AeroSafety world
Maintenance Fatigue Awareness training needed Managing Anomalies Cockpit cooperation essential Visualizing Safety Turning data into pictures Disorientation, Poor CRM Toxic Captains Cockpit unhappy, unsafe Spiral Dive
The Journal of Flight Safety Foundation march 2012
EsEXECUTIVE’sXMeECUTIVE’ Messagessage Value Proposition
n the last issue, I wrote about some of the high Look for the new membership structure to be points of what we are doing at Flight Safety unveiled about October, and please think about Foundation. This month, I am going to go a your budget in order to join for 2013. You are go- little deeper into our operations and how we ing to hear me say this many times: If you have to Iare able to function. First off, the support of our choose one safety resource to keep you in touch members is very valuable, and if you are one, we with what is taking place in the industry, Flight thank you! If you aren’t, then you should be. The Safety Foundation is the one. largest amount of our operating budget comes The other area that I would like to draw your from members’ support. The technical projects, attention to is our outreach activities. Outreach research, advocacy, safety communication and keeps our members and the aviation/aerospace shaping of safety culture and policy come from the industry informed on current hot topics such as support you provide through your membership. lessons learned from an incident or accident, and As a matter of fact, 47 percent of the Founda- on the long-range issues that need our attention. tion’s operating funds come from all entities of While our outreach activities do not directly con- membership support. When I say all entities, I stitute a large percentage of the contributions to mean the individuals, institutions, governments, our operating funds, they are very important to manufacturers, corporations, students, business maintain our visibility as an effective, impartial, aviation operations, airlines, airports, and the independent and international organization. maintenance, repair and overhaul facilities that We do a variety of interviews with print, constitute our membership. radio and television media. Bill Voss, our chief Later this year, the Foundation will roll out a executive officer, maintains an intensive sched- new membership structure and “value proposi- ule, traveling to locations all across the globe to tion” for each category of membership. Value attend and speak at industry conferences, visit proposition is a large part of what we believe a government and industry organizations, and call member should receive for their support. We are on our members. I also have increased my travel often told by many of our members that they be- as of late, doing the same; however, my main lieve that supporting the Foundation is the right function is to keep the offices running smoothly thing to do. After all, we have been an advocate and efficiently. for the best practices in aviation safety since 1947. The Foundation appreciates your support. However, others tell us that within their organiza- Be safe. tions they have to answer the question, “What do we get for our membership?” This newly defined value proposition will answer that question, and make it easier to make a case for supporting the Foundation. At the very minimum, you can tell those who ask that the information from the Foun- dation’s website and AeroSafety World magazine Capt. Kevin L. Hiatt keeps you on top of developments in the realm of Chief Operating Officer safety worldwide, but there’s more. Flight Safety Foundation flightsafety.org | AeroSafetyWorld | March 2012 | 1 AeroSafetyWorld
contents March 2012 Vol 7 Issue 2 features
12 CoverStory | Spiral Dive Near Beirut
17 MaintenanceMatters | Fatigue Awareness
17 20 SafetyCulture | IHTAR Anomaly Model
26 ThreatAnalysis | Extraterrestrial Debris
20 28 SafetyOversight | Safety Data Visualization
34 SafetyRegulation | Making Room for UAS
39 FlightDeck | The Toxic Captain
43 TrafficControl | Rapid ATSAP Report Growth
45 HelicopterSafety | HEMS Pilots’ Weather Decisions 26 departments
1 Executive’sMessage | Value Proposition
5 EditorialPage | The Rare Go-Around
7 SafetyCalendar | Industry Events
9 InBrief | Safety News
2 | flight safety foundation | AeroSafetyWorld | March 2012 43
28 34
AeroSafetyWORLD telephone: +1 703.739.6700 49 DataLink | LOSA Audit of IranAir William R. Voss, publisher, FSF president and CEO [email protected] 52 Info Scan | NextGen-SESAR Interoperability J.A. Donoghue, editor-in-chief, FSF director of publications 57 OonRec rd | Taxiway Takeoff [email protected], ext. 116 Mark Lacagnina, senior editor [email protected], ext. 114 Wayne Rosenkrans, senior editor [email protected], ext. 115 Linda Werfelman, senior editor [email protected], ext. 122 Rick Darby, associate editor [email protected], ext. 113 Ka ren K. Ehrlich, webmaster and production coordinator [email protected], ext. 117 Ann L. Mullikin, art director and designer About the Cover [email protected], ext. 120 This 737 flew a meandering path before plummeting into the Mediterranean. Susan D. Reed, production specialist © Thomas Ingendorn/Jetphotos.net [email protected], ext. 123
Editorial Advisory Board David North, EAB chairman, consultant We Encourage Reprints (For permissions, go to
flightsafety.org | AeroSafetyWorld | March 2012 | 3 Serving Aviation Safety Interests for More Than 60 Years
Officers and Staff light Safety Foundation is an international membership organization dedicated to Chairman, Board of Governors Lynn Brubaker the continuous improvement of aviation safety. Nonprofit and independent, the Foundation was launched officially in 1947 in response to the aviation industry’s need President and CEO William R. Voss F for a neutral clearinghouse to disseminate objective safety information, and for a credible Chief Operating Officer Capt. Kevin L. Hiatt and knowledgeable body that would identify threats to safety, analyze the problems and General Counsel and Secretary Kenneth P. Quinn, Esq. recommend practical solutions to them. Since its beginning, the Foundation has acted in the public interest to produce positive influence on aviation safety. Today, the Foundation provides Treasurer David J. Barger leadership to more than 1,075 individuals and member organizations in 130 countries. Administrative
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flight safety foundation | AeroSafetyWorld | March 2012 Editorialpage The Rare Go- Around
et’s face it: Go-arounds are incon- excursions are the result of unstable ap- • Inadequate management knowl- venient. They make you late, burn proaches. Statistically, approximately 97 edge about the state of operations, more gas, complicate air traffic percent of unstable approaches continue i.e., no or poor monitoring pro- situations and often scare the heck to landing, despite policies and proce- grams in place. Lout of your passengers, who probably dures that dictate otherwise. The runway • Both pilot flying and pilot monitor- think you did something wrong. Incon- excursion accident rate can be dramati- ing must be empowered to call for venient, yes, but essential to safe flying. cally reduced by a higher compliance rate a go-around. It should go without The Foundation’s Approach and Land- of go-around policies, specifically — the saying that airline policies do not ing Accident Reduction Tool Kit was de- decision to go around when appropriate.” penalize pilots who do go around. veloped to reduce the risk of this most He asked, essentially, why go-arounds common form of accident, and one of the are so rare and how that can be changed. Many real-world situations dirty the wa- key elements of the advice it contains is the The discussion on this topic has been ter when discussing clear guidelines for warning against unstabilized approaches. very good. These points have been raised: when a go-around is crucial. Even though Early in the approach, the focus should be the decision is cast as a binary yes/no, “we • Whenever pilots fight through an on maintaining or regaining a stabilized will always have some gray area, and the unstabilized approach to a safe land- approach. At the end, however, there is challenge is to define that area so well that ing, unsafe behavior is reinforced. but one remedy if the approach is still it can be handled in standard operating unstabilized: go around. • Pilots are motivated by pride or com- procedures, training in pilot decision Most pilots are aware of this advice pany pressure to “get the job done.” making, approach planning, conducting and do not dispute its general validity. • Reduced fuel loads arriving at the approach, etc.,” one commenter said. However, recent studies from Airbus and destinations. A good example of this is an approach the U.S. Federal Aviation Administration where all of the elements are nailed except • The fatigue issue, which boosts the have shown that although unstabilized ap- for one, and that one is drifting toward “need” to get down while dimin- proaches are rare — only 3–4 percent of all the correct numbers. ishing the pilot tools available to approaches — only 2–3 percent of the un- You’ll be hearing more about this in the achieve the desired outcome. stablized approaches end in a go-around. very near future as the industry go-around Right now, the Foundation is participat- • Inadequate training on stabilized information effort gets into some meat in ing in an industry effort to understand approaches and go-arounds, and its study. It will be worth following closely. the problem more fully, but earlier this on crew resource management, to year, Rudy Quevedo, FSF deputy director avoid getting into situations where of technical programs, launched a social a go-around is necessary. network discussion on LinkedIn. • Inadequate management response “Annually approximately 30 percent to evidence of high rates of J.A. Donoghue of the industry accidents are runway ex- unstabilized approaches and low Editor-in-Chief cursions,” Quevedo said. “Many of these rates of go-arounds. AeroSafety World flightsafety.org | AeroSafetyWorld | March 2012 | 5 The Foundation would like to give special recognition to our Benefactor, Patron and Contributor 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.
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6 | flight safety foundation | AeroSafetyWorld | March 2012 ➤ safetycalendar
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8 | flight safety foundation | AeroSafetyWorld | March 2012 inBrief Safety News Fatigue Survey New Standards for First Officers
eppesen is planning an industry- ilots hired as first wide survey later this year to gather officers for U.S. Jfatigue data from pilots and cabin Ppassenger and crewmembers; the data ultimately will cargo airlines would be be used as part of a study to determine required to have 1,500 how crew fatigue issues develop. flight hours under a Jeppesen said sleep and perfor- proposal outlined by mance scientists will use the infor- the Federal Aviation mation gathered through the survey, Administration. scheduled for April, to help “improve The proposed rule and evaluate scientific fatigue models would require first such as the Boeing Alertness Model.” officers to hold an
Jeppesen is a subsidiary of The airline transport pilot © meanmachine77/iStockphoto Boeing Co. (ATP) certificate and Jeppesen said that, to coincide an aircraft type rating, which requires training and testing for a specific airplane with the study, a variation of the type. Under current requirements, first officers must hold a commercial pilot CrewAlert application — CrewAlert certificate and have a minimum of 250 hours of flight time. Most major airlines, Lite — is available free on the iTunes however, already have requirements that are considerably higher. App Store. The application is de- The proposed rule would make exceptions for pilots with fewer than 1,500 signed to “simplify capturing sched- flight hours if they have an aviation degree or experience as a military pilot; those ule information, sleep and wake pilots could receive a “restricted privileges ATP” if they complied with certain periods and fatigue assessments … other requirements. [and enable] crew to predict fatigue The proposed rule stems from a requirement included in a 2010 law that man- risk using the Boeing Alertness dated that airline first officers have at least 1,500 flight hours. Model,” Jeppesen said. Public comments on the proposed rule will be accepted until April 29.
First I-4D Flight
he first “initial four-dimensional (I-4D) flight” — a flight (SESAR) program and the first step toward more predict- involving the usual three-dimensional trajectory, plus able flights, SESAR said in a statement discussing the Feb. 10 Ttime — was conducted in early February, with test pilots flight. flying an Airbus A320 from Toulouse, France, to Copenhagen, “Greater certainty about the positions of every airspace Denmark, and Stockholm, Sweden. user in the sky at any given moment will improve safety as well I-4D flight is considered a cornerstone of the Single as flight predictability,” the SESAR program said. “The more European Sky ATM [Air Traffic Management] Research efficient resource planning which this allows will in turn enable a greater carrying capacity for both airports and the European sky in general.” SESAR characterized I-4D as a “major step toward full 4D operations.” In I-4D, “the capability of the aircraft FMS [flight management system] to provide very accurate trajec- tory predictions and execute a required time of arrival (RTA) at a defined three-dimensional waypoint can be exploited by both en route controllers for demand/capacity balancing, metering of flows by applying a controlled time over or by TMA [terminal maneuvering area] controllers sequencing for arrival management by applying a controlled time of ar- rival,” SESAR said. I-4D is expected to be implemented in Europe in 2018, SESAR said. © Airbus S.A.S. 2012
flightsafety.org | AeroSafetyWorld | March 2012 | 9 inBrief
Air Safety Targets New ATC Network
urope has met he U.S. Federal Aviation Administration the safety targets (FAA) has approved the use of an ARINC Eestablished by the Thigh frequency data link (HFDL) network for European Civil Aviation future data link air traffic control communications. Conference (ECAC) ARINC said that the FAA’s action means for reducing accidents that aircraft that already use HFDL for long related to air traffic distance operational communications also will © ESA/P. Carril management (ATM), be able to use it for communications with ATC. the Eurocontrol Safety Regulation Commission (SRC) says. The technology is known as FOH, or In 2010, Eurocontrol received more data on ATM-related incidents FANS (Future Air Navigation System) 1/A than in previous years, “which reflects an improvement in the reporting Over HFDL. ARINC said that FOH data link culture,” the SRC said in its annual safety report for 2011. “provides an inexpensive global alternative to Data analysis identified a number of safety areas in need of improve- satellite-based global communications and … ment, the report said, adding that “a critical concern is raised on the lack is expected to be most beneficial in controlled of resources and qualified staff at a national level dedicated to safety data oceanic airspace such as the North Atlantic and collection and analysis.” Pacific flight routes.”
Tests Urged for Overhead Bins
he installation design for overhead luggage bins and attached the NTSB said, noting that Boeing records show that the clamp passenger service units (PSUs) in some Boeing 737s should was designed in 1980 and based on an older clamp design but Tbe modified to prevent the PSUs, which contain passenger with modifications to improve its strength and fit. supplemental oxygen and reading lights, from separating during The NTSB recommended that the FAA “modify the design accidents and potentially injuring passengers, the U.S. National and test requirements for the attachment points of passenger Transportation Safety Board (NTSB) says. service units to account for the higher localized loading that results In a series of safety recommendations to the U.S. Federal from the relative motion of the attachment structure.” Aviation Administration (FAA), the NTSB noted that sev- The FAA also should require modification of the instal- eral accidents have occurred in the past three years in which lation design of the overhead bins and PSUs manufactured overhead bins and PSUs on next generation 737s (737NGs, in- by Boeing and installed in 737NGs “so that the PSUs remain cluding 737-600s, -700s, -800s and -900s) separated from their attached to the bins or are captured in a safe manner during attachments. This probably increased the number of passenger survivable accidents,” the NTSB said. injuries, especially head and facial injuries, the NTSB said. Another recommendation called on the FAA to “review the In the most recent of four accidents cited by the NTSB, an designs of manufacturers other than Boeing for overhead bins Aires Airlines 737-700 crashed short of the landing runway at and … PSUs to identify designs with deficiencies similar to those San Andreas Island Airport in Colombia on Aug. 16, 2010, kill- identified in Boeing’s design and require those manufacturers, ing two of the 127 people aboard. Fifteen others were seriously as necessary, to eliminate the potential for PSUs to separate from injured and 66 received minor injuries. their attachments during survivable accidents.”
The accident is still under investigation by the Colombian © Paul Velgos/iStockphoto Civil Aviation Authority, but early findings showed that 24 of the 30 PSUs installed in rows 1 through 5 fell when their outboard clamps fractured, along with nearly all of the PSUs in rows 10 through 27, the NTSB said. Preliminary information indicates that some passengers received skull fractures, cuts on the head and face, and other head injuries. In all four accidents, the NTSB said, “the overhead bin and PSU installations were of common design and manufactured, installed and inspected per Boeing specifications.” In all cases, “two polymer plastic clamps attach the out- board side of the PSU to the aircraft rail and fuselage side wall,”
10 | flight safety foundation | AeroSafetyWorld | March 2012 inBrief
U.S. Government Says No to LightSquared
.S. federal agencies say there is “no practical way” to mitigate the potential interference of the LightSquared Uplanned wireless mobile broadband network with existing global positioning system (GPS) receivers and have taken steps to bar the company from beginning commercial operations. The National Telecommunications and Information Ad- ministration, the agency that coordinates government use of the radio spectrum, said in mid-February that, after months of tests to identify the scope of the problem and analysis of proposed solutions, “it is clear that LightSquared’s proposed implementa- tion plans, including operations in the lower 10 MHz, would impact both general/personal navigation and certified aviation GPS receivers. © Mark Evans/iStockphoto “We conclude at this time that there are no mitigation strategies that both solve the interference issues and pro- lift an earlier order that prohibited LightSquared’s commercial vide LightSquared with an adequate commercial network operations “unless harmful interference issues were resolved.” deployment.” After the FCC’s action, LightSquared Chairman and CEO In response, the Federal Communications Commission Sanjiv Ahuja said that company officials are “committed to (FCC), noting that it had “clearly stated from the outset [of finding a solution and believe that if all the parties have that LightSquared’s presentation of its plans] that harmful interfer- same level of commitment, a solution can be found” (ASW, ence to GPS would not be permitted,” said that it would not 2/12, p. 1). He subsequently resigned as CEO.
Expanded Directive In Other News …
he European Aviation Safety Agency (EASA) has expanded on its January espite heavy snowfall and directive for detailed visual inspections of the wings of certain Airbus A380s unusually cold temperatures, T(ASW, 2/12, p. 9) and is now calling for high frequency eddy current inspec- DEuropean airports are do- tions of the wings of all A380s currently in service. ing a better job than they did a year Airworthiness Directive (AD) 2012-0026, issued Feb. 8, says that all A380s ago in clearing snow from runways, that have accumulated fewer than 1,216 flight cycles must undergo the inspections deicing aircraft and coordinating ac- “before or upon completion of” 1,300 flight cycles. tions with officials at other airports, Airplanes with more than 1,216 flight cycles but fewer than 1,384 cycles must according to Siim Kallas, European have the inspections within six weeks or 84 flight cycles, whichever occurs first Union vice president responsible after the Feb. 13 effective for transport. … The International date of the AD. Civil Aviation Organization says Airplanes with 1,384 that its Continuous Monitoring and flight cycles or more must Oversight section — responsible for undergo the inspections the Universal Safety Oversight within three weeks after Audit Programme (USOAP) — has Feb. 13. been recertified to the ISO 9001:2008 If any cracks are standard for quality management detected, Airbus must be systems. … After years of short-term contacted for approved budget extensions, the U.S. Congress instructions prior to the and President Obama have agreed on © Illuminativisual/Dreamstime.com next flight, the AD said. a $63.4 billion authorization bill to Inspection results are to be reported to Airbus within two days after the eddy cur- fund the Federal Aviation Adminis- rent inspections, the AD says. tration through 2015.
Compiled and edited by Linda Werfelman.
flightsafety.org | AeroSafetyWorld | March 2012 | 11 Coverstory
BY MARK LACAGNINA
SpiralAn overwater departure on a Divedark, stormy night ends in the Mediterranean.
ollowing a night takeoff from Beirut, mismanagement of the aircraft’s speed, altitude, Lebanon, the flight crew of Ethiopian headings and attitude through inconsistent Airlines Flight 409 acknowledged an air flight control inputs, resulting in a loss of con- traffic controller’s assignment of a heading trol.” The report also faulted the flight crew for Fto keep the Boeing 737-800 away from isolated “their failure to abide by CRM [crew resource thunderstorms over the Mediterranean. The in- management] principles of mutual support and struction was repeated — and acknowledged — calling deviations.” several times, but the crew never established the Contributing factors were “the increased aircraft on the assigned heading. Ground radar workload and stress levels that … most likely showed that the 737 flew a meandering path for led to the captain’s reaching a situation of loss of about five minutes before entering a steep turn situational awareness similar to subtle incapaci- and descending rapidly to the sea, killing all 90 tation and the [first officer’s] failure to recognize people aboard. it or to intervene accordingly,” the report said. Based on the findings of an investigation team commissioned by the Lebanese Ministry Unfamiliar Airport of Public Works and Transport, the final report Flight 409 was bound for Addis Ababa, Ethiopia, concluded that the probable causes of the with 82 passengers, a flight security officer, five
Jan. 25, 2010, accident were “the flight crew’s cabin crewmembers and the two pilots. The Ingendorn/Jetphotos.netThomas
12 | flight safety foundation | AeroSafetyWorld | March 2012 coverStory
flight crew had flown to Beirut the previous day Beirut and a meal which could have affected and had 25 hours of rest. the quality of their sleep prior to … the flight. The captain, 45, held type ratings for the However, their tone of voice and discussions 737-700/800 and the Fokker 50. His 10,233 were normal during that phase. The captain flight hours included 188 hours as pilot-in- was also heard confirming that this was his first command (PIC) of 737s and 1,042 hours as a flight into Beirut.” Fokker PIC. He was hired by Ethiopian Airlines Spiral Dive in 1989 and flew agricultural aircraft for nine Clearance Changes years before being assigned as a first officer in After the passengers were boarded, the crew ob- de Havilland Twin Otters, 737s and 757s. He tained their instrument flight rules clearance to was promoted to a Fokker captain in 2008 and Addis Ababa. The clearance included a standard completed training as a 737 captain less than instrument departure that initially called for a two months before the accident. slight right turn after takeoff from Runway 21 to The captain’s most recent training in CRM intercept the 220-degree radial of a VOR (VHF and upset prevention and recovery had been omnidirectional radio) located on the airport; completed in December 2007. the initial altitude was 3,000 ft. “Interviews conducted with the captain’s su- The crew was taxiing the aircraft to Runway periors, trainers and next of kin revealed that he 21 when the airport traffic controller told them had a nice personality, was very polite, open to to line up on the runway and report ready for take criticism, healthy, did not smoke or drink takeoff. The first officer, the pilot monitoring, alcohol, [and] was keen on reading and sports,” reported ready for takeoff at 0235 local time. the report said. The controller cleared the crew for takeoff The first officer, 24, had 673 flight hours, and issued a revised departure procedure that including 350 hours as a 737 first officer. He called for an “immediate” right turn toward had been transferred to the operations division CHEKA, a VOR located 31 nm (57 km) north of Ethiopian Airlines after graduating from its of the airport. flight academy in January 2009. He completed The 737 was lifting off the runway when the CRM and upset prevention and recovery train- controller again revised the clearance, instruct- ing in March 2009 and was endorsed as a 737 ing the crew to turn right to an initial heading first officer in August. of 315 degrees (Figure 1, p. 14). The first officer Investigators “Interviews with the first officer’s superiors, acknowledged the instruction and set the as- determined that trainers and friends revealed that he had a nice signed heading on the aircraft’s mode control the captain likely personality and was a good student, who [had] panel (MCP). experienced spatial graduated among the best six in the flight acad- The captain was hand flying the aircraft. disorientation emy,” the report said. Company procedure called for engaging the au- and lost control Weather conditions at Beirut Rafic Hariri topilot at 400 ft above ground level on departure of this 737. International Airport at the time of the accident but allowed for hand flying with flight direc- were described as fair, with calm winds and no tor guidance below 10,000 ft in good weather precipitation, but there was significant thunder- and low traffic activity to maintain proficiency. storm activity west and southwest of the airport, Noting that the flight crew was aware of the over the Mediterranean. convective activity in the area, the report said, “During the preflight preparation phase, “The captain’s decision to fly manually was a the crew was heard on the CVR [cockpit voice major contributor toward the degradation of the recorder] discussing various operational issues situation.” … and conducting the appropriate briefing The first officer did not call for the “After and checklists,” the report said. “In addition … Takeoff” checklist, as required by standard op- the crew was heard discussing their layover in erating procedure, and there was no indication
flightsafety.org | AeroSafetyWorld | March 2012 | 13 Coverstory
29,000 ft). The first Ethiopian 409 Flight Path officer acknowledged the instruction and set the assigned Stick shaker activation Stick shaker activation altitude in the MCP. 9 The control- 9,000 ft , ft 7,700 ft 8 ler then said, “Sir, I suggest for you, due NM to weather, to follow NM N 6 7 E heading two seven zero to be in the clear 5 for fifteen to twenty miles, then go to CHEKA.” , ft
NM The captain asked 4 the first officer, “Two N NM one, say again?” The
E first officer relayed 3 the question to the controller, saying, 2 “Confirm heading two one zero?” The controller replied, Beirut International Airport “Ethiopian 409, sir, 1 negative. To proceed
1 0036:33 Takeoff power set 7 0039:02 HDG selection 270 degrees direct CHEKA, sir, 2 0037:08 Rotation 8 0039:46 ATC: “Ethiopian 409 turn right heading 270” turn left now, head- 3 0037:20 Landing gear up 9 0040:03 Max pitch attitude: 38° nose up ing two seven zero.” 4 0037:39 ATC: “check turn right initially heading 315” 10 0040:21 ATC: “Turn right heading 270 now” The captain asked, 5 0038:18 Flaps 1 degree 11 0041:05 ATC: “Ethiopian 409 you’re going to the “Left heading two 6 0038:36 ATC: “Sir, I suggest due to weather to follow mountain, turn right heading 270” heading 270” 12 00:41:14 Max roll angle: 118.5° left seven zero?” as the first officer was ATC = air traffic control; HDG = heading acknowledging the Note: Coordinated universal times shown instruction, saying, Source: Lebanese Ministry of Public Works and Transport “Roger, left heading Figure 1 two seven zero.” The captain asked, “OK, on the cockpit voice recording that the pilots what heading did he say?” As the first officer set accomplished the checklist items. the assigned heading on the MCP, he told the captain, “Two seven zero is set.” ‘What Heading?’ During this exchange, the captain had The aircraft was in a right turn and climbing continued the right turn through the selected through 2,000 ft at 0238, when the first officer heading of 315 degrees, and the bank angle had established radio communication with Beirut increased beyond 35 degrees, triggering two Control. The controller cleared the crew to enhanced ground-proximity warning system climb to Flight Level 290 (approximately “BANK ANGLE” warnings.
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About 54 seconds after confirming the as- The first officer replied, “Right heading two signed heading, the controller said, “Ethiopian seven zero, roger,” and told the captain, “Two 409, follow heading two seven zero, sir. Follow seven zero set.” heading two seven zero. Turn right heading two The aircraft was climbing through 7,250 ft seven zero now.” when indicated airspeed decreased from 159 “This was associated with a sharp left kt to 141 kt and the stick shaker (stall warning) [control] wheel input … which resulted in a roll activated. The stick shaker remained on for 27 angle of 45 degrees, reaching a maximum of 64 seconds. The 737’s angle-of-attack reached 18 degrees left [bank] and triggering five automatic degrees, and two more “BANK ANGLE” warn- ‘BANK ANGLE’ calls,” the report said. ings were generated. “What is that?” the captain asked. He re- Out of Trim peated the question two more times in a louder The captain apparently was not following the voice. The report said that the question likely flight director commands on his primary flight did not refer to a single item, such as the stick display and “was most likely unaware of the shaker or bank angle warnings, but to “the glob- bank angle he was himself generating,” the al situation, indicating that he didn’t understand report said. Moreover, despite almost constant why the situation was degrading in such a way.” manual flight control inputs, the captain did not trim the controls. “That surely increased ‘Go Around’ [his] workload and was surely not compatible Indicated airspeed had decreased to 120 kt with basic flying skills requiring the aircraft to when the aircraft stalled at about 7,700 ft, be continuously in trim when flying manually pitched nose-down and rolled left, reaching a in order to relieve the pressure on the control bank angle of 68 degrees. The captain “reacted column, allowing the pilot to focus on managing by significantly pulling the control column the flight.” back and bringing the wheel to the right, while The captain The 737 was turning left through 237 de- putting some pressure on the right rudder grees when the captain rolled right and eased pedal,” the report said. “Those actions did not apparently was not forward pressure on the control column. The completely match what was expected as a reac- aircraft began to pitch nose-up, and the indi- tion to a stall” — that is, to apply nose-down following the flight cated airspeed, which had reached 243 kt, began elevator control. to decrease. While making these control inputs, the cap- director commands The report said that the flight crew likely tain said “go around” five times. The first officer on his primary became preoccupied at this point with a sud- replied, “Roger, go around.” den onset of heavy rain, the sound of which “The throttles were pushed full forward for flight display. was recorded by the CVR. The captain told [an] instant, then pulled back a little for a few the first officer to engage the autopilot, which seconds and then pushed again violently enough indicated that he “felt uncomfortable with [for the sound] to be recorded on the CVR,” the manually controlling the aircraft and that he report said. was looking for a solution,” the report said. The CVR again recorded sounds consistent There was no reply from the first officer, who with heavy rain as the controller said, “Ethio- may not have heard the command. In addition, pian 409, follow heading two seven zero, sir. Fol- the captain continued to make manual flight low heading two seven zero. Turn right heading control inputs, which would have prevented two seven zero now.” The first officer replied, the autopilot from engaging. “Roger, roger.” At 0239, the controller again said, “Ethiopian One minute before impact, the captain 409, follow heading two seven zero. Turn right pushed the control column forward, and heading two seven zero.” airspeed increased to 238 kt as the airplane flightsafety.org | AeroSafetyWorld | March 2012 | 15 Coverstory
descended through 6,000 ft. “The column was nose-down, large left and right wheel inputs then relaxed toward neutral, and the airplane were made,” the report said. began to pitch up, [climb] and slow down again Airspeed was more than 7 kt above the … while the left wheel input and right rudder aircraft’s maximum certified dive speed of 400 input were maintained,” the report said. kt and vertical acceleration was 4.76 g (that is, The captain relaxed pressure on the right 4.76 times standard gravitational acceleration) rudder pedal, and the aircraft rolled left. when the 737 struck the water about 5 nm (9 The captain again Airspeed was decreasing through about 200 km) south of the airport at 0241:30. The impact kt when the first officer said, “The speed is occurred four minutes and 59 seconds after the cross-controlled dropping.” The captain replied, “OK, try to do initiation of the takeoff roll; the aircraft had something. Hold this thing.” The report said that been airborne for four minutes and 17 seconds. the aircraft, the captain’s statement indicated that he needed The investigation revealed no sign that icing applying full help but was not able to specify what type of or a mechanical malfunction played a role in help he needed. The first officer responded only the accident, and there was no evidence that the left aileron by saying “speed.” aircraft had been struck by lightning. “The flight The aircraft’s pitch attitude began to decrease profile was the direct result of the flight control while holding after reaching a maximum of 31 degrees nose- inputs and thrust settings,” the report said, not- right rudder. up, but the left bank angle continued to exceed ing that post-accident simulations indicated that 35 degrees. Two more “BANK ANGLE” warn- the upset was recoverable with proper control ings were recorded before the captain applied and power inputs until the last few seconds of right aileron and right rudder. The stick shaker the flight. activated again as angle-of-attack increased, The report said that the captain’s performance reaching a maximum of 26 degrees as the air- likely had been affected by spatial disorientation, craft stalled for the second time. loss of situational awareness and subtle inca- The captain again cross-controlled the pacitation that resulted from the high stress and aircraft, applying full left aileron while holding workload induced by the late-night departure in a right rudder. He then applied increasing back relatively unfamiliar aircraft and from an unfamil- pressure on the control column for 17 seconds. iar airport flanked by high terrain on one side and Airspeed was 150 kt when the 737 reached 9,000 thunderstorms on the other, with a junior first of- ft. The captain neutralized the flight controls, ficer, and possible indigestion and fatigue from the but the left bank continued to increase. meal that had affected the quality of his sleep. The “passiveness” of the first officer, evident ‘Overwhelmed’ from the absence of callouts of deviations from The aircraft was heading east, toward mountain- flight control parameters and air traffic control ous terrain on shore, when the controller said, instructions, was ascribed to his possible reluc- “Ethiopian 409, you’re going to the mountain. tance to challenge the captain. The experience Turn right now, heading two seven zero.” gradient between the pilots “could also explain The first officer keyed the microphone why [the first officer] did not take over control for about three seconds but made no verbal of the aircraft, even when requested to help,” the response. The report said that he likely “was report said, noting that the first officer might overwhelmed by what was going on, which had have asked himself, in effect, “If the experienced left him speechless.” captain cannot handle it, will I be able to?” The left bank angle reached a maximum of This article is based on the Lebanese Ministry of Public 118.5 degrees as the aircraft descended in a spi- Works and Transport “Investigation Report on the ral dive through 7,300 ft, with airspeed increas- Accident to Ethiopian 409, Boeing 737-800, Registration ing through 228 kt. “Over the next 10 seconds, ET-ANB, at Beirut, Lebanon, on 25th January 2010.” ET as the pitch attitude reached 63.1 degrees 409, January 2012.
16 | flight safety foundation | AeroSafetyWorld | March 2012 MAINTENANCEMATTERS Fatigue Awareness Report urges awareness, education and data-gathering to combat fatigue among aviation maintenance personnel.
BY LINDA WERFELMAN
viation maintenance manag- ers and their employees must be made more aware of the risks associated with Afatigued workers, specialists in avia- tion maintenance human factors say, calling for development of a basic awareness campaign as the most important step in fighting workplace fatigue. They presented their recom- mendations in a December 2011 report released by the U.S. Federal
© Chris Photography Sorensen Aviation Administration (FAA)
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Office of Aerospace Medicine. The proposals — “continue and expand fatigue countermeasure in the form of a prioritized list — were devel- education.” oped during a March 2011 workshop aimed “Training efforts must demonstrate the ben- ‘We must make at addressing fatigue in aviation maintenance efits of proper rest to the employee and to the (“Top 10 Anti-Fatigue Actions”). employer,” the report said, citing several studies. fatigue a public “We must make fatigue a public issue if “It must show ‘what’s in it for me.’ It must also change is going to occur,” the report said. “An teach executives and managers to schedule work, issue if change is organized and integrated movement may be overtime and rest in a safe manner. Education going to occur.’ necessary to change laws, improve education must present the science of sleep and scheduling and create awareness.” in an understandable and useful manner. Most Workshop delegates — representing the FAA, importantly, education must motivate learners Transport Canada and the aviation industry — to modify any poor habits that cause fatigue.” said the fatigue awareness campaign should be Fatigue education for maintenance person- led by the FAA and should involve labor unions, nel should begin during their initial training, professional and industrial organizations, scien- the report said. tists and government. In addition, fatigue education should extend Increased awareness of the problem is likely to friends and family members, “who must learn to fuel efforts to develop a means of measuring about proper rest and schedules to ensure that fatigue, the report said, citing efforts in the au- their loved one is safe at work,” and to the U.S. tomobile and trucking industry to use eye-blink Congress, which has “applied considerable pres- technology to gauge driver fatigue. sure to alter fatigue-related rules for pilots” but “High-visibility events drive public and not for maintenance personnel, the report said. industrial awareness of fatigue,” the report said. Workshop delegates “felt that such education “Events that expose might encourage the FAA to address the fatigue fatigued pilots or air safety risk with improved regulations,” the Top 10 Anti-Fatigue Actions traffic controllers re- report added. “Of course, the industry delegates ceive extensive media from both management and labor used the ad- 1. Enhance employer and worker fatigue coverage. For each age, ‘Be careful what you wish for.’” awareness. of the public events, The FAA Maintenance Fatigue Research 2. Continue and expand fatigue counter- measure education. numerous other Program already has developed and distributed 3. Support and regulate fatigue risk occurrences avoid materials for fatigue education, including post- management systems (FRMS). discovery.” ers, videos, a fatigue symptom checklist and a 1 4. Quantify safety and operational ef- Fatigue is preva- fatigue risk assessment tool. ficiency impact of fatigue. lent in industries such 5. Regulate hours of service limits. as aviation mainte- FRMS 6. Establish baseline data of fatigue risk nance that operate The workshop delegates also called for action with existing event reporting systems. day and night, the to support and regulate fatigue risk manage- 7. Integrate fatigue awareness into report added, and the ment systems (FRMSs) in aviation maintenance safety culture. related risks “must (ASW, 9/11, p. 23). 8. Ensure that FRMS is considered in remain high priority FRMS has not been widely implemented in safety management system programs. even when the topic is aviation maintenance organizations although it 9. Create and implement fatigue assess- not in the news.” has become common in the railroad and com- ment tools. Along with fa- mercial trucking industries, and for flight crews. 10. Improve collaboration of FRMS within tigue awareness, the Where an FRMS is in place, improvements and across organizations. workshop delegates have been noted in personal health and well- Source: U.S. Federal Aviation Administration emphasized the being, safety and cost, the report said. For associated need to example, one international trucking firm has
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reported savings of millions of dollars formal fatigue data are relatively lim- agreement among those voting that the in health care costs. ited, the report said. FAA should propose a duty-time rule FRMSs must be designed specifical- “When fatigued mechanics or crew- for maintenance personnel. ly for each organization, the report said, members make errors, they are often “At the workshop and in the work- adding, “One size does not fit all. Effec- attributed to procedural errors, memory ing group, delegates felt that neither tive fatigue risk management requires lapse or mistaken communication,” the industry nor individuals would fully that everyone take responsibility for the report said. “Typically, an event inves- address fatigue without a regulation,” problem and use multiple strategies to tigation does not have a sufficient root- the report said. “Many believed that an reduce fatigue.” cause analysis to determine if fatigue FRMS could supplement the hours- In an aviation maintenance FRMS, was a significant contributing factor.” of-service limits if equivalent levels of the first goal is to reduce fatigue to an ac- As a result, the cost and the impact safety were demonstrated.” ceptable level by using fatigue-reduction on safety of fatigue-related errors are The report noted that, worldwide, interventions such as “duty time limits, unknown. regulatory duty-time limits vary widely. scientific scheduling, napping, education, The report cited sweeping changes In China, for example, no more than excused absences and, in some instances, in the U.S. trucking industry after im- eight hours of work may be scheduled medical testing and treatment.” provements in data gathering, including each day. The current FAA rule allows The second goal is to reduce “semi-annual fatigue countermeasure for 24 hours, and the International fatigue-related errors. training, health and wellness coaching, Federation of Airworthiness (IFA) “Despite efforts to ensure that em- evaluation of sleep disorders and proac- recommends a limit of 12 hours, or 16 ployees are well-rested and alert when tive fatigue management.” Anticipated hours with overtime. Maximum hours they report for duty, it is not possible regulatory changes include the addition that may be worked per month range to eliminate fatigue from the work- of sleep apnea testing to routine com- from 196 to 646 hours, the report said, place,” the report said. “Interventions mercial motor vehicle physical exams. noting IFA’s recommendation of a can involve two approaches: measures Among the data needed by govern- maximum of 288. directed toward reducing the risk of ment and the aviation industry are The report suggested that a U.S. the individual and measures directed estimates of the financial effects of regulation could be developed using toward reducing the risk of a task for a fatigue and fatigue-related damage, the IFA recommendations, information fatigued worker. extent of risk to flight safety because gathered through the fatigue working “For example, reducing the risk of of maintenance fatigue, the cost of group and FRMS data. a task by taking work breaks and sim- implementing FRMSs and the prob- An “hours of service” rule alone is plifying work task steps can help. We ability that having an FRMS could have not adequate, the report said, adding should not assign fatigued workers to prevented a fatigue-related event. that regulations should be implemented critical tasks. Matching the worker to After the industry has data on the fi- that are “flexible to different types of the task is part of an FRMS.” nancial and safety risks of fatigue, appro- operations and maximize safety.”
The workshop delegates said that, priate interventions can be implemented This article is based on OAM report DOT/FAA/ as an alternative to an FRMS, they further and the effects of those interven- AM-11-19, “Fatigue Solutions for Maintenance: favored allowing companies to demon- tions can be assessed, the report said. From Science to Workplace Reality,” written strate how they plan to manage fatigue by Katrina E. Avers, William B. Johnson, Joy among maintenance personnel, in part 2010 Survey O. Banks, Darin Nei and Elizabeth Hensley. Johnson is the FAA chief scientific technical by establishing a maximum service The workshop delegates also endorsed adviser for human factors in maintenance; the limit and detailing “how they will man- a regulatory move to limit hours of others are employed by the FAA Civil Aerospace age fatigue if they choose to exceed the service — a move the report character- Medical Institute. regulated service limits.” ized as consistent with the high priority assigned to FRMS regulation. The Note Better Data report cited a 2010 survey by the FAA- 1. The information is available on the Despite anecdotal evidence of long Industry Maintenance Fatigue Work- Maintenance Fatigue Section of the FAA hours and fatigue-related mistakes, ing Group that resulted in unanimous website,
BY CHRIS NUTTER AND THOMAS ANTHONY
A three-step process for managing anomalous events — and maintaining aircraft control. © Chris Photography Sorensen IHTAR Model The IHTAR
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ilots are problem solvers. Recently, with International Airport. Air traffic control (ATC) the proliferation of automated cockpits, provided vectors to allow the crew time to deal problems have elicited the question: “Why with the problem. About an hour later, the DC-8 is the airplane is doing that?” These types crashed near the airport, due to what the NTSB ofP problems, involving anomalous events with concluded was “the failure of the captain to unknown causes, often are the hardest to solve monitor properly the aircraft’s fuel state and to and present some especially difficult hazards. properly respond to the low fuel state and the Anomalous events can divert the attention of the flight crew from their normal safety-critical duties and create abnormal levels of confusion “I have the aircra and radios; you’ve got everything else.” and pressure. The power of anomalous events to absorb the flight crew’s attention cannot be underestimated. In some cases, they have the unnerving and completely absorbing effect of a hand grenade rolling into the cockpit and stop- IHTARcrewmember’s advisories regarding fuel state. ping between the two pilots. This resulted in fuel exhaustion to all engines. The IHTAR (“I have the aircraft and radios; His inattention resulted from preoccupation with you have everything else”) model is a process a landing gear malfunction and preparations for for managing anomalous events and preventing a possible landing emergency. Contributing to them from becoming anomalous emergencies. the accident was the failure of the other two flight This procedural model is designed to do two crewmembers either to fully comprehend the things: first, to maintain the operational integ- criticality of the fuel state or to successfully com- rity of the aircraft (“fly the airplane”); and sec- municate their concern to the captain.” ond, to establish a communication process that Nearly 29 years later, on Sept. 28, 2007, Ameri- facilitates the solving of the anomalous event. can Airlines Flight 1400, an MD-82, was departing Although exacerbated by increasing automa- from St. Louis when the crew observed an engine tion, the power of anomalous events to seduce fire indication and several other abnormalities, flight crewmembers into trying to solve the including the absence of an indication that the nose problem while diverting them from the essential landing gear had extended during the return to the task of flying the aircraft is not new. Several ac- airport (ASW, 9/09, p. 34). The crew conducted a cidents serve as clear examples. go-around, used emergency procedures to extend Eastern Airlines Flight 401, a Lockheed L-1011, the gear and landed without further incident. The crashed near Miami on Dec. 29, 1972, follow- engine fire, which substantially damaged the ing a suspected nose landing gear malfunction MD-82, had been caused by an improper starting on approach, a go-around and assessment of the procedure. Regarding the crew’s handling of the problem in level flight on a downwind leg. The U.S. anomalous event, NTSB concluded that “the pilots National Transportation Safety Board (NTSB) con- failed to properly allocate tasks, including checklist cluded that the flight crew became preoccupied execution and radio communications, and they did with the malfunction and failed “to monitor the not effectively manage their workload; this adverse- flight instruments during the final four minutes ly affected their ability to conduct essential cockpit of flight and to detect an unexpected descent soon tasks, such as completing appropriate checklists.” enough to prevent impact with the ground.” These crews were all highly trained, experi- Six years later, on Dec. 28, 1973, the crew enced and professional. What went wrong? of United Airlines Flight 173, a McDonnell Douglas DC-8, heard an unusual noise and felt Anomalous Event Management the airplane yaw when the landing gear was We believe that current airline training pro- extended on descent to Portland (Oregon, U.S.) grams over-focus on practicing checklist flightsafety.org | AeroSafetyWorld | March 2012 | 21 safetyculture
responses to discrete failures. The time has The captain stabilizes the aircraft on the come to integrate procedures that enable the assigned vector and altitude, and summarizes crew to manage and solve anomalous events. the situation: “Here is the way I see it [HITSI]. The IHTAR model provides a framework for ATC has taken us out of the pattern, so we have anomalous event management (AEM). enough time and altitude to look into the warn- This AEM process comprises three steps ing light situation. Our destination remains the akin to three waypoints on an airway to resolu- same. Does that sound right to you?” The first tion (Figure 1). These waypoints are: IHTAR, officer concurs, and the captain reiterates, “OK, HITSI and WAYFI. The following scenario again, I have the aircraft and the radios, you illustrates the model in action. look into the warning light.” An air carrier aircraft is at 3,000 ft on an in- The first officer proceeds to investigate the strument approach. Everything is normal until, cause of the warning light. After a suitable inter- at about the same moment, the captain — the val, the captain asks the first officer, “What are pilot flying (PF) — and the first officer — the you finding [WAYFI]?” pilot not flying/pilot monitoring (PNF/PM) — The captain listens as the first officer notice a warning light illuminate. There is no reports her assessment but continues to pay apparent cause of the configuration warning. primary attention to control of the aircraft. The captain acknowledges the situation. The He asks the first officer to restate what she first officer confirms. has found so far because something about the The captain then says, “OK, I have the assessment does not make sense or seems out aircraft and the radios [IHTAR]. You’ve got of place. The captain seeks clarity or further everything else.” The captain stabilizes the assessment by saying, “Huh, I wonder why that aircraft in airspeed, altitude and position. would be occurring.” He reiterates to the first officer, “I have the ATC calls and asks if the crew needs more time. aircraft and ATC. See what you can find out The captain replies in the affirmative. Just as this happens, the first officer says, “I think I’ve found it.” She explains the apparent cause of the problem Waypoints to Resolving Anomalous Events and the solution. The captain affirms that the first IHTAR HITSI WAYFI KRES officer’s findings are correct and works with her to complete the appropriate checklists. During this process, the captain has com- municated with dispatchers and flight at- IHTAR = I have the aircraft and the radios, you’ve got everything else. tendants, and apprised the passengers of the HITSI = Here is the way I see it. WAYFI = What are you finding? situation, while maintaining the aircraft in KRES = Resolution International level flight on the assigned vector and at the Source: Chris Nutter and Thomas Anthony assigned altitude. Having assurance that the aircraft has been Figure 1 returned to normal operating condition, the about the condition.” The crew agrees to abort captain radios ATC: “We are back to normal the approach and climb to a safe altitude to operations and request the approach.” ATC as- manage the problem. signs vectors and an approach clearance, and the The captain tells the approach controller, flight lands without incident. “We have an aircraft configuration problem and In this scenario and in the accident flights are unable to continue our approach. We need summarized previously, the initiating anomalous a little time to sort this out.” The controller pro- events were similar, but there were different event vides vectors out of the approach pattern and management strategies and different outcomes. assigns a higher altitude. In the accident flights, there was no established
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process for handling the anomalous events. In HITSI is a transitional step that allows this case, the crew used the IHTAR model. both crewmembers to start the process of anomalous event management with the same Task Prioritization mental picture, minimizing preconceptions. The Oxford English Dictionary defines anoma- lous as “unequal, unconformable, incongruous.” An anomalous event doesn’t fit. It doesn’t make sense. It’s one that we can’t figure out. The IHTAR model provides pilots with a means of “Here is the way I see it.” making sense of an anomalous event and solv- ing it while maintaining control of the aircraft. HITSI The first step, IHTAR — “I have the aircraft While the captain might have more experience and radios, you’ve got everything else” —effec- to draw from in order to frame the situation, tively accomplishes the “aviate, navigate, com- the first officer may also bring perspectives municate” task prioritization that has served so that would help. well throughout the history of aviation. It does The final step, WAYFI — “What are you so as “Job 1” in a deliberate process designed for finding?” — presents an important question that redundancy using dynamic maneuvering monitor- does not focus the first officer on any particu- ing and established checklist procedures to assure lar concern or limit cognition to a predefined flight control. Dynamic maneuvering monitor- system or component. Rather, it is open-ended, ing clearly identifies roles as to who is expected asking for the view of the situation from another to monitor what and when — and in doing so, set of eyes and an independent assessment about ensures that both crewmembers do not become the initial indication or condition. directly involved in the solution of the anomalous WAYFI enables discovery. It does not force event or fail to ensure that aircraft path and con- the first officer to “solve the problem” and thereby figuration changes are accomplished safely. create a condition of myopic problem fixation. The model acknowledges the captain’s Rather, by asking the first officer to report what responsibility to designate the PF and the PNF/ he/she is finding, it allows the flight crew — as PM, and allows for the captain, if desired, to a problem-solving team — the opportunity to designate the first officer as PF while he or she notice non-linear, non-obvious relationships that exercises as PNF/PM what might be vastly more are significant to resolving the anomalous event. experience in directly working the problem. In In essence, while the first officer proceeds any case, IHTAR ensures that one pilot main- to investigate and report what he/she is finding tains aircraft control and situational awareness, regarding the problem, the first officer is the and continues to communicate with ATC, which “pilot flying the problem,” and the captain is the can provide the time and space needed to allow “pilot monitoring the problem.” for resolution of the problem. Because an anomalous event is a problem The second step, HITSI — “Here is the way I that defies direct identification, it is necessary see it” — follows the assignment of the essential that a method of resolving such situations be flying and problem-assessment tasks, and allows able to draw from the combined and complete the captain to summarize the situation as he/ experience of the flight crew. These situa- she sees it and to identify the critical elements. It tions are ill-suited to linear checklist solutions puts the captain and the first officer on the same until the exact cause of the anomalous event is page and, just as importantly, gives the first identified. The WAYFI step allows the captain officer the opportunity to provide additional in- to utilize his comprehensive training in a non- sight and perspective in answering the question: directive manner while monitoring the reports “Does that sound right?” of the first officer. It, in essence, facilitates the flightsafety.org | AeroSafetyWorld | March 2012 | 23 safetyculture
subconscious processing of information leading case in the real world of aircraft operations and to problem resolution. It evokes perceptions and especially not in the case of anomalous events. questions such as, “Huh? That doesn’t sound NTSB Member Robert Sumwalt, a former right.” It allows the “little voice” at the back of airline captain and president of a research organi- every pilot’s mind the opportunity to be heard. zation called Aviatrends, pointed out the critical WAYFI is a structured dialog. And dialog, in importance of effective flight crew monitoring itself, is heuristic, which loosely translates from skills in a review of several reports and studies the Greek heurka to: Eureka, I have found it! A (Flight Safety Digest, 3/99, p. 1). A common finding heuristic process is a process of discovery. It is a among the studies was that many of the observed synergistic process that facilitates and generates monitoring problems involved preoccupation with new insights among the participants. It is like other duties. Sumwalt also noted the finding of a a handball game in which the ball gains energy, relationship between monitoring errors and the rather than loses it, each time it strikes the wall. crews’ preoccupation with non-monitoring tasks. Another analogy is William Faulkner’s ob- The results of a recent study of 1,020 U.S. air servation about the process of writing. He said, carrier and commuter airline accidents from 1990 “I never know what I think about something to 2002 indicated the potential benefit of developing until I read what I’ve written on it.” specific event management training, standardized throughout a company and perhaps the commercial New Approach aviation industry.2 The study found that: The evidence that event management should • Overall, nearly 70 percent of the commercial be considered as a new approach in pilot train- aviation accidents were associated with some ing is compelling. type of aircrew or supervisory error. Investigators faulted In their book The Multitasking Myth, authors the flight crew’s Loukia Loukopoulos, R. Key Dismukes and • Approximately half of the accidents were as- task allocation Immanuel Barshi make the point that standard sociated with at least one skill-based error, and after an engine operating procedures, including emergency pro- more than a third involved decision errors. fire and several cedures, are presented as serial procedures — that • Crew resource management (CRM) was a other abnormalities is, to be conducted in order, one step at a time.1 factor in approximately 20 percent of the afflicted an MD-82 This creates the expectation that emergencies can major air carrier accidents. in 2007. be resolved in a serial manner. Such is not the • There had been little impact on reducing any specific type of human error over the study period.
The finding that, despite a low accident rate, the industry had not improved on human error for more than a decade, is stunning. It implies that highly trained, experienced and professional crews will continue to make errors that result in fatal accidents. It is a warning shot that we need something new, different, more effective and more reliable to manage anomalous events. Basic “skills training” may have reached a prac- tical limit, and what may be needed is a well devel- oped event management strategy — a context in which to employ those skills. As the airline industry prepares for an era of retirements, a new generation
U.S. National Transportation Safety Board Safety Transportation National U.S. of pilots and ever-increasing automation, the time
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has come to improve what hasn’t worked and to lay Regarding the Jan. 15, 2009, ditching of a foundation for more effective training. US Airways 1549 in the Hudson River, NTSB concluded that a contributing factor in the Training for the Real World survivability of the accident was “the decision We believe that anomalous event management making of the flight crewmembers and their crew training, as represented in the IHTAR model and with associated AEM policies and procedures, can improve airline pilot training programs. AEM involves a comprehensive plan and a disciplined execution. Training today does not emphasize “What are you nding?” enough how to develop that plan and how to execute the plan in a manner that keeps everyone “on task” and avoids distraction, omission and WAYFIresource management.” This accident highlighted undetected error. the challenges that crews face in managing abnor- It should be recognized as well that problem- mal and emergency events, and the success that is solving in an environment pressurized by an achievable when these events are well-managed. anomalous event presents an additional factor The IHTAR model directly addresses the that must be included in the training syllabus. challenges presented by anomalous events, giving Many of today’s training programs are excel- crews a redundant, highly reliable and repeatable lent, but accident/incident investigations and data process to initiate AEM. Dynamics will always analyses have shown that we need new training impose requirements to modify the process, but that embraces real-world factors and incorpo- at least a well-trained AEM process can help rates a new topic: event management. The indus- crews embark on a path to maintain aircraft con- try needs to design, develop and train new ideas trol and logically manage all of the components for systematic methods to manage events; use of an event for a successful conclusion. redundant processes to assure a high reliability We believe that the IHTAR model estab- operation; and integrate CRM, threat and error lishes an AEM procedure that optimizes the management (TEM) and line operations safety abilities of a crew to communicate and resolve audit (LOSA) lessons and best practices. anomalous events before they become anoma- In a column titled “Myths and Training,” Wil- lous emergencies. liam R. Voss, president of Flight Safety Founda- Chris Nutter is a staff instructor at the University of tion, raised the same issues in relation to the Air Southern California Aviation Safety and Security Program, France 447 accident (ASW, 7–8/11, p. 1): and a captain and check airman for a major airline. “This tragedy compels us to ask some tough Thomas Anthony is director of the Aviation Safety and questions about training. Do we spend so much Security Program at the Viterbi School of Engineering, time driving simulators around at low altitudes University of Southern California. with one engine out that the real risks are only discussed in the break room? This issue extends Notes far beyond Air France and Airbus; it is about an industry that has let training get so far out of 1. Loukopoulos, L.D.; Dismukes, R.K.; Barshi, I. The Multitasking Myth: Handling Complexity in date that it is irrelevant, and people are left fill- Real-World Operations. Burlington, Vermont, U.S.: ing in the blanks with folklore.” Ashgate Publishing Co. 2009. While flying as a line captain for US Air, 2. Shappell, S.; Detwiler, C.; Holcomb, K.; Hackworth, Robert Sumwalt established a cockpit procedure C.; Boquet, A.; Wiegmann, D. Human Error and similar to the IHTAR call-out to clearly identify Commercial Aviation Accidents: A Fine-Grained who was flying the aircraft and who had respon- Analysis Using HFACS. DOT/FAA/AM-06/18. FAA sibility to perform other tasks. Office of Aerospace Medicine. July 2006. flightsafety.org | AeroSafetyWorld | March 2012 | 25 threatanalysis Debris
The controlled re-entry of NASA's Upper Atmosphere Research Satellite in September 2011 likely deposited about 500 kg (1,100 lb ) of surviving debris into an ocean.
A notice to airmen that spacecraft fragments could fall through European airspace prompted a quick risk assessment.
By Wayne Rosenkrans
he remote possibility that an uncontrolled consumed by burning) — will not be greater than re-entry of orbital debris, also called space 1 chance in 10,000, says the U.S. National Aero- debris, could endanger civil airspace falls nautics and Space Administration (NASA).2 far outside normal experience. Space In January, a de-orbiting spacecraft inspired Tdebris is defined at the international level as “all the Russian Federal Space Agency (ROSCOS- man-made objects, including fragments and ele- MOS) and Eurocontrol to direct the world’s ments thereof, in Earth orbit or re-entering the attention to orbital debris re-entry issues such as atmosphere, that are non-functional.”1 reasonable preparedness, mitigations and limiting Before initiating controlled spacecraft re- human casualty risk. The issues somewhat paral- entries, U.S. programs must demonstrate that leled those surrounding the April 2010 eruption the probability of human casualty from the of the Eyjafjallajökull volcano in Iceland. “surviving” debris — that is, debris not rendered Equivalent gaps in decision-making methods Images: U.S. National Aeronautics and Space Administration National Aeronautics Images: U.S. Extraterrestrial Extraterrestrial harmless by atmospheric demise (objects being regarding orbital debris re-entry events — beyond
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alerting the aviation community — have “On Sunday, the middle of the re- — air drag becomes less effective, and not been identified, based on a brief entry window, the [Eurocontrol] Network objects will generally remain in orbit ASW review of space agency summaries Management Operations Centre received for many decades.” of known risks and mitigations. a copy of an international NOTAM [no- NASA and its counterparts draw A number of documents outline the tice to airmen] from the Russian authori- sharp distinctions between the relative high-level issues and specify mitigation ties, requesting European states to close risks to people from controlled versus procedures required by national authori- their airspace for a two-hour period.” uncontrolled re-entries of spacecraft, ties. For example, according to the Inter- On that day, Eurocontrol facilitated including implications of the survival Agency Space Debris Coordination a coordination process and conducted a of debris long enough to reach aircraft Committee (IADC), a forum for space teleconference for European air navi- altitudes. NASA said, “An uncontrolled agencies from 11 nations and Europe, gation service providers (ANSPs) and re-entry is defined as the atmospheric “If a spacecraft or orbital stage is to be aircraft operators. re-entry of a space structure in which disposed of by re-entry into the atmo- “A number of ANSPs issued a NO- the surviving debris impact cannot be sphere, debris that survives to reach the TAM warning operators of the poten- guaranteed to avoid landmasses. … surface of the Earth should not pose an tial hazard but given the uncertainty Usually, large objects that have impact- undue risk to people or property. This as to the area of possible re-entry, no ed the ground are from uncontrolled may be accomplished by limiting the further action [such as closing airspace entries or orbital decay, so the impact amount of surviving debris or confining or grounding aircraft] was proposed,” point cannot be calculated exactly.” the debris to uninhabited regions, such Eurocontrol said. “The satellite landed To read an enhanced version of this story, go to as broad ocean areas. … The operator of in the Pacific Ocean, some distance
FLIGHTSAFETY.ORG | AeroSafetyWorld | March 2012 | 27 safetyOVERSIGHT
By Wayne Rosenkrans
Visualization of synthesized safety data confirms the theories of analysts and investigators. Now I See
urning numbers into pictures often happens results, data visualization facilitates and guides Visualization 1 (top); at a late stage, or as an afterthought, within analysis from the earliest stage. Some specialists Visualization 2 aviation safety processes, say several special- noted that overlaying data on geospatial/terrain (right) ists involved in U.S. government-industry imagery in Google Earth Pro, ESRI ArcGIS or Tsystem safety efforts and accident investigation. equivalent software offers this capability. Awareness of revolutionary data visualization Geospatial software has been used since the techniques has accelerated, however, among ana- October 2009 launch of the U.S. Federal Aviation lysts and investigators. The implications affect sift- Administration (FAA) Aviation Safety Informa- ing through vast volumes of recorded flight data tion Analysis and Sharing (ASIAS) program. for operator-level insights, generating tables and “The ability to blend all ASIAS data sources easily charts from the templates built into worksheets or has greatly improved,” said James M. Reed, senior databases, and replaying individual aircraft events multi-discipline systems engineer, Aviation Safety with flight data animation software, they said. Analysis, at the MITRE Corp. Center for Ad- Instead of expecting aviation safety analysts vanced Aviation System Development (CAASD), or accident investigators to focus first on raw the not-for-profit, FAA-funded research center data, then graphically communicate analytical that has stewardship of ASIAS data.
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Developers of one of the data visualization programs of all participants (ASW, 11/11, p. 32). software tools used by CAASD, called Tableau, Boeing Commercial Airplanes shared additional have summarized common obstacles to effective data visualization experiences during Flight visual analysis of data: “A major stumbling block Safety Foundation’s 64th annual International Air to widespread adoption is that most people are Safety Seminar (IASS) in Singapore in November. not trained in the graphical design principles needed to construct graphical presentations that Beautiful Evidence support their reasoning process or communicate To study traffic alert and collision avoidance their analytical results to others. … They struggle system (TCAS) resolution advisories (RAs) near with numbers that are slow to read and do not a U.S. general aviation airport located along an show patterns or trends. … Users typically start approach to a major airport, ASIAS and CAASD visual analysis with vague tasks in mind, which analysts conducted data fusion, integration and are refined and transformed as they see graphical analyses with several types of data visualization, views of data. … Skilled users … require a system said Randy McGuire, program manager, Aviation that attends to the graphic details so that they can Safety Analysis, CAASD. One of the final prod- stay in the flow of visual analysis.”1 ucts was a heat map (Visualization 1), a method ASIAS and CAASD briefed AeroSafety World of depicting the concentration of RAs with the and provided examples of using data visualiza- densest shown as a red circle, he said. This image tion for extracting system-level, risk-reduction is a close-up view of one of several dozen concen- insights from government-owned and airline- trations published by ASIAS on a U.S. map (ASW, owned data sources. ASIAS equips and trains 8/09, p. 34). its participating airlines to compare their own “The highest concentration of events is at the safety metrics with industry benchmarks derived center of the circle, and as viewers move away from de-identified, aggregate data contributed by from that, fewer and fewer events have occurred the flight operational quality assurance (FOQA) per unit area,” Reed said. “The two-dimensional Images: © MITRE Corporation
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[2-D] clustering algorithm does not take into Michael Basehore, the FAA program manager account the differences in altitude of RAs, so for ASIAS. “Each of the yellow spheres is where in reality many are invisibly stacked up on top the FOQA aircraft itself got a TCAS RA,” he of each other. We prefer high-fidelity, 3-D tools said. “When we put these actual RAs on top to look at the altitude dimension. These tools of the radar tracks, we saw that they coincided enable us to ‘fly around,’ change the perspective, with the incoming Federal Aviation Regulations and change the vertical scale and symbols/col- Part 121 traffic, and where each RA intersects ors. We fuse a lot of data into a common picture with the general aviation traffic. The reason the that we can then manipulate.” RAs don’t match up identically with the radar The first step en route to the heat map was tracks is that FOQA data are de-identified but visualizing the flow of aircraft into the airport they did confirm that the RAs occurred where using about two hours of radar track data from the typical traffic pattern was.” the FAA’s National Offload Program, McGuire The next-to-last step (Visualization 4) said. “As it turns out, the major flow [depicted replayed actual radar-track data through emula- as purple lines, Visualization 2, p. 29] overflies … tion software, generating purple diamonds the yellow tracks of a traffic pattern with pilots where TCAS RAs hypothetically could occur doing practice touch-and-go landings in the given how TCAS algorithms had handled the familiar racetrack pattern.” real-world encounters (ASW, 10/11, p. 26). “All Another step (Visualization 3) added evi- that the FOQA data could indicate was that Visualization 3 dence to the analysts’ preliminary theory, said TCAS RAs occurred in these locations,” Mc- Guire said. “The data did not tell us anything about the other aircraft involved in the RAs. We went back and looked at the radar data, and then we were able to develop the software emu- lator using the radar data as an input and, as an output, whether or not TCAS RAs would occur. We replayed all the traffic for hot spot areas in the National Airspace System to determine if we could find out why those RAs were occurring.” McGuire noted that, to declutter this image, some yellow/blue lines (radar tracks) underlying the purple diamonds were hidden to emphasize the major flows on the approach route stud- ied. Tracks of aircraft just passing by the area also were hidden even if the aircraft crew had received an RA. ASIAS receives FOQA data from about 30 percent of the total commercial flights in the United States, Basehore said. “We can now run the radar tracks through this emulator, and the emulator extrapolates where we could have seen a TCAS RA if we had had FOQA data from all the flights,” he said. The results of this data visu- alization further confirmed what was occurring near the two airports under review. ASIAS also performs dynamic analysis of airspace, in which real-time data visualizations
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show aircraft symbols moving along their radar tracks in relation to surrounding aircraft and to Google Earth Pro terrain. Dynamic analy- sis helps analysts to comprehend the complex geometries of aircraft interaction from any angle, altitude or direction. “We can display one data source at one point, then bring up another source of data on another screen and see if that confirms what is happen- ing,” Basehore said. “We’ve got the capability to do these on multiple screens using multiple databases at one time.”
Airline Data Visualization Less visually arresting — but equally important — types of data visualization also are available to both ASIAS analysts and analysts at participat- ing airlines. “We use Tableau quite extensively for data-manipulation analytics as our preferred deviations events differ from normal opera- Visualization 4 method now for visualizing the aggregate data,” tions, Basehore said. said Alex Alshtein, project team manager, Avia- “One of the ASIAS metrics in Tableau is tion Safety Analysis, CAASD. “Tableau is very ‘missed approach,’ so an airline analyst can see an powerful for us because we can see over time aggregate view of all airports, or drill down into how things may change such as a different air- a specific airport or a specific runway end over space or a different runway end.” time,” Alshtein said, showing a map of the United ASIAS focuses, with rare exceptions, on States generated by this software. “The size of systemic solutions. “Tableau generates curves each circle representing an airport symbolizes the telling us the normal behavior for all the aircraft number of operations at the airport. Circles also using this particular airport or runway end, for are color-coded so that if their rate of missed ap- example,” Basehore said. “We would look at a proaches is higher than usual, the airport is red; if particular aircraft if we saw something out of it is lower than usual, the airport is green.” the norm — far off on the tail of the curve — Such a data visualization may show, for and see why it was different from all the others.” example, that the root of most unstabilized ASIAS researchers are working on a capabil- approaches among all the airlines serving an air- ity for airline analysts to use Tableau’s dashboard port has been a complicating geographic factor interface to query the FAA’s radar surveillance at just one runway end under certain prevailing data, instantly and automatically generating winds, Basehore said. overlays on geospatial imagery and helping us- Data visualization focuses analysts’ attention, ers to think more clearly about spatial relation- at an opportune moment, on whether a signifi- ships, Alshtein said. (Dashboards are groups cant safety issue exists, Basehore added. “Instead of possible selections and windows containing of having to look at everything, the tool at least query results, all of which change to fit the con- ‘taps them on the shoulder’ and says, ‘You need text of the information sought.) to go over here and look at this aspect in more Tableau dashboards customized by ASIAS detail’ or ‘Something is different here than also graphically display trends and quickly everywhere else.’” reveal “rapid upticks at a particular loca- One caveat emphasized to participating
Images: © MITRE Corporation tion,” and by how many statistical standard airlines is that FOQA-event definitions adopted
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by ASIAS — such as the one for un- way of looking at the data,” he said. “It is in overlaying 2-D and 3-D objects such stable approach — may differ from difficult to form a 3-D mental picture of as flight paths created from data, and those used operationally by an airline’s what is happening on a flight path based selecting or deselecting these objects flight crews or by the airline’s FOQA solely on parameter traces.” during analysis. Most such objects are analysts, he said. CAASD analysts visit FOQA-data animations — highly created by converting recorded data these airlines to learn about their safety regarded for the depiction of spatial and derived data into place marks research and to train airline analysts to relationships — “make some beautiful — points specified by latitude, longi- take full advantage of Tableau and other pictures and some very realistic-look- tude, altitude and time — via Keyhole data visualization methods “to get them ing scenes, probably more realistic than markup language, an international all up to the same level so that they can some of the data that underlies them geospatial standard. take advantage of the processes we are — and there is a danger in that,” accord- Lie presented one data visualization developing at ASIAS,” Basehore added. ing to Lie. Moreover, investigators find of the flight path of a Boeing 737-300 themselves repeatedly “fast-forwarding” depicting the effects of an onboard Google Earth Pro and “rewinding” through the sequential navigation problem and subsequent During aircraft accident investigations, images of animations when trying to safe landing at an airport that the data synthesis and visualization with explain complex causal relationships flight crew found by visual searching. Google Earth Pro extend the capabili- separated by time intervals. The image was based on coordinates ties of older methods, said Simon Lie, Other animation shortcomings recorded by the flight data recorder. A associate technical fellow and senior include limitations in the models false track generated and recorded by air safety investigator, Aviation Safety, of aircraft performance, instrument one of the inertial reference computers Boeing Commercial Airplanes. Other depiction and scenery. “In particular, on the airplane was compared with an geospatial software that models and the instruments and the functions estimated actual track derived from presents 3-D data also would support on the photorealistic primary flight heading, airspeed and altitude data the methods Boeing uses in safety display and other instruments are very determined to have been accurate. investigations. He said that data visual- complex,” he said. The simulation may In another example, data visualiza- ization already stands out as a proven incorporate technically inappropri- tion of intersecting coverage by two “high-bandwidth communication tool” ate content from a flight operations radar antenna sites in relation to a 737- — that is, promoting comprehension manual instead of from the complete, 400 track, overlaid on Google Earth Pro of complex data far more quickly than proprietary engineering description, terrain imagery, clarified whether an older methods. The capability sup- Lie noted. aircraft could have flown out of radar ports today’s investigations involving Combining chronological and spa- range before it was lost at sea. thousands of flight data parameters, tial relationships in ways that are natural The most revealing advancement so messages via aircraft communications and intuitive even for non-experts, far has been overlaying non-geometric addressing and reporting systems, and Google Earth Pro “capitalizes on the in- data on geospatial imagery. Lie cited data from emergency locator trans- nate ability to process visual scenes that Boeing’s investigation of one flight mitters and non-volatile memory in each and every one of us has,” Lie said. crew’s effective response to a 777 en- aircraft systems. The visualizations have been effective at gine power rollback event. “We colored Conventional time-history plots of showing both types of relationships all the flight path based on the difference data points from flight data recorders in one scene, he said. The main limita- in oil temperature between the two remain an important tool for detailed tion noticed is the lack of the precise engines,” Lie said. This data visualiza- study of parameter values such as alti- values or parameters seen in a conven- tion helped investigators to identify sig- tudes and airspeeds, and their variation tional worksheet, table or plot. nificant moments during the sequence over time, Lie said. With the chronologi- The value to aviation safety of of ice accretion on the fuel-oil heat ex- cal advantages of such plots comes a Google Earth Pro is not so much the changer, engine rollback, descent, time significant shortcoming: “The learning satellite-based terrain imagery “painted” interval for flight crew intervention by curve required to quickly interpret the onto geometric contour shapes. Rather, retarding throttles, melting of ice and plot shows it is not necessarily a natural Boeing investigators are most interested the resumption of normal flight.
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Visualization 5
To analyze an approach-phase ac- the thrust asymmetry as yellow lines settings, there was no asymmetry,” he cident, investigators included simul- protruding from the flight path, and the said. “During level off, there was a lot taneous overlays of non-geometric contemporaneous control wheel inputs of thrust asymmetry. … It appears that parameters on both terrain and a scaled as red lines. For example, a large control they never recognized it.” approach chart. The non-geometric wheel displacement was clearly visible In summary, CAASD’s Reed said, method supports the use of layers rep- during straight and level flight. “Visualization gives us the ability … to resenting data for thrust asymmetry as “When both parameters are com- link patterns to our expert knowledge. a yawing force, N1 rotor speed in rela- bined, the relationship between thrust The insights — the various clues to tion to throttle position, control wheel asymmetry and control wheel becomes improve safety — would be much more displacement, radar altimeter data, au- instantly evident — as does the com- difficult to obtain if we did not have tothrust disconnect location, airspeed, bined effects … just prior to the loss of these tools.” stick shaker activation, location of a control,” Lie said. “Google Earth allows stall recovery attempt, satellite weather this 3-D scene to be rotated and viewed Note images, lightning strike data, and text from different angles.” 1. Mackinlay, Jock D.; Hanrahan, Pat; from transcribed cockpit voice record- Once the autothrottle had been Stolte, Chris. “Show Me: Automatic ers and air traffic controller voices. disconnected in this situation, the Presentation for Visual Analysis.” IEEE One product in the set (Visualiza- asymmetric thrust condition became [Institute of Electrical and Electronics Engineers] Transactions on Visualizations tion 5) included vectors — perpendicu- a function of the flight crew’s selection and Computer Graphics. Volume 13 lar lines representing magnitude and within the available thrust range. “At (November 2007). © Boeing Commercial Airplanes © Boeing Commercial path. The purpose was to show over time no asymmetry; at very high thrust presentation-visual-analysis>. flightsafety.org | AeroSafetyWorld | March 2012 | 33 safetyRegulation ith 900 types of unmanned aircraft — must be safely integrated will be flown in the same airspace as aircraft systems (UAS) into the system no later than Sept. 30, traditional aircraft — should be ac- worldwide and a legisla- 2015, and that a comprehensive plan complished within six months of the tive mandate to speed UAS for accomplishing the integration must bill-signing date, in cooperation with Wintegration into the national airspace, be developed within nine months. That the National Aeronautics and Space the U.S. Federal Aviation Administra- plan should provide not only a timeline Administration and the Department of tion (FAA) is poised to propose rules but also a definition of “acceptable Defense, which already operate their later this year to regulate some aspects standards for operation and certifica- own test sites. of UAS operations.1 tion of civil unmanned aircraft systems,” “Technology is advancing to the Although proposed regulations requirements for operators and pilots, point where we now know these have been under development for and a designation of airspace for “coop- systems can reliably fly,” said Michael months, the legislation, signed into erative manned and unmanned flight Toscano, president and CEO of the law by President Obama on Feb. 14, operations,” the law says. Association for Unmanned Vehicle specifies that unmanned aircraft (UAs) The new law also dictates that the Systems International (AUVSI). “The — sometimes called unmanned aerial first phase of the effort — the designa- next step is to work on the regulations vehicles, drones or radio-controlled tion of six test ranges in which UAs that govern the rules of the sky to A new law sets a timetable for incorporating unmanned aircraft into U.S. airspace. JoiningBY LINDA WERFELMAN In U.S. Federal Aviation Administration Aviation Federal U.S. 34 | flight safety foundation | AeroSafetyWorld | March 2012 safetyRegulation The U.S. National Aeronautics and Space Administration has flown Northrop Grumman’s Global Hawk to study hurricane development. ensure that unmanned aircraft do no harm to managed by government or a private company, … manned aircraft or to people or property on what research activities should be undertaken the ground.” and what geographic and climate factors should The Air Line Pilots Association, Interna- influence the site selection. The FAA plans to tional (ALPA) has been cautious about the idea accept comments through early May and then of sharing airspace with an increasing number to develop test site requirements, designation of unmanned aircraft. standards and oversight. “No UAS should be allowed unrestricted Under the new law, some of the smallest access to public airspace unless it meets all the UAs could be in the air very soon. The law high standards currently required for every says that, within 90 days of its Feb. 14 enact- other airspace user,” ALPA said in a UAS white ment, plans should be in place for a simplified paper.2 “The aircraft must be designed to have process to allow government public safety the same types of safety features; reliable, redun- agencies to operate UAs that weigh 4.4 lb (2.0 dant systems; and maneuverability as the other kg) or less, provided the UAs are operated dur- airspace users. UAS operators must meet all ing daylight, within the operator’s line of sight the certification and fitness requirements of air at less than 400 ft above ground level (AGL), in carriers, and the ‘pilots’ flying the UAS aircraft uncontrolled airspace and at least 5 mi (8 km) must meet equivalent training qualification and from any airport “or other location with avia- licensing requirements as pilots of aircraft in the tion activities.” same airspace.” The goal, according to AUVSI and other The FAA asked in early March for public supporters, is to “get law enforcement and comments on the process to be used in selecting fire fighters immediate access to start flying the six test sites, which Transportation Secretary small systems to save lives and increase public Ray LaHood said would “help us ensure that our safety.” Detractors, including the American high safety standards are maintained as the use Civil Liberties Union (ACLU), worry less of these aircraft becomes more widespread.” about aviation safety than they do about fears The agency said it was especially interested that these smallest UAs represent an assault in comments on whether the sites should be on privacy, “bringing us a large step closer to a and Space Administration National Aeronautics U.S. flightsafety.org | AeroSafetyWorld | March 2012 | 35 safetyRegulation temporary loss of control of a U.S. Navy MQ-8B Fire Scout, an unmanned helicop- ter manufactured by Northrop Grumman, that strayed into restricted airspace around the U.S. Capitol. News reports at the time quoted military officials as saying that they considered sending fighter jets to shoot it down. The reports said that the aircraft had taken off from the Bell Helicopter’s surveillance society in which our every move is Navy’s Patuxent Eagle Eye originally monitored, tracked, recorded and scrutinized River test facility in southern Maryland on a was intended for use by the authorities.”3 routine test flight. About 75 minutes later, it in surveillance and Other provisions of the new law call for the lost its control link with Navy operators on reconnaissance work. development within six months of plans that the ground. The aircraft then flew about 23 will allow “small” UAs — those weighing less nm (43 km) northwest and into the restricted than 55 lb (25 kg) — to operate “for research Air Defense Identification Zone around and commercial purposes” in the U.S. Arctic, Washington.4,5 day and night, beyond lines of sight. The law is A report in the Navy Times said that Navy intended to designate permanent areas for the operators switched to a different ground control these UAS operations and to “enable overwater station to restore the control link and direct the flights from the surface to at least 2,000 ft in aircraft to return to the Navy airfield, where it altitude, with ingress and egress routes from se- landed. No one was injured and the aircraft was lected coastal launch sites.” A notice of proposed not damaged in the incident, which officials at- rulemaking (NPRM) is expected later this year tributed to “a software anomaly that allowed the to propose regulations dealing specifically with aircraft not to follow its pre-programmed flight small UAs. procedures.” The software subsequently was The law also will require the FAA to create modified, they said. and update annually a five-year “roadmap” for In another incident, an Air Force Lock- introducing UAS into the National Airspace heed C-130 cargo plane and an AAI Corp. System (NAS). Under the legislative timetable, RQ-7 Shadow UA collided over Afghanistan the first version of the roadmap is due to be ap- on Aug. 15, 2011. Preliminary reports said no proved early in 2013. one was injured in the incident and that the The FAA also will be required to study UAS C-130 received minor damage but was landed human factors and the causes of UAS accidents. safely.6 Several occurrences — most of them An earlier accident — the April 25, 2006, involving military UAs — already have crash of a General Atomics Aeronautical U.S. Coast Guard Coast U.S. been reported, including the Aug. 2, 2010, Systems Predator B near Nogales, Arizona, U.S. 36 | flight safety foundation | AeroSafetyWorld | March 2012 safetyRegulation — prompted the U.S. National Trans- ground, perhaps many miles away from technology” are likely to include oil portation Safety Board (NTSB) to issue the aircraft, and some related ques- and pipeline monitoring, crop dust- its first report on a UA crash, as well as tions, including whether a UAS cockpit ing and other civil and commercial 22 safety recommendations, many of should be required to have the same operations. Those commercial opera- which involved the integration of UAS door security system as the flight deck tions are likely to include photog- into the NAS, and to voice its concerns of a commercial airliner and whether a raphy, aerial mapping, monitoring about differing standards for UAs and UAS pilot should be required to wear a crops, advertising, communications traditional, manned aircraft (ASW, seatbelt. and broadcasting. 12/07, p. 42).7 “A whole new industry will emerge, “This investigation has raised Military Roots inventing products and accomplishing questions about the different stan- Historically, UAS have been flown in tasks we haven’t even thought of yet,” dards for manned and unmanned support of military and security opera- Toscano said. aircraft and the safety implications tions, and the U.S. military currently Under existing procedures, the of this discrepancy,” said Mark V. has about 7,500 UAS in service, many FAA issues certificates of authoriza- Rosenker, who at the time was the of them in Afghanistan. In recent tion (COAs) that permit flights of chairman of the NTSB. Noting the years, UAS use has spread to public public use UAS. The FAA says that, need for rigorous pilot training, use aircraft — those operated by law in issuing a COA, which usually is regardless of whether the trainee enforcement and government agen- effective for a specified length of handles a manned aircraft or a UAS, cies — which fly them on operations time — typically one year — and he added, “The pilot is still the pilot, including search and rescue, border with specified requirements, it may whether he [or she] is at a remote patrol, fire fighting, environmental limit operations in some way, such console or on the flight deck.” monitoring and disaster relief. Other as by including a requirement to flights involve research by public operate only under visual flight rules ‘Inherent Differences’ universities. or only during daylight. Under a The FAA has echoed that sentiment, AUVSI’s Toscano said future COA, an operator may be required although the agency says that “the uses of the “revolutionary-type to coordinate flights with air traffic inherent differences from manned air- craft, such as the pilot removed from the aircraft and the need for ‘sense and avoid,’ [mean that the] introduc- tion of UAS into the NAS is challeng- ing for both the FAA and aviation community.”8 Those challenges have prompted a re-examination of some of the most fundamental aspects of aviation safety, the agency said in its FAA Safety Briefing magazine, which quoted UAS Program Policy and Regulatory Lead Stephen Glowacki as saying, “What we’ve experienced with UAS is almost a retrograde action in terms of trying to understand aviation. In many ways, The SIERRA, designed by the U.S. Naval Research we’re forced to re-evaluate the same Laboratory and developed by the U.S. National things we thought we understood.”9 Aeronautics and Space Administration, has been used in As an example, he cited the new air sampling and low-altitude surveys of remote areas. concept of having a cockpit on the and Space Administration National Aeronautics U.S. flightsafety.org | AeroSafetyWorld | March 2012 | 37 safetyRegulation control and to equip its UAS with regulation, and from critics who view unmanned aircraft, or compromise the a transponder before operating in them as a threat to manned general safety of persons or property on the some types of airspace. In addition, aviation aircraft as well as to people ground.” because a UAS cannot “see and avoid” and property on the ground. other aircraft, it must be accom- Notes Critical Issues panied by an observer or a chase 1. A UAS includes not only a UA but also aircraft that stays in contact with the The FAA has faced a number of key the supporting system, typically consist- UAS during operations outside of issues in drafting the NPRM, including ing of a ground control station and com- restricted airspace.10 the need for UAS, whose pilots are not mand and control links, that enables its The number of COAs being issued in a position to actually see other air flight. has soared in the last few years, from traffic, to instead be equipped to sense 2. ALPA. ALPA White Paper: Unmanned 146 in 2009 to 298 in 2010. Through and avoid potential conflicts. Aircraft Systems — Challenges for Safely June 2011, 251 COAs were issued. An Army official has been quoted Operating in the National Airspace System. Existing policies also permit private as saying, for example, that if the RQ-7 3. Stanley, Jay; Crump, Catherine. Protecting recreational operators to operate model involved in the Afghanistan midair Privacy From Aerial Surveillance. ACLU, aircraft under terms discussed in FAA collision had been equipped with a December 2011. Advisory Circular 91-57. Operations sense-and-avoid system, the accident 4. Cavas, Christopher P. “Lost Navy UAV 12 typically are restricted to below 400 ft could have been avoided. Enters Washington Airspace.” Navy AGL and away from airports and air Other issues include the lack of Times. Aug. 25, 2010. of small UAS, from their supporters, the agency said. “It is critical that UAS 12. Warwick, Graham. “UAV Collision who believe that, because of their size, do not endanger current users of the Bolsters Sense-and-Avoid.” Aviation Week they should be subject to minimal NAS, including manned and other & Space Technology. Aug. 18, 2011. 38 | flight safety foundation | AeroSafetyWorld | March 2012 FlightDeck hortly after takeoff from Douala, Cam- The Cameroon Civil Aviation Author- eroon, on a dark night with convective ity determined the probable cause to be “loss activity in the area, the pilots of Kenya of control of the aircraft as a result of spatial Airways Flight 507, a Boeing 737-800, lost disorientation ... after a long slow roll, dur- controlS of their aircraft. The captain experienced ing which no instrument scanning was done, confusion and spatial disorientation while try- and in the absence of external visual refer- ing to manually recover. His inputs greatly exa ences on a dark night. Inadequate operational cerbated the bank angle, and the aircraft entered control, lack of crew coordination, coupled an unrecoverable spiral dive. with the non-adherence to procedures of flight A captain who makes the cockpit environment acrimonious can be a safety risk. The Toxic Captain BY ROBERT I. BARON © bojan fatur/iStockphoto flightsafety.org | AeroSafetyWorld | March 2012 | 39 FlightDeck monitoring, [and] confusion in the utilization Polar Opposites of the [autopilot], have also contributed to A crew pairing such as this, where there is a cause this situation.”1 strong, domineering captain combined with a This accident was the result of missed reserved and nonassertive first officer, represents opportunities, at the organizational level, to polar opposites in terms of crew coordination, address the captain’s documented deficien- adherence to CRM principles, standard oper- cies in both his flying skills and crew resource ating procedures and general communicative management (CRM). The official investigation ability. Another perspective suggests that the highlighted the captain’s known psychological “trans-cockpit authority gradient” in this ac- traits and deficiencies before, as well as on the cident crew was much too steep.4 At best, a crew day of, the accident. They included his strong pairing should fall into what I call the “ideal character and heightened ego; authoritative crew-pairing zone” (Figure 1). In the Kenya and domineering attitude with subordinates; Airways accident, the crewmembers were at the paternalistic attitude toward the first officer left and right extremes. on the accident flight; documented deficien- The topic of crew pairing deserves much cies in upgrade training, which included CRM, more attention. However, the main subject adherence to standard procedures, cockpit scan of this article is the behavioral tendencies of and situation awareness; a “touch of arrogance” “toxic captains” and how the organization and “insufficient flight discipline.” There had handles them. been numerous recommendations that he attend The term “toxic captain” is not likely to be remedial training.2 found in a flight training manual. Some people Sometimes a captain with a personality of know from unhappy experience what it implies. this type is paired with a first officer who lacks I define a toxic captain as a pilot-in-command the ability and/or experience to voice concerns who lacks the necessary human and/or flying related to the captain’s decisions and actions. skills to effectively and safely work with another The Cameroon accident investigation revealed crewmember in operating an aircraft. Addition- that the first officer was known to be reserved ally, the toxic captain, at times, can make the and nonassertive, and that he was subdued by cockpit environment so acrimonious that the the captain’s strong personality. He was con- successful outcome of the flight may be in seri- cerned about the weather but did not question ous jeopardy. the decision to depart.3 The pilot-in-command of Flight 507 could be categorized as a toxic captain. His deficien- ‘Ideal Crew-Pairing Zone’ Versus Kenya Airways Flight 507 cies were not hidden or hard to detect. In fact, deficiencies documented in the captain’s records clearly indicated red flags and potential prob- lems. Additionally, multiple first officers did not want to fly with the accident captain because of The cockpit his reputation for an overbearing personality Captain First officer and arrogant attitude. left extreme right extreme One of the clearest ways to determine if there is a “toxic captain problem” is to collect and ana- lyze reports, provided they are made. If only one first officer has reported an issue with a particular Note: The ideal crew pairing is in the center of a scale from dominating, at left, to submissive, captain in, for instance, a one-year period, it was at right. The extremes represent the situation on the flight deck of Kenya Airways Flight 507. probably just an isolated incident. However, if 15 Source: Robert I. Baron different first officers during that year went on Figure 1 record that they did not feel comfortable with, 40 | flight safety foundation | AeroSafetyWorld | March 2012 FlightDeck or want to fly with, a certain captain, it is safe to a first officer so disrespectfully. Yet, this type of assume the problem lies with the captain. toxic behavior seems to be more ubiquitous in The toxic captain may not have had an ac- aviation than many realize. cident; however, it may just be a matter of time, as the toxic leadership behaviors go unchecked. Hiding in Plain Sight Take, for example, the following report from an The fundamental question is why are these toxic air carrier first officer that was submitted to the captains, who pose a significant safety risk, U.S. National Aeronautics and Space Admin- allowed to fly for a commercial operator? They istration (NASA) Aviation Safety Reporting typically are not concealed in the system. They System (ASRS): are usually well known to other flight crewmem- bers and to flight attendants. They may even The captain slapped I just finished a trip with the most unprofes- have documented deficiencies that have been sional, nonstandard, weak and violation- the headset off ignored by the airline, as with the Flight 507 prone captain at my air carrier, on a 13-day captain. the first officer’s intra-Asia flight. I must have caught 30 Reasons may exist at the organizational level or more of his mistakes. If I missed some, or at the individual level. The following are head while the first it was because I was getting yelled at. The examples from the organizational aspect: whole trip he tried to get me to quit, but I officer was flying didn’t. On the 12th day, he tried to get off • It could be one of the unusual cases in the trip, but the company didn’t let him. We which the airline is unaware of the toxic an approach. are both under company review. This man is captain. a menace to aviation and an accident wait- • The organization has, perhaps tacitly, ing to happen.5 recognized the captain’s behavior but be- Two additional examples come from the U.S. lieves it is a personality issue rather than Federal Aviation Regulations Part 135 char- a safety risk. ter domain in which toxic captains created an • The organization is fully aware, by virtue of extremely hazardous flight deck environment. safety reports and deficiencies documented In the first example, the captain slapped the in training records, that the captain may headset off the first officer’s head while the first be a safety risk. However, the organization officer was flying an approach. The captain was feels that the safety risk is minimal and not reacting to the new first officer having trouble worth the effort to mitigate. maintaining the proper approach speed. In the second example, the captain lashed out at • The managers responsible, at the organi- the first officer for the duration of a four-hour zational level, for addressing technical and flight because, according to the captain, the first behavioral deficiencies in flight crews do officer “could not do anything right.” During not want an awkward confrontation with a the entire trip, the first officer was subjected to captain, perhaps very senior, who has been harsh criticism about his flying skills and other with the airline for decades. In my opin- negative comments. So bad was the climate in ion, that was at least partially the case with the cockpit that after they landed and stepped the Flight 507 captain. There was a lack of out of the aircraft, the first officer punched the assertiveness, or the ability to speak up to captain in the face. The captain then struck the captain, from the instructor level up to back, and a full-fledged altercation ensued. Both and including upper-level management. pilots spent the night in jail. All of this was exacerbated by Kenya’s I knew both of these first officers. While, at “high power distance” culture, in which the time, they were both new and inexperienced, citizens tend to accept authoritarianism in there is never justification for a captain to treat employee-to-employer relations.6 flightsafety.org | AeroSafetyWorld | March 2012 | 41 FlightDeck Some factors at the individual level are these: traits and attributes. In many cases, reme- diation may be out of the question. Some of • Above all, the captain may not acknowl- those vitriolic personality traits may never be edge that he or she has a problem. Many reversible. captains believe that the other crewmem- That brings us to the second option for bers are the source of cockpit strife. resolution of the toxic captain, termination • Some of the captain’s arrogance and ego- of employment. This can be a very awkward, tism may actually be a coping mechanism uncomfortable undertaking by the airline. used to ameliorate personal insecurities. However, in some cases, where remediation has The captain may feel more in control of been, or would be, ineffective, this may be the situations by making other crewmembers only viable option. At the time of the Flight 507 feel weak. accident, the captain clearly should not have been in command of a commercial aircraft with • Captains from a military background, responsibility for 114 lives, including his own. where strong hierarchical gradients and All perished in that accident. clear positions of power are standard, I recommend that all flight operations take may have difficulties adapting to their the toxic captain issue seriously. There are new environment. It is hard for some typically red flags and incidents that precede captains to fully assimilate into civil far more serious events. If not considered aviation, where effective leadership styles part an operation’s safety management system may be diametrically opposed to those (SMS), this type of aberrant behavior undoubt- used in the military. edly needs to be addressed in the safety risk • Related to the above, the captain may management section of the operator’s SMS. If not buy into CRM principles and the Kenya Airways had approached this differently, teamwork concept. He or she may believe the outcome of Flight 507 might have been that CRM is only for weak pilots and that different. CRM is psychobabble with the sole pur- Do you have a toxic captain in your flight pose of making crewmembers enjoy each operation? other’s company on a long trip. Robert I. Baron, Ph.D., is the president and chief consul- tant of The Aviation Consulting Group. He has more than Remediation or Termination? 23 years of experience in the aviation industry and is an An airline has basically two options for taking adjunct professor at Embry-Riddle Aeronautical University a proactive position toward the toxic captain. and Everglades University. The first option is remediation, or an attempt Notes by the airline to confront the captain and apply some kind of intervention. The second option 1. Cameroon Civil Aviation Authority (n.d.). Technical Investigation Into the Accident of Kenya Airways is termination, which may be appropriate; how- B737-800, p. 57. ever, there may be union issues that complicate this option. Termination may also mean that 2. Lacagnina, M. “Beyond Redemption: Spatial Disorientation Turned a Minor Upset Into a Major the captain simply goes to another airline and Accident.” AeroSafety World 5(7), 24–27. August 2010. continues to be a safety risk. 3. Ibid. Remediation of a toxic captain is the pre- ferred option. However, this can be difficult. 4. Edwards, E. “Stress and the Airline Pilot.” In BALPA It is extremely hard to change ways of doing Medical Symposium. London, 1975. things when they have been done that way 5. NASA ASRS Accession no. 603942. for a long time. It is also very difficult to try 6. Hofstede, G. Cultural Dimensions. ITIM to change someone’s ingrained psychological International, 2009. 42 | flight safety foundation | AeroSafetyWorld | March 2012 TRAFFICCONTROL © Chris Photography Sorensen Air Traffic Safety Action Program reports boost the quantity and quality of NASA’s ASRS database content. Voluntary Revelations he Air Traffic Safety Action Program (AT- since ASRS began processing copies of these SAP) in the United States has generated reports on Nov. 12, 2009. a far higher volume of voluntary safety Before ATSAP was launched, ASRS — the reports from air traffic controllers1 com- 36-year-old program funded by the U.S. Federal Tpared with this work group’s historic reporting, Aviation Administration (FAA) and administered new data show. Officials of the Aviation Safety by the National Aeronautics and Space Admin- Reporting System (ASRS) say that the candor, istration (NASA) Ames Research Center — had details and other subjective attributes of ATSAP been the only independent U.S. program to By Wayne Rosenk r ans By Wayne report quality also have improved significantly directly receive such reports from controllers. FLIGHTSAFETY.ORG | AeroSafetyWorld | March 2012 | 43 TRAFFICCONTROL Controller reports in 2010 and Under the ASRS model, NASA reads said. Of these, 17,216 (68 percent) were 2011 jumped from about 1 percent and triages all reports within three days ATSAP reports — all received near the of the previous total annual ASRS (typically 1.14 days in 2012). If the report end of 2009, in 2010 and in 2011. intake of reports to about 10 percent, fits ASRS acceptance criteria, the control- Over the 10-year period, the direct- says Linda Connell, program director, ler who filed the report receives specified to-ASRS reports totaled 8,077 (32 NASA ASRS. protections against FAA disciplinary ac- percent of all controller reports), with Direct intake of reports by ASRS tion, except when events involve criminal the lowest number, 56, in 2011 and the from controllers about their errors, activities or accidents. highest number, 1,689, in 2006. Follow- safety events and concerns now is much “In our mission, we stay away from ing the transitional year of 2009, the lower than in the past (Figure 1). “There enforcement or corrective action or annual total of ATSAP reports reached is still some flow [of non-duplicative follow-up,” Connell said. “To the best 8,474 in 2010. In 2011, the program controller reports in 2012] that does not of our abilities, we provide information received 7,826 ATSAP reports. come through the ATSAP mechanism,” that is relevant for somebody else to ASRS analysts assign “reported Connell said. “We never know whether look at and move forward. If we look at anomaly” types at the intake stage those controllers still are not aware of a pilot-initiated report and match it to for both ATSAP and direct-to-ASRS ATSAP, or they don’t want to talk about an ATSAP report about the same event, reports, said Charles Drew, ASRS a certain issue through that mechanism.” we can ask, ‘Why did this happen?’ … program manager for Booz Allen Direct reports assure the information is with rich information to begin to un- Hamilton, a NASA contractor. These still obtained, she added. tangle the answer. If people only work categories are not mutually exclusive. ATSAP operates under a relatively with ‘stove-piped’ information, they In 2011, the predominant categories new model, labor agreement and FAA [risk making] decisions about the cause — those to which more than 10 percent policy, with different rules for the confi- in isolation, in a vacuum.” of reports were assigned — were “ATC is- dential and non-punitive treatment of re- From 2001 through 2011, ASRS sue–all types” (84.7 percent), “deviation– ports accepted, investigated and resolved intake included 25,293 direct-to-ASRS procedural/published material/policy” by local event review committees (ERCs). and ATSAP reports from controllers, she (62.2 percent), “airspace violation–all types” (20.5 percent), “deviation–proce- FAA Controllers1 Accelerate Voluntary Safety Reporting dural/clearance” (18.3 percent) and “con- flict–airborne conflict” (14.6 percent). 10,000 ASRS keeps a subset of data, exclud- Direct-to-ASRS reports ATSAP report intake by ASRS ing the narrative, from every report 8,000 received (219,092 in 2008–2011) in its internal screening dataset. Analysts then 6,000 subjectively select a subset of all reports 4,000 for the Full Form Database accessible on- line to the public (an estimated 22 percent Number of reports 2,000 were controller reports in 2008–2011, compared with 13 percent from all work 0 groups). 2005 2006 2007 2008 2009 2010 2011 Year To read an enhanced version of this story, go to Source: Ames Research Center, U.S. National Aeronautics and Space Administration engaged in and/or supporting air traffic services and only to events that occur Figure 1 while acting in that capacity.” 44 | flight safety foundation | AeroSafetyWorld | March 2012 HelicopterSafety he U.S. National Transportation Safety The multi-leg operation began about 2023 Board (NTSB) has cited the pilot's deci- when the helicopter left Conway–Horry County sion to fly into instrument meteorologi- Airport (HYW) in Conway to pick up a patient cal conditions (IMC) as the probable from Georgetown Memorial Hospital for transfer causeT of two fatal crashes in late 2009 and to the Medical University of South Carolina in early 2010 of emergency medical services Charleston (MUSC). After the transfer was com- (EMS) helicopters. pleted, the helicopter was flown to Charleston Air Each crash killed all three people aboard Force Base/International Airport for refueling. — the pilot and two aeromedical personnel — At 2302, the pilot told MUSC flight control that and each involved a Eurocopter AS350. The he was leaving Charleston for HYW with a flight NTSB issued final reports on both accidents in nurse and flight paramedic aboard; at 2316, he mid-January. said he was flying at 110 kt and 1,000 ft above The first of the two crashes occurred at 2331 mean sea level (MSL) and that he expected to ar- local time on Sept. 25, 2009, 1.92 nm (3.6 km) rive at HYW in 29 minutes. southwest of Georgetown County Airport in A routine flight update was due 15 minutes Georgetown, South Carolina. later, but there were no further communications NTSB cites pilot determination to return to home base in connection with two fatal EMS helicopter crashes in 2010. HeadingBY LINDA WERFELMAN for Home © Dave Logan/iStockphoto © Dave flightsafety.org | AeroSafetyWorld | March 2012 | 45 HelicopterSafety Regulations Part 135 competency/proficiency Eurocopter AS350 check, conducted in December 2008, he “satisfac- torily demonstrated inadvertent IMC recovery,” the NTSB said in its final report on the accident. The pilot had worked the day shift, from 0800 to 2000, from Sept. 22–24 and switched to the night shift, from 2000 to 0800 on the day of the accident. The helicopter was manufactured in 2000. It had 2,967 total hours of operation on Sept. 17, when its last 500-hour inspection was completed. Although it was not approved by the U.S. Federal Aviation Administration (FAA) for operations in IMC, it was equipped with instruments to operate in case of inadvertent entry into IMC. However, it did not have on-board weather radar, a night vi- sion imaging system, an autopilot or a helicopter he Eurocopter AS350 is a light five/six-seat utility helicopter first flown in 1974. terrain awareness and warning system. T The first versions to be marketed were AS350 Bs, with either Omniflight’s operations manual said that the Avco Lycoming or Turbomeca Arriel turboshaft engines. The AS350 pilot-in-command was responsible for obtaining B2s, with uprated engines and transmissions, were certified in 1989; weather information before any series of flights, the B3s, with digital engine controls, were first flown in 1997. and Omniflight pilots told accident investigators Both models have a maximum takeoff weight of 4,960 lb (2,250 that they routinely obtained the information kg). Maximum cruising speed at sea level is 134 kt for the AS350 B2 and 140 kt for the B3, and maximum rate of climb at sea level is 1,752 from a base computer at the beginning of each fpm for the B2 and 2,028 fpm for the B3. Range at recommended cruis- shift and advised the Omniflight Operations ing speed with maximum fuel is 362 nm (670 km) for the B2, and 352 Center (OCC) of conditions during their flights. nm (652 km) for the B3. They also called the OCC before beginning a Source: Jane’s All the World’s Aircraft series of flights. Accident investigators did not recover the weather data that the pilot obtained before the from the helicopter, and MUSC flight control acti- accident flight, but actual weather conditions vated the emergency action plan. Sheriff’s deputies reported by the pilot, as well as information located the wreckage about 0206 on Sept. 26. associated with the operations center’s approval The 45-year-old commercial pilot had of the flights, indicated that visual meteoro- reported two months earlier that he had 4,600 logical conditions had prevailed when the flight hours, including 3,736 hours as a naval operation began and during the early portion aviator in the U.S. Marine Corps. He had of the flight. ratings for single- and multi-engine airplane, When the operations coordinator spoke with rotorcraft helicopter, instrument airplane and an MUSC communications specialist at 2242, instrument helicopter, and a second-class the coordinator said that if the pilot called OCC medical certificate. before takeoff from Charleston, they could re- Although he had experience in IMC, he view the weather for the return flight. The pilot was no longer instrument current and was not did not call, and OCC did not contact him, the required to be, because the operator — Omni- report said. flight Helicopters, doing business as Carolina Life The Omniflight base manager at Savannah, Care — conducted its AS350 B2 operations under Georgia, who also was operating a helicopter in © Carlos Alemán/Airliners.net visual flight rules. In his last U.S. Federal Aviation South Carolina the night of the accident, said 46 | flight safety foundation | AeroSafetyWorld | March 2012 HelicopterSafety that, although the weather was deteriorating, autopilots and that pilots be trained to use the forecast called for it to remain “well above them when flying without a copilot. The FAA minimums” for his return to MUSC. He said he said it would study the “feasibility and safety spoke with the accident pilot, who warned him consequences” of requiring either an autopilot about “bad thunderstorms” near Georgetown or a second pilot. and expressed concern that he might not be able to return that night to his base at HYW. ‘Beat the Storm’ Witnesses who saw the helicopter shortly be- The second crash occurred at the end of the pi- fore the accident said it was flying northbound lot’s 12-hour overnight shift at 0600 local time toward the Georgetown airport about 1,000 ft March 25, 2010, near Brownsville, Tennessee. above ground level (AGL) in moderate to heavy He had dropped off a patient at a hospital heli- rain, “with its searchlight turning on and off,” pad in Jackson at 0534, and called the flight- the report said. following center MedCom and the company “Although the pilot encountered an area pilot whose shift began at 0530 — both times of deteriorating weather and IMC, this did to ask about weather conditions, including a not have to occur, as the pilot did not have nearby storm system. to enter the weather and could have returned He told the other pilot that he was waiting to Charleston Air Force Base/International on the helipad for the flight nurses to return Airport or landed at an alternate location,” the and that he “wanted to get the helicopter out” report said. “The pilot, however, chose to enter and return to Haywood County EMS Heliport the area of weather, despite the availability of in Brownsville. The other pilot said that he safer options. checked a computer-based radar weather de- “Based on the pilot’s statement to the piction and saw a front about 65 mi (105 km) Savannah-based pilot regarding bad thunder- southwest and approaching the heliport at 25 storms in the area, he was aware of the weather mph 40 kph). and still chose to fly into it. In addition, the The accident pilot told the other pilot that pilot’s inability to maintain a steady state cruise he believed he had “about 18 minutes to beat the altitude during the flight and the declining storm and return to home base, so he was going The accident pilot altitude throughout the flight likely reflected his to leave the flight nurses behind and bring the attempt to stay below the cloud level. These cues helicopter back,” the report said. ... believed he had should have indicated to the pilot that it was not The helicopter took off from the helipad safe to continue flight into IMC. This decision- about 0551. Both flight nurses had arrived in 'about 18 minutes to making error played an important causal role in time to board. Satellite-recorded data showed beat the storm and the accident.” that the helicopter was flown about 1,000 ft MSL In its final report on the accident, the NTSB for most of the flight segment; the last recorded return to home base.' noted two safety recommendations it had issued altitude was 752 ft MSL (about 350 ft AGL), after previous crashes. with the helicopter flying at 105 mph (91 kt). One, issued in February 2006, called on the FAA to require EMS operators to use “formal- Arrival in 30 Seconds ized dispatch and flight-following procedures After their conversation, the other pilot again that include up-to-date weather information and checked weather radar and saw that the line of assistance in flight risk-assessment decisions.” thunderstorms was about 18 mi (29 km) from The FAA responded with a pending notice of the helicopter’s base. When he went outside, proposed rulemaking. he could not see the helicopter and telephoned The second safety recommendation, issued one of the flight nurses, who told him that they in September 2009, asked the FAA to re- “had the weather beat” and would arrive at the quire that EMS helicopters be equipped with heliport in about 30 seconds. flightsafety.org | AeroSafetyWorld | March 2012 | 47 HelicopterSafety “At the time of the conversation, the on- moving through an area that included the coming [other] pilot observed that it was rain- accident site. Radar showed IMC, heavy rain, ing lightly but that the wind had picked up, lightning and wind gusts of up to 20 kt; the perhaps to about 20 kt,” the report said. “Then, area immediately in front of the system would just after hanging up, he heard an ‘immedi- have been prone to extreme low-level wind ate’ loud clap of thunder and saw lightning shear, the report said. that made him jump. He looked out, saw no Witnesses reported lightning and thunder helicopter and tried to call the nurse without near the accident site, along with high winds success. He then called MedCom and ran and bands of heavy rain. Information from two up the hill to contact the ambulance service organizations that gathered lightning-strike located there.” data showed a number of lightning strikes from Rescuers found the helicopter in a field about 0545 and 0615 but none within 90 seconds of 2.5 mi (4.0 km) east of the helicopter’s base. the accident. The pilot, 58, had a commercial pilot certifi- At the time of the accident, Hospital Wing cate with ratings for single-engine and multi- used a formal risk assessment program that 'The pilot made a engine land airplanes, rotorcraft helicopter, called for an evaluation, at the beginning of a instrument airplane and instrument helicopter. pilot’s duty time, of a number of risks, includ- risky decision to He had about 4,000 flight hours in March 2009, ing low pilot experience, inoperative aircraft when he received his second-class medical equipment, poor weather and lack of night attempt to outrun certificate; records indicated he had about 2,615 lighting. Numerical values were assigned the storm in night hours of helicopter flight time. in each area, and higher numbers indicated He completed his most recent airman higher risks; a score of more than 14 meant the conditions.' competency/proficiency check in August 2009 flight could not be conducted. The evaluation and his most recent instrument competency allowed for subtraction of points in acknowl- check in February 2010. edgment of high levels of pilot experience, use The day before the accident, the pilot had of NVGs and other factors. flown 0.4 hour at night. The previous day, he The accident pilot calculated a total risk of had flown 0.2 hour during the day, 0.2 hour at “3”; two points had been subtracted for pilot night without night vision goggles (NVGs) and experience and NVG use. 0.5 hour at night with NVGs. He had been off The NTSB said that the encounter with duty the previous day. deteriorating weather conditions “did not have The helicopter was an AS350 B3, manu- to occur, as the pilot could have chosen to stay factured in 2008 and delivered to the operator at the hospital helipad. … The pilot made a — Memphis Medical Center Air Ambulance risky decision to attempt to outrun the storm Service, doing business as Hospital Wing — in in night conditions. … This decision-making May 2009; it had accumulated 248 hours total error played an important causal role in the time, and the most recent 200-hour and annual accident.” inspections were performed March 1, 2010. It The report added that although the accident was equipped with NVGs and NVG-compatible occurred near the end of a 12-hour overnight lighting, an autopilot and an enhanced ground duty shift, accident investigators lacked com- proximity warning system. plete information about the pilot’s sleep and The accident investigation revealed no sign rest activities and could not determine whether of pre-impact problems with the helicopter. fatigue contributed to his “faulty decision to at- tempt to outrun the storm.” Line of Storms This article is based on NTSB accident reports ERA- Weather radar showed that, about the time 09FA537 and ERA10MA188 and accompanying of the accident, a line of thunderstorms was documents. 48 | flight safety foundation | AeroSafetyWorld | March 2012 DataLink BY RICK DARBY Drawing the Line A line operations safety audit at IranAir pinpoints safety issues and leads to solutions. ata collected through the line opera- recorder (QAR)/flight data recorder (FDR) tions safety audit (LOSA) process “have analysis and line checks. “QAR/FDR [analy- shown that the source of a large number sis] cannot identify human behavior or flight of errors is the lack of efficient training” crew performance and environmental context; Dand that LOSA represents “the best informa- it also has a high cost-to-efficiency ratio,” they tion to improve training systems, crew resource said. “The other method is the line check to management and flight proficiency checks, evaluate pilots’ performance, and it can be and to refine standard operating procedures,” punitive for pilots who fail. Therefore, pilots according to Roohollah Khoshkhoo, one of the are under high pressure to fake qualification authors of a paper presented at the 64th annual and capability. LOSA is non-jeopardy assur- International Air Safety Seminar, held in Singa- ance for pilots. It avoids the weaknesses of the pore in November 2011.1 A flight safety and op- two other methods. LOSA is different from erations quality expert at IranAir, he described and complementary to other proactive safety the first LOSA conducted at the airline in 2009, programs.” its operational findings and their application to The authors said, however, that LOSA crew training for threat and error management. is only a tool for collecting data, not itself A second LOSA was conducted to determine the a solution: “After LOSA data collection, the improvement since the first. organization must analyze the data, find The authors compared LOSA with other problems to investigate and react in ways that proactive safety programs, quick access improve safety.” © Vlue/Dreamstime.com flightsafety.org | AeroSafetyWorld | March 2012 | 49 DataLink In the first LOSA, observed data were col- lected during three months. Following that, a IranAir Weekly Departures During LOSA Observations LOSA steering committee checked the data and Number of Number of Number of Percentage Observations, Observations, input them to analytical software. Based on Fleet Departures of Flights First LOSA Second LOSA the analysis, the committee devised goals for Boeing 747 34 8.59 11 10 improving crews’ ability to counter threats and Airbus A310 47 11.9 15 15 avoid errors. Airbus A300 67 16.92 21 21 Threats are “uncontrollable external condi- Airbus A320 22 5.5 10 10 tions for the flight crew and must be managed Boeing 727 27 6.82 10 10 by them,” the authors said. They are of two Fokker 100 199 50.26 65 60 types — expected and unexpected. “Expected Total 396 1001 132 126 threats, like thunderstorms, can be anticipated by the flight crew,” they said. “Unexpected LOSA = line operations safety audit Note: threats, such as cargo loading error by ground 1. Individual percentages do not equal 100 because of rounding. staff, occur suddenly. The flight crew has no Source: Roohollah Khoshkhoo et al., IranAir advance warning.” Errors are “crew actions that lead to a devia- Table 1 tion from crew or organizational intentions or expectations.” They come in three varieties: spon- Threats in IranAir First LOSA, by Phase of Flight taneous; linked to threats; and an error chain that causes further errors. “Many errors are managed, Phase of Flight Percentage of Threats but the others lead to another error or undesired Preflight/taxi 50 aircraft state (UAS), possibly culminating in an Takeoff/climb 15 accident,” the authors said. UASs are either air- Cruise 8 craft deviations or incorrect configuration. Descent/approach/landing 19 “Threats must be recognized at the best Taxi/parking 8 time, because after an accident or incident it’s LOSA = line operations safety audit too late to investigate threats,” they said. “On Source: Roohollah Khoshkhoo et al., IranAir the other hand, by LOSA most threats can be proactively identified.” Table 2 At the time of the first LOSA, IranAir had mixed aircraft fleets including Boeing 727s and Threats in IranAir First LOSA, by Type 747s, Airbus A300s, A310s and A320s, and Fokker 100s. “LOSA was undertaken on all Threat Type Percentage of Threats fleets both on short-haul domestic and medium- Environmental 35 haul international routes,” the authors said. A Adverse weather 11.5 minimum of 10 LOSA observations for each Air traffic control 11.5 fleet were obtained in both the first and second Other 12.0 LOSAs (Table 1). Airline 65 In the first LOSA, 73 percent of flights Aircraft malfunction/MEL 30.7 involved at least one threat, with an average of Ground maintenance 14.0 2.19 threats per flight. The greatest number of Dispatch/paperwork 4.4 threats on one flight was seven. Other 15.9 Half the threats occurred during the LOSA = line operations safety audit; MEL = minimum equipment list preflight/taxi phase, the highest percentage Source: Roohollah Khoshkhoo et al., IranAir (Table 2). In descending order of percentage, other threats occurred in descent/approach/ Table 3 50 | flight safety foundation | AeroSafetyWorld | March 2012 DataLink the environment or the airline (Table 3). About Errors in IranAir First LOSA one-third were environmental; two-thirds Percentage of flights with at least one error 94 were airline-associated threats. Environmental Average number of errors per flight 5.71 threats were more or less equally divided among Most errors on one flight 20 adverse weather, air traffic control and “other.” Total number of errors 754 Airline-related threats were most often associ- LOSA = line operations safety audit ated with aircraft malfunction or the minimum Source: Roohollah Khoshkhoo et al., IranAir equipment list. The first LOSA identified one or more Table 4 flight crew errors on 94 percent of flights (Table 4), with as many as 20 errors on a Errors in IranAir First LOSA, by Phase of Flight single flight. “It is obvious that the preflight/taxi-out and Phase of Flight Percentage of Errors then descent/approach/landing phases [had] Preflight/taxi 31.0 the most errors,” the authors said (Table 5). Takeoff/climb 9.0 “Based on the first LOSA results to detect Cruise 14.0 threats and errors, some changes were made for Descent/approach/landing 26.5 improving and enhancing operational perfor- Taxi/parking 9.5 mance and training objectives,” the authors LOSA = line operations safety audit said. “[Changes were made] in standard oper- Note: This assignment of error to phase of flight represents 90 percent of errors. ating procedures (SOPs) in some fleets, [and] Source: Roohollah Khoshkhoo et al., IranAir stabilized approach and sterile cockpit policies Table 5 in the operations manual. Considering the first LOSA results, related memos were sent to pilots of each fleet. Finally, useful changes were Error Types and Outcomes in IranAir First and Second LOSAs made in initial and recurrent training course Percentage of flight Percentage of flight syllabi, especially crew resource management segments with at least segments with at least Error Type one error, first LOSA one error, second LOSA and human factors.” Technical error The changes generated as a result of the SOP cross-verification 59.0 20 first LOSA paid off in the results of the sec- Briefing 36.5 12 ond LOSA (Table 6). Errors were categorized Sterile cockpit 23.0 15 into technical and non-technical types, with Checklist 17.0 9 subcategories of each. In every subcategory, the Manual flying 15.0 9 second LOSA showed improvement. Standard callout 11.5 7 “The most frequent type of technical er- Unstable approach 11.5 5 rors [was] SOP cross-verification, followed by Non-technical error briefing,” the authors said. “The most frequent Crew-to-crew communication 46.0 30 type of non-technical error [was] crew-to-crew communication.” LOSA = line operations safety audit; SOP = standard operating procedure Source: Roohollah Khoshkhoo et al., IranAir Notes Table 6 1. Khoshkhoo, R.; Goodarzi, F.; Sharafbafi, F. “Evaluation and Enhancing of Operational Performance and Training Objective in Accordance landing, takeoff/climb and cruise, which was with Line Operations Safety Audit (LOSA).” equal to taxi/parking. Proceedings of the 64th annual International Threat types in the first LOSA were analyzed Air Safety Seminar. Flight Safety Foundation, according to whether they were associated with November 2011. flightsafety.org | AeroSafetyWorld | March 2012 | 51 InfoScan Harmonic Convergence The United States is collaborating with Europe on ATC modernization, but some industry skepticism remains. BY RICK DARBY REPORTS In 2006, the FAA and the European Com- mission signed a memorandum of understand- Interoperability Is the Goal ing that led to joint meetings and interactive Next Generation Air Transportation: Collaborative Efforts research. In 2011, the FAA and the EU signed a with European Union Generally Mirror Effective Practices, but Near-Term Challenges Could Delay Implementation memorandum of cooperation (MOC) that for- U.S. Government Accountability Office (GAO). GAO-12-48. Tables, malized a “collaborative structure” for NextGen figures, appendixes. November 2011. Available at 52 | flight safety foundation | AEROSafetyWorld | March 2012 InfoScan is “a public-private partnership, where EU accountability reports. … Stakeholders repre- government agencies and private sector entities senting U.S. airlines, the U.S. aviation industry have management roles.” and European avionics manufacturers told us “SJU [the SESAR Joint Undertaking], made that they were aware that work was progress- up of Eurocontrol, the European Commission ing to ensure the interoperability of systems, and 15 member organizations — including air- but they were not aware of specific details. For port operators, air navigation service providers, example, stakeholders in the aerospace equip- manufacturers of ground and aerospace equip- ment industry expressed concerns about the ment, and aircraft manufacturers — is managing differences in NextGen and SESAR’s data comm the development phase and following the master [data communications] implementation time- plan,” the report says. lines but could not say whether the collaborative The report says that the GAO has previously structure of the 2011 MOC could help resolve identified practices that can help enhance and these differences, because they were not familiar sustain collaborative work among U.S. agen- with the details of the MOC’s structure and cies, which can be reasonably expected to apply governance.” to international collaboration. Some of these The lack of complete transparency about practices are “defining and articulating a com- particulars of the collaboration has reinforced mon outcome; establishing mutually reinforcing latent doubts about NextGen and SESAR or joint strategies to achieve the outcome and benefits, the report says: “Some stakeholders establishing compatible procedures; agreeing we interviewed on both sides of the Atlantic upon respective roles and responsibilities; [and] expressed skepticism about whether or when reinforcing individual accountability for col- the future benefits of NextGen and SESAR laborative efforts through agency performance will be realized, echoing concerns that have management systems.” been raised in the past. We have reported on The trans-Atlantic connection appears to be stakeholder concerns about FAA’s not follow- following the proven practices, the GAO says. ing through with its NextGen efforts, which The trans-Atlantic “FAA and SJU officials we interviewed, as made some airlines hesitant to invest in new well as industry stakeholders representing orga- equipment. connection appears nized labor, airlines, and airframe and aerospace “This hesitancy arose after an airline equipment manufacturing companies, generally equipped some of its aircraft with a then-new to be following agreed that the 2011 MOC is a positive develop- data comm system, but because of funding cuts, ment toward ensuring the interoperability of among other things, FAA canceled the program, proven practices, NextGen and SESAR and establishes a means and the airline could not use the system. … In the GAO says. for FAA and SJU to operate across agency Europe, an air navigation service provider rep- boundaries,” the report says. Another promising resentative said that experiences such as FAA’s development is that “the 2011 MOC and related canceling the earlier data comm program have documents define FAA and SJU roles and led airlines to take a cynical view of promised responsibilities.” benefits.” In addition, “FAA’s performance manage- The airlines’ “show me” attitude results in ment system is designed to incorporate all of the their hesitancy to equip their airplanes with responsibilities and duties of each staff member, NextGen/SESAR technologies because “some according to FAA officials we interviewed.” of the key benefits, such as increased capacity Nevertheless, some stakeholders remain and more direct, fuel-saving routing, will not partially in the dark. The report says, “FAA be realized until a critical mass of equipped has not externally reported its collaborative aircraft exists,” the report says. There will be efforts with EU entities in public documents, no first-mover advantage. “It is difficult for an such as its strategic plan or performance and airline to make a business case showing that the flightsafety.org | AEROSafetyWorld | March 2012 | 53 InfoScan near-term benefits of equipping [their airplanes] FOQA Writ Small will outweigh the cost,” the report says. Perceptions and Efficacy of Flight Operational Quality Assurance (FOQA) Programs Among Small-Scale Operators Influencing the unpredictability of Next- Lowe, Shelley E.; Pfleiderer, Elaine M.; Chidester, Thomas R. U.S. Gen/SESAR harmonization are possible FAA Federal Aviation Administration (FAA) Civil Aerospace Medical budget cuts, according to the report, which cites Institute. DOT/FAA/AM-12/1. January 2012. 22 pp. Tables, figures, already-existing restrictions on travel for meet- references. ings. “To reduce travel costs, action plan teams espite safety and economic advantages, have endeavored to schedule their meetings as well as endorsements by the Interna- to coincide with other meetings, and officials “Dtional Civil Aviation Organization, the are making use of technological substitutes for FAA, the National Transportation Safety Board travel,” the report says. “However, a Eurocon- and Congress, not all U.S. operators have trol official said that he does not consider these chosen to participate in FOQA programs,” the virtual meetings to be as effective as face-to- report says. “Participation in FOQA is par- face interactions, and an official representing ticularly low among small operators.” A recent European air navigation service providers told report by the U.S. Government Accountability us that overuse of this technology could impede Office (GAO) said that the majority of U.S. harmonization and result in higher costs over Federal Aviation Regulations Part 121 flights the long run.” are currently operated by airlines with FAA- The 2011 MOC is still in the early stages of approved FOQA programs, but only 17 percent implementation. “Because the components of of smaller carriers have them. the MOC have not yet been put into action, we The report cites the Flight Safety Foundation were unable to judge its effectiveness in facilitat- (FSF) FOQA task force’s efforts to identify issues ing collaboration toward interoperability,” the that might discourage FOQA adoption among report says. “The real test of the MOC’s effec- operators. “Recognizing that data security was tiveness will come when NextGen and SESAR critical, a special working group was created move toward final decisions about implement- from within the FOQA task force to concentrate ing solutions and system components. In on these issues,” the report says. “The working the past, FAA and Europe jointly developed group identified two main areas of concern: that systems that were either not implemented or data in the possession of the federal government were implemented differently by each side … . could be released in response to Freedom of The structure of the 2011 MOC is designed to Information Act requests or through civil litiga- prevent such results in the future. However, the tion, and that information from FOQA data absence of effective collaborative practices does could be used in enforcement or disciplinary not guarantee failure, nor does their presence actions against pilots.” ensure success.” Since FOQA’s early days, “the combined In its conclusion, the report recommends efforts of the FAA and the airline industry have that the FAA provide the industry with more produced procedural guidelines for protecting specific information about its efforts and the FOQA data and engendering trust in the pro- provisions of the MOC. “These details could al- gram,” the report says. Nevertheless, “according low stakeholders to judge for themselves wheth- to [the GAO] report, pilots’ concern about data er interoperability efforts are moving ahead misuse continues to be one of the primary fac- deliberately, as planned, and provide assurance tors that prevent their participation in voluntary that FAA is serious about collaborating on safety programs. … Considered in conjunction interoperability and implementing NextGen.” It with pilots’ attitudes and pressure from pilot reiterated an earlier recommendation that FAA unions, airlines might find it difficult to justify provide current information about how budget the cost of implementing and maintaining a decisions will affect the progress of NextGen. FOQA program if they are dubious about its 54 | flight safety foundation | AEROSafetyWorld | March 2012 InfoScan benefits or concerned about its risks. Increased says. Included in the PFOQA were 16 items FOQA participation among small-scale air in which the respondent chose a number on a carriers might depend on demonstrating that scale representing agreement or disagreement significant safety benefits can be gained, and with a statement. In this experiment, statements positive perceptions of the program sustained, of both positive and negative attitudes toward with minimal cost to the operator.” FOQA were included — for example, “I expect The report describes two experiments about FOQA data to be used to take action to correct FOQA in connection with small-scale flight safety problems” and “I worry that FOQA data operations: will be used for disciplinary actions.” “Disappointingly, approximately 83 percent • “Experiment 1 evaluates pilots’ percep- of the pilots with high negative perceptions scale tions of a FOQA program maintained by scores (45 percent of the total sample) worried a small-scale government operator. The that FOQA data will be used for enforcement [FAA] Office of Aviation System Stan- actions,” the report says. “This is an area where dards (AJW) employs approximately 180 the FAA has perhaps taken its strongest stand pilots and operates within strict budgetary and for which an industry history of honoring constraints. As such, this organization those protections has been clearly demonstrated. faces many of the same challenges as com- This signals that the issue is so important that parable small-scale commercial operators. organizations should strive to consistently re- The FOQA program at AJW has been fully mind pilots of regulatory protections and make operational since 2006, and so pilots’ expe- sure that every demonstration of compliance is rience and attitudes about FOQA should communicated to them.” be well developed in this group.” Experiment 2 involved feedback reports • “Experiment 2 examines operational ef- to AJW pilots based on FOQA data. Analysis ficacy using time series analysis. Trends found that these “interventions” were correlated suggesting improved pilot performance with reductions in the rate of exceedances — in may simply be a function of monitor- which aircraft are operated beyond established normal parameters. ing alone, or might represent a natural ‘The issue is so progression over the course of time. “The overwhelming reduction trend in ex- Time series analysis removes systematic ceedance rates of these events over the course of important that trends so the actual effects of interven- the time series was impressive,” the report says. tions may be evaluated. Time series “Simply by measuring selected flight param- organizations analysis of FOQA event rates should eters, informing pilots what had been observed, should strive to determine whether quarterly reports explaining why exceedances represented an unacceptable risk, and recommending strategies providing feedback to pilots (a cost- consistently remind effective intervention method) can for avoiding these circumstances, AJW pilots produce significant safety benefits.” were able to profoundly and quickly reduce pilots of regulatory the frequency of these events. This is remark- In experiment 1, the researchers used a pre- able because it only required measurement and protections.’ viously validated survey instrument called feedback (i.e., issues endorsed by pilots in the the Perceptions of Flight Operations Quality positive perceptions scale). It did not require Assurance Questionnaire (PFOQA). “Ques- identification of individual pilots, disciplin- tionnaire items were based on the concerns ary action or public disclosure of findings (i.e., and recommendations proposed by the FSF concerns reported by pilots on the negative per- FOQA task force created to identify issues that ceptions scale) to bring about this change. This might hinder or prevent the implementation accomplishment should motivate other small of FOQA programs in this country,” the report operators to consider FOQA programs.” flightsafety.org | AEROSafetyWorld | March 2012 | 55 Let AeroSafety World give you d Quality an Quantity Chances are, you’re reading this magazine because Number of copies each issue Annual rate for you want to be up on everything that matters in (11 issues per year) each recipient (plus shipping) aviation safety. 25–149 US$38.50 Why not order it in bulk for your front-line 150–299 $33.00 employees? 300-499 $27.50 500 or more $22.50 That way, you can be sure there’ll be enough copies to go around, and crewmembers will have more opportunity to read AeroSafety World when it best suits their schedule. We offer annual bulk subscriptions at attractive rates. Shipments can be sent to one location or multiple locations. For more information or to order, contact Susan Lausch, [email protected], +1 703.739.6700, ext. 212. OnRecord Taxiway Takeoff Pilots were distracted by a ‘sudden surge in cockpit workload’ during line-up. BY MARK LACAGNINA The following information provides an aware- responsibility for taxiing solely to pilots-in- ness of problems that might be avoided in the command and “did not provide a sufficiently future. The information is based on final reports robust process for the verification of the de- by official investigative authorities on aircraft parture runway before commencement of the accidents and incidents. takeoff roll.” The passenger terminal is on the east JETS side of the Hong Kong airport and between parallel east-west runways, both 3,800 m Controller Called for Abort (12,467 ft) long and 60 m (197 ft) wide. Airbus A340-300. No damage. No injuries. The south runway was closed for scheduled he flight crew had been instructed by air traf- maintenance, and the A340 flight crew was fic control (ATC) to expedite their departure told to taxi to Runway 07L for their departure Tand were completing a variety of tasks when to Helsinki, Finland. Visual meteorological they inadvertently turned onto a parallel taxiway conditions (VMC) prevailed, with 10 km (6 and began a rolling takeoff. The A340 was ac- mi) visibility. The report did not specify the celerating through 75 kt when the air movements number of people aboard the A340. controller told the crew to stop. The pilots re- The aircraft was about 1,400 m (4,593 ft) jected the takeoff and, after waiting for the brakes from the end of the outer parallel taxiway, to cool, departed without further incident. Taxiway B, when the air movements controller The serious incident occurred at Hong Kong confirmed that the crew was ready for de- International Airport the night of Nov. 27, 2010. parture and asked them to expedite their taxi The final report by the Accident Investiga- and to line up on Runway 07. Another aircraft tion Division of the Hong Kong Civil Aviation was on an 18-nm (33-km) final approach to Department said that a causal factor was “a Runway 07L, and the controller planned for combination of a sudden surge in cockpit work- the A340 to depart before the other aircraft load and the difficulties experienced by both the landed. The A340 was nearing the end of captain and the first officer in stowing the EFB Taxiway B when the controller cleared the [electronic flight bag] computers at a critical crew for takeoff. point of taxiing shortly before takeoff, [which] When the aircraft reached the end of distracted their attention from the external Taxiway B, the captain made a right turn onto environment [and] resulted in a momentary Taxiway A1, which crosses the inner taxiway, degradation of situation awareness.” Taxiway A, and leads to Runway 07L. Instead of The report also faulted company standard taxiing the aircraft onto Runway 07L, how- operating procedures (SOPs) that delegated ever, the captain turned onto Taxiway A and flightsafety.org | AEROSafetyWorld | March 2012 | 57 OnRecord transferred control to the first officer, who changes in the lighting, marking and signage began a rolling takeoff, per company procedure. at the hot spot. “This abnormal maneuver was detected by The report noted that information in the the ground movements controller on the ad- Hong Kong Aeronautical Information Publica- vanced surface movement guidance and control tion about the hot spot had not been incorpo- system,” the report said. The ground controller rated in the A340 operator’s airport briefing. alerted the air movements controller, who radi- Among the recommendations generated by the oed the crew to “stop rolling.” investigation were that the operator ensure that The crew brought the aircraft to a stop 1,400 safety-significant information is incorporated m from the west end of the taxiway at 0124 local in airport briefings in a timely manner and that time, or about 14 seconds after initiating the Hong Kong ATC managers ensure that clear- rejected takeoff. After waiting about 50 minutes ance for takeoff on Runway 07L is not issued at for the wheel brakes to cool, the crew departed night until ensuring that the aircraft has passed from Runway 07L. Taxiway A or has entered the runway. Investigators found that neither the captain, the first officer nor the relief pilot stationed in Approach to a Closed Runway an observer’s seat realized until the controller’s Boeing 777-300. No damage. No injuries. call that the takeoff had been initiated on the n route from Narita, Japan, with 117 pas- taxiway. While turning the aircraft onto the sengers and seven crewmembers, for a taxiway, the captain had made a public-address E50-minute flight to Kansai International announcement for the flight attendants to be Airport the night of Aug. 30, 2010, the flight seated, activated the weather radar system and crew had briefed for the instrument landing transferred control to the first officer. Both system (ILS) approach to Runway 24L. Near- pilots completed the “Line-Up Checklist,” and ing Kansai, however, the crew accepted an both had difficulty stowing their EFBs. During offer by ATC to expect a visual approach to the turn, the first officer disengaged the air- the runway. conditioning packs and checked the fuel load The report by the Japan Transport Safety just before setting thrust for the company- Board said that although VMC prevailed, “a visu- preferred rolling takeoff. The relief pilot was al approach to the airport is very difficult at night looking down during the turn, trying to make due to a lack of light in the vicinity.” The longer, ‘No queries were sure that his EFB was stowed and that there parallel runway, 24R, was closed for maintenance, were no loose items on his tabletop. but its approach lights and precision approach ever raised among “Both [operating] pilots stated that they path indicator (PAPI) lights were on. the three pilots saw the red stop bar lights perpendicular to the Soon after the approach controller issued centerline but dismissed them as part of the a heading of 100 degrees, a vector to establish concerning the lighting system leading to the displaced runway the 777 on a right downwind leg for Runway threshold,” the report said. “No queries were 24L, the crew reported that the runway was in correct positioning ever raised among the three pilots concerning sight. The approach controller cleared the crew the correct positioning of the aircraft.” for a visual approach and instructed them to of the aircraft.’ Taxiway A1 was a known hot spot. Prior establish radio communication with the airport to the incident, three other flight crews had traffic controller. initiated takeoffs on Taxiway A, rather than When the crew reported that the aircraft was on Runway 07L. These incidents also had established on downwind, they were cleared to occurred after midnight, with good visibil- land on Runway 24L. The first officer, the pilot ity and light traffic, and after the crews were flying, disengaged the autopilot, turned onto a cleared for takeoff before reaching Taxiway right base leg and told the captain to perform A1. The previous incidents had led to several the landing checklist. He then saw runway and 58 | flight safety foundation | AEROSafetyWorld | March 2012 OnRecord PAPI lights, and turned onto final approach to Transport Canada subsequently issued an what he thought was Runway 24L. airworthiness directive requiring compliance Both pilots noticed Both pilots noticed that their navigation dis- with a Bombardier service bulletin that in- plays showed abnormal indications for the ILS formed CRJ operators about the accident and abnormal indications approach to Runway 24L and realized that they recommended replacement and rerouting of the were on final approach to Runway 24R. Almost oxygen line. for the ILS approach simultaneously, at 2155 local time, the airport to Runway 24L traffic controller advised the crew that they were Gust Spoils Landing Dassault Falcon 10. Substantial damage. No injuries. approaching the closed runway and asked if they and realized that could make a left turn to align the aircraft to he flight crew had to circumnavigate several land on 24L. thunderstorms during the flight to Sellers- they were on At the time, the 777 was about 3 nm (6 km) Tburg, Indiana, U.S., the night of March 23, from Runway 24R, and the crew decided that 2011. The airport’s automated weather observa- final approach to side-stepping to Runway 24L would be difficult. tion system was reporting VMC, with surface Runway 24R. They conducted a go-around and subsequently winds from 310 degrees at 19 kt, gusting to 27 landed the aircraft on Runway 24L without fur- kt. Nearing the airport, the crew canceled their ther incident. During the go-around, the lights instrument flight plan and conducted a visual for Runway 24R were turned off. approach to Runway 36, which was 5,500 ft (1,676 m) long and 100 ft (30 m) wide. ‘Electrical Anomaly’ Ignites Fire “The captain [the pilot flying] reported Bombardier CRJ200. Substantial damage. No injuries. that the landing reference speed (VREF) was hortly after external electrical power was 110 kt, which included a 5-kt gust factor,” the applied to the CRJ in preparation for its de- NTSB report said. “As the airplane touched Sparture from Tallahassee (Florida, U.S.) Re- down on its main landing gear, it encountered gional Airport the morning of Feb. 28, 2009, the a wind gust that raised the left wing. The captain and a flight attendant, the only people captain corrected with a left roll input as he aboard the airplane, heard a hissing sound and simultaneously reduced the airplane’s pitch detected smoke and signs of a fire. They evacu- in an attempt to place the nosewheel onto the ated through the cabin door. runway, but the airplane became airborne and “Evidence suggests that the fire initiated as a drifted off the runway. result of an electrical anomaly in the top portion “The airplane touched down for the second of the JB-1 junction box, near bus bar and con- time in the grassy area alongside the runway, tactor components,” said the report by the U.S. where the subsequent landing roll was complet- National Transportation Safety Board (NTSB). ed without further incident.” The junction box, located in the upper fuselage The pilots and their passenger were not between the cockpit and cabin door, contains injured, but the Falcon’s right main landing gear, components associated with the distribution of right wing spars and forward pressure bulkhead electrical current from the auxiliary power unit were substantially damaged. Additionally, “both and external power sources. engines appeared to have ingested foreign object “The fire ignited combustible materials, debris past their first compressor stages,” the including insulation blankets, and spread report said. upwards toward a flexible oxygen line mounted above the JB-1 junction box,” the report said. Turbulence Triggers Control Loss “The flexible oxygen line ignited when exposed Cessna Citation 680. Substantial damage. No injuries. to the fire, and the fire burned through the he flight crew did not obtain forecasts or aircraft’s fuselage” before it was extinguished by recent pilot reports of moderate or greater fire fighters. Tturbulence along the route before departing flightsafety.org | AEROSafetyWorld | March 2012 | 59 OnRecord from Denver for a positioning flight to Eagle, Canada, the afternoon of Jan. 2, 2010, when Colorado, U.S., the morning of Feb. 13, 2010. one of the medical technicians aboard in- The Citation encountered extreme formed them that there was smoke in the mountain-wave turbulence after leveling at cabin. At the time, the King Air was in instru- 18,000 ft. “The extreme-turbulence encoun- ment meteorological conditions (IMC) about ter caused a brief loss of control that lasted 5 nm (9 km) from the runway at Sept-Îsles less than a minute,” said the NTSB report. Airport, which had 2 mi (3,200 m) visibility in “The airplane then made an uneventful de- freezing drizzle and fog, and broken ceilings at scent and landing. 900 ft and 2,000 ft. “A postflight inspection of the airplane re- “The crew had little time to assess the vealed overstress damage that caused wrinkling situation and take appropriate action,” said and debonding of portions of the top skin on the report by the Transportation Safety both wings.” Board of Canada. They did not declare an emergency or conduct the “Smoke and Fume Unsecured Tow Bar Separates Elimination” checklist, which requires in Boeing 737-800. Minor damage. No injuries. part the donning of oxygen masks. However, tractor was pushing the 737 from the gate the captain did turn off the switches for the at Dallas–Fort Worth International Airport fluorescent cabin reading lights and the “No Awhen the tow bar separated from the Smoking” and “Fasten Seat Belts” signs, and airplane’s nose landing gear the evening of Feb. closed the engine bleed air valves. He did not 20, 2011. The 737 then rolled backward, and its pull any circuit breakers. right wing struck the nose of a parked McDon- The first officer, the pilot flying, trans- nell Douglas MD-82. ferred control to the captain and went to the The communications cord between the trac- cabin, where “he observed the presence of tor and the 737’s flight deck had been severed, gray smoke, which appeared to be dissipat- and “the captain and first officer, who were ing,” the report said. The first officer then re- in the process of starting the engines, were turned to the cockpit and briefed the captain unaware that the airplane was rolling freely,” the on what he saw. NTSB report said. The King Air was landed without further None of the 145 people aboard the 737 was incident. After taxiing to the company’s facility, injured, and damage was minor. However, dam- however, the crew again saw smoke but were age to the unoccupied MD-82, which was oper- unable to determine the source. While the three ated by the same airline, was substantial. medical technicians exited the aircraft and the The airline examined the tow bar and stretcher patient was removed by ambulance found no mechanical failures or abnormalities. attendants, the first officer used his cellphone NTSB concluded that the tractor driver had to advise the airport’s flight service specialists not confirmed that the tow bar was secured of the situation and to request the assistance of properly to the airplane before beginning the municipal fire fighters. push-back. An examination of the aircraft revealed that paint on the upper left fuselage was burning. TURBOPROPS “The crew again opened the main [cabin] door and discharged three portable fire extinguish- Connector Ignites Cabin Fire ers,” the report said. “When the Sept-Îsles Beech King Air 200. Substantial damage. No injuries. municipal fire fighters arrived, the fire was he flight crew was conducting an emer- under control.” gency medical services (EMS) flight from The aircraft was manufactured in 1976 TLa Romaine to Sept-Îsles in Quebec, and had more than 19,300 flight hours. The 60 | flight safety foundation | AEROSafetyWorld | March 2012 OnRecord source of the fire was traced to arcing between the wings and deicing boots. NTSB concluded an electric power supply and connector for the that the probable cause of the accident was “the fluorescent lights in an upper cabin panel. The failure of the pilot to maintain adequate airspeed arcing had ignited a strip of fabric. Components during the approach, resulting in a stall” and damaged by the fire included two interior panels that a contributing factor was “the accumulation and a portion of the fuselage skin. Repairs in- of structural icing during the flight.” cluded replacement of cabin insulation material and installation of newer fluorescent lighting Seized Gearbox Forces Deadstick Landing power supplies. Pilatus PC-12/45. Substantial damage. No injuries. The report noted that, based on several he PC-12 was climbing through 18,000 Components similar occurrences, the manufacturer had ft during an EMS flight with four people issued recommendations in 2002 that the fluo- Taboard from Derby to Kununurra, West- damaged by the fire rescent light power connectors “be thoroughly ern Australia, the night of Jan. 29, 2010, when included two interior cleaned and not be handled with bare hands the pilot felt the airframe shudder significantly in order to avoid contaminating them, and the and heard a loud humming and whining noise. panels and a portion electrical plug that fits the connector be tight “Seconds later the engine ‘CHIP’ caution light and free of dirt.” The manufacturer also had illuminated, indicating the detection of metal of the fuselage skin. advised that loose or contaminated connectors chips in the engine oil,” the Australian Transport can increase electrical resistance “that could Safety Bureau report said. produce sufficient heat to damage the connec- The pilot declared an urgency and turned tor and power supply.” back toward Derby, which was about 56 km (30 nm) away. Shortly thereafter, engine oil pres- Icing Factors in Approach Stall sure and torque decreased, and the inter-turbine Beech C-99. Substantial damage. No injuries. temperature increased. he pilot was conducting a cargo flight The aircraft was about 11 km (6 nm) from the morning of Jan. 6, 2010, to Kearney, Derby when the low oil quantity caution light TNebraska, U.S., which had 1/2 mi (800 m) illuminated. The pilot shut down the engine, visibility in freezing fog, a 200-ft overcast and and the propeller feathered and stopped surface winds from 130 degrees at 4 kt. He said rotating immediately. The pilot declared an that the C-99 accumulated light to moderate emergency and glided the PC-12 to a landing icing during the ILS approach, and he cycled at the airport. the wing deicing boots once before reaching the Examination of the engine revealed that the final approach fix. propeller reduction gearbox had seized. “The Indicated airspeed was 120 kt, and the C-99 investigation found that four of the six first- was configured with the landing gear and 30 stage reduction gearbox bolts had failed due to percent flaps extended, when the pilot gained vi- fatigue cracking,” the report said, noting that sual contact with Runway 36 about 250 ft above another bolt had fractured due to overstress. ground level. He made a slight left turn and a “Debris from the failed bolts was released into right turn to align the airplane with the runway the first-stage sun and planet gears, causing centerline. significant damage.” “When the airplane was wings-level and Pratt & Whitney found that a number of about 25 ft above the runway, the left wing reduction gearbox bolts for PT6A-67 series en- stalled, and the airplane landed hard on the left gines had not been “cold-rolled” during manu- main landing gear, bending the rear spar of the facture by the supplier to increase their hardness left wing,” said the NTSB report. and strength. The company subsequently issued Examination of the airplane revealed 3/8 two service bulletins recommending replace- to 1/2 in (1 to 1 1/4 cm) of ice on portions of ment of the bolts. flightsafety.org | AEROSafetyWorld | March 2012 | 61 OnRecord Overrun on a Short, Icy Runway stronger winds than the day before. “However, Cessna 208B Caravan. Substantial damage. No injuries. when it came to demonstrating stalls, the exam- he Caravan was on a scheduled flight to iner asked for slow flight up to the first indica- Kipnuk, Alaska, U.S., the afternoon of Jan. tion of stall and not an actual stall,” the report T6, 2011. Surface winds at the airport were said. “He asked for call-outs and a minimum from the northeast at 10 kt, and the captain said loss of altitude [in the] recovery.” that he landed long on Runway 33 to avoid a The SAS circuit breaker, apparently inten- bump on the 2,120-ft (646-m) runway. tionally, was not reset before the flight began. “As the airplane touched down on the run- “The commander undertook the tasks of adding way, he applied brakes and moved the propeller power and retracting gear and flaps on the can- into beta,” the NTSB report said. “During the didate’s request,” the report said. “During this landing roll, he realized the airplane was still exercise [in IMC], the crew lost control of at- traveling too fast on the snow- and ice-covered titude and airspeed.” Radar data showed that the runway to stop, and he did not have enough area Merlin climbed about 400 ft before descending to abort the landing.” at up to 10,000 fpm into the North Sea. The can- With maximum wheel braking applied, the didate, commander and examiner were killed. Caravan overran the runway and struck a ditch. “This accident highlights the need for a Damage was substantial, but the four passen- change in the current training on initial stall- gers, the first officer and the captain escaped recovery techniques, especially the focus on mini- injury. mum loss of altitude at the expense of breaking the stall by lowering the nose and, thus, reducing ‘Unsuitable Weather’ for a Check Ride the angle-of-attack,” the report said. Fairchild Merlin. Destroyed. Three fatalities. he English summary of an accident report PISTON AIRPLANES issued by the Norwegian Accident Inves- Ttigation Board in December 2011 said Airspeed Anomaly Cited in Overrun that weather conditions were “not suited” for Cessna 402C. Substantial damage. No injuries. a check ride administered in June 2008 to a he commuter airplane was descending to newly hired airline first officer. A “low ceiling, join the landing pattern at Watertown, New rain showers, winds up to 40 kt and turbu- TYork, U.S., the afternoon of Feb. 1, 2010, lence” prevailed in the area of Bergen Airport when the pilot noticed the indicated airspeed Flesland, the report said. decrease from 145 kt to 85 kt. He applied full On the first day of the check ride, June 19, power and lowered the airplane’s nose, but the “turbulence caused the stick pusher to activate indicated airspeed did not change. during the demonstration of slow flight,” the re- Weather conditions were deteriorating, with port said. “The commander decided to pull the low clouds and snow squalls near the airport. circuit breaker for the stall avoidance and stabil- The pilot “considered climbing to a higher ity augmentation system (SAS), presumably to altitude in order to troubleshoot the airspeed avoid nuisance activations of the stick pusher.” anomaly; however, due to the weather condi- The candidate found the next task, a stall tions, he decided to land as soon as possible,” demonstration, “frightening” and “experienced the NTSB report said. great difficulties, having to use all her available The pilot perceived that the 402’s ground- physical strength to remain in normal flight speed was higher than the 85-kt indicated with the engines on full power and [the aircraft] airspeed, but he did not cross-reference the in IMC,” the report said. airspeed indicator on the right side of the The examiner required the same tasks to instrument panel. He extended the landing gear be performed the next day, which had even and 20 degrees of flap on final approach to the 62 | flight safety foundation | AEROSafetyWorld | March 2012 OnRecord 5,000-ft (1,524-m) runway, which was covered that the pilot misidentified these as the lines with 1/2 in (13 mm) of snow. depicted on the maps,” the report said. “Nei- “The airplane touched down about 1,000 ther of the sets of power lines [was] equipped ft [305 m] beyond the threshold of the runway with spherical visibility markers or similar and bounced slightly,” the report said. “The identification devices.” nose landing gear made runway contact about Department employees who had flown with mid-field. … The pilot applied the brakes but the pilot on previous deer-surveying missions observed the braking action to be nil.” told investigators that during his preflight brief- The landing gear collapsed and all the pro- ing, he had asked the passengers to watch for peller blades were bent when the 402 overran obstructions. However, the report said, “At the the runway onto snow-covered terrain. The six time of the accident, the state agency did not passengers and the pilot were not injured. have any formal safety or operational train- “Post-accident testing revealed that the ing systems in place for passengers who fly on pitot tubes were warm to the touch when the surveying missions.” pitot heat switch was turned on,” the report said. “Unregulated air pressure was applied Collective Mistaken for Brake to the [pitot system]. The corresponding Sikorsky S-92A. Substantial damage. No injuries. airspeed indicators displayed needle move- marshaller was guiding the commander in ment, with no leaks detected. Since no further ground-taxiing the helicopter to a stand examination of the pitot-static system was Aat Scatsta Airport in the Shetland Islands conducted, the cause of the airspeed anomaly the morning of March 30, 2011. “When the could not be determined.” helicopter reached the parking position, [the marshaller] signaled the pilot to stop,” said the HELICOPTERS report by the U.K. Air Accidents Investigation Branch. “In accordance with [SOPs], the copilot Wire Strike in a River Valley in the left seat stated ‘disc, brakes, lights.’ The Bell 206B. Substantial damage. Four fatalities. commander leveled the [rotor] disc, exerted toe he JetRanger was two hours into a public- pressure on the foot brakes and then intended to use deer-surveying mission and was being raise the parking brake handle.” Tflown along a river valley near Auberry, Instead, the commander inadvertently California, U.S., when the main rotor struck a raised the collective control lever, the hand power-transmission cable, or skyline, the after- grip of which is located just to the right of the noon of Jan. 5, 2010. The helicopter descended parking brake handle between the crew seats. to the ground, killing the pilot and the three “The helicopter lifted approximately 6 ft [2 m] passengers, who were employees of the state’s into the air, with a slight roll to the left, and the wildlife department. commander instinctively released the collective The NTSB report said that the helicopter lever,” the report said. “The helicopter immedi- was being flown southbound, and the position ately descended and landed heavily.” of the sun would have hindered the pilot’s ability Examination of the S-92 revealed fuselage to see the skyline and four other cables strung deformations in two places and a cracked main between towers about 1,300 ft (396 m) above the landing gear wheel rim. valley. The cables were depicted on a sectional “As a result of this occurrence, the operator aeronautical chart and on a survey map found in promptly issued a flying staff instruction to en- the wreckage. sure that the pilot flying or the pilot monitoring However, another set of power lines has control of the flying controls during critical about 200 ft (61 m) below the cables was not phases of flight or when on the ground, rotors depicted on the maps. “As such, it is possible running,” the report said. flightsafety.org | AEROSafetyWorld | March 2012 | 63 Preliminary Reports, January 2012 Date Location Aircraft Type Loss Type Injuries Jan. 5 Steen River, Alberta, Canada Eurocopter AS 350 major 1 minor/none The helicopter was being landed at a logging staging area when the external long line struck the tail boom, tail rotor and horizontal stabilizer. Jan. 7 Sampit, Indonesia Xian MA60 minor 68 minor/none The flight crew was attempting to turn around after landing when the left main landing gear ran off the side of the runway and sank into soft ground. Jan. 8 Barrancabermeja, Colombia Bell 412 total 4 minor/none Day visual meteorological conditions (VMC) prevailed when the helicopter crashed on a rooftop in a petroleum refinery. Jan. 9 Guayaramerín, Bolivia Xian MA60 major 21 minor/none The fight crew landed the twin-turboprop on its belly after attempting unsuccessfully to extend the landing gear. Jan. 10 Salisbury, Wiltshire, England Eurocopter Gazelle total 3 minor/none The pilot apparently lost control of the helicopter while making a 180-degree turn at low altitude. Jan. 15 Timmins, Ontario, Canada Pilatus PC-12 major 3 none The engine malfunctioned during cruise, but the pilot decided to continue the flight to Timmins, using a higher-than-normal approach speed. The PC-12 overran the runway into snow-covered terrain. Preliminary examination of the engine revealed a leaking oil line attachment. Jan. 15 Raipur, India Hindustan Aeronautics Dhruv total 1 serious, 4 minor/none Witnesses said that the helicopter, which was on a test flight, descended from a height of 100 ft to a hard landing. Jan. 15 Fairbanks, Alaska, U.S. PZL Swidnik SW-4 major 3 none The helicopter struck the runway under unknown circumstances while maneuvering during cold-weather testing at the airport. Jan. 16 Nad Ali, Afghanistan Bell 214 total 3 fatal The helicopter, operated by the U.S. Department of Defense, crashed under unknown circumstances in a remote area. Jan. 17 Chilliwack, British Colombia, Canada Eurocopter AS 350 total 1 fatal The helicopter, operated by the Royal Canadian Mounted Police, emitted smoke while hovering during a training flight and then descended into a wooded area. Jan. 18 Auyantepui, Venezuela Bell 206 total 5 fatal Bad weather was reported in the area when the 206 struck the tabletop mountain. Jan. 19 Puerto Montt, Chile Piper Cheyenne major 8 none After the right engine malfunctioned during a night approach, the pilot landed the airplane with the landing gear retracted on open ground near the airport. Jan. 22 Rio de Janeiro, Brazil Eurocopter AS 350 major 1 minor/none The engine lost power during cruise flight, and the pilot landed the helicopter in a rugged area near a beach. Jan. 22 Dallas, Texas, U.S. Bell 206 major 4 none The tail boom was damaged when the pilot landed the helicopter on a golf course after the engine lost power. Jan. 24 Orange, Texas, U.S. Cessna Citation V major 8 none The nose landing gear collapsed when the Citation veered off the runway while landing in strong winds and heavy rain. Jan. 28 Shishmaref, Alaska, U.S. Reims-Cessna 406 Caravan II major 7 minor/none A main landing gear collapsed as the twin-turboprop was rolling out on landing. Jan. 30 Baltimore, Maryland, U.S. Gulfstream G150 major 2 minor/none The nose landing gear collapsed when the airplane veered off the runway onto soft ground during a night landing. Jan. 30 McBride, British Columbia, Canada Bell 212 major 1 minor After dropping off skiers, the pilot landed at a staging area at the bottom of the hill. He was shutting down the engine when the helicopter was struck by an avalanche. This information is subject to change as the investigations of the accidents and incidents are completed. Source: Ascend 64 | flight safety foundation | AEROSafetyWorld | March 2012 Registration Open CASS april 18–19, 2012 57th annual corporate aviation safety seminar san antonio, texas For details, visit our Web site at flightsafety.org. To advertise in AeroSafety World Magazine, contact Emerald Media. To register or exhibit at the seminar, contact Namratha Apparao, Cheryl Goldsby Kelly Murphy tel.: +1.703.739.6700, ext. 101, [email protected]. [email protected] [email protected] To sponsor an event, contact Kelcey Mitchell, ext. 105, [email protected]. tel: +1 703 737 6753 tel: +1 703 716 0503 To receive membership information, contact Susan Lausch, ext. 112, [email protected]. ASW3.12_Layout 1 2/21/12 1:33 PM Page 1 ARGUS PROS The Global Leader in Aviation Safety Auditing ARGUS PROS is the worldwide leader in on-site safety audits. We have performed over 1,500 audits on 6 continents. In the last 2 years alone, we have performed more than 400 audits to a range of standards including IOSA, IS-BAO, ARGUS Platinum, BARS, HEMS, and FAR Parts 91/135/141/121. 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