety Board (NTSB) concluded
12 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | SEPTEMBER 2016 COVERSTORY
that the probable cause was “the pilot’s conduct of directional control after touchdown.1 The of an approach in structural icing conditions single- turboprop climbed about 10 ft before without turning on the airplane’s wing and hor- descending in a left turn and striking trees. izontal stabilizer deice system, leading to ice ac- Damage was substantial, but the pilot, who was cumulation on those surfaces, and without using alone in the airplane, was not hurt. The NTSB the appropriate landing performance speeds for concluded that the probable cause of the acci- the weather conditions and airplane weight.” dent was “the pilot’s failure to maintain aircraft Based on the findings of the investigation, control while performing a go-around.” the NTSB called for the development of equip- After the 2010 accident, the pilot successfully ment for single-pilot jets that warns the pilots completed a certificate re-examination by the U.S. when the ice-protection systems should be Federal Aviation Administration (FAA) that com- activated. The safety board also recommended prised a one-hour oral examination and a one- the development of training beyond what is hour flight examination that included instrument currently required to pass a type rating check approaches, missed approaches and landings. ride in such airplanes. “FAA records also indicated that the pilot received an enforcement action for violating a Slow Progress temporary flight restriction on August 18, 2011,” The pilot, 66, was a physician and chief execu- the report said. tive officer of a clinical research company. He He had received training in the EMB-500 at held an airline transport pilot certificate and an two different facilities. “The company instruc- EMB-500 type rating, which he had received tor who initially conducted the pilot’s transition about seven months before the accident. training in the EMB-500 characterized the pilot The pilot had about 4,737 flight hours, includ- as highly motivated, very intelligent and pos- ing 136 hours in the EMB-500, 1,500 hours in sessing a strong aptitude for memorization,” the Socata TBM-700s and 60 hours in an Aero Vodo report said. chody L-39C, a former Czech fighter-trainer. “He stated, however, that the pilot had diffi- The NTSB accident report noted that the culty with planning and workload management, pilot had been involved in a previous accident and sometimes became ‘task saturated,’ freezing while landing a TBM-700 at Gaithersburg. up or fixating on a subtask at the expense of That accident occurred on March 1, 2010, other critical subtasks. He said that, as a result, © Jonathan Morgan|Airliners.net during an attempted go-around following loss the pilot’s training progress was slow.”
‘Significant Weaknesses’ The pilot had requested an abbreviated transi- tion training course in the EMB-500, but the instructor had convinced him that, based on his experience, a full course was required. “However, after the pilot completed the [full] course, the instructor did not believe that he met the required standards to obtain a type rating in the EMB-500 and advised the pilot to receive more training,” the report said. The pilot subsequently received 24 addition- al hours of flight instruction at another training facility before receiving his type rating. “Although his instructors said that he was
Photos: U.S. National Transportation Safety Board Transportation National U.S. Photos: proficient by the time he passed his check ride
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | SEPTEMBER 2016 | 13 COVERSTORY
and that all of the required special emphasis two passengers from Horace Williams Airport areas were addressed in some manner, evidence in Chapel Hill, North Carolina, to Gaithersburg from the flight before the accident flight — as for a business meeting. That morning, the pilot well as errors made by the pilot during the acci- called a line service facility at the Chapel Hill dent flight — revealed significant weaknesses in airport to advise that he would be departing at his capabilities,” the report said. 0930 local time. During the flight before the accident flight, The line service technician who helped the data captured by the pilot pull the Phenom from its hangar told inves- EMB-520 Airspeed Display airplane’s cockpit tigators that the pilot “was ‘in a bit of a hurry’ but voice and data record- did not appear to be careless,” the report said. er (CVDR) “showed However, other factors led investigators to that the pilot had conclude that “the pilot’s actions before takeoff 130 problems managing for the accident flight were consistent with non- 120 altitude during arriv- compliance with standard operating procedures.” 110 enotes . times the al,” the report said. Elapsed time from start of the first engine to speed for stic pusher The airplane initially takeoff was six minutes, “which left the pilot lit- activation 1000 flew over the airport tle time to perform the procedures for the Power 8 9 Mar s an airspeed t 5,400 ft above ground Up, Before Start, Engine Start (for the second faster than the onset of level (AGL), descend- engine) and After Engine Start checklists,” the 808 the aural stall warning ed to 1,000 ft AGL on report said. 70 an extended straight- CVDR data indicated that one item ne- Mar s the airspeed for in approach and then glected on the Before Takeoff checklist was an 60 the activation of the aural stall warning climbed to 1,500 AGL airplane-configuration check. The CVDR did 50 before descending to not record an aural annunciation of “takeoff the runway. OK,” which confirms that the flaps and pitch “The pilot also trim are set properly for takeoff, and the parking attempted to set flaps brake is not engaged. The annunciation is gener- 130 2 on final without ated when the pilot presses the “T/O CONFIG” enotes . times the lowering the gear button on the center console. 120 speed for stic pusher (which was out of se- 110 activation Mar s an airspeed t quence) and received Unheeded Warnings 100 faster than the onset of a ‘landing gear’ aural The airplane departed from Chapel Hill at about 0 the aural stall warning 808 9 warning as a result,” 0945 local time. CVDR data indicated that the 8 Mar s the airspeed for the report said. Phenom encountered instrument meteorologi- 80 the activation of the The report also cal conditions about 15 minutes after takeoff. aural stall warning 70 noted that the pilot’s The pilot manually activated the engine 60 records showed that anti-ice system, which routes bleed air to the he had flown the Phe- inlet cowls, and the wing and horizontal stabi- 50 nom only about seven lizer deice system, which comprises pneumatic hours in each of the boots on the leading edges. The systems were two months preceding deactivated about two minutes later and re- Notes: The top display shows stall-warning indications the accident. mained off for the duration of the flight. similar to what the accident pilot saw. The bottom display shows indications appropriate for icing conditions, which The airplane was cruising at Flight Level (FL) would have been presented if the ice-protection system had been activated. ‘Bit of a Hurry’ 230 (approximately 23,000 ft) when the pilot
Source: U.S. National Transportation Safety Board The accident flight received the Gaithersburg automated weather was intended to observing system (AWOS) broadcast, which indi- Figure 1 transport the pilot and cated that surface winds were from 070 degrees at
14 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | SEPTEMBER 2016 COVERSTORY
fix 11.3 nm (20.9 km) from the runway at 3,000 ft and cleared him to conduct the GPS approach. Shortly thereafter, a pilot on the ground at Gaithersburg used the com- mon traffic advisory frequency (CTAF) to ask the pilot if there was “any precip out there.” The pilot replied, “We’re kind of in and out of the clouds here at three thousand.”
Loss of Control The airplane was 5.5 nm (10.2 km) from the runway, with an indicated air- 2 kt, visibility was greater than 10 mi (16 weight less than the airplane’s actual speed of 140 kt, when the pilot selected km) and that there were a few clouds at weight,” the report said. approach flaps. Airspeed subsequently 2,300 ft and an overcast ceiling at 2,800 began to slowly decrease. ft. Temperature was minus 1 degree C ‘In and Out of Clouds’ The pilot told the right-seat passen- (30 degrees F) and the dew point was The pilot began the descent from FL ger, “Your job is to find the airport. Just minus 9 degrees C (16 degrees F). 230 at 1011. After establishing radio look straight ahead and say airport in The report said that the AWOS contact with Potomac Approach Con- sight.” Shortly thereafter, the passen- broadcast, as well as several pilot reports trol about 10 minutes later, he advised ger said “snow,” and the pilot replied, of structural icing, indicated that icing that he had the current weather obser- “Wow, there’s snow.” conditions could be expected during the vation at Gaithersburg. At 1040, the passenger told the descent and approach to Gaithersburg. The airport is uncontrolled and has pilot that he had the airport in sight. “Based on the AWOS-reported a single, 4,202-ft (1,281-m) runway. It The pilot confirmed the observation, weather conditions, the pilot should has one straight-in global positioning selected full flaps and announced on have performed the Descent checklist system (GPS) approach, a circling GPS the CTAF that the airplane was 3 nm (6 items that appeared in the Normal Icing approach and a VOR (VHF omnidirec- km) from the runway. Conditions checklist, which included tional radio) approach. At this point, airspeed was de- turning on the engine anti-ice and wing The pilot requested, and received, creasing below 115 kt as the autopilot and horizontal stabilizer deice systems,” clearance to conduct the straight-in increased pitch to maintain the GPS the report said. “That action, in turn, GPS approach to Runway 14. glide path. Airspeed had decreased would require the pilot to use landing Because of a temperature inversion, to 92 kt at 1041:33 when the pilot distance performance data that take into the airplane encountered colder air increased power, which momentarily account the deice system’s activation.” during the descent. Total air tem- arrested the deceleration. However, as The performance data called for the perature (TAT) was 12 degrees C (54 the pitch attitude and angle-of-attack use of a landing reference speed of 121 degrees F) above 6,000 ft but then de- (AOA) continued to increase, decelera- kt with the deice system activated and creased below 5 degrees C (41 degrees tion resumed. at the airplane’s landing weight. F).2 TAT remained below 5 degrees C “Because the deice system was not “CVDR data show that, before for the duration of the flight. activated by the pilot before landing, beginning the descent, the pilot set the Investigators determined that the the band indications (low speed aware-
landing reference (VREF) speed at 92 airplane encountered icing conditions ness) on the airspeed display did not knots, indicating that he used perfor- for at least 15 minutes during the de- appropriately indicate the stall warning mance data for operation with the wing scent and approach to Gaithersburg. speed,” the report said. and horizontal stabilizer deice system At 1031, the approach controller “There would have been sufficient
U.S. National Transportation Safety Board Safety Transportation National U.S. turned off and an airplane landing told the pilot to cross an intermediate warning of an aerodynamic stall had
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | SEPTEMBER 2016 | 15 COVERSTORY
Awareness and Training Based on the findings of the investigation, the NTSB recommended that the FAA and the General Aviation Manufacturers Association “work together to develop a system that can automatically alert pilots when the ice protec- tion systems should be activated on turbofan airplanes that require a type rating and are certified for single-pilot operations and flight in icing conditions.” “In a single-pilot operation, no additional crewmember is present to help detect an error of omission,” the report said. “Because pilots The NTSB the wing and horizontal stabilizer deice system who may have neglected to activate the ice pro- investigation led to been used during the approach.” tection systems per procedures would receive a recommendation The report explained that when the wing a reminder of the need to do so, the NTSB for better training and horizontal stabilizer deice system is acti- believes that the benefit of active alerting to in winter-weather vated, an aural stall warning is generated when support the safe operation of this group of operations for pilots AOA reaches 9.5 degrees, and the stick-pusher airplanes in icing conditions outweighs any po- of very light jets like activates at 15.5 degrees. When the deice system tential drawbacks related to pilot overreliance the EMB-500. is not selected, the stall warning horn sounds on such prompting.” at an AOA of 21 degrees, and the stick-pusher Citing ongoing work by the National activates at 28.4 degrees. Business Aviation Association to improve the The Phenom’s AOA reached 9.5 degrees safety of very-light-jet operations, the NTSB about 20 seconds before the pilot lost control of recommended that the association lead an effort the airplane. to develop “enhanced pilot training guidelines The airplane was still on autopilot at 840 ft pertaining to risk management in winter weath- (300 ft above field elevation) when it began to er operations, including the use of ice protection roll left and right. Airspeed was 88 kt and AOA systems and adherence to checklist, with special was 21 degrees when the stall warning sounded emphasis given to deficiencies in pilot perfor- and the autopilot disengaged at 1041:35. The mance identified in this accident, and make the aural stall warning continued, but there was no results of this effort available to the community indication that the stick-pusher activated. of pilots who fly these airplanes.”
“Once the airplane stalled, its altitude was This article is based on U.S. National Transportation too low to recover,” the report said, noting that Safety Board Accident Report NTSB/AAR-16/01, 300 to 500 ft of height typically is lost during a “Aerodynamic Stall and Loss of Control During stall recovery in the Phenom. Approach, Embraer EMB-500, N100EQ, Gaithersburg, Several large roll oscillations occurred Maryland, December 8, 2014.” The report is available at
approach end of the runway at 1041:55. 1. NTSB accident report ERA10CA155. Fire engulfed the airplane and one of the 2. Total air temperature, also called stagnation tem- houses. The three occupants of the house on perature and free stream air temperature, is warmer fire died of smoke inhalation; the pilot and his than outside air temperature due to compression two passengers sustained multiple fatal impact heating. TAT is shown on the pilot’s primary flight
U.S. National Transportation Safety Board Safety Transportation National U.S. injuries. display in the EMB-500.
16 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | SEPTEMBER 2016 ASW_sep16_p17.pdf 1 8/26/16 4:51 PM
Seeking A Few Good Ideas…
Now is the time for all those with great ideas for aviation safety presentations, panel, and interactive sessions to talk with us. Through Friday, September 16, Flight Safety Foundation is accepting Call for Papers submissions for two of its 2017 events:
SINGAPORE AVIATION SAFETY SEMINAR ndannualBusinessAviationSafetySummit
SASS2017 BASS2017 March 28–30, 2017 | Singapore Aviation Academy May–PhoenixArizona
Co-organized with the In partnership with the Singapore Aviation Academy National Business Aviation Association (NBAA) Singapore Sheraton Wild Horse Pass, Phoenix, Arizona, USA
Visit <flightsafety.org/aviation-safety-seminars> for details or contact owever else European nations knowledge with and to learn from the key risk areas to achieve prop- may or may not unite, their peers worldwide. erly coordinated safety efforts. … The collaboration in pursuit of civil The International Civil Aviation Or- region is an ‘atypical environment’ as aviation safety yields practices ganization’s (ICAO’s) Regional Aviation regards its regulatory framework (na- Hvaluable for non-Europeans to study. Safety Group–Europe (RASG-EUR) in tional, sub-regional and ICAO).”1 A review of representative documents 2015 described its safety environment Under the regional government by AeroSafety World found that on as follows: “The region is very complex structure, the European Aviation Safety the whole, the documents reflect with various regional safety–related Agency (EASA) has primary responsi- openness and candor about signifi- players, each compiling safety data and bility for guiding and coordinating risk cant challenges, successes and failures producing safety information from a mitigations by states. “Europe plays a — along with strong emphasis on different angle. … One of the main leading role as regards aviation safety,” professional obligations to share challenges, therefore, is to decide on the agency says in its current European EUROPEAN Tour BY WAYNE ROSENKRANS U.S. National Aeronautics Aeronautics National U.S. Administration and Space 18 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | SEPTEMBER 2016 border expertise. wealth ofcross- capitalize ona and safetynets just culture prioritization, Risk WWW.FLIGHTSAFETY.ORG | WORLD AEROSAFETY (SMS) into and initial continuing airworthiness, Plan for Aviation for Plan Safety, working with EASA member states to imple- 2020. “An increased emphasis put has been on using safety promotion oversight and focused tional issues are, for commercial air transport technology ontechnology board aircraft to mitigate risk the the principlesthe of safety management systems ment state safety programs (SSPs) as required resources exist needed. when helicopter operations, [key safety actions are to] prevention of and recovery from upset- scenari pilot training provisions in order to address the copter safety through safety promotion.” during go-around or climb; and introduce key elements of emphasis this are incorporating os; identify measuresos; identify to prevent loss of control of runway excursions,” EASA’s report said. “For by aeroplanes, [to] and review promote new by ICAO, and working with national aviation safety inEurope; and develop risk awareness strengthen requirements design for helicopter gearbox lubrication; improve offshore helicopter activities toactivities mitigate safety risks.” and training material improve to further heli- authorities (NAAs) that so adequate human “The key safety actions to“The address opera - Regarding region’s the systemic issues, the | SEPTEMBER 2016 which covers which 2016– 2 ‘new’ business models and to related identify safety (long-term) leasing.” included also They better vided by non-certified service providers by service andvided non-certified within an individual operator, [such as] increased when authoritieswhen with such deal operators or EU-wide occurrence-reportingEU-wide data an so air unmanned aircraft systems and by other terms); to commercial air transport that could from arise tors has increased. …Upon request the of member tion industry, number the of interfaces between through state’s the oversight processes. model used by used model an airline generates safety risks mobility pro of pilots,- safety-critical services management systems “capture hazards new that remotely piloted aircraft systems known (also as risks posed to aviation the risks posed system,” report the said. nizing European Union governing (EU)rules not adequately anticipated —or unknowable — people certified by national the people certified aviation authority line’s safety culture benchmarked, can- be periodi cally surveying a network surveying analystscally of expert about of cooperation and sharing that practices so best organisations, and regula - contracted their services of another member state, aircraft the operator’s breaches of computer harmo- network security; safety issues, including overcoming safety threats states, [EASA] tasked aworking group of national aviation authorities to assess airlines’ emerging and determining ifany or new emerging business are introduced by different employment models new concerns,new among and building expertise “Due to increased complexity the of avia the - The working group recommended forms new Corresponding priorities apply to emerging safety professionals to anticipate, recognize REGIONALSAFETY - | 19 © Katerina_Andronchik | iStockphoto REGIONALSAFETY and mitigate business model–induced of control on the ground, collisions risks, including those involving the with obstacles, and runway under- airline’s safety-related governance and shoots and overshoots); controlled financial situation. flight into terrain (CFIT); and loss of control–in flight (LOC-I). Deciding Relative Risks “In 2015, a complete review of the EASA’s prioritization of highest risk ar- [previous plans’] actions was per- eas in commercial air transport is based formed with a view to aligning the on 2004–2013 fatal accidents, nonfatal various programming activities,” the ikimedia CC-BY-SA 2.0 ikimedia CC-BY-SA W accidents and serious incidents. This report said. Most recently, for example, | article cites a select few examples from EASA began treating aircraft tracking, all the challenges and responses covered aircraft rescue and fire fighting, and in the report. accident investigation as key systemic “The main objective of [the European issues — often deficiencies in orga- — CDG © Eric Salard Plan for Aviation Safety] is to create a nizational processes and procedures common focus on European aviation with a significant effect on an event’s about the short-term future. … This safety issues as a continuation of the outcome — being considered within [emergent issue] area gives some con- European work to increase aviation the context of accident/incident causa- sideration to safety issues derived from safety and to comply with ICAO stan- tion. Also new is the treatment of key operations or regulations that have not dards,” the report said. “This approach operational issues of the commercial been fully deployed and where data [are] improves traceability and reinforces air transport–fixed wing sector with not always available,” the plan said. commitment to the current initiatives specific consideration of how design Through ICAO’s Universal Safety while contributing to avoiding duplica- and maintenance improvements can Oversight Audit Program Continuous tion, overlapping of safety initiatives and be applied to prevent technical failures, Monitoring Approach, and its own work, competition for resources. While some and with extra attention to risk mitiga- EASA recognizes significant variations safety issues stay at [the] national level tion in ground operations. among member states in levels of effec- and are addressed within the [SSP of a “Ground safety includes both ground tive implementation of ICAO oversight country] alone, there are other instances collisions and ground handling. … standards, often because of variation in where common issues of pan-European Ground handling occurrences are the NAA resources. As a result, one part of scope require a collective action.” fourth most frequent risk area for fatal the plan advocates cross-border sharing accidents,” the report said. “The safety ac- of resources by methods such as pro- Aligning With ICAO tions related to ground safety are aimed moting “the concept of ‘pooling’ avail- Although ICAO’s Global Aviation Safety at bringing improvements in the follow- able expertise among NAAs in order to Plan influences oversight objectives in ing areas: incorporation of weight and make subject matter experts available, in 2017–2019 for national aviation author- balance measuring systems and ground a cost-effective way, to those states that ities throughout Europe, each state’s contamination of aircraft systems.” need resources,” the report said. priorities — for scheduled commercial The proactive aspect of the plan fo- “The [plan’s] safety actions related to air transport operations especially cuses on ways to anticipate and identify safety management are aimed at intro- — are tied closely to analyses done emerging issues. The first is concentra- ducing safety management requirements within the region, according to EASA. tion on airlines’ use of new business in the domains of initial and continu- Therefore, the plan does address Eu- models, as noted, and another involves ing airworthiness, ensuring a common rope’s efforts on the ICAO-designated explicit reminders to examine human understanding at the international high-risk areas of runway safety events factors and human performance in an level, working with member states to (including abnormal runway contact, integrated manner as part of every EASA implement the SSPs, and enabling the bird strikes, ground collisions, damage risk-mitigation initiative. “The safety usage of flight data monitoring (FDM) during ground handling, runway excur- data we can collect tells us about the past programmes to identify safety risks and sions, runway incursions, aircraft loss and it can be used to make predictions take action in a predictive manner.” 20 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | SEPTEMBER 2016 REGIONALSAFETY committee — noting that “the main purpose is to include in the European provisions elements from ICAO Doc 9625 [Manual of Criteria for the Qualifi- cation of Flight Simulators, Edition 4, Volume I – Aeroplanes] for the use of [flight simulation training devices] in flight training. … Harmonisation with the U.S. Federal Aviation Administra- tion (FAA) should be considered.” In one part of EASA’s plan regard- ing UPRT, the report said, “The overall goal is to mitigate the safety risk (for Paris Charles de Gaulle Airport large aeroplanes) of loss of control or loss of the flight path of the aircraft Assisting Non-Europeans establishment of a new European risk during the go-around or climb phases Consideration of how European classification for effective comparison of executed from a low-speed configu- practices may benefit other regions is events across the industry, and intro- ration and close to the ground. The explicit in some parts of the plan. For duction of performance indicators to second objective is to prevent an example, SMS implementation objec- continuously measure and verify ATM excessive nose-up trim condition when tives within air traffic management safety performance by ANSPs. transitioning from a low-speed phase (ATM) and air navigation service In the commercial air transport– of flight to go-around or climb when providers (ANSPs) are considered both fixed wing sector, the plan asked airlines high level of thrust is applied. This may an internal and external matter. in 2016 to devote special attention within be achieved by different means, such as “[Objectives include] support to their FDM programs to precursors of increasing the flight crew awareness of ANSP SMS implementation, [especially] LOC-I and CFIT, and assigned to EASA the low speed/excessive nose-up trim outside the EU; a structured approach the task of establishing “good practices condition, or incorporating active sys- to the identification of safety key risk [in] enhancing the practical implemen- tems preventing an unusual configura- areas and to gathering information tation of operators’ FDM programmes” tion (low speed/excessive nose-up trim on operational safety and SMS best including integration with their other condition) from developing.” practices from the industry; harmonise processes. “Member states should set up As part of encouraging all mem- SMS approaches in functional airspace a regular dialogue with their national air- ber states to incorporate LOC-I risk blocks [and] develop and promote SMS craft operators on [FDM] programmes mitigation into their SSPs, EASA will guidance and best practices for air traffic [in the framework of just culture],” the supplement ICAO’s complete regula- management,” the report said. report said, encouraging airlines to tory package on UPRT with relevant The plan calls for EASA, in 2016, to conduct analyses that also will help safety promotion material to help states help member states share knowledge to to prevent runway excursions, midair inform and influence their airlines and overcome any operator’s inexperience collisions and other high-priority issues the approved training organizations using FDM-based risk indicators, and described in their home country’s SSP. from the European perspective. for EASA itself to “further assess, to- “On average, there are three fatal gether with member states, the benefits Loss of Control accidents every year related to LOC-I of FDM-based indicators for addressing Regarding airplane upset prevention worldwide and one every second year national safety priorities.” This is com- and recovery training (UPRT), the involving an EASA member state opera- plemented by regionwide distribution of plan commits to adapting the exten- tor,” the report said. “Loss of control in accident summaries with key findings sive standards and recommendations flight shall be addressed by the member and lessons learned. Complementing from ICAO — which originated in part states on their SSPs. This will include, as this effort in 2017 will be mandatory with and were driven by a European a minimum, agreeing on a set of actions WWW.FLIGHTSAFETY.ORG | AEROSAFETYWORLD | SEPTEMBER 2016 | 21 REGIONALSAFETY and measuring their effectiveness.” The plan also highlights the importance of mitigating the effects of startle. Beyond pilot training, EASA’s plan presents relevant LOC-I risk mitiga- tions related to less-often mentioned causal factors. “Erroneous weight or centre of gravity have been identi- fied as a potential safety issue leading to LOC‑I accidents. The [plan’s] task is to perform a survey of approval processes for the use of the electronic flight bags with a focus on applications for performance calculations including weight and balance, and to identify best practices,” the report said. crew when tire pressure is abnormal or deployment of ground-based ATM Equipment Design and Maintenance out of tolerance. safety nets with “high-level specifica- Regarding the plan’s focus on im- tions complemented by safety promo- proved designs for aircraft equipment, Safety Nets tion material for system safety defences EASA said the objective is limiting the Regarding the safety nets mentioned (short-term conflict alert, approach probability of equipment-related and in EASA’s report, Eurocontrol has said, path monitoring and area proximity maintenance-related causal factors in “The implementation of safety nets is warning).” unsafe events. “Technical failure is the mandated by four objectives contained Increasing the effectiveness and most frequent cause of accidents and in the [Single European Sky ATM expanding the deployment of airborne serious incidents in Europe,” the report Research (SESAR) program] documents. safety nets also is covered. “Prepare said. “Excluding post-crash fires, it is … Not only are safety nets inherently studies to further evolve airborne safety also the second highest cause of fatal complex, they also have to operate in an nets [traffic alert and collision avoid- accidents. The safety actions related to increasingly complex environment. This ance system (TCAS), and terrain aware- design and maintenance are aimed at calls for sustained effort to optimise and ness and warning system],” the report bringing improvements in the follow- improve safety nets. New technological said in one objective. “These studies ing areas: assessment and coordination developments need to be exploited. will collect information on the current of the responsibilities of maintenance “Ground-based safety nets are an performance of safety nets and forecast organisations, protection of occupants integral part of the ATM system. Using their performance for possible future on board large aeroplanes through primarily [air traffic services’] surveil- operational environment. In addition, improved seat crashworthiness, engine lance data, they provide warning times [these] studies will assess the perfor- bird ingestion, aeroplane-level safety of up to two minutes. Upon receiving an mance implications of the envisaged assessments, tyre inflation pressures alert, air traffic controllers are expected changes to the safety nets.” remaining within specifications, as well to immediately assess the situation as the process to review the airworthi- and take appropriate action. Airborne Notes ness status of the aircraft.” safety nets provide alerts and resolution 1. RASG-EUR. 2014 Safety Report. First Edi- For example, the plan has identified advisories directly to the pilots. Warning tion, August 2015. the need for not only adequate legal times are generally shorter, up to 40 sec- 2. EASA. European Plan for Aviation Safety obligations for each state to properly onds. Pilots are expected to immediately 2016–2020. Final, Jan. 25, 2016. 3 conduct tire pressure checks but also take appropriate avoiding action.” 3. Eurocontrol. HindSight 22. Special issue to include tire pressure monitoring Part of EASA’s plan is to pro- on safety nets in air traffic management. © NATS Holdings © NATS systems that reliably alert the flight mote and support the Europe-wide Winter 2015. 22 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | SEPTEMBER 2016 ZAS ASW Ad Sept 2016.pdf 1 8/10/2016 1:39:21 PM C M Y CM MY CY CMY K AUDITREVIEW perational audits show that some contracted aviation operations in the (also called remotely piloted aerial aircraft operators are having mining and resource sector. It has since systems or drones) and aerial muster- continuing difficulty in tracking expanded to include aviation opera- ing of livestock; 400 audits have been the recent experience and the tions in humanitarian, government and completed. Oduty and rest limits of their pilots, as insurance organizations. Between November 2010 and well as conducting risk assessments for The April BARS Finding Data November 2015, BARS audits identi- new routes or new operations. Analysis Report1 notes that the Program fied 9,219 non-conformances out of a These and other weaknesses are now includes member organizations total of 118,870 audit issue questions detailed in a data analysis report from in 30 countries on six continents. The examined in 361 audits. Some 990 non- Flight Safety Foundation’s Basic Avia- basic audit protocol has been revised conformances were not analyzed for tion Risk Standard (BARS) Program, six times, and new BAR standards have the report because of structural changes which was implemented in 2010 in been developed for offshore helicopter in the program that made meaningful Australia to address safety issues facing operations, unmanned aircraft systems comparisons impossible. Information BARS auditors probe aircraft operators’ weaknesses. BY LINDA WERFELMAN 24 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | SEPTEMBER 2016 © vectorarts|iStockphoto a second finding against control.” this ence to procedure was root the cause of lacktwo of cases, oversight or adher regulatoryof authority. local the …In line with minimum the requirements crew were checked being annually, in among nine BARS regions. 21 operators were distributed evenly undergo two checks flight ayear. The regulations” bydefined local and must checkedbe annually “to astandard other things, that crewmembers must check and training, say, which among with requirements for crew flight tors were found innon-conformance supported by more robust procedures.” conformance, and were [these] later robustly enough to ensure ongoing that solution the …was not managed alater infivefinding, cases, audit found tions were implemented to out close the pilots,” report the said. “Where solu- recency, that especially of contract issues inavailable facilities to track report the said.central Africa, and 25percent were from western and were from southern and eastern Africa, ence; of 33operators, the 57percent tracking pilots’ their recent- experi flight percent of audit issue questions. percent of non-conformances, all and 8.1 issues1). These accounted for just 4.9 regulatory or contractual breach” (Figure would indicate “a potential safety, legal, issues that, by ifneglected operator, the “P1” priority as high issues —described greatestthe rate of conformance involved Analysis of audit the data showed that ‘A Potential …Breach’ audit participants was deidentified. reportin the associated with individual FLIGHTSAFETY.ORG “Most often,” report the said, “flight audits, initial On their 21opera- issues incompliance“The included operatorsThirty-three had difficulty Three P1issues out. stood | WORLD AEROSAFETY | SEPTEMBER 2016 - having atablet [computer] with which as can stark respect this be as each pilot difference regions the between “The in robust solution,” document the added. developed or managed to provide a instituted were as afix not well enough made on later audits systems the when report said. able systems available, or inuse,” the involveddifficulty a“lack of suit- authority.” stringent regulatory than local the BARS limits “may more well be or less time, report the said, noting that the requirement to crew track flight flight not inconformance with BARS the from regions two the Africa —were report added. a third for time same the operator, the The issued finding has for never been Figure 1 Source: BasicAviation Standard Risk Program BAR Standard requirementsP3 =Non–safety-critical ofthe significant importance” Standard, oraviation bestpractices “of P2 =Requirements derived from theBAR contractual breach” and “a potential safety, legal, or regulatory would indicate asignificant non-conformance issuesthat, ifneglected, P1 =High-priority by Priority andFindings,Questions “A number of repeat findings were The reasons for operators’ the Eighteen operators —89percent 7.5% 3.8% Questions Findings 4.9% P3 P2 P1 8.1% 87.6% 88.1% audit issue questions. non-conformances and 3.8percent of accountedwhich for 7.5percent of ofbecause equipment limitations” — to comply maywhich difficult be with safety-critical requirements, some of with “P3” as “non– issues —described percent of audit issue questions, and percent of non-conformances and 88.1 portance” accounted —which for 87.6 aviation practice of best significant im- drawn from BAR the Standard, or an as “a BARS Program requirement as sociated with “P2” issues —described ofods communicating data.” their remote devoid bases of reliable- meth for organization, the leaving pilots at there only being one computer available spoke [customized] software system, to can updatethey and flight duty- to abe — involved failure targets to set or non-conformance —cited 72times (Figure 3,p. 26).The most frequent tors resulted in681non-conformances showed that 189audits of 104opera- safety management systems (SMS) A breakdown of findings related to Systems Management Safety were excluded from comparison.) this lowtoo to ensure anonymity, they so but number the of participants has been have undergone and audits, sixth fifth as yet undetermined.” (Some operators regions],African factors the of are which South Pacific] and an uptick [two inthe finding numbers in[Australia and the report said, is aplateau “There inoverall next (Figure 2,p. 26).Nevertheless, the audit of an individual operator to the declining number of findings from one were examined; general the trend was a least four audits, results of first four the Of operators that had undergone at Fewer Findings Other, issues less critical were as- AUDITREVIEW | 25 AUDITREVIEW in 2012, 44 BARS OHO audits have Average Number of Non-Conformance Findings, by Region been conducted for 22 operators 70 in 11 countries. Some 1,294 non- conformances have been issued, includ- 60 1st audit 2nd audit 3rd audit 4th audit ing 256 “within the specific operational 50 category of offshore operations.” The audit area most frequently cited 40 involved emergency response plans 30 (ERPs), especially two audit issue ques- tions that require the operator to “con- Average number of Average 20 sider worst-case scenarios in its ERP non-conformances per question non-conformances 10 drills — specifically that they should 0 cover helicopter ditching at last-light ASP EUR NAC SAM SEA and WCA in adverse weather with increased time Region of missing aircraft location.” Half of all ASP = Australia and South Pacific; EUR = Europe; NAC = North and Central America; BARS OHO organizations audited were SAM = South America; SEA = Southern and Eastern Africa; WCA = Western and Central Africa cited for non-conformance with that Source: Basic Aviation Risk Standard Program standard, the report said. Figure 2 “Of the 11 organizations subject to this finding, six … did not pres- Non-Conformance Findings on SMS Elements ent evidence of having conducted any ERP drills and five did conduct drills, 100 90 Average number of though not with the rigour demanded ndings per question AOs a ected 80 by the standard,” the report said. “The 70 root causes tendered by the operators 60 basically fell into two camps, one that 50 40 documented procedures simply did 30 not exist, or alternatively, that the BAR 20 Standard exceeded existing regulatory 10 Number of non-conformances 0 or contractual requirements.” Safety policy Risk management Safety assurance Safety promotion Repetitive Findings AO = aircraft operator SMS = safety management systems Source: Basic Aviation Risk Standard Program A separate but related analysis ex- amined “repetitive findings” — non- Figure 3 conformances that were identified not only in a current audit but also in a pre- performance metrics for safety, an item Smaller totals of non-conformances vious audit of the same operator — and that was grouped in the audit’s “safety were cited in three other audit areas: found that many of the findings most assurance” area, which overall drew safety policy, safety risk management likely to be cited repeatedly were in 443 non-conformances, more than any and safety promotion. audit areas where BARS requirements other area. “exceed local regulatory requirements, “The identification and setting of Offshore Helicopter Operations and implementation evidence is not metrics with which to measure safety As part of the analysis of audit findings available at finding closure, ordinarily performance was troublesome for a involving the BARS Program designed with the corrective action addressing number of [operators],” the report said, specifically for offshore helicopter op- only documentation.” adding that the absence of metrics also erations (BARS OHO), the report said These repetitive findings were most complicated auditors’ work. that, since BARS OHO was introduced likely “within an [operator] whose 26 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | SEPTEMBER 2016 AUDITREVIEW internal procedures are not robust insufficiently robust procedures, such implementation was neglected, so we enough to ensure ongoing conformity, as temporary documents that “go adrift see an increase in ‘lack of adherence or in an [operator] with poor control or do not find their way into proce- to published policy or procedure,’ ‘lack and oversight over their external service dure.” This causal factor was cited in 25 of specified training or education’ and providers,” the separate BARS Repetitive of the repetitive findings. ‘lack of oversight’ in subsequent audits.” Findings Analysis Report said.2 The other common causal factors Operators sometimes incorrectly Analysts began this task by review- included that “the previous corrective identify the root causes of non- ing 8,495 P1 and P2 findings from audits action only addressed the documenta- conformances, the report said, adding that were conducted from November tion and no implementation correction that in case of eagerness to close the 2010 through December 2014, ultimate- was carried out,” cited in 19 repetitions; finding, “an easy root cause fix may ly identifying 213 separate issues that “ambiguous or incomplete evidence be proffered” and that if an operator yielded a total of 473 repetitions. They presented and accepted in order to is sensitive to criticism, “a root cause then focused on the top 10 issues that close the corrective action,” cited in palatable to the organization will be resulted in the most repetitive findings. 18 repetitions; and “disturbances in produced.” Often, if a drop-down These 10 issues represented 5 percent of [operator] continuous improvement menu in an online program allowed all issues that resulted in repetitive find- processes, i.e., interfaces between per- the operator to identify a root cause, ings; the repetitive findings associated sonnel or departments are not defined,” “findings which were later repeated with these 10 issues accounted for 25 cited in 15 repetitions. were three times more likely to [prompt percent of all repetitive findings. the operator to respond by saying that] At the top of the list was an audit Corrective Actions the … ‘BARS requirements exceed that issue question that said, “The appointed After BARS audit findings are issued, of local regulatory requirements,’” the maintenance organization(s) should en- operators are expected to take correc- report said. “None of the later repeated sure that the initial and then recurrent tive action to resolve the issues and findings has a thought-out [root cause training for maintenance personnel close each finding, but an auditor’s analysis].” includes human factors for mainte- ability to check on the corrective action The report concluded by noting that nance elements.” The data showed that taken (CAT) can be difficult because the BARS Program Office is commit- auditors had documented 21 instances the auditor likely has moved on to ted to strengthening both the BARS of repetitive findings. another, unrelated audit, with limited Program and the auditing process, in The remaining issues on the top 10 time available for reviewing CATs, the part through eliminating unnecessary list included scheduling of ERP drills; report said, adding, “Where time pres- repetitive findings. ensuring that maintenance organizations sure and difficulties in communication “There will be cases where a repeti- have programs for initial maintenance exist, the variability of the output of tive finding has a legitimate cause,” the training, as well as recurrent training, to checking CATs increases.” report said. “However, good auditing be conducted at least every 36 months; The issues associated with the practices, adequate preparation and and ensuring that, when passenger greatest numbers of repetitive findings robust effort on the part of the [aircraft operations are involved, the number and are also issues that may be difficult operator] in providing a thorough cor- weight of baggage items are recorded on to resolve quickly, and in some cases, rective action will reduce the number of a manifest for each flight. corrective actions may be decided events experienced in the program.” upon but their implementation may be Causal Factors delayed, the report said. Notes After further review of the top 10 is- “As implementation is far off, 1. Ayre, Peter. BARS Finding Data Analysis sues, analysts identified the most com- documented procedures and/or Report, No. 3. Melbourne, Australia: Flight mon causal factors, which accounted schedules are accepted [by the audi- Safety Foundation, April 2016. for 80 percent of the detected issues, tor] as conforming for the purposes of 2. Bisciotti, Eduardo; Ayre, Peter. BARS the report said. closing the finding,” the report added. Repetitive Findings Analysis Report, No. At the top of the causal fac- “At the next audit, the documents pass 1. Melbourne, Australia: Flight Safety tors list were issues associated with [as actual implementation], though Foundation, April 2016. FLIGHTSAFETY.ORG | AEROSAFETYWORLD | SEPTEMBER 2016 | 27 Powerful new insights gained Teledyne Controls is helping to from aircraft data are fueling power the global aircraft industry: greater efficiencies and Technology leadership: With over 50 years’ experience and a history 1.310.765.3600 reducing costs. This is the of firsts, we are revolutionizing teledynecontrols.com power of data at work. aircraft data management. New functionality: Creative data usage is driving new benefits for companies and passengers alike. Responsive relationships: Around the globe, we work side by side with customers in support of their vision. Unlimited Visibility. FLIGHTTECH H C A O R P P A Advances in visual and aural cues and warnings target wing angle-of-attack and energy state awareness. hile airplane upset prevention and of large commercial jets, and AOA management ROSENKRANS BY WAYNE recovery training (UPRT) continues using them should be demonstrated. Airline pilots’ to be implemented by airlines (ASW airplane-specific systems knowledge is expected 7–8/16, p. 29) over the next few to include “understanding of AOA indicators (if Wyears, complementary strategies call for tech- installed) or interpretation of other representations nologically enhanced applications of angle-of- of AOA such as [‘barber pole’ on speed tape, pitch attack (AOA) data and energy state alerting. limit indicator [PLI] and flight path symbology Discrete AOA displays in military aircraft relative to pitch attitude on a head-up display] that cockpits have long been standard, but equivalent can assist in stall prevention.”1 civilian technology has been characterized as an LOC-I accidents continue to influence option for large commercial jets since the 1990s AOA discourse worldwide. In April, for ex- — influenced then, as now, by desire to mitigate ample, while looking back on AOA-awareness risks of loss of control–in flight (LOC-I) to the issues identified while investigating the Air extent feasible. France Flight 447 LOC-I accident, an investiga- Since 2015 in the United States, Federal Avi- tor from the Bureau d’Enquêtes et d’Analyses ation Administration (FAA) guidance on stall- (BEA) of France said in a conference presenta- related training reminds the industry that optional tion: “In a normal situation on a majority of Illustration: Jennifer Moore Illustration: Jennifer Aircraft Based on image © Icon AOA indicators already exist in the current fleet modern aircraft, [the primary flight display Unforgettable AOA FLIGHTSAFETY.ORG | AEROSAFETYWORLD | SEPTEMBER 2016 | 29 30 | FLIGHTTECH business jets. commercial jetsand counterparts inlarge to theiroptional military jetsand counterparts in to theirstandard have similarities in GAaircraft — reference andonly pilots’ supplemental approved strictlyfor above) —eachFAA- Systems AOAGriffin, indexer (Alpha example ofanAOA p. 29)andan Safety System, A5 AngleofAttack AOA indicator(Icon An exampleofan (NASA) National Aeronautics and Space Administration a literature published review in2014by U.S. the mercial airplanes, by advocacy U.S. the National aircraft, onuse military sparse equipage of com- displays at oftypes AOA that included time their The context for to introduce Boeing optional displays on airplane models inproduction. then were trained to standard use AOA data–derived indications and associated crew procedures.” must considered be and accounted for inthe to crew, aflight ful [many complex] parameters tional range. …For AOA information- use to be to crew normal flight inthe the opera- useful airplanethe nears stall,” article said. the “It is less 2016. “Awareness of AOA is vitally important as and training implications —not UPRT unlike in sessment of technological, the human factors AOA indications first requires athorough as- that any airline’s decision to introduce optional and inAOA generally. The authors cautioned prevention of upset incidents and accidents — try’s heightened interest 16years ago inthe aviation the article reflects The Boeing indus - Previous AOA Philosophy recovery procedurestall is not applied.” ‘stall’aircraft energy; is not [and] verbalized; the is to keep wings the level, not to control the in Peripheral Vision,” p. focus initial 32);[their] than on pitch/thrust “Energy State (see Alerts morebe dependent tape on indications speed awareness …[Their] energy fragile. appears to … Crews’ awareness of aircraft the seems energy trends speed [bandthe adjacent tape]. to speed or boundaries. Current is ‘projected’ speed via equivalent), represent which thresholds visual green dot,speed], [lowest or speed] selectable to ‘known’ limits ([maximum Mach operating number). Current inrelation is assessed speed tape displays(PFD)] speed current (araw speed 2000 by Boeing Commercial2000 by Airplanes Boeing prominent article published inatechnical in during evolution the of AOA displays are providing discrete AOA information. Another emphasis was that pilots already Philosophical and technological changes 4 —including and benefits the risks of 3 2 and in the article said.the option for 737,767-400and the 777airplanes,” dependent AOA indicator is offered being as an with airline customers [as of 2000].…[This] in- PFD recently developed incooperation has been safety priorities of operators, as noted. indication of AOA incommercial airplanes, and Transportation Safety (NTSB) Board of avisual aviation (GA)aircraft. of that those FAA the now approves for general thatscribing characteristics adevice had several conducted prior to 1980s.” the mation directly cockpit inthe was primarily In research fact, into displaying AOA infor however, “Studies of nature this were not found. aircraft,the report the said. The author noted, ofscope and uses of benefits displaying AOA in requirements for AOA and of evidence full the tem failure,” report the said. upset recovery and/or diagnosis of air data sys- maythey aid apilot state inenergy awareness, commercial transport It jets. on “how focused potential of benefits discrete AOA displays in 2014, summarizes what studies reveal about The NASA literature review, covering 1958– NASA Summary tary jet fighterjet aircraft included one (U.S.tary Navy examples of AOA-display systems on U.S.- mili After 1980s, according the to NASA the report, Prevailing Designs and ‘Too Slow! Too Slow!’] pilot’s inthe headset.” annunciations [‘Check AOA,’ ‘Caution, Too Slow’ remote audio [ corresponding to AOA the of aircraft. the …The driven color-coded segments …illuminate which chevron and bar–styled, [light-emitting diode]– angles-of-high attack. awareness of available during lift operations at tem is primarily to designed improve pilot’s the Indicator] Reserve KLR10[Lift sys “The device, issued bybook by BendixKing Honeywell for its “A dedicated AOA indicator shown on the NASA cited also aprescient 1960study de- Many of for studies the called detailed For example, according to pilot’s the hand- FLIGHT FOUNDATION SAFETY interface system] provides warning 5 … The KLR10display has | 6 WORLD AEROSAFETY | SEPTEMBER 2016 - - 7 Illustration: Jennifer Moore Based on image © Alpha Systems FLIGHTTECH F/A-18) with the indicator of true aircraft, displaying AOAs as digits, an- as in Air France Flight 447 … an AOA AOA in degrees on the head-up display gles, normalized units or symbols. “The indicator can be a single point of refer- (HUD) and with an AOA indexer scale on the indicator may display AOA ence where the pilot can see the margin to shown on the left side of the HUD. The in arbitrary units [e.g., colored arcs/ stall and determine whether the aircraft first device shows an AOA bracket to wedges on a circular scale], normalized is in a stall,” her report said. “An AOA the left of the HUD velocity vector sym- units [e.g., 0.0 to 1.0 with 0.6 showing indicator would have given the [flight bol when landing gear are extended, and that approximately a 30 percent margin crew] knowledge of how the wing was a vertically centered bracket indicates above stall exists] or actual degrees flying. … Current [post-1977] studies the optimum approach AOA. [e.g., 0 to 30]. The dial-type scale not researching the use of AOA indicators as Another military jet fighter (U.S. only gives current AOA information an aid in airplane energy state aware- Air Force F-16) provides the pilot with but also can function as a rate-of- ness or upset recovery were not found. a vertical-tape–style AOA indicator in change indicator,” the report said. … Current research into the use of AOA true degrees with moving color arcs along as a verification for pitot static system the right edge rectangular AOA indexer LOC-I Accidents failure was not found.” This Airbus on the top left side of the glareshield; the LOC-I accidents (Table 1) since 2000 A330 flight from Rio de Janeiro to Paris indicator operates regardless of landing influenced the NASA author to advocate crashed in the Atlantic Ocean on June gear status, the report said. research and development into untapped 1, 2009, killing all 228 people on board. AOA indexers are most associated possibilities for AOA displays. “When NASA’s report discussed NTSB with discrete AOA data in military stall warning systems are misunderstood, Safety Recommendation A-96-094, issued to the FAA after investigation of CAST Efforts to Address Airplane State Awareness (ASA) the controlled flight into terrain crash of American Airlines Flight 965. It stated, Automation Crew Resource Confusion/ Ineffective Inappropriate “Require that all transport-category Loss of Control–In Flight Accident (LOC-I) Distraction Management Awareness Alerting Control Actions aircraft present pilots with angle-of- Formosa Airlines Saab 340 attack info in a visual format, and that Korean Air 747-200F all air carriers train their pilots to use Flash Airlines 737-300 the info to obtain maximum possible Adam Air 737-400 airplane climb performance.” In cor- Kenya Airways 737-800 respondence between October 1996 Aeroflot-Nord 737-500 and January 2001, NTSB and FAA Gulf Air A320 disagreed about whether the require- Icelandair 757-200 (Oslo) ment was warranted. FAA’s responses Armavia A320 said, in part, “The FAA contends that Icelandair 757-200 (Baltimore) there is adequate angle-of-attack in- MidwestExpress 717 formation already displayed in current Colgan Air DHC-8-Q400 aircraft indicator displays. The FAA Provincial Airlines DHC-8 considers that current industry safety Thomsonfly 737-800 programs, like the flight management West Caribbean MD-82 systems with vertical navigation capa- XL Airways A320 bility and global positioning [system], Turkish Airlines 737-800 are addressing the underlying causes Empire Air ATR-42 that result in situations where maxi- Issue applies to accident ASA issue theme has been addressed by CAST safety enhancements mum possible airplane performance Note: “Ineffective Alerting” is notable as one of the ASA issue themes, related to airline pilots’ angle-of- attack and energy state awareness, among 12 in the original source table. is necessary.” The Boeing 757 crashed Source: CAST (U.S. Commercial Aviation Safety Team) ASA Joint Safety Implementation Team near Cali, Colombia, on Dec. 20, 1995, killing 151 of 159 crewmembers and Table 1 passengers on board. FLIGHTSAFETY.ORG | AEROSAFETYWORLD | SEPTEMBER 2016 | 31 FLIGHTTECH Energy State Alerts in Peripheral Vision ne aviation company developing a retrofittable system attitude, power setting, bank angle and altitude — in which to alert airline pilots to energy state mismanagement AOA can remain low while the airplane is rapidly losing air- Owas motivated by the frequency of this causal factor ap- speed. In these situations, an alerting system based only on pearing in reports from investigators of loss of control–in flight AOA will be completely ineffective,” Skow said. (LOC-I) and approach-and-landing (ALA) accidents. Aerospace The ESA Display was designed to alert pilots to deterio- engineer Andrew Skow, president of Tiger Century Aircraft, rating energy state early enough so that their control inputs told AeroSafety World in August that he decided initially that will interrupt an LOC-I accident sequence, for example, long LOC-I risk could be mitigated further by generating visual and before a stall. “It has been designed so that energy state visual-aural alerts primarily from airspeed and aerodynamic information can be extracted by a pilot at a brief glance — load (g force) data — with angle-of-attack (AOA) data used as instantly recognizable, clear and unambiguous, without eye a less important parameter by the alerting algorithm. or head movement,” he said. At this stage of development, the algorithm fuses flight In June, a company test pilot completed a 16-hour parameters from the existing aircraft databus to immediately evaluation of the ESA Display in a high-fidelity, transport make the flight crew aware of any trend toward too-high or category research simulator operated by the U.S. National too-low energy. LOC-I and ALA accident scenarios involve Aeronautics and Space Administration, he said. In this simu- high cognitive loads for the flight crews, Skow said, yet ener- lator, the pilot tested its stable approach monitor mode, gy state information provided by the vertical moving speed conducting automation-coupled and visual approaches to tape format on a primary flight display (PFD) may contribute runways at San Francisco International Airport. The test pilot to what he calls the “already cluttered PFD environment,” intentionally mismanaged the energy and glide slope track- resulting in “weak salience.” The scenario also may include ing, as actually has occurred when a flight crew assumed cognitive impairment from degraded hand-flying skills, inad- incorrectly that automation was handling control inputs and equate training, fatigue or a medical reason. proper energy state. When flight crews exhibit over-reliance on automation, “Our silver dollar–size disk [approximately 38 mm/1.5 in “the perceived need to check airspeed is reduced,” he said. diameter] with 12 red-green-blue, light-emitting diodes was “The most common LOC-I accident sequence begins with an installed at the left edge of the simulator’s glareshield within unintended and unnoticed loss of airspeed — not an unin- each plot’s peripheral vision,” Skow said. During the simulator tended increase in AOA that results in loss of airspeed.” Flying approaches, if the pilot flying was within operator-specified, with optional AOA indicators and indexers, airline flight crews stable-approach criteria of acceptable deviation from the must look directly at them to interpret the energy state and VREF (reference landing speed), for example, the ESA Display the margin to stall, he said. showed solid green lights. Solid yellow lights with an aural After two years of research, Skow and Peter Reynolds com- alert indicated the aircraft had slowed below the acceptable pleted the design for a device they named the Energy State VREF deviation. If speed dropped to 15 kt less than VREF, the Awareness (ESA) Display. (Reynolds, a retired vice president of device displayed flashing yellow lights and emitted a 1-Hz flight test at Bombardier Aerospace, died in April 2014.) aural alert. At stick shaker AOA, the pilots saw a solid red “Although discrete displays of AOA are perfect for flying “donut” symbol and got the standard aural alert from the intentionally near stall, AOA has no chance to mitigate LOC-I. existing stall warning system, he said. There are many flight situations — combinations of pitch — WR The NASA report also cited the Regarding the Turkish Airlines Flight and the pitch increase until the moment 2012 safety recommendation from TK1951 LOC-I accident, the Dutch the stick shaker was activated. Subse- the investigation of Air France Flight Safety Board noted, “As Flight TK1951 quently, the approach to stall recovery 447, in which the BEA advised “that disengaged the autopilot beyond the procedure was not executed properly, EASA [the European Aviation Safety critical angle-of-attack, the accident causing the aircraft to stall and crash. … Agency] and the FAA evaluate the aircraft was flown by the crew into a stall Despite the indications in the cockpit, relevance of requiring the pres- on autopilot. … As the airspeed [had] the cockpit crew did not notice the ence of an angle-of-attack indicator continued to drop, the aircraft’s pitch [extent of] decrease in airspeed until the directly accessible to pilots on board attitude [had] kept increasing. The crew approach to stall warning. … Boeing, aeroplanes.”8 failed to recognise the airspeed decay FAA and [EASA] should assess the use 32 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | SEPTEMBER 2016 FLIGHTTECH of an auditory low-speed warning signal regardless of external visibility — but one World Aviation Training Conference and as a means of warning the crew and — if particular ASA JSIT focus for existing, Tradeshow (WATS 2016), April 19, 2016. such a warning signal proves effective — non–fly-by-wire aircraft is low-airspeed 3. Cashman, John E.; Kelly, Brian D.; and mandate its use.”9 The 737-800 crash on alerting. Nield, Brian N. “Operational Use of Angle approach to Amsterdam (Netherlands) Regarding current production and of Attack on Modern Commercial Jet Schiphol Airport on Feb 25, 2009, killed in-development non–fly-by-wire trans- Airplanes.” Aero (QTR_04 2000), pp. 10–22. Boeing Commercial Airplanes Group. nine of 135 passengers and crew. port category airplane type designs, the AOA-relevant ASA JSIT research focus 4. Le Vie, Lisa R. “Review of Research on Angle- AOA Work Under Way of SEs includes low-airspeed caution of-Attack Indicator Effectiveness.” Langley The present U.S. Commercial Aviation alerting and “energy state cues, such as Research Center, NASA. Report number NASA/TM–2014-218514. August 2014. Safety Team (CAST) strategy for ensur- flight path, acceleration, and speed de- ing adequate AOA awareness among viation, in a manner similar to modern 5. Boeing said in 2000, “The [optional AOA] airline flight crews comprises safety head-up displays … as part of a virtual- indicator itself consists of an analog scale and pointer. … Stall warning AOA is shown enhancements (SEs) published on the VMC display and as a standalone with a red tick mark, which will change Eurocontrol SKYbrary website FLIGHTSAFETY.ORG | AEROSAFETYWORLD | SEPTEMBER 2016 | 33 BARS: SAFETY IN NUMBERS ● 400 external third-party quality controlled and assured audits ● 28 Industry participants governing standard ● 140 aircraft operators over 29 countries and 5 continents ● 10,000 audit findings now with 100% closure assurance ● Program participants — lowest accident numbers in resource sector BARS Program Office Flight Safety Foundation 16/356 Collins Street Headquarters: Melbourne, Victoria 3000 701 N. Fairfax Street, Suite 250 ® Australia Alexandria, Virginia 22314-1774 Tel.: +61 1300 557 162 U.S.A. Fax: +61 1300 557 182 Tel.: +1 703.739.6700 [email protected] Fax: +1 703.739.6708 flightsafety.org/bars flightsafety.org flightsafety.org BARSAd2016.indd 1 4/21/16 8:39 AM © arsenik | iStockPhoto FLIGHTSAFETY.ORG | WORLD AEROSAFETY | SEPTEMBER 2016 Pattern A according to ateam of aeromedical researchers. identify those most likely those identify such to perpetrate events, able pattern of motivations that to help used could be commit suicide or murder-suicide reveals no identifi- n analysis of pilots inwhich aircraft their cases used to Clear Clear Research failstoidentify preventing pilotsuicides ways ofpredicting or BY LINDAWERFELMAN No No HUMANFACTORS and murders. 1 | 35 HUMANFACTORS similar to other cases of homicide-suicide (in- Pilot Suicides Involving Large Aircraft cluding multiple stressors) emerged.” Date Event The report emphasized that suicide by July 20, 2012 A SkyWest pilot wanted by police on charges of killing his former girlfriend aircraft and murder-suicide by aircraft are two and placed on leave by the airline, tried to steal a Canadair RJ-200 in St. “distinct forms of pathology, with unique risk George, Utah, U.S., crashed while taxiing and shot himself.1 factors that should be recognized and consid- Oct. 11, 1999 An Air Botswana captain who had been grounded for medical reasons stole an ATR-42 and crashed it into two parked aircraft at the airport in ered separately.” Gaborone, Botswana. Overall, the researchers identified 71 occur- July 13, 1994 A Russian Air Force engineer who, according to media reports, wanted to rences involving aircraft and suicide, including commit suicide, stole an Antonov 26 and flew until it ran out of fuel and crashed. three events in which pilots used commercial Note: airliners to kill themselves (Table 1), six events in 1. Miller, Jessica; Neugebauer, Cimaron. “SkyWest Pilot Kills Self After Trying to Steal Plane at which passengers were killed after jumping from St. George Airport.” The Salt Lake Tribune. July 18, 2012. aircraft, and 62 events in which pilots used general Source: Kenedi, Christopher; Friedman, Susan Hatters; Watson, Dougal; Preitner, Claude. “Suicide and Murder-Suicide aviation aircraft in successful suicide attempts. Involving Aircraft.” Aerospace Medicine and Human Performance Volume 87 (April 2016): 388–396. In addition, the researchers identified 18 Table 1 occurrences that they believed “were consistent with strong evidence suggesting homicidal and Researchers from New Zealand and the suicidal intent by the pilot or passenger”; of United States reviewed medical and aviation these, 13 events involved a pilot as the perpetra- safety databases, conducted internet searches tor, including six cases in which the pilots were and examined relevant articles to identify 65 flying passenger airliners. cases of pilot suicide and 13 cases of murder- The report cited data from the U.S. Centers suicide committed by pilots during a 60-year for Disease Control and Prevention that placed period that ended April 17, 2015.2 They the suicide rate among the general population in also identified six cases of passengers who the United States at 13 per 100,000 people and jumped from aircraft and five cases in which identified risk factors that include mental illness, people other than the pilots used aircraft substance abuse, family history of completed in murder-suicide events — these people suicides, impulsive or aggressive tendencies, typically were passengers who disabled the and the diagnosis of progressive and debilitating pilots. diseases such as cancer. Generalizations about causes of suicide Pilots, however, “should have a lower rate or murder-suicide involving an aircraft as the of suicide than the general public because they method, or weapon, were difficult, the research- are screened for mental illness, monitored for ers said in a report on their work, published in significant physical illness and substance abuse, the April issue of Aerospace Medicine and Hu- required to demonstrate problem-solving skills, man Performance, the journal of the Aerospace and usually do not have prior suicide attempts,” Medical Association. the report said. “There does not seem to be a clear pattern “In addition, most pilots will be part of a of background factors or motivations which sense of community involving other pilots and could suggest a recognizable pattern of which air staff. This reduction in risk factors and expo- pilots would be more likely to commit suicide sure to protective elements are not universally or homicide-suicide,” the report said. “There protective; they only reduce the risk.” [are] not enough data to suggest that mental illness plays a significant role in either suicide or Estimating Suicide Flights homicide-suicide by pilots. Rather, perpetrators The researchers said that their review of official were often noted to have other stressors, such accident reports left them with “a strong sense as relationship or financial problems. Patterns that suicide is only identified when there is 36 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | SEPTEMBER 2016 HUMANFACTORS incontrovertible data” and noted that earlier of mental illness — or for whom post-accident research generally estimated that aircraft crashes tests found antidepressants in their systems, attributed to pilot suicide in the United States they said. accounted for between 0.29 percent and “less The study found that pilots do not necessarily than 2 percent” of all crashes. Data from Ger- lose their medical certificates because of mental many placed the estimate between 0.17 and 3 illness — including previous suicide attempts. percent; in the United Kingdom, 0.72 percent of Several countries, including Australia and New fatal crashes were considered definite suicides, Zealand, consider pilots’ treatment, continued and 1.69 percent were “probably suicide or in- remission and their support systems, among volved some degree of self-destructive behavior,” numerous other factors, in determining whether the researchers said. they should be granted aeromedical certification. For the 65 suicide flights, the average age of the pilots was 40. Sixty-three of the pilots were Legalities and Relationships men, and alcohol or recreational drugs were The study found that personal legal or financial involved in nearly half of the flights for which issues played “a significant but not major role” such information was available. Of the 44 cases in pilot suicides, noting that 21 occurrence in which background information was available, reports contained information indicating that 36 percent involved pilots with a known history the pilot had legal or financial problems. “This Changing Rules n the aftermath of the March 24, 2015, crash of Germanwings Flight 9525, an Airbus A320 flown into the ground in the French Alps by its suicidal copilot, the International Civil Aviation Authority (ICAO) and many national aviation authori- ties and airlines have adopted new requirements or new recommendations to prevent accidents involving pilot suicide or I 1 murder-suicide. Several years before the Germanwings crash, in August 2012, the Aerospace Medical Association (AsMA) recommended that the aviation community — and especially aeromedical examiners — pay more attention to issues involving pilots’ mental health. ICAO agreed, including updated mental health information in the 2012 revision of its Manual of Civil Aviation Medicine (Doc 8984), along with recommended questions for examiners to ask when evaluating pilots’ mental health. Within days after the crash, the European Aviation Safety Agency (EASA) issued its first recommendation for airlines to keep at least two crewmembers, including at least one qualified pilot, in the cockpit at all times during flight. Similar require- ments had already been in place in some countries, including the United States, and in the months since the Germanwings crash, the requirement has become common at international airlines. An EASA task force also recommended that pilots be required to undergo psychological testing before starting work at an airline and that airlines establish internal pilot-support systems. In its final report on the Germanwings crash, issued in March 2016, the French Bureau d’Enquêtes et d’Analyses (BEA) issued nearly a dozen mental health–related recommendations, including some calling for a clear determination of the ap- propriate balance between medical confidentiality and public safety, and a requirement that follow-up conditions be defined whenever a Class 1 medical certificate is issued to a pilot with any history of psychiatric trouble. In the United States, the Federal Aviation Administration (FAA), airlines and pilots’ unions agreed to increase the use of programs to aid pilots with mental health problems, and the FAA asked the Aerospace Medical Association to develop recom- mendations on how to handle the issue of medical confidentiality versus physicians’ reporting responsibilities. Note 1. BEA. Final Report: Accident on 24 March 2015 at Prads-Haute-Bléone (Alpes-de-Haute-Provence, France) to the Airbus A320-211, Registered D-AIPX, Operated by Germanwings. March 2016. Available at —LW FLIGHTSAFETY.ORG | AEROSAFETYWORLD | SEPTEMBER 2016 | 37 HUMANFACTORS The researchers cited an earlier, general Pilot Murder-Suicides With Pilot as Perpetrator study of 408 murder-suicides in the United Date Deaths Event States (cases not related to aviation) and found March 24, 2015 150 The first officer of a Germanwings Airbus A320 that only 10 percent involved a victim who was locked the captain out of the flight deck and flew not a member of the perpetrator’s family. That the airplane into the ground in the French Alps. earlier study discussed “adversarial” murder- Nov. 29, 2013 33 Investigators concluded that the captain of a LAM Mozambique Airlines Embraer ERJ-190 crashed the suicides in which the perpetrator believes that airplane in Bwabwata National Park, Namibia, after another person — typically an employer or the first officer left the flight deck.1 another authority figure — has “wronged him.” Feb. 18, 2010 2 A pilot flew his Piper Dakota into a U.S. Internal (1 on the ground) Revenue Service office building in Austin, Texas, U.S.2 The researchers added, “Though he may March 5, 2007 2 A student pilot involved in a custody dispute target a single person whom he perceives as crashed a Cessna 150M into his mother-in-law’s the source of his distress, others may be killed house. The pilot and his only passenger — his young daughter — were killed.3 as well. This is in distinction to a ‘pseudo- Oct. 31, 1999 217 An EgyptAir Boeing 767 crashed into the Atlantic commando’ homicide-suicide, where a crowded Ocean about 30 minutes after takeoff from public place is chosen so that the perpetrator Kennedy International Airport in New York, killing all passengers and crew. The U.S. National can kill as many people as possible, people with Transportation Safety Board (NTSB) said the crash whom he does not usually have any relationship resulted from “the relief first officer’s flight control inputs.” Egyptian authorities disputed the conclusion and who happen to be there.” that the crash was intentional.4 Motives for murder-suicide are complex, the Feb. 9, 1982 24 A Japan Air Lines McDonnell Douglas DC-8 was researchers said, adding that these cases “can (150, including ditched in Tokyo Bay by the captain as the first officer pilot, survived) and flight engineer fought him for the controls. arise from a primary homicidal motive or a primary suicidal motive” and that depression or Notes: 1. Aviation Safety Network. Aviation Safety Database. other psychological problems may play a part. 2. NTSB. Report No. CEN10FA124. Feb. 18, 2010. “Family pressures and social stressors, 3. NTSB. Report No. CHI07FA079. March 5, 2007. including work difficulties, legal issues and 4. NTSB. NTSB/AAB-02/01, Aircraft Accident Brief: EgyptAir Flight 990, Boeing 767-366ER, SU- separations” also are common in cases of GAP; 60 Miles South of Nantucket, Massachusetts; October 31, 1999. March 31, 2002. murder-suicide, the researchers said. Source: Kenedi, Christopher; Friedman, Susan Hatters; Watson, Dougal; Preitner, Claude. “Suicide and Murder-Suicide Involving Aircraft.” Aerospace Medicine and Human Performance Volume 87 (April 2016): 388–396. As an example, they cited a 2007 event in which the pilot of a small aircraft, a man Table 2 involved in a child custody dispute, flew an included a pilot wanted for murder who crashed airplane — with his child as a passenger — into a commercial airliner while taxiing and then the home of his mother-in-law. killed himself,” the study said. Although the number of murder-suicides Twenty-six occurrence reports contained committed by pilots is low, the statistical impact information suggesting that a “relationship con- is “not negligible,” the researchers said, noting flict” played a part in a pilot’s suicide; of these, that, since 1945, the annual death toll in aviation two reports involved pilots of large commercial accidents has ranged between 224 and 2,429 transport aircraft. Six of the pilots with relation- per year. During that time, 572 deaths occurred ship conflicts also were included among those in commercial airline crashes attributed to with legal or financial issues. murder-suicide (Table 2). The number of murder-suicide events also ‘Difficult … to Predict’ was too small to detect patterns in background Murder-suicide involving an aircraft is “difficult factors, the researchers said. Nevertheless, of the to both predict and prevent,” the researchers nine cases in which the pilot’s age was available, said, noting the rarity of such events as well as the average was 37 years; in addition, in all cases “the difficulty of meaningful study because the in which background information was available, perpetrator and victim(s) are dead.” the perpetrators were men. 38 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | SEPTEMBER 2016 HUMANFACTORS Of 14 murder-suicide events (in- in psychiatric literature, the research- treat a pilot “for any condition that cluding those in which someone other ers said. may impair him/her,” the researchers than the pilot was responsible), three “In two cases, a family member was said. “These laws circumvent privacy perpetrators had legal issues, two had the murder victim,” they wrote. “Anger restrictions on the sharing of informa- financial problems and four had rela- appeared as a prominent emotion in tion to further public safety and public tionship conflicts, the researchers said. multiple homicide-suicides: In four confidence in the aviation system.” “Four appeared to have occupation- cases in which there had been occupa- Such mandatory reporting re- al or workplace conflict,” they added. tional strife, the boss or supervisor was quirements might limit suicide and “Four of the perpetrators [all pilots] targeted, and in another case, the IRS murder-suicide events, but “due to the who destroyed aircraft in flight had [U.S. Internal Revenue Service] was disparate patterns of motivations and reports of mental illness.” targeted. Many perpetrators were under background factors we found in this In five of the six cases involving stress at the time, be it financial/work- study … , [they] would not provide the pilot of a commercial jetliner, the related, romantic or legal issues. Unlike a total shield,” they wrote. Moreover, researchers said, “the pilot appeared to the vast majority of homicide-suicide they said that mandatory reporting wait for the copilot to leave the flight cases with other methods/weapons would have no effect on cases involv- deck before destroying the aircraft”; in such as guns, family members were ing personal financial, occupational or the sixth case, the first officer and flight only rarely the victims when aircraft legal factors. engineer forced the suicidal captain off were involved.” A more practical mitigation of this of the flight controls. In three cases, the The researchers noted that risk might involve the requirement — pilots may have had mental illnesses. In cases of suicide using aircraft as the implemented by a number of regulators two cases, the pilots had “occupational weapon should not be considered after the Germanwings crash — that the issues” and two had relationship issues. the same as cases of murder-suicide flight deck must always be staffed by (One of these pilots had both relation- using aircraft. two crewmembers. ship issues and a history of mental “They are not identical events,” The researchers cited an earlier illness.) they said. “Just as we would not equate study that concluded that chances of a The researchers said that in their someone who shot himself in a car suicide were 38.4 percent lower when sample of 14 murder-suicide reports, outside a movie theater with a person two people were on the flight deck. 29 percent “suggested the presence who entered a mall and shot others be- However, they also said that there of mental illness,” compared with 36 fore taking his own life, we should not could be drawbacks to the presence percent of the 43 suicide reports. Both equate pilots who kill themselves with of another person on the flight deck, numbers were “smaller than we would pilots who choose to kill others.” which would lead to “more flow, more expect for similar behavior in the gen- distractions”; in addition, in most juris- eral population,” the researchers said. New Requirements dictions, non-flying crewmembers have They said their data were “clearly In recent years — and particularly after had less rigorous aeromedical screening incomplete” and that no conclusions the March 24, 2015, crash of German- than pilots, including less screening for could be drawn because of the small wings Flight 9525, an Airbus A320 mental illness. sample sizes. flown into the ground by its suicidal Notes Nevertheless, they added that they copilot (ASW, 5/16, p. 12) — regulatory had detected an unexpected trend — authorities have adopted new require- 1. Kenedi, Christopher; Friedman, Susan Hatters; Watson, Dougal; Preitner, Claude. that in all six of the cases in which the ments or issued new recommendations “Suicide and Murder-Suicide Involving perpetrator was the pilot of a pas- intended to prevent accidents involving Aircraft.” Aerospace Medicine and Human senger airliner, all of those killed were pilot suicide or murder-suicide (see Performance Volume 87 (April 2016): occupants of the airplane; the pilots “Changing Rules,” p. 37). 388–396. did not crash their aircraft in popu- In addition, some countries, 2. The researchers excluded from their count lated areas. including Canada and New Zealand, politically and religiously motivated ter- The motives for the pilot murder- require medical practitioners to file a rorist attacks, such as the September 2001 suicides were similar to those described report with relevant authorities if they attacks in the United States. FLIGHTSAFETY.ORG | AEROSAFETYWORLD | SEPTEMBER 2016 | 39 The World Food Programme (WFP) is the food aid branch of the United Nations, and the world's largest humanitarian organization. WFP provides food to about 90 million people each year, including 58 million children. From its headquarters in Rome and offices in more than 80 countries, WFP helps people who are unable to produce or obtain enough food for themselves and their families. The Aviation SafetyUnit (ASU) of WFP is responsible for the aviation safety of the humanitarian air services provided by WFP - flights to many of the highest-risk parts of the world every day forclients' needs and, often, survival. The WFP aviation safety activities are designed to reduce the risk of accidents and to enhance safety awareness among all users and service providers. They strive to offer professional and safe air transport service through quality control. We need you! Your volunteer efforts, industry experience, safety expertise, and/or financial support are needed. Flight Safety Foundation will assist the WorldFood Programme's effortsto further enhance the training and education needs of its AviationSafety Unit by providing FSF products and services, instructional seminars, expertise, knowledge and lessons learned to this vital aspect of the World Food Programme. For more information on how you can help, contact Susan Lausch in the WFP FSF Development Department at [email protected] or phone United Nations +1.703.739.6700, ext. 112. FLIGHT - f., World Food t _ J .,,.(.11 SAFETY YI � }� e Programme ..._•• fZZ(} FO UNDATIO N HUMANFACTORS Safety specialists inevitably struggle to comprehend murder and/or suicide attributed to a flight crewmember. The RogueBY THOMAS ANTHONY Pilot Composite Illustration: Moore Composite Jennifer | iStockphoto TatianaKrylova Image: © Pilot Phenomenon FLIGHTSAFETY.ORG | AEROSAFETYWORLD | SEPTEMBER 2016 | 41 HUMANFACTORS he March 24, 2015, crash of German- wings Flight 9525 brought the rogue pilot–intentional crash phenomenon to the forefront of aviation safety discourse. TUnlike most aircraft accident investigations that first delve into physical evidence and data at the accident site, a rogue pilot–related investigation takes the accident investigator into non-traditional areas of inquiry, includ- ing the personal, and often private, lives of the flight crew. While accident investigators have adeptly addressed human factors for decades via the lenses of crew resource management, threat and error management and human factors analysis and classification, intentional crash- ing of an aircraft by the pilot remains largely a dark corner of their professional knowl- edge. This article focuses on understand- ing these events from perspectives outside their domain so that investigators can take a confident step forward when indications of possible homicide and/or suicide arise in an accident investigation. The article is not intended to review facts or conclusions of the Germanwings crash — which, the French Bureau d’Enquêtes et d’Analyses (BEA) said, occurred after the first officer locked the captain out of the cockpit and flew the Airbus A320 into the ground in the French Alps, killing all 150 passengers of my U.S. Federal Aviation Administration and crew. Rather, the article covers several (FAA) and Transportation Security Adminis- events that fall into the rogue pilot–intentional tration career to the investigation and mitiga- crash category and a few broader theories of tion of unlawful acts against civil aviation. causality. Unlawful implies intentional. Unlawful and Precedents provide context. Also necessary intentional are two elements of the rogue is a clear understanding of the terms that may pilot–intentional crash phenomenon. apply to these events (see “Definitions,” p. I led the Los Angeles portion of the Egypt 44). Let’s examine the rogue pilot–intentional Air Flight 990 crash investigation1 in coopera- crash phenomenon from two complementary tion with the U.S. Federal Bureau of Investiga- perspectives outside the field of aviation tion (FBI), and I have directed and participated safety: first, as a crime that takes place within in dozens of investigations into intentional acts an aviation context; and second, as a human of unlawful interference against civil avia- factors–psychological situation that has pro- tion, most notably hijackings and bombings of found aviation safety repercussions. aircraft. I am not a mental health professional, but This article draws primarily from the as a former investigator, I dedicated 18 years work of two authors: John E. Douglas, special | Oil on Canvas Park” State “Malibu Creek © Jeanine | Bernard 42 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | SEPTEMBER 2016 HUMANFACTORS offender’s imagination.” In his time with the FBI Behavioral Analysis Unit, Douglas offered the following metaphor to new investigators learning criminal profiling: “If you want to understand the artist, you have to look at the painting.” In other words, the crime provides insights into the criminal. This observation has been significant because of the planned and premeditated nature of most of these cases. The specifics of the crime are planned and chosen, and reflect intention. Training by Douglas also stresses the concept of victimology, in which a complete understanding of the relationship between the killer and the victim can often yield insights into the motive or the reason for the action to have taken place. Some experts so far have concluded that a mass murderer will likely have an unusu- ally active fantasy life. The internet has fed this, because, as Douglas said, “Old concepts of boundaries and borders and limitations are gone. ... People did things in cyberspace they might have never done anywhere else.” Using the internet to research suicidal/homicidal in- tentions offers a sense of privacy, although law enforcement authorities typically can obtain records of this research after an event. Some investigative organizations use a psychological model that can be called the The rogue pilot– agent (retired) of the FBI Behavioral Analy- three selves as a way of looking at any indi- sis Unit — who is considered the father of vidual’s behavior. This model posits that each intentional crash criminal profiling — and Thomas Joiner, a of us can be seen as having “three selves.” psychologist and expert on murder-suicide, The first is the social self, who is known in commercial a phenomenon that provides many relevant to friends, colleagues and other individuals air transport insights into rogue pilot–intentional crash with whom we routinely come into contact. psychology. The second self is the personal self, who is fits within the only shared with our spouse or other confi- Mass Murder dants. The third self is the private self, who is definition of The rogue pilot–intentional crash in com- shared with no one else. It is often within this mass murder. mercial air transport fits within the defini- private self where the fantasy life exists and tion of mass murder in the list of definitions where, for some people, the seeds of plans to noted. The commonalities and characteristics commit a violent crime or suicide grow. The of individuals who commit mass murder, collision of this private self and fantasy life therefore, can inform our understanding. with the real lives of the two external selves Douglas says, “Most violent crime careers can be devastating. In 1998, for example, the © Jeanine Bernard | “Malibu Creek State Park” | Oil on Canvas Park” State “Malibu Creek © Jeanine | Bernard have a quiet, isolated beginning within the U.S. Customs Service broke up an internet FLIGHTSAFETY.ORG | AEROSAFETYWORLD | SEPTEMBER 2016 | 43 HUMANFACTORS child pornography ring. As a result of the enforcement authorities as another example public disclosure of their involvement, four of impenetrable secrecy and of his private self individuals committed suicide. planning real homicides in his fantasy life. Cases have shown that the degree to which During one appointment with state psychia- mass murderers succeed in keeping secret the trists in a period when he was not incarcerated criminal intentions developed in their fantasy — a day following one of the murders — lives is the most notable characteristic. In a Kemper was assessed as no longer a threat to case in 2000, in Olathe, Kansas, U.S., a middle- himself or others. aged man named John Robinson contacted six women via the internet, developed a cyber- Psychology of Murder-Suicide relationship with them and killed each of them Joiner’s book titled The Perversion of Virtue ex- over time. When convicted, neighbors recalled plains his theory of murder-suicide. As noted, only normal behavior from him, and his wife the rogue pilot–intentional crash phenomenon and children denied that he was responsible. in commercial air transport fits the definition The case of serial murderer Edmund of murder-suicide and the definition of mass Emil Kemper also has been cited by law murder. The central idea from Joiner’s research is that cases of murder-suicide begin with an individual’s intention to commit suicide. He Definitions states that suicide “is not only primary, but it is also the source of all that follows, especially in- cluding the appalling murders; murder occurs Homicide — The action, by a human being, of killing a human being (The Oxford English Dictionary). because of suicide, as a consequence of suicide having been settled on.” Murder — The unlawful taking of human life.1 The rogue pilot has no right to take the lives of the passengers; therefore this action is, at its Joiner says that the thinking of such indi- most basic level, murder. viduals can be summarized as “if I am to die, it is only virtuous that they do, too.” He calls Mass murder — The unlawful killing of four or more victims by the same offender(s) acting in concert, at one location in a single continu- this thinking perversion of virtue. His theory ous event that may last minutes, hours or days.2 holds that an individual reaches the conclu- Murder-suicide — The term that suicide researcher Thomas Joiner sion — by suicidal ideation and commit- uses in The Perversion of Virtue to describe “a murder followed by a ment — to kill himself first and, only after suicide.” Joiner says that the intention to commit suicide comes first, this conclusion, moves to an internal justi- and only once suicide is decided upon does the individual seek to fication of the murder of others. One type justify his own death by the murder of others. He said, “Given the of ideation associated with some suicides contingent nature of suicide and murder in these incidents, and includes making conclusions about personal given that both are tied together in perpetrators’ minds by a perver- sion of virtue, it is not a surprise that the time interval between burdensomeness and lack of effectiveness. murder(s) and suicide is almost always on the order of minutes or The person concludes, “I am just a burden hours.” Further, Joiner said that “far from being impulsive,” murder- upon those that I care about” and “I really suicide is premeditated.3 don’t belong.” Psychosis — The mental disorder of not being able to distinguish real- He describes four ideation themes, which ity from unreality; that is, of being delusional. he calls virtues that are operative in the minds —TA of many of those studied after committing Notes murder-suicide: justice, glory, mercy and 1. Douglas, B.B. Crime Classification Manual (3rd Edition). duty. The justice-oriented thinking is, “Soon 2. Ibid. I’ll be dead. But is it fair that I suffer that end 3. Joiner, Thomas. The Perversion of Virtue. Oxford, England: Oxford University while those who have deeply wronged me go Press, 2014. unpunished and live happily on?” The case of a mentally ill university student, Seung-Hui 44 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | SEPTEMBER 2016 HUMANFACTORS Suicide Risk of Individuals With Select Conditions 40 35 30 25 20 15 10 5 T T 0 Previous Depression Manic- Opiates Alcohol Schizophrenia Personality Anxiety AIDS Huntington’s Multiple Cancer Suicide Depression Disorders Disorders Disease Sclerosis Attempt Psychiatric Condition Substance Abuse Mental Disorders Health Conditions Note: This table shows the increased likelihood, as measured against the average, of someone with one of the identified conditions committing suicide. For example, an individual with cancer is twice as likely as the average person of committing suicide. Source: Study by E. Clare Harris and Brian Barraclough; from Night Falls Fast by Kay Redfield Jamison. New York: Alfred A. Knopf, 1999. Figure 1 Cho, who killed 32 people at Virginia Tech from the University of Texas Tower — found University in April 2007, has been cited as an that he was motivated to act on his previous example. In Cho’s writings, he described his fantasies, he told others, by news of the July peers as “deceitful charlatans” and “rich kids” 1966 killings of eight nurses in their Chi- who engaged in “debauchery.” Joiner points cago dormitory. out that in the eyes of an individual enacting Joiner also argues that because of psy- murder-suicide, the actions are not “cowardly, chological and practical barriers involved in vengeful, or selfish.” They are instead com- succeeding at suicide, suicides and murder- pelled to act by the perverse logic about virtue. suicides typically are not carried out on Copycat behavior — a way of attain- impulse or on the spur of the moment. Mental ing glory in this logic — emerged as a health professionals note that a person may psychological element cited often in two follow a path leading through incidents of cases in the history of U.S. murder-suicides. non-lethal self-harm and ultimately to lethal News reports said that in the 1999 attack at self-harm, he said. Columbine High School in Colorado, U.S., How common is murder-suicide? Based Eric Harris and Dylan Klebold killed 13 on 24 studies in the United States covering people before shooting themselves. Mes- 2004–2013, the range varied from 0.17 to sages left said they had sought to achieve 0.55 murder-suicides per 100,000 population, greater infamy than Timothy McVeigh, who or a mean value of 0.32 per 100,000. Accord- killed 168 people in the bombing of the U.S. ing to the Boeing 2013 Statistical Summary, Federal Building in Oklahoma City in 1995. one rate of occurrence familiar to investiga- Similarly, the mass murder investigation of tors in the operation of large commercial jets Charles Whitman — who on Aug. 1, 1966, from 2004 through 2013 was 0.33 fatal acci- killed 13 people and wounded 30 by gunfire dents per 1 million departures, Joiner noted.3 FLIGHTSAFETY.ORG | AEROSAFETYWORLD | SEPTEMBER 2016 | 45 HUMANFACTORS In terms of death toll, murder-suicides serotonin. Serotonin regulates emotion, sleep resulted in 10 times more people killed than and appetite. Further, several studies have in commercial air transport crashes over 10 shown that suicidal predisposition is trans- years. To put an even finer point on it, Joiner mitted genetically through families and their based this conclusion on data showing that descendants, he said. there are 1,574 deaths per year due to murder- Joiner also adds something that may seem suicide in the United States. A 10-year aver- contradictory. People can conduct activities age of commercial aviation fatalities in the that indicate that they are planning for the United States from 2003 through 2012 was future yet also planning their own death in 15.3 per year. the short term. “Attention and emotion do not As with murder-suicide, 90 percent of always operate in lockstep,” he says. individuals who commit murder are male. And What does all this mean to an aircraft while 75 percent of the victims of murder are accident investigator or other aviation safety also male, 76 percent of the victims of murder- professional? Situational awareness of a suicide are female. colleague’s risk factors and adverse behav- It is important, however, to point out that ioral changes — and our own — can be a the individual committing murder-suicide, precursor of seeking help and influencing according to Joiner, is generally not a psy- the favorable outcomes seen most often. chopath. Psychopathic murderers derive Pilot suicides are extremely rare, and the pleasure from killing. This is not the same as incidence of rogue pilot–intentional crashes the murder-suicide mentality noted, involving has been infinitesimal. Nevertheless, just be- perversion of virtues. cause a pilot already has paid in full for his Since most cases of murder-suicide vacation next month, and his social self and involve the suicide as the precondition for personal self seem fine, we should recognize both actions, what conditions increase an that potentially lethal problems of another individual’s likelihood of committing sui- person’s private self may be impossible to cide? The results of 250 clinical studies done identify in time to intervene. by E. Clare Harris and Brian Barraclough in Thomas Anthony is the director of the Aviation Safety England show the habituation to self-harm and Security Program at the University of Southern that Joiner says is necessary emotionally to California. move along a path to lethal self-harm. The results show depression and manic-depression Notes (also known as bipolar disorder) as the pri- 1. U.S. National Transportation Safety Board mary preconditions seen for suicide, which (NTSB). NTSB/AAB-02/01, Aircraft Accident also complements Joiner’s explanation that Brief: EgyptAir Flight 990, Boeing 767-366ER, SU- suicidal ideation is based upon feeling a lack GAP; 60 Miles South of Nantucket, Massachusetts; of belonging and a lack of effectiveness. October 31, 1999. March 31, 2002. Flight 990 crashed into the Atlantic Ocean near Nantucket, Two risk factors that increase a person’s Massachusetts, U.S., on Oct. 31, 1999, killing all likelihood of suicide are living alone and the 217 people on board. U.S. accident investigators death of a partner within the previous two said the crash resulted from the relief first officer’s months. Joiner points out that disturbed sleep control inputs. Egyptian authorities challenged that and nightmares also are related to suicide. conclusion. Insomnia has also been linked to advanced de- 2. NTSB. Accident Report DCA88MA008. Dec. 7, pression and thoughts of suicide. He presents 1987. genetic and neurobiological explanations for 3. According to Joiner, there are approximately 38,500 these behaviors. The most significant neuro- deaths by suicide annually in the United States. chemical in the depression-suicide evolution is Murder-suicides account for 2 percent of the total. 46 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | SEPTEMBER 2016 DATALINK Accidents, Fatalities Down in 2015 BY FRANK JACKMAN he global accident rate for The crash of Germanwings Flight declined to six, from seven in 2014 and scheduled commercial operations 9525 in March 2015 killed 150 passen- nine in 2013. Fatal accidents in the past involving aircraft with a maxi- gers and crew, including the co-pilot, five years peaked at 19 in 2011 (Fig- mum takeoff weight (MTOW) of who investigators determined intention- ure 3, p. 48). Tmore than 5,700 kg (12,566 lb) declined ally flew the aircraft into the ground in ICAO has identified runway safety– to 2.8 accidents per 1 million depar- the French Alps. The October crash of related events, loss of control–in flight tures in 2015 — its lowest point in the Metrojet Flight 9268 in Egypt resulted in (LOC–I) and controlled flight into terrain past five years, according to the ICAO the deaths of 224 passengers and crew. (CFIT) as high-risk accident occurrence Safety Report 2016 Edition, released in ICAO has placed Germanwings in the categories (HRC). According to ICAO July by the International Civil Aviation “other” category and Metrojet in the analysis, these three high-risk categories Organization (ICAO). The 2014 acci- “unknown” category. accounted for 57 percent of accidents, 50 dent rate was 3.0 accidents per million The number of fatal accidents in percent of fatal accidents and 10 percent departures (Figure 1). scheduled commercial aviation last year of fatalities in 2015 (Figure 4, p. 48). The ICAO statistics for 2015 show declines in the number of accidents, ICAO Global Accident Rate the number of fatal accidents and the number of fatalities when compared to 4.1 2014 data. The total number of sched- 3.2 2.9 3.0 uled commercial aviation accidents 2.8 declined to 92 last year. That represents a 5.1 percent improvement from 2014’s Accidents per 97 accidents, but still is greater than the departuresmillion 90 accidents recorded in 2013, which 2011 2012 2013 2014 2015 is the low point for the five-year period Year under review. The number of fatalities Source: ICAO Safety Report 2016 Edition recorded in 2015 fell sharply from 2014, but still was significantly higher than in Figure 1 2013 (Figure 2). “The 474 fatalities in 2015 repre- Accidents Involving Scheduled Commercial Flights sent a substantial decrease from the 904 fatalities in 2014, despite the tragic 2015 92 474 events of the Germanwings and Metrojet 2014 97 904 accidents, which caused significant loss of life,” the ICAO report said. “The Year 2013 90 173 aviation community remains focused on 2012 99 388 achieving the highest level of coopera- Number of accidents tion among the various safety stakehold- 2011 125 424 Number of fatalities ers. To keep pace with expansion and Number of accidents progress sector-wide, ICAO continues to Source: ICAO Safety Report 2016 Edition promote the development and imple- mentation of new safety initiatives.” Figure 2 FLIGHTSAFETY.ORG | AEROSAFETYWORLD | SEPTEMBER 2016 | 47 DATALINK For the first time in recent history, scheduled Accident and Fatal Accident Trend commercial operations did not suffer any CFIT accidents in 2015. Runway safety-related events Nonfatal accidents Fatal accidents 19 accounted for 53 percent of all accidents last 7 106 11 9 6 year and 17 percent of fatal accidents, but only 88 90 81 86 0.2 percent of all fatalities. LOC-I accounted for 3 percent of all accidents, but 33 percent of fatal accidents and 9 percent of fatalities, ICAO said. Number of accidents of Number The Germanwings and Metrojet accidents ac- 2011 2012 2013 2014 2015 counted for 79 percent of all fatalities recorded Year in 2015. Eighteen accidents fell into the turbu- Source: ICAO Safety Report 2016 Edition lence encounter category and 12 into the system component failure category (Figure 5). Figure 3 ICAO analyzes safety data based on its Regional Aviation Safety Group (RASG) High-Risk Category Accident Distribution geographic areas. There are five RASGs: Pan America (PA), which comprises North and High-risk categories Others South America and the Caribbean, Africa (AFI), Fatalities 10% 90% the Middle East (MID), Europe (EUR) and the Asia and Pacific (APAC) region (Table 1). Fatal accidents 50% 50% The PA region, which is one of the largest regions geographically, accounted for roughly 13 Accidents 57% 43% million, or 40 percent, of worldwide scheduled commercial departures in 2015, and for about 37 Percentage percent, or 34, of the 92 total accidents (Figure 6). The region had only one fatal accident and Note: ICAO has identified runway-safety related events, loss of control–in flight and controlled flight into terrain as high-risk accident occurrence categories, and uses these two fatalities. The region’s overall accident rate categories as a baseline in its safety analysis. was 2.6 accidents per million departures. The Source: ICAO Safety Report 2016 Edition APAC and MID regions had the lowest accident rates at 2.5 accidents per million departures each. Figure 4 The EUR accident rate was 3.0 and the AFI rate was 7.3 accidents per million departures. Commercial Aviation Accidents by Category, 2015 The EUR and MID regions, with the Ger- manwings and Metrojet accidents, accounted 49 for 32 and 47 percent, respectively, of all the fatalities. The APAC region, however, had half of the fatal accidents — three, which resulted in 98 18 fatalities. The AFI region did not suffer any fatal 12 7 accidents in 2015. Number of accidents of Number 3 2 1 0 Each ICAO member state is expected to RS TURB SCF OTH LOC-I UNK F-NI CFIT establish and implement an effective safety Category oversight system, and ICAO’s Universal Safety CFIT = controlled flight into terrain; F-NI = fire–non-impact; LOC-I = loss of control–in flight; Oversight Audit Programme Continuous Moni- OTH = other; RS = runway safety; SCF = system component failure; TURB = turbulence encounter; UNK = unknown toring Approach (USOAP CMA) is intended to measure the effective implementation (EI) of a Source: ICAO Safety Report 2016 Edition state’s safety oversight program. To standardize Figure 5 audits conducted as part of USOAP CMA, ICAO 48 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | SEPTEMBER 2016 DATALINK has established protocol questions that are based Overview by RASG Region on its safety-related standards and recommended practices established in the various annexes to the Estimated Departures Percent of Accident Fatal Chicago Convention, Procedures for Air Navi- RASG (in millions) Departures Accidents Rate** Accidents Fatalities gation Services, ICAO DOC-series documents AFI 0.8 2% 6 7.3 0 0 and guidance material. Each protocol question APAC 9.8 30% 24 2.5 3 98 contributes to assessing the effective implementa- EUR 8.1 25% 24 3.0 1 150 tion of one of eight critical elements in one of the MID 1.2 3% 3 2.5 1 224 eight audit areas. USOAP results for 2015 show PA 13.0 40% 34 2.6 1 2 that the EI percentage is highest in the airwor- World 32.9 — 92* 2.8 6 474 AFI = Africa; APAC = Asia and Pacific; EUR = Europe; MID = Middle East; PA = Pan America; thiness audit area (73.5 percent) and lowest in RASG = regional aviation safety group accident investigation (54.4 percent). *One accident occurred in oceanic airspace and is not attributed to any region. Six years ago, ICAO, the U.S. Department ** Per million departures of Transportation, the European Commission Source: ICAO Safety Report 2016 Edition and the International Air Transport Association Table 1 (IATA) signed a memorandum of understand- ing on a Global Safety Information Exchange Accident Overview by RASG Region (GSIE), the object of which is to identify informa- 37% tion that can be exchanged between the parties PA 0.4% to enhance risk reduction activities. The GSIE 17% developed a harmonized accident rate through 3% MID 47% close cooperation between ICAO and IATA to 17% align accident definitions, criteria and analysis 26% EUR 32% methods. The joint analysis includes accidents 17% meeting the ICAO Annex 13, Aircraft Accident 26% APAC 21% and Incident Investigation, criteria for all typical 50% commercial airline operations for scheduled and 7% AFI 0% non- s cheduled flights, ICAO said. 0% Percentage of accidents Percentage of fatalities Percentage of fatal accidents A total of 104 accidents, including scheduled Percenta e and non-scheduled commercial operations and AFI = Africa; APAC = Asia and Pacific; EUR = Europe; MID = Middle East; PA = Pan America; ferry flights for aircraft with an MTOW of more RASG = regional aviation safety group than 5,700 kg were considered as part of the Note: Numbers do not total 100 percent because of rounding. harmonized criteria. The GSIE accident rate last Source: ICAO Safety Report 2016 Edition year was about 2.75 accidents per million sectors, Figure 6 down from nearly 3.5 accidents per million sectors in 2014. The harmonized injuries-to-persons ac- strike and hard landing events. OD is defined as cident rate was just under 0.5 per million sectors. damage sustained by the aircraft while operat- GSIE has seven accident categories: CFIT, ing under its own power, and includes in-flight LOC-I, runway safety (RS), ground safety, opera- damage, foreign object debris and all system tional damage (OD), injuries to and/or incapaci- or component failures. MED covers all injuries tation of persons (MED), other and unknown. or incapacitations sustained by anyone coming More than 50 of the 104 accidents considered into direct contact with any part of the aircraft under GSIE were categorized as RS-related, with structure. It includes turbulence-related injuries; the next two most common categories — MED injuries to ground staff coming into contact with and OD — both coming in at just under 20 ac- the structure, engines or control surfaces; and on- cidents each. RS events include runway excur- board injuries or incapacitations and fatalities not sions and incursions, undershoot/overshoot, tail related to unlawful external interference. FLIGHTSAFETY.ORG | AEROSAFETYWORLD | SEPTEMBER 2016 | 49 SKYbrary Partners SKYbrary was initiated by EUROCONTROL in partnership with the following organisations: • ICAO • Flight Safety Foundation The initiative aims at developing a comprehensive source of aviation safety information and make it available to users worldwide. www.SKYbrary.aero ONRECORD ‘In the Same Boat’ Deteriorating weather and dwindling fuel forced the pilots of two 737s to attempt landings below minimums. BY MARK LACAGNINA The following information provides an awareness of problems that might be avoided in the future. The in- formation is based on final reports by official investigative authorities on aircraft accidents and incidents. JETS Inaccurate Forecasts — first, to indicate the possibility of fog develop- Boeing 737-800s. No damage. No injuries. ing at Adelaide and, subsequently, to indicate that he forecasts obtained by the flight crews fog had developed at the airport but was expected of two 737s the morning of June 18, 2013, to clear by 0900, before the aircraft arrived. Tindicated that the weather conditions at The 737s were nearing Adelaide when the fog their common destination — Adelaide, South decreased visibility below approach minimums, Australia — would be such that planning for and the forecast for improvement was revised to alternate airports was not even required. 0930. Based on this information and on reports However, as the aircraft proceeded toward of significantly better weather at Mildura, about Adelaide, unexpected fog began to significantly 200 nm (370 km) east of Adelaide, the crews of affect conditions in the area. both aircraft elected to divert to Mildura. The aircraft were operated by different However, the weather conditions at Mil- airlines. One of the 737s, Flight 1384, departed dura also began to deteriorate rapidly. A special from Brisbane, Queensland, with 85 passengers weather observation at 0918 indicated that and six crewmembers, at 0638 Australian East- visibility was better than 10 km (6 mi) but that ern Standard Time (AEST), with an expected the ceiling had lowered to 200 ft. Subsequent time of arrival at Adelaide of 0920 AEST. observations indicated that visibility also was The other aircraft, Flight 735, departed from decreasing in mist. Sydney, New South Wales, at 0727 AEST, with As the 737s neared the airport at 0936, visibil- 146 passengers and six crewmembers, and was ity had decreased to 2,100 m (about 1 1/4 mi). scheduled to arrive in Adelaide at 0917 AEST. Although the visibility was sufficient for the “Both flight crew uploaded sufficient fuel for global positioning system (GPS) approach to the originally forecast conditions in accordance Runway 27 at Mildura, the ceiling was below with their operators’ fuel policy and Civil Avia- the minimum of 660 ft (493 ft, above ground tion Safety Authority requirements,” said the re- level, AGL). port by the Australian Transport Safety Bureau The report said that, at this point, neither (ATSB). As mentioned, however, extra fuel to aircraft had sufficient fuel to divert to another reach alternate airports was not required. airport. The crew of Flight 735 radioed on the As the aircraft proceeded westbound toward uncontrolled airport’s common traffic advisory the destination, the forecast was revised twice frequency that they were going to conduct the FLIGHTSAFETY.ORG | AEROSAFETYWORLD | SEPTEMBER 2016 | 51 ONRECORD GPS approach “due to fuel.” The crew of airport from the northeast. The pilot and turned right to take evasive action. Flight 1384 then radioed that they were had been cleared to descend to 4,000 ft. Recorded radar data showed that the “in the same boat.” Both aircraft were being handled by a aircraft passed within 1 nm (2 km) At 0946, the crew of Flight 735 radi- student controller under the supervision laterally and 100 ft vertically. oed that they had gained visual contact of an instructor controller. The student The Premier pilot landed at Port with the runway after descending below controller had been on duty for four Elizabeth without further incident. The the cloud base at 150 ft AGL and had sub- hours, and both controllers had returned CAA credited his evasive action as like- sequently landed. The crew also reported from a break about 13 minutes earlier. ly having prevented a major accident. that the fog appeared to be clearing. When one of the R22 pilots checked The helicopter pilots never saw the jet The crew of Flight 1384 entered a in on the approach control frequency, and were not aware of the near-head-on holding pattern while awaiting improve- the student controller instructed him to collision until after they landed. ment in the weather. However, with climb to 3,000 ft. “The pilot incorrectly no indication of improvement in the read back 4,000 ft, but there appears to Battery Bus Fails weather conditions, they attempted the [have been] a lapse in concentration by Boeing 737-300. Minor damage. One minor injury. GPS approach. They were unable to the [student] controller, who did not n route from Spain, the 737 was see the runway on the first attempt and notice this error,” said the report by the descending to land at England’s initiated a go-around from 132 ft AGL South African Civil Aviation Authority EEast Midlands Airport the evening at 1004. (CAA). The error also was not noticed of Sept. 3, 2014, when the commander “The aircraft was positioned for by the instructor controller, who was noticed that the public-address system a second approach, during which the working on the duty roster at the time. wasn’t working. cabin crew were briefed and prepared Moreover, the altitude read-back Several indications then disap- for an emergency landing, briefing the error was not detected by either of the peared from the pilots’ flight displays, passengers to brace accordingly,” the re- helicopter pilots, and the climb was and faults occurred with an equipment port said. “At 1014, [Flight 1384] landed continued to 4,000 ft. cooling fan, the weather radar, standby at Mildura in foggy conditions with fuel The conflict between the helicop- instruments and other equipment. below the required reserves.” ter and the jet was detected by the The flight crew diagnosed the The report said that, in response to approach control facility’s clear level anomalies as having been caused by ATSB recommendations based on the alert monitoring (CLAM) system, but failure of the battery bus. The aircraft investigation of the incident, Airservices neither the student controller nor the was landed successfully, but while it Australia and the Bureau of Meteorology instructor controller noticed the warn- was being taxied to the stand, an acrid had taken steps to improve the dissemi- ing displayed on their radar screens. mist began forming in the cabin and nation of information about significantly “The CLAM amber warning on both flight deck, said the report by the U.K. deteriorating weather conditions. the controllers’ display screens was on Air Accidents Investigation Branch for four minutes without any interven- (AAIB). ‘Lapse in Concentration’ tion by either controller,” the report said, The commander declared an Beech Premier, Robinson R22. No damage. No injuries. noting that the system’s aural warning emergency and ordered an evacuation. isual meteorological conditions feature was deactivated at the time. One passenger sustained minor injuries (VMC) prevailed at Port Elizabeth, The report also noted that a red during the evacuation. VSouth Africa, the afternoon of Sept. short-term conflict warning did not Investigators found that the bus fail- 2, 2014. The R22 pilots were engaged in appear on the radar screens because the ure was caused by relay terminals that an instrument instructional flight and helicopter was traveling more slowly had become loose, causing a break in had established radio communication than the 90-kt threshold programmed continuity. This resulted in deactivation with approach control while climbing in the system software. of the air cycle machine cooling fans, northeast-bound during a go-around The Premier was level at 4,000 ft which caused dust and oil residue on from Runway 06 at the airport. when the pilot received a traffic-alert hot duct surfaces to ignite and release At the time, the Premier, with four and collision avoidance system (TCAS) fumes that subsequently entered the passengers aboard, was nearing the warning on his primary flight display cabin and flight deck. 52 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | SEPTEMBER 2016 ONRECORD TURBOPROPS ‘Insufficient Fuel’ Propeller Moves Into Beta Beech King Air C90. Substantial damage. One serious injury, DeHavilland Twin Otter. Substantial damage. One serious injury, two minor injuries. one minor injury. efore beginning a multiple-leg business he two pilots and their passenger were flight the afternoon of Sept. 19, 2013, the conducting an aerial observation flight that Bpilot checked the fuel gauges and found Tbegan in Washington, Pennsylvania, U.S., that the nacelle tanks were full, with about 60 the morning of Sept. 6, 2015. VMC prevailed gal (227 L) in each, but that the main tanks that afternoon as the pilots prepared to land on were nearly empty. He had 30 gal (114 L) of the 2,650-ft (808-m) runway at a private airport fuel pumped into each of the main tanks before in Louisburg, North Carolina. departing with two passengers from Idaho Falls, As the pilot reduced power on final approach, Idaho, U.S., for the first leg to Pocatello, about he heard sounds similar to the right propeller 45 nm (83 km) away. moving into beta mode, in which the blade angle After another passenger was boarded, the varies from ground idle to maximum reverse. King Air was flown to Boise, about 165 nm (306 The pilot increased power, and the sound ceased. km) from Pocatello. The pilot later told investi- “As the airplane got closer to the runway, he gators that, after landing, the nacelle tanks ap- decreased the engine power, and the sound re- peared to be full and that the main tanks “were turned,” said the NTSB report. “In addition, the not empty.” airplane began to yaw right. The pilot applied However, he “did not note the actual quan- left aileron and rudder inputs to remain above tity of fuel,” said the report by the U.S. National the runway centerline without success.” Transportation Safety Board (NTSB). When the pilot applied full power to initiate The pilot had 40 gal (151 L) of fuel added to a go-around, the Twin Otter yawed 30 degrees the main tanks at Boise. After a five-hour meet- right, touched down in a grassy area and struck ing, the pilot flew the airplane back to Pocatello, trees. The passenger was not hurt, but the copi- where the passenger who had been picked up lot was seriously injured and the pilot sustained there earlier deplaned. minor injuries. Although the precise amount of fuel remain- Investigators found that the airplane had ing in the airplane could not be determined, been flown for nine hours after the right pro- investigators concluded that the pilot took off peller was overhauled two days earlier. Post- from Pocatello to Idaho Falls with “significantly accident tests revealed no anomalies, “However, less” fuel than the manufacturer’s recommended the speed settings were improperly configured minimum of 39.5 gal (150 L) in each wing fuel [and] the beta valve travel from the neutral posi- system. Beech Aircraft calculated that the King tion was out of tolerance,” the report said. Air would have consumed about 28.5 gal (108 L) “Although this could have let oil pressure during this last leg of the flight. port to one side of the spool or the other — and “While on final approach to the home air- thus changed the propeller blade angle — it port, both engines stopped developing power, could not be determined whether this occurred and the pilot conducted a forced landing to a during the accident landing.” field about 1.2 [nautical] miles [2.2 km] short of the runway,” the report said. Stressed and Distracted One passenger was seriously injured, the Piper Cheyenne II. Substantial damage. No injuries. other passenger and the pilot sustained minor he Cheyenne was en route on a medevac injuries, and the airplane was substantially dam- flight from Reno, Nevada, U.S., to Oakland, aged during the forced landing. TCalifornia, the night of Sept. 23, 2014. The FLIGHTSAFETY.ORG | AEROSAFETYWORLD | SEPTEMBER 2016 | 53 ONRECORD pilot later told investigators that he struggled to passenger and the three crewmembers were not keep the airplane on the localizer and glide path injured. while conducting an instrument landing system “The pilot recalled that when he selected (ILS) approach to Oakland. the landing gear, he may have put the handle “As the airplane descended through 800 in neutral rather than keeping his hand on the to 900 feet above the ground, he broke out lever and waiting for the three green lights to of the cloud layer but had difficulty locating illuminate, confirming the extended position,” the runway in the dark night conditions,” the the report said. NTSB report said. “During the landing flare, he The pilot also said that he did not conduct reduced the throttle, and as the airplane touched the Before Landing checklist because of the de- down on the runway surface, he realized the mands of the ILS approach. “He also cited a few landing gear were retracted; he did not hear any stressors in his life that may have contributed [warning] horns.” to a distraction, including a change of airplanes The Cheyenne’s lower fuselage and engine and few ILS approaches performed in the recent mounts were substantially damaged, but the six months,” the report said. PISTON AIRPLANES VMC Roll separation and distortion of the crankcase Cessna 421C. Destroyed. One fatality. halves, and other internal damage. Investigators he pilot was conducting the first flight of determined that there had been a loss of torque the 421 the afternoon of Dec. 8, 2012, fol- on the crankcase bolts, but they were unable to Tlowing an annual inspection and repaint- determine the reason due to impact- and fire- ing. He performed a lengthy engine run-up related engine damage. before initiating the takeoff from Lantana, The 421’s maintenance records showed that Florida, U.S. there was no requirement for the crankcase bolts “The airplane lifted off about halfway down to be loosened since the most recent overhaul of the runway and initially climbed at a normal the engine more than three years and 314 flight rate,” the NTSB report said. “Several witnesses hours earlier. then observed the airplane suddenly yaw to the left [as] the airplane’s nose continued to pitch Discontinued Go-Around up. … The airplane rolled left and descended Piper Aztec. Destroyed. No injuries. vertically, nose-down.” nstrument meteorological conditions (IMC) One witness, a flight instructor, told and a 10-kt tailwind prevailed as the pilot investigators that the 421 appeared to have Iconducted an NDB (nondirectional beacon) entered an uncommanded roll at VMC (mini- approach to St. Mary’s Airport on England’s mum controllable airspeed with one engine Scilly Isles the afternoon of Aug. 20, 2015. inoperative). “At MDA [minimum descent altitude], hav- The NTSB concluded that the probable ing not acquired any visual references, the pilot cause of the accident was “the pilot’s failure to commenced a go-around,” the AAIB report said. follow established engine-out procedures and to “Shortly thereafter, the pilot saw the precision maintain a proper airspeed after the total loss of approach path indicators (PAPIs), discontinued [left] engine power.” The left propeller had been the go-around and continued to land.” feathered, but the landing gear had not been The Aztec touched down about 200 m (656 retracted. ft) beyond the threshold of the 603-m (1,978- Examination of the left engine revealed con- ft) runway. “Believing the aircraft was too fast tact between the piston domes and the valves, to stop before the end of the runway [with a 54 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | SEPTEMBER 2016 ONRECORD precipice beyond], the pilot steered it to the the Duchess veered off the runway into a grassy right,” the report said. area. Damage was substantial, but the occupants The report said that the aircraft was dam- were not hurt. aged beyond economic repair during the Examination of the landing gear revealed excursion, but the pilot and his two passengers that incorrect bushings — made from alumi- escaped injury. num bronze rather than corrosion-resistant steel — had been installed on the lower lugs of the Incorrect Bushings shock absorber. Beech 76 Duchess. Substantial damage. No injuries. The steel bushings require no lubrication, student pilot under the supervision of a and there was no provision for lubricating the flight instructor was conducting touch- aluminum-bronze fittings. Friction between the Aand-go landings at Weston Airport near bushings and the shock absorber pin caused Dublin, Ireland, the afternoon of Sept. 20, 2013. increased wear on the components and the After a series of circuits of the airport, the left eventual failure of the pin and collapse of the main landing gear collapsed on touchdown, and landing gear. HELICOPTERS Obstacle Alert Skewed Tail Rotor Bearing Eurocopter AS350-B3. Destroyed. Three fatalities. Airbus EC130-B4. Substantial damage. No injuries. ight VMC prevailed when the pilot and n route on a positioning flight the afternoon of two medical crewmembers departed from Aug. 12, 2014, the helicopter was on approach NMemphis, Tennessee, U.S., to pick up a Eto Norway’s Rørvik Airport to refuel. As it patient at a hospital in Bolivar, Tennessee, on crossed 5 to 10 m (16 to 33 ft) above the threshold Oct. 22, 2013. at 30 kt, the helicopter began to rotate left. Satellite tracking data showed that the heli- “The pedals had no effect, and the rotation copter was following a highway when it entered increased rapidly, said the report by the Acci- a right, climbing turn near Somerville, Tennes- dent Investigation Board Norway (AIBN). see, and crashed in a wooded area at 1,116 ft. “The helicopter rotated twice around its own “The helicopter impacted the trees at a steep axis before it was landed on the runway. … The angle, and the orientation of the main wreckage helicopter hit the ground somewhat hard.” The pi- was indicative of a loss of control before impact,” lot and loadmaster were not hurt, and the helicop- the NTSB report said. ter was not damaged during the forced landing. A nearby airport was reporting a few clouds Examination of the helicopter revealed that at 800 ft and a broken ceiling at 1,200 ft. Two the tail rotor shaft had fractured due to the obstacles were near the impact site: an unlighted incorrect installation of a shaft bearing during and nonoperational cellular tower and a water scheduled maintenance 98 flight hours before the tower. The NTSB concluded that the pilot likely incident. The AIBN determined that the bearing lost control after inadvertently entering IMC had not been positioned correctly on the shaft. while responding to an obstacle warning by “The work was performed without the the on-board helicopter terrain awareness and correct measuring tools, and the described warning system. procedure in the AMM [aircraft maintenance There were night vision goggles aboard manual] was not followed,” the report said. the helicopter, and the pilot had been trained “This caused a skewed installation of the bear- on their use. However, “the helicopter was not ing. … The incorrect installation led to cyclic equipped for flight under instrument flight loads in the tail rotor shaft which eventually rules,” the report said. caused a fracture,” the report said. FLIGHTSAFETY.ORG | AEROSAFETYWORLD | SEPTEMBER 2016 | 55 ONRECORD Preliminary Reports, June 2016 Date Location Aircraft Type Aircraft Damage Injuries June 3 Mountain City, Tennessee, U.S. Bell 407 substantial 1 minor, 3 none The pilot heard a loud bang as the medevac helicopter departed from a parking lot and began yawing left. He sustained minor injuries during the subsequent forced landing. June 4 Ilaga, Indonesia Cessna 208B substantial 2 NA No fatalities were reported when the Grand Caravan overran the runway while landing and traveled down a hillside before striking a fence. June 4 Yambio, South Sudan Antonov 30A-100 substantial 30 NA No fatalities were reported when the An-30 touched down at midfield on the 1,000-m (3,281-ft) airstrip, overran the runway, crossed a highway and came to a stop after the nose landing gear collapsed. June 5 Neryungri, Russia British Aerospace 125-800B substantial 8 none Night instrument meteorological conditions (IMC) prevailed when the Hawker struck trees on approach about 18 km (10 nm) from the runway. The flight crew regained control and landed the substantially damaged aircraft without further incident. June 6 Seoul, South Korea McDonnell Douglas MD-11F substantial 4 NA No fatalities were reported when the nose landing gear collapsed and the engines struck the ground as the freighter overran the runway during a rejected takeoff. June 10 Apopka, Florida, U.S. Cessna 310G substantial 1 none The pilot was conducting a post-maintenance check flight when the left brake failed on landing and the 310 veered off the side of the runway. June 11 Marina di Cecina, Italy Pilatus PC-6 destroyed 2 fatal, 7 none The parachute on the last skydiver to exit the Turbo Porter opened prematurely and snagged the aircraft’s tail. The pilots were killed when the aircraft struck the ground out of control, but the skydiver survived by activating his emergency parachute. June 12 Jonesboro, Arkansas, U.S. Robinson R44 destroyed 1 fatal A witness said the pilot told him that he was going to put on an air show. He saw the R44 climb steeply before descending out of sight behind hangars. He heard the sound of an impact and saw the helicopter rise above the hangars with apparent damage to the landing skids and tail rotor. The R44 then struck terrain and burned. June 14 Bishop, California, U.S. Bell 206L-1 substantial 3 none The LongRanger was descending to land when the pilot heard an explosion in the engine compartment. The helicopter touched down hard during the subsequent autorotative landing. June 14 Lolat, Papua, Indonesia Cessna 208B destroyed 4 none, 3 NA Three people in a house were injured when it was struck by the Grand Caravan during approach. June 14 Bor, South Sudan Antonov 32A substantial 3 none No fatalities were reported when the An-32 overran the runway while landing. June 16 State College, Pennsylvania, U.S. Piper Navajo destroyed 2 fatal IMC prevailed when the Navajo struck trees during an instrument landing system approach to Runway 24. June 19 Beja, Portugal Pilatus PC-6 destroyed 1 fatal, 7 NA The Turbo Porter was climbing when the skydivers on-board heard a bang in the tail section. The pilot was killed and the passengers were injured when the aircraft crashed out of control. June 19 Kharg, Iran British Aerospace 146-300 substantial 88 NA No fatalities were reported when the aircraft overran the runway while landing. June 19 Hayward, California, U.S. Piper Apache destroyed 1 fatal The Apache struck a railroad utility vehicle after the pilot radioed that the left engine had lost power on approach. June 23 Wikieup, Arizona, U.S. Robinson R66 destroyed 2 fatal The R66 was en route from Prescott, Arizona, to Riverside, California, when it struck terrain. June 26 Dervenochoria, Greece Canadair CL-215 destroyed 2 minor The CL-215 was on a fire fighting mission when the left engine caught fire. The aircraft was destroyed during the subsequent forced landing. NA = not available This information, gathered from various government and media sources, is subject to change as the investigations of the accidents and incidents are completed. 56 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | SEPTEMBER 2016 e Foundation would like to give special recognition to our BARS Benefactors, Benefactor and Patron members. We value your membership and your high levels of commitment to the world of safety. Without your support, the Foundation’s mission of the continuous improvement of global aviation safety would not be possible. bars benefactors benefactors patrons FSF_BENEFACTORS_AD.indd 1 8/26/16 9:47 AM IASS2016_PrintAd_Letter_RegisterNow.pdf 1 8/26/16 6:50 AM Register SAFETY MATTERS Now! November 14–16 Dubai 69th annual International Air Safety Summit Conrad Dubai Hotel Organized by IASS is aviation’s independent, impartial, premier safety event for Hosted by 69 years and counting. Will you be there? 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