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Trailing Indicators AeroSafety WORLD NO GO-AROUND The psychology of continued unstable approaches UNINTENDED CONSEQUENCES Fatal control movements in EC135 CEASE FIRE Suppressing cargo airplane fires BENEFITS OF WAKE VORTEX MEASUREMENT TRAILING INDICATORS THE JOURNAL OF FLIGHT SAFETY FOUNDATION FEBRUARY 2013 The Foundation would like to give special recognition to our BARS Benefactors, Benefactor and Patron members. We value your membership and your high levels of commitment to the world of safety. Without your support, the Foundation’s mission of the continuous improvement of global aviation safety would not be possible. bars benefactors benefactors Snecma patrons PRESIDENT’SMESSAGE CHANGE AT The Helm n Jan. 1, I assumed the helm of the Flight Traveling on behalf of the Foundation took Safety Foundation, the most respected countless hours away from the office and, most independent and impartial interna- importantly, away from his family. Without his wife, tional aviation safety organization in Carol’s, support and understanding, that would Othe world. Following in the sizeable footsteps have not been possible. For that, I would like to rec- of our founder, the late Jerry Lederer, and the ognize and thank her on behalf of the Foundation. Foundation’s most recent president and CEO, Throughout Bill’s tenure at the Foundation, he Bill Voss, will not be an easy task, but it is a was known for his insight into individual safety challenge that I sought and about which I am issues. He has a gift for shaping an issue so it can very excited. be understood by everyone, inside and outside Bill’s background as a pilot and air traffic of the aviation community. For that, we will be controller gave him a well-rounded perspective forever indebted. of the basics of aviation safety. His many years This spring, Bill plans to write one more at the U.S. Federal Aviation Administration column for AeroSafety World, and to provide and the International Civil Aviation Organiza- us with his unique perspective on global avia- tion gave him an appreciation for what can be tion safety and on his tenure at the Foundation. achieved when regulators and industry partners I look forward to reading that piece and seeing work together to improve aviation safety. When and consulting with Bill as he embarks on a new he joined the Foundation in November 2006, Bill flight path here in Washington. immediately began visiting state regulators, avia- As the new president and CEO, I am excited tion organizations and industry groups, resulting to share my thoughts with you each month in this in dozens of trips annually, hundreds of speeches column as I, along with the Foundation Board and presentations, and even more meetings, con- of Governors and a very dedicated and talented ferences and one-on-one sessions — all in quest staff, move the Foundation into a new generation! of advancing aviation safety. His appearances were not limited to the de- veloped world. Bill traveled to areas where help was needed most, where regulators, operators and industry needed to become better informed on safety issues. Sudan and the Middle East were among the places where Bill made a significant Capt. Kevin L. Hiatt difference in how aviation operations and safety President and CEO are handled. Flight Safety Foundation FLIGHTSAFETY.ORG | AEROSAFETYWORLD | FEBRUARY 2013 | 1 AeroSafetyWORLD contents February 2013 Vol 8 Issue 1 features 12 Cover Story | Wake Vortex Perspectives 12 18 2012 Review | CFIT’s Unwelcome Return 22 Flight Ops | Dissecting Go-Around Decisions 18 29 Causal Factors | Abrupt Collective Input 33 Cargo Safety | Fire Detection and Suppression 37 Av Weather | Fathoming Superstorm Sandy 42 Seminars IASS | Pan American Accomplishments 22 departments 1 President’s Message | Change at the Helm 5 Editorial Page | The Right Decision 7 Safety Calendar | Industry Events 8 Air Mail | Letters From Our Readers 2 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | FEBRUARY 2013 29 37 33 AeroSafetyWORLD telephone: +1 703.739.6700 9 In Brief | Safety News Capt. Kevin L. Hiatt, publisher, FSF president and CEO 47 Data Link | C-FOQA Trends [email protected] Frank Jackman, editor-in-chief, FSF director of publications 52 Info Scan | SMS Under the Microscope [email protected], ext. 116 Wayne Rosenkrans, senior editor 57 On Record | Fatal Flight Test [email protected], ext. 115 Linda Werfelman, senior editor [email protected], ext. 122 Rick Darby, associate editor [email protected], ext. 113 Jennifer Moore, art director [email protected] Susan D. Reed, production specialist About the Cover [email protected], ext. 123 Operations at London Gatwick. © Steve Morris/Jetphotos.net Editorial Advisory Board David North, EAB chairman, consultant We Encourage Reprints (For permissions, go to <flightsafety.org/aerosafety-world-magazine>) Frank Jackman, EAB executive secretary Share Your Knowledge Flight Safety Foundation If you have an article proposal, manuscript or technical paper that you believe would make a useful contribution to the ongoing dialogue about aviation safety, we will be glad to consider it. Send it to Director of Publications Frank Jackman, 801 N. Fairfax St., Suite 400, Alexandria, VA 22314-1774 USA or [email protected]. Steven J. Brown, senior vice president–operations The publications staff reserves the right to edit all submissions for publication. Copyright must be transferred to the Foundation for a contribution to be published, and National Business Aviation Association payment is made to the author upon publication. Sales Contact Barry Eccleston, president and CEO Emerald Media Airbus North America Cheryl Goldsby, [email protected] +1 703.737.6753 Kelly Murphy, [email protected] +1 703.716.0503 Don Phillips, freelance transportation Subscriptions: All members of Flight Safety Foundation automatically get a subscription to AeroSafety World magazine. For more information, please contact the reporter membership department, Flight Safety Foundation, 801 N. Fairfax St., Suite 400, Alexandria, VA 22314-1774 USA, +1 703.739.6700 or [email protected]. AeroSafety World © Copyright 2013 by Flight Safety Foundation Inc. All rights reserved. ISSN 1934-4015 (print)/ ISSN 1937-0830 (digital). Published 11 times a year. Russell B. Rayman, M.D., executive director Suggestions and opinions expressed in AeroSafety World are not necessarily endorsed by Flight Safety Foundation. Aerospace Medical Association, retired Nothing in these pages is intended to supersede operators’ or manufacturers’ policies, practices or requirements, or to supersede government regulations. FLIGHTSAFETY.ORG | AEROSAFETYWORLD | FEBRUARY 2013 | 3 Select the Integrated Air Safety Management Software Solution... SMS IAMS FAA Airline Quality JSA IOSA Flight Control Safety Audits Risk Matrix Safety Integrated JSA Aviation Security IAMS SMS IOSA Environmental JSA FAA Risk Management IAMS SMS SMS IATA Operational Safety Audit Flight Control Job Safety Analysis IATA Risk Matrix Safety Management System Job Safety Analysis FAA IOSA Risk Assessment JSA Integrated Airline Management System IATA JSA Environmental Federal Aviation Administration IOSA IOSA Reporting Airline Industry IAMS Aviation Risk Assessment FAA Airline Safety JSA SMS Safety Audits Aerosafety Risk Management Flight Control Flight Control Safety Audits Safety Audits Reporting JSA Risk Matrix SMS Airline IOSA FAA SMS Airline IAMS IAMS Air Safety IATA Quality Integrated Airline Safety IOSA Reporting Flight Control Job Safety Analysis Aerosafety Safety Audits Risk Management IATA Airline Industry FAA SMS SMS JSA Aviation FAA Best Practices: Integrated modules for Aviation Safety Management: ...with the most VALUE Document Control • Reporting • Audits • Training • Job Safety Analysis CAPA • Safety Incident Reporting • Risk Assessment ...and more! Safety Assurance: Handles daily events, hazard analysis, and controls related to Aviation Safety Management System Assessment & Corrective Action: Uses intelligent Decision trees to determine whether event conform to requirements, and take Corrective Action to known events Safety Risk Management: Intuitive process for determining potential hazards using Job Safety Analysis, FMEA and similar tools Risk Assessment: Identifies, mitigates, and prevents high-risk events in the Aviation Safety Management System Change Control: Implement Controls to mitigate risks and Change Management to change processes related to known hazards Integration: Integrates with 3rd party business systems Scalable: Readily adapts to enterprise environments, and multi-site Deployments Business Intelligence: Enterprise reporting tracks KPIs, aids in decision-making with hundreds of configurable charts and reports 800-354-4476 • [email protected] www.etq.com/airsafety EDITORIALPAGE THE RIGHT Decision everal years ago, my wife and I were flying to Ph.D.; and Capt. William F. Curtis of The Presage the U.S. Virgin Islands for a little mid-winter Group. I’d like to thank all three gentlemen for their R&R sans kids. Moments before anticipated work on the Foundation’s go-around project and touchdown at St. Thomas’ Cyril E. King Air- for the hours they put into crafting the article. I’m Sport, it flashed through my mind that the airplane looking forward to the next installment. was landing long. Almost at that same moment, we As always, we welcome feedback from our heard and felt the roar of the engines as the pilots opt- readers. ed to go around and try again. A little spooked, my wife asked what had just
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