Aerosafety World January 2009
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AeroSafety WORLD CONDITIONAL FOQA Acceptance through adaptation SMS UPDATE State programs need work into THE SEA Flawed gas platform approach GROUND SUPPORT Blessings from a dispatcher DOWN AND OUT PILOT INCAPACITATION CONSIDERED THE JOURNAL OF FLIGHT SAFETY FOUNDATION JANUARY 2009 “Cessna is committed to providing the latest safety information to our customers, and that’s why we provide each new Citation owner with an FSF Aviation Department Tool Kit.” — Will Dirks, VP Flight Operations, Cessna Aircraft Co. afety tools developed through years of FSF aviation safety audits have been conveniently packaged for your flight crews and operations personnel. These tools should be on your minimum equipment list. The FSF Aviation Department Tool Kit is such a valuable resource that Cessna Aircraft Co. provides each new Citation owner with a copy. One look at the contents tells you why. Templates for flight operations, safety and emergency response manuals formatted for easy adaptation Sto your needs. Safety-management resources, including an SOPs template, CFIT risk assessment checklist and approach-and-landing risk awareness guidelines. Principles and guidelines for duty and rest schedul- ing based on NASA research. Additional bonus CDs include the Approach and Landing Accident Reduction Tool Kit; Waterproof Flight Operations (a guide to survival in water landings); Operator’sMEL Flight Safety Handbook; item Turbofan Engine Malfunction Recognition and Response; and Turboprop Engine Malfunction Recognition and Response. Here’s your all-in-one collection of flight safety tools — unbeatable value for cost. FSF member price: US$750 Nonmember price: US$1,000 Quantity discounts available! For more information, contact: Feda Jamous, + 1 703 739-6700, ext. 111 e-mail: [email protected] PRESIDENT’sMESSAGE CHANGING THE Conversation have been in the news lately — at least in A million things can create a dysfunctional North America. I have had to make strong discussion. Mergers and acquisitions can put statements about the loss of voluntary re- management and labor at each other’s throats. porting systems at a couple of the world’s A regulator may have been battered by legisla- Ibiggest airlines. tor inquiries, or a labor leader may be sweating Flight Safety Foundation has made a major a close election. Those all affect the day-to-day effort to protect these programs from the threat of operation of many large airlines. They cannot be criminalization. But this time, problems developed allowed to affect the future of safety systems. amid discussions among management, labor and So how do we change the conversation — and the regulator. Disagreement developed around the result? Maybe in the U.S. it’s time to make the extent of protection within the systems. In these vital voluntary reporting systems such as one case, the disagreement was triggered by a flight operational quality assurance (FOQA) and specific event, in another by the need to renew aviation safety action program (ASAP) manda- the program. tory through legislation, as they are in many In my experience the people who participate parts of the world. Legislation could include in those discussions are real professionals. They protection so the use of the data doesn’t have to work hard to keep industrial issues and safety be decided at every trial. There would still be issues apart. But, given the dynamics of the difficult implementation issues, but no longer a situation, sometimes they fail. Perhaps we are question as to whether these programs will exist, discussing these safety programs in an environ- or if their data will be protected. ment that is “spring-loaded to the screw-up To make this work, everybody would have to position.” give up some power and flexibility. But for us it In both cases, the loss of the reporting system would not be the first time. Ever since I was 16 I was driven by issues besides safety. Let us be have made choices about how I lived my life so realistic about the dynamic that exists in those that, some day, a parent would feel comfortable discussions and consider if this is really where trusting the safety of their child to me in an air- we want the fate of these vital safety programs to plane. This is just another of those choices. If we be determined. You have somebody representing all take a second to remember why we got into this labor who can only sit at that table if the member- business, I think we can agree to live with it. ship believes he or she is taking an appropriately hard line with management. On the other side is a manager who can’t go back to his boss and say that he or she has given the other side everything it wanted. In the middle is a regulator who will be held accountable if the resulting deal makes William R. Voss things look too “cozy” between the regulator President and CEO and industry. Flight Safety Foundation WWW.FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JANUARY 2009 | 1 AeroSafetyWORLD contents January2009 Vol 4 Issue 1 features 12 CoverStory | Down and Out 18 FlightOps | Ground Support 12 24 SafetyCulture | Into the Mainstream 18 31 SmokeFireFumes | No Smoking in the Cockpit 38 HelicopterSafety | ‘Flying Into the Sea’ 43 StrategicIssues | Fairly Disciplined departments 1 President’sMessage | Changing the Conversation 5 EditorialPage | Still Needed: Trained People 7 SafetyCalendar | Industry Events 8 AirMail | Letters From Our Readers 9 InBrief | Safety News 24 35 LeadersLog | Nicholas A. Sabatini 2 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JANUARY 2009 43 31 38 AeroSafetyWORLD telephone: +1 703.739.6700 37 FoundationFocus | Donoghue Recognized William R. Voss, publisher, FSF president and CEO [email protected] 49 | Disparate Measures DataLink J.A. Donoghue, editor-in-chief, FSF director of publications 52 InfoScan | Picture This [email protected], ext. 116 Mark Lacagnina, senior editor [email protected], ext. 114 57 OnRecord | ‘Don’t Say Anything’ Wayne Rosenkrans, senior editor [email protected], ext. 115 Linda Werfelman, senior editor [email protected], ext. 122 Rick Darby, associate editor [email protected], ext. 113 Karen K. Ehrlich, web and print production coordinator [email protected], ext. 117 Ann L. Mullikin, art director and designer [email protected], ext. 120 Susan D. Reed, production specialist [email protected], ext. 123 About the Cover Patricia Setze, librarian In-flight pilot incapacitation remains a threat. Photo composite: pilot © istockphoto; clouds © istockphoto [email protected], ext. 103 Editorial Advisory Board We Encourage Reprints (For permissions, go to <www.flightsafety.org/asw_home.html>) David North, EAB chairman, consultant Share Your Knowledge William R. Voss, president and CEO If you have an article proposal, manuscript or technical paper that you believe would make a useful contribution to the ongoing dialogue about aviation safety, we will be Flight Safety Foundation glad to consider it. Send it to Director of Publications J.A. Donoghue, 601 Madison St., Suite 300, Alexandria, VA 22314-1756 USA or [email protected]. The publications staff reserves the right to edit all submissions for publication. Copyright must be transferred to the Foundation for a contribution to be published, and J.A. Donoghue, EAB executive secretary payment is made to the author upon publication. Flight Safety Foundation Sales Contacts J. Randolph Babbitt, partner Europe, Central USA, Latin America Asia Pacific, Western USA Oliver Wyman Joan Daly, [email protected], tel. +1.703.983.5907 Pat Walker, [email protected], tel. +1.415.387.7593 Steven J. Brown, senior vice president–operations Northeast USA and Canada Regional Advertising Manager National Business Aviation Association Tony Calamaro, [email protected], tel. +1.610.449.3490 Arlene Braithwaite, [email protected], tel. +1.410.772.0820 Subscriptions: Subscribe to AeroSafety World and become an individual member of Flight Safety Foundation. One year subscription for 12 issues Barry Eccleston, president and CEO includes postage and handling — US$350. Special Introductory Rate — $280. Single issues are available for $30 for members, $45 for nonmembers. Airbus North America For more information, please contact the membership department, Flight Safety Foundation, 601 Madison St., Suite 300, Alexandria, VA 22314-1756 USA, Don Phillips, freelance transportation +1 703.739.6700 or [email protected]. reporter AeroSafety World © Copyright 2009 by Flight Safety Foundation Inc. All rights reserved. ISSN 1934-4015 (print)/ ISSN 1937-0830 (digital). Published 12 times a year. Suggestions and opinions expressed in AeroSafety World are not necessarily endorsed by Flight Safety Foundation. Russell B. Rayman, M.D., executive director Nothing in these pages is intended to supersede operators’ or manufacturers’ policies, practices or requirements, or to supersede government regulations. Aerospace Medical Association WWW.FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JANUARY 2009 | 3 Managing your LOW RISK air safety flight ops risk... HIGH RISK in-flight safety HIGH RISK maintenance ...has its rewards. Safety Management • Safety reporting module integrates incident data across all departments • Risk assessment calculates and guides decision-making to resolve incidents • Automatically trigger corrective actions from incidents • Schedule and execute safety audits (IOSA) across multiple departments • Consolidate and standardize document control and training across the organization Quality Management