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
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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- biggestI 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 | 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 • Risk assessment determines critical vs. non-critical events, guides decisions • Schedule and track maintenance and equipment calibration • Powerful reporting tool with over 50 reports out-of-the-box • Over 20 integrated modules available: • Incidents • Document Control • Employee Training • Corrective Action • Audits • Calibration & Maintenance • Centralized Reporting... and more! Supplier Management • Foster collaboration with suppliers and contractors • Create visibility into supplier quality and supplier safety • Supplier rating automatically updates scorecards based on quality/safety events Integrated Approach • Integration of Quality, Safety, Environmental, and Supplier data across the enterprise • Holistic Integrated Airline Management System
v i s i t o u r w e b s i t e fo r a f r e e a u t o m a t e d d e m o c a l l fo r a f r e e l i v e d e m o n s t r a t i o n w w w. e t q . c o m / a i r s a f e t y Editorialpage
Still Needed: Trained People
earing in mind the economic chaos positions haven’t been canceled. The Therefore, hundreds of bets have been today around most of the world, it first possibility is a judgment that the placed on a rosy future, and the judg- seems reasonable to expect that or- current malaise is going to be short term, ment of all those smart people must be ders for new aircraft last year would and growth will come storming back so respected. Bhave been, uh, subdued. True, it wasn’t strong it will make up for lost time. This Now, let’s go back to what we were until the year was well under way that the has happened in the past, although not talking about at the start of 2008, a extent of the trouble began to manifest after such a steep decline. History sug- shortage of trained skilled personnel itself, but by midyear the combination of gests that the upward growth line will to run the system — pilots, engineers, murderous fuel prices and declining mar- slide to the right for a year or so, then controllers and so forth — a concern kets had all signs pointing way down. regain the growth slope registered before that faded when fuel prices spiked. Airlines in many regions cut or re- the downturn. The panic measures that airlines took duced routes, and flying capacity was The second possible rationale is to cope with those ridiculous prices down in key markets. Importantly, air- simple strategic positioning, maintain- that suddenly evaporated have become, lines imposed fuel surcharges and gener- ing delivery positions without a firm instead, preemptive measures to deal ally raised the price of a ticket, previously understanding the buyer will need or will with the economic crisis, and the airline considered heresy in the context of mod- be able to afford the aircraft, but with a industry is — surprise, surprise — not ern airline pricing patterns. conviction that someone will need them, about to fall off of a cliff, and should be in Yet, approaching the end of 2008, treating the order as an aircraft futures decent economic health to take advantage when this was written, Airbus was as- market play. of rebounding traffic. sured of having at least its fourth best And finally, there is the balancing Which leads to the point of this sales year ever, with around 800 net air- strategy, available to operators with good ramble: Keep your eye on the skilled- planes sold, and Boeing had sold around financials, that allows for the purchase of personnel issue. The smart money is on 660, a very strong year for that company, aircraft with the assured knowledge that staff being needed sooner rather than for a total of 1,460. This comes on the newer technology aircraft will reduce fuel much later; it is time to refocus on that heels of the all-time record for sales in burn, a hedge against the return of higher issue. 2007 when the two split the market fairly oil costs. This type of player is not making evenly, selling 2,881 aircraft. Aerospace a pure bet for growth; a failure to achieve Industries of America forecasts that U.S. growth expectations can be handled by manufacturers’ sales of civil aircraft will retiring older, less fuel-efficient aircraft. rise 7 percent this year. All three of these scenarios are based J.A. Donoghue There are three reasons that orders on firm expectations of resumed growth; Editor-in-Chief have stayed strong and more delivery only the third has a moderating element. AeroSafety World www.flightsafety.org | AeroSafetyWorld | January 2009 | 5 Serving Aviation Safety Interests for More Than 60 Years
Officers and Staff light Safety Foundation is an international membership organization dedicated to Chairman, the continuous improvement of aviation safety. Nonprofit and independent, the Board of Governors Amb. Edward W. Stimpson 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 General Counsel and knowledgeable body that would identify threats to safety, analyze the problems and and Secretary Kenneth P. Quinn, Esq. recommend practical solutions to them. Since its beginning, the Foundation has acted in the Treasurer David J. Barger public interest to produce positive influence on aviation safety. Today, the Foundation provides
Administrative leadership to more than 1,170 individuals and member organizations in 142 countries.
Manager, Support Services Linda Crowley Horger MemberGuide Flight Safety Foundation Financial 601 Madison St., Suite 300, Alexandria, VA, 22314-1756 USA Chief Financial Officer Penny Young tel: +1 703.739.6700 fax: +1 703.739.6708 www.flightsafety.org Accountant Feda Jamous
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Director of Communications Emily McGee Member enrollment ext. 105 Ann Hill, director, membership and development [email protected] Technical Seminar registration ext. 101 Director of Namratha Apparao, membership services coordinator [email protected] Technical Programs James M. Burin Seminar sponsorships ext. 105 Technical Ann Hill, director, membership and development [email protected] Programs Specialist Norma Fields Exhibitor opportunities ext. 105 Ann Hill, director, membership and development [email protected] Technical Specialist/ Safety Auditor Robert Feeler FSF awards programs ext. 111 Feda Jamous, accountant [email protected] Manager of Aviation Safety Audits Darol V. Holsman Technical product orders ext. 111 Feda Jamous, accountant [email protected] Library services/seminar proceedings ext. 103 Past President Stuart Matthews Patricia Setze, librarian [email protected] Founder Jerome Lederer Web Site ext. 117 1902–2004 Karen Ehrlich, web and print production coordinator [email protected]
flight safety foundation | AeroSafetyWorld | January 2009 ➤ safetycalendar
JAN. 13–15 ➤ Safety Manager Course. MARCH 16–18 ➤ 21st annual European MAY 4–6 ➤ 6th International Aircraft Rescue Aviation Research Group/U.S. Houston. Kendra Aviation Safety Seminar (EASS). Flight Fire Fighting Conference and Exhibits. Christin,
Speed limits reduce their speed. The controller’s re- the pilots must insist on their request irst of all, let me thank and congrat- sponse sounds so familiar to me: “Only (the controller will not take the blame ulate you for your extremely valu- if you want to join the back of the pack.” for the overrun). Under any circum- Fable and interesting publication! The pilots, conditioned to maintain stance, the response to a pilot’s request While studying your article about ambitious schedules, react accordingly: must never be a threat such as delaying English language proficiency require- “Okay, we’ll pin our ears back.” Years the flight. ments (ASW, 11/08, p. 34), I noticed of campaigns for stabilized approaches Thanks again for helping to keep (with a smile) that the cited language just vanished in seconds. the sky safe! sample would equally serve in an article Both the pilot’s and the controller’s about sources of approach and landing reaction were not adequate. Where the Capt. Matthias Schmid accidents. For possibly good reasons, the controller must take safe speeds into Saferflight pilots of an arriving aircraft request to account when planning his traffic flow, Ueken, Switzerland
FSFSeminars 2009 Exhibit and Sponsorship Opportunities Available EASS 2009 March 16–18, 2009 Flight Safety Foundation, Eurocontrol and European Regions Airline Association 21st annual European Aviation Safety Seminar Hilton Cyprus Hotel, Nicosia, Cyprus CASS 2009 April 21–23, 2009 Flight Safety Foundation and National Business Aviation Association 54th annual Corporate Aviation Safety Seminar
Hilton Walt Disney World, Orlando, Florida Kelly / iStockphoto.com Tom © Dainis Derics/ iStockphoto.com;
8 | flight safety foundation | AerosafetyWorld | January 2009 Safety News inBrief ADS-B Expansion
.S. officials have approved plans increased airport capacity,” Antonio for the nationwide deploy- Tajani, vice president of the European Ument of automatic dependent Commission and commissioner for surveillance–broadcast (ADS-B), which transport, said as the program was provides for the tracking of aircraft by launched in early December. their satellite-based position reports In November, U.S. President George instead of radar. Bush signed an executive order to speed The European Union has inau- up implementation of the Next Genera- gurated development of a similar air tion Air Transportation System, or traffic management program using NextGen, as the satellite-based air traffic satellite navigation and data links. control system is called. The SESAR system, founded by the Bush’s action cleared the way for European Community and Eurocon- Robert A. Sturgell, acting administrator trol, also is supported by six regional of the U.S. Federal Aviation Adminis- U.S. Federal Aviation Administration and national air navigation service tration (FAA), to commission essential providers, manufacturers and major services for ADS-B in Florida, where 11 services will be available everywhere in European airports. ground stations are being installed. the United States where radar cover- The €2.1 billion SESAR system is “The next generation of air travel age exists today, and also in the Gulf expected to improve safety by 2020 “by has arrived,” Sturgell said. “ADS-B is the of Mexico and mountainous portions a factor of 10” and to enable a threefold backbone of the future of air traffic con- of Alaska, which currently are without increase in capacity. trol. NextGen is real … and NextGen radar coverage. “The positive impact of SESAR’s is now.” Sturgell said ADS–B would re- goals on the day-to-day activities of the Sturgell said that 310 ground stations duce the risk of midair collisions and airspace users, passengers, air traffic are scheduled to be in operation by 2010; weather-related accidents, provide more controllers and citizens will include by 2013, plans call for the deployment to efficient routes for flights during poor fewer delays, lower fuel consumption, be complete, with 794 ground stations in weather and improve pilots’ situational improved efficiency, time gains and operation. He said that by 2013, ADS-B awareness.
Aviation Job Growth Forecast
espite the economic downturn, demand is likely to in- crease in the coming years for pilots, air traffic controllers Dand maintenance personnel, Roberto Kobeh González, president of the Council of the International Civil Aviation Organization (ICAO), says. In remarks prepared for International Civil Aviation Day in early December, Kobeh said that the demand for workers would be fueled by “a massive wave of retirements” by current pilots, © Guodingping/ Dreamstime.com © Guodingping/ controllers and maintenance technicians, as well as the influx into the system of thousands of new aircraft and the develop- strategies to ensure that the future world air transport system is ment of new technologies that will “transform the very nature supported by enough competent and qualified professionals.” of aviation jobs.” In addition, although the current economic ICAO’s plans call for an effort to help member states main- recession will slow air traffic, the situation is expected to turn tain high standards of training by identifying not only the num- around by 2010, and the industry is expected to begin growing ber of pilots, controllers and maintenance personnel that will be again, according to ICAO projections. needed but also the related training requirements, and ensuring “Human resource development is vital to a safe, efficient that ICAO standards conform with modern training methods. and sustainable air transport system,” Kobeh said. “ICAO Other elements of ICAO’s plans include identifying activities recognizes that professional competence is a critical element in that can be initiated with partners in the aviation industry and achieving optimum levels of safety and is developing training uniting all segments of the industry around a common strategy.
www.flightsafety.org | AeroSafetyWorld | January 2009 | 9 inBrief
Upset Recovery Training
n aviation industry working group The training aid, which discusses — headed by representatives of high altitude aerodynamics and flight g T in urb W o t- f ep a w n S A Airbus, The Boeing Co. and Flight techniques, was developed at the FAA’s e i Industry Solutions for Larg r Than 100 Passengers p ore la ne M s ing Training Aid Typically Seat A Revision 2 Safety Foundation — has developed a request as a result of safety recom- supplement to its Airplane Upset Recov- mendations issued by the U.S. National ery Training Aid that focuses on issues Transportation Safety Board after its associated with flight operations at high investigation of a high altitude loss of altitudes. control accident, as well as other recent The High Altitude Operations accidents and incidents that occurred in supplement, available on the Flight similar high altitude conditions. “experienced an environmental situa- Safety Foundation Web site at “There have been … recent accidents tion where airspeed slowly decayed at
EMS Changes Proposed
he U.S. Federal Aviation Administration (FAA) has published a plan to revise regulatory requirements for he- Tlicopter emergency medical services (HEMS) operations, including stricter weather minimums and specific preflight planning for many HEMS flights. “The FAA has determined that safety in air commerce and the public interest [require] additional hazard mitigation for HEMS operations,” the agency said in its proposal, published in the Federal Register. The plan says that if “any flight or sequence of flights” wikimedia.org includes a segment conducted under Federal Aviation Regula- tions Part 135, “Commuter and On-Demand,” then all visual The plan also says that HEMS flights conducted under flight rules segments of the flight “must be conducted within instrument flight rules will be permitted to land at locations the weather minimums and minimum safe cruise altitude without weather reporting “if an approved weather reporting determined in preflight planning.” source is located within 15 nm [28 km] of the landing area or if Pilots will be required during preflight planning to identify an area forecast is available.” a minimum safe cruise altitude and minimum required ceiling The FAA’s action follows a rash of fatal HEMS accidents in and visibility for the flight. 2008 (ASW, 9/08, p. 12).
10 | flight safety foundation | AeroSafetyWorld | January 2009 inBrief
Safety Audit Requirements Uncommanded Engine Rollback
he International Air Transport he U.S. National Transportation Association (IATA) says that nine Safety Board (NTSB) is investi- Tairlines have lost membership after Tgating a Nov. 26, 2008, incident failing to meet interim safety goals involving an uncommanded engine associated with the IATA Operational rollback on a Delta Air Lines Boeing Safety Audit (IOSA) and, ultimately, as © brazzo/iStockphoto 777 during the cruise phase of a flight many as 20 may have their membership for those that do not make the stan- from Shanghai, China, to Atlanta. terminated. dard, there is no place in our associa- The airplane was at Flight Level IATA has made passing the audit a tion,” Bisignani said. (FL) 390 (approximately 39,000 ft) condition of membership, effective at He said that IATA has begun to when the rollback occurred in the the end of 2008. Airlines in eight coun- extend its auditing program to ground right Rolls-Royce Trent 895 engine. tries currently are required by national handling through the IATA Safety Audit The crew conducted the applicable law to meet IOSA standards. for Ground Operations (ISAGO). At flight manual procedures and de- IATA Director General and CEO press time, 20 headquarters audits and scended to FL 310; the engine recov- Giovanni Bisignani said in mid- 23 station audits were expected to be ered and functioned normally for the December that by the end of 2008, completed by the end of 2008, he said. remainder of the flight. more than 260 airlines, including 210 IATA data show that, on Dec. 1, the A similar incident involving a 777 IATA members, were expected to be worldwide accident rate was 0.77 per 1 with the same engine type occurred placed on a registry of those in compli- million flights, compared with 0.82 in Jan. 17, 2008, during final approach to ance with IOSA standards. 2007. For IATA members, the rate was London Heathrow International Air- “IATA’s biggest satisfaction is to 0.47 per 1 million flights, compared port. The airplane crashed short of the bring all our members on board, but with 0.68 in 2007. runway. An investigation is continuing.
In Other News … Monitoring Pilot Brain Activity
ohn McCormick will succeed he U.S. National Aeronautics and Bruce Byron as director of aviation Space Administration (NASA) is Jsafety and CEO of the Australian Tconducting research to determine Civil Aviation Safety Authority (CASA) the best method of monitoring brain in March. McCormick has more than activity as part of a larger project to 20 years of top level experience in the help pilots recognize if they are func- industry, with the Royal Australian tioning with dangerously high levels of Air Force, Qantas and Cathay Pacific. stress, fatigue or distraction. … New pilots in Australia will receive The research, being conducted formal instruction in critical thinking at NASA’s Glenn Research Center © Pixac/Dreamstime.com skills, according to new requirements in Cleveland, uses a process called being implemented by CASA. Instruc- functional near infrared spectroscopy to measure both the flow of blood in the tion will be designed to improve their brain’s cortex and the oxygen level of the blood. Researchers say this technol- communication, interpersonal dealings, ogy is non-invasive, safe, portable and inexpensive, and that the project is judgment and decision making, and be- intended to “improve the interaction between the increasingly sophisticated ginning in mid-2009, they will be tested automation being used in aircraft and the humans who operate those aircraft. on their knowledge of human factors The goal is to aid pilot decision making to improve aviation safety.” and threat and error management. … NASA biological engineer Angela Harrivel, who heads the project, said, “No Bluebird Cargo, based in Iceland, has matter how much training pilots have, conditions could occur when too much begun using Q-Pulse IMS software to is going on in the cockpit. What we hope to achieve by this study is a way to manage compliance with national and sensitively — and ultimately, unobtrusively — determine when pilots become international regulations and standards. mentally overloaded.”
Compiled and edited by Linda Werfelman.
www.flightsafety.org | AeroSafetyWorld | January 2009 | 11 Coverstory
he risk of a pilot becoming incapacitated told the first officer that if he did not begin to in flight is very low, recent studies show, cooperate, he would be considered incapacitated but an incident early last year — and and dealt with accordingly. others in the past — exemplify another The first officer did not respond, so the Tpoint made in the studies: In the rare event that commander told the lead flight attendant to © Jian Tan/Jetphotos.net © Jian incapacitation does occur, a flight can be seri- “secure the first officer away from the controls” ously threatened. and enlist the aid of other cabin crewmembers In its report on the incident, the Irish Air to remove him from the flight deck, the report Accident Investigation Unit (AAIU) said there said. One crewmember sustained a wrist injury were signs that something was not right with while doing so. Two physicians among the 146 the first officer when he reported late for duty passengers attended the first officer, who was at Toronto’s Pearson International Airport the described as confused and disoriented. morning of Jan. 28, 2008.1 The commander After communicating via data-link with said that the first officer appeared to be “quite company dispatch personnel in Toronto, the harried” when he arrived on the flight deck of commander declared a medical emergency and the Boeing 767-300. The commander assured told air traffic control that he was diverting the first officer that all the preflight prepara- the flight to Shannon, Ireland, which had good tions for the flight to London Heathrow Air- weather conditions. port had been completed and encouraged him Before beginning the descent, the com- to “settle down.” mander asked the lead flight attendant to The commander became increasingly check the passenger list, to see if any company concerned about the first officer’s behavior after pilots were aboard. “No line pilots were on the flight got under way. The first officer left board, but one of the flight attendants held a the flight deck several times and did not follow commercial pilot’s license with a multi-engine standard procedure when he returned. rating and a noncurrent instrument rating,” “In conversation, he remarked several times the report said. The commander summoned that he was very tired,” the report said. “With her to the flight deck. the workload now light in cruise, the command- “The flight attendant provided useful as- er suggested that [he] take a controlled rest sistance to the commander, who remarked in a break on the flight deck. The commander was statement to the investigation that she was ‘not concerned not only for the well-being of his first out of place’ while occupying the right-hand officer but of the possibility of having to carry seat,” the report said. out a CAT III autoland approach at Heathrow After an uneventful landing, the flight was due to low weather [conditions]. He considered met by physicians who assisted the first officer it prudent to let his colleague rest now and be fully alert for the descent and approach at the destination.” There is no checklist for pilot incapacitation, ‘Confused and Disoriented’ a rare but serious threat. BY MARK LACAGNINA The aircraft was midway across the North Atlantic when “it soon became apparent that the first officer was quite ill,” the report said, noting that his speech began to have a “rambling and disjointed nature.” After another extended rest break, his behavior became “belligerent and uncooperative.” After calling the lead flight attendant to the flight deck, the commander
12 | Downflight safety foundation | AeroSafetyWorld | January 2009 and Out coverStory
A first officer appeared to be under considerable stress as the transatlantic flight got under way and eventually would be carried off the flight deck of this 767.
There is no checklist for pilot incapacitation, a rare but serious threat. BY MARK LACAGNINA © Nathan Cox/iStockphoto
Down andwww.flightsafety.org | AeroSafetyWorld | January 2009 Out | 13 Coverstory
and assessed his medical condition. fatigue, alcohol, drugs and “other Single-Pilot Fatalities The first officer then was transported toxic substances,” the TP says. Subtle A study by the Australian Transport to a local hospital. “[He] remained incapacitation also can be triggered by Safety Bureau (ATSB) in 2007 focused under hospital care for 11 days, where a stroke or brain tumor. on 98 pilot-incapacitation events that a gradual improvement in his condi- Symptoms of subtle incapacitation occurred from 1975 through March tion was made,” the report said. “On 8 are likely to be noticed during periods 2006.3 Noting that these events com- February, he was flown home [by air of high stress or workload. “The victim prised 0.6 percent of all occurrences in ambulance] to Canada, where his care may not respond to stimulus, may the ATSB accident/incident database continued.” make illogical decisions or may appear during the period, the report said, “The The report provided no details to be manipulating controls in an inef- results of this study demonstrate that about the first officer’s medical condi- fective or hazardous manner,” the TP the risk of a pilot suffering from an in- tion and did not specify his age. says. It recommends that, if the victim flight medical condition or incapacita- does not respond normally to two tion event is low.” Serious Incident consecutive challenges or one signifi- Nevertheless, the report said that The AAIU commended the command- cant warning, such as when an aircraft pilot incapacitation “represents a seri- er and flight attendants. “Incapacitation is flown below decision height without ous potential threat to flight safety.” The of a member of a flight crew is a serious the required visual references, the other pilot-incapacitation events included 10 incident,” the report said. “The com- pilot should take the following actions: fatal accidents, in which 24 people were mander, realizing he was faced with a • “Do whatever is necessary to killed, and six nonfatal accidents. difficult and serious situation, used tact maintain control of the aircraft.” All the fatal accidents involved and understanding, and kept control of single-pilot flight operations, including • “If you need to restrain the the situation at all times. The situation four conducted by charter or business victim, do only what is needed to was dealt with in a professional man- pilots. Eight fatalities occurred when a deal with an immediate threat to ner, employing the principles of crew Beech Super King Air 200 crashed in control. You will have time [later] resource management.” September 2000.4 ATSB determined to further secure the victim.” The report cited a Transport that the cabin likely depressurized • “Climb to and maintain a safe Canada technical publication (TP) while the airplane was climbing to altitude.” that provides guidance on recognizing 25,000 ft for a charter flight of about 1.5 and dealing with pilot incapacitation.2 • “If you are on an approach which hours’ duration; the King Air continued Differentiating between sudden, serious has destabilized, initiate a missed flying for about 3.5 hours after passing and subtle incapacitation, the TP says approach following standard pro- the destination. that the leading causes of sudden pilot cedures. You may not have access Overall, the greatest cause of pilot incapacitation are gastrointestinal prob- to a checklist, so take extra care to incapacitation was acute gastroin- lems such as stomach cramps, nausea accomplish essential tasks.” testinal illness, typically from food and diarrhea. • “Keep your thoughts organized. poisoning, in 21 cases, followed by “Heart problems and fainting are Saying your actions out loud exposure to smoke or toxic fumes, in the main causes of serious incapacita- may help you stay focused. If the 12 cases. Nine pilots lost conscious- tion,” the TP says. “Complaints of chest aircraft is autopilot-equipped, ness for unspecified reasons. Eight pain (often confused with indigestion), engage the autopilot at an op- suffered heart attacks, five of which weakness, palpitation or nausea should erationally safe altitude to lessen were fatal. Five pilots suffered symp- be taken seriously. Pallor [paleness], your workload.” toms of infectious diseases, mostly unusual sweating, repeated yawning or The TP says that other crewmembers or viral infections, although one case shortness of breath should all trigger passengers should be enlisted to secure involved malaria. Five others were suspicion.” the incapacitated pilot — by moving his incapacitated by trauma resulting Common causes of subtle pilot or her seat to the full-aft position and from bird strikes, a windshield shat- incapacitation include hypoxia, hypo- tightening the shoulder harness — or to tered by hail and an injury during an glycemia (low blood sugar), extreme remove the pilot from the seat. emergency ground evacuation. Four
14 | flight safety foundation | AeroSafetyWorld | January 2009 coverStory
Recent U.S. Pilot-Incapacitation Events*
une 30, 2008 — The pilot engaged the services of a flight A physician assistant aboard as a passenger recommended instructor to prepare for a re-examination required by that the captain be removed from the flight deck and placed Jhis involvement in a previous aviation incident. During on the floor of the forward galley for treatment. The first departure from Rochester, New Hampshire, the Beech 95’s officer declared a medical emergency and kept a flight at- cabin door opened, and the pilot turned back to the airport. tendant on the flight deck to assist him during the diversion He did not line up properly with the runway, and the instruc- to Dayton, Ohio. “After landing, the first officer moved over tor assumed control. With no wheel-brake controls on his to the left seat and taxied the aircraft to the gate, where side of the cockpit, the instructor told the pilot several times emergency medical assistance was standing by,” the incident to apply the brakes after landing, but there was no response. report said. The airplane received minor damage when it overran the May 30, 2006 — A few minutes after a Bell 206L-3 was land- runway. The incident report did not specify the cause of the ed on a platform off the shore of Grand Isle, Louisiana, the pilot’s incapacitation. 55-year-old pilot was found unconscious. He was removed Feb. 24, 2008 — The pilot of a Cessna 525 CitationJet was from the helicopter and transported to a hospital, where conducting a night flight with three passengers when he he was pronounced dead; the cause of death was coronary became woozy and declared an emergency. He landed insufficiency from cardiac disease. without further incident at Worcester, Massachusetts. He was Aug. 28, 2005 — The captain of an Embraer 145 suffered a examined at a local hospital and released after no medical mild heart attack while departing from Pittsburgh for a flight abnormalities were found. to Portland, Maine. The first officer assumed control, returned Dec. 17, 2007 — Five carbon dioxide cylinders had been to Pittsburgh and landed the airplane without further inci- loaded improperly, and without safety caps over their valves, dent. “Further investigation revealed that the captain was in a Beech 1900. During departure from Aniak, Alaska, the incapacitated and unresponsive in flight and on the ground pilots heard a “hissing” sound, rejected the takeoff and taxied after this event occurred,” the incident report said. “The back to the ramp. Soon after the engines were shut down, captain was taken to a hospital and is expected to make a full both pilots lost consciousness; the copilot sustained minor recovery.” injuries when he collapsed while trying to open the forward May 5, 2005 — The pilot of a Gulfstream 695A Commander door. suffered a fatal heart attack during a flight from North Las June 17, 2007 — A Boeing 777-200 was en route from Vegas Airport to San Diego. The passenger in the right front Chicago to an unspecified destination when the first of- seat, who was not a licensed pilot, flew the airplane back ficer apparently suffered a stroke. The captain returned to to the departure airport while the rear-seat passenger held Chicago, where the first officer was transported to a hospital. the pilot away from the flight controls. Both passengers were injured, one seriously, when the Commander stalled June 5, 2007 — The first officer of a 737-500 complained of at low altitude and struck terrain during the fourth landing severe stomach cramps during a fight from Tulsa, Oklahoma, attempt. to Denver. The captain requested and received expedited handling from air traffic control, and landed without further — ML incident in Denver. * Selected from reports compiled by Air Data Research from U.S. May 7, 2007 — The captain of a 737-500 suffered an appar- Federal Aviation Administration and U.S. National Transportation ent heart attack during a flight from Washington to Chicago. Safety Board databases.
pilots suffered respiratory symp- and that pilots receive different crew gastrointestinal illness some hours toms of acute pneumonia and severe meals to help reduce the overall risk.” later,” the report said. emphysema. Pilots also should be careful of what While heart attack was involved in Noting the prevalence of gastroin- they eat and drink before flying and only eight of the 98 pilot-incapacitation testinal illness, the report said, “It is im- during layovers. “Contaminated events, it accounted for half of the fatal portant that crew meals are prepared to food and water consumed in these accidents and the deaths of seven passen- the highest possible hygiene standards periods may then produce an acute gers. The report said that “cardiovascular www.flightsafety.org | AeroSafetyWorld | January 2009 | 15 Coverstory
disease still ranks as the single biggest • A Boeing 727 freighter captain during an approach and struck cause for medical disqualification of and flight engineer temporarily terrain. All three flight crew- pilots” and that cardiac events may be lost consciousness after the flight members were seriously injured under-reported “especially in difficult engineer inadvertently depressur- in the crash. postmortem circumstances” following ized the cabin at 33,000 ft. The The latter two events, the only ac- accidents. first officer donned his oxygen cidents among the 47 flights, both The study results show that “there is mask and performed an emer- involved pilot impairment, which a low chance of a medical condition or gency descent. the report characterized as insidi- incapacitation event adversely affect- ous. “When a dramatic incapacitating ing the outcome of a flight,” the report • While taxiing after landing, the event such as a heart attack or epileptic said. “The medical certification system “captain stiffened so violently seizure occurs, it is often obvious and appears to be working well. However, during an epileptic seizure” that can be dealt with by the unaffected it remains important that this system he suffered a broken shoulder and crewmember,” the report said. “In the continues to evolve with, and be based back, and applied sufficient pres- two impairments that ended in aircraft on, the changes and developments in sure on the right rudder pedal and accidents, the pilots were probably not scientific research and medical practice.” wheel brake to cause the airplane aware there was a problem. … It may to suddenly turn and stop. be that subtle impairment of a pilot is Insidious and Dangerous • An Airbus A300 captain suffering more dangerous than obvious medical A 2004 study by the U.S. Federal Avia- a cerebral infarction (blood-flow incapacitation.” tion Administration (FAA) focused on 47 blockage) did not call for landing Notes flights during a six-year period ending in gear extension during approach 1998 in which pilots became incapacitat- and “simply nodded agreement 1. AAIU Synoptic Report no. 2008-027. Nov. ed or impaired — that is, able to perform when the first officer questioned 19, 2008. only limited flight duties.5 The report on him about it.” While taxiing to the 2. Transport Canada. Pilot Incapacitation. TP the study said that the rate of in-flight gate, he applied full takeoff power 11629E. April 2007. pilot incapacitations/impairments was twice before the first officer shut 3. Newman, David G. Pilot Incapacitation: 0.058 per 100,000 flight hours. down the engines and called for Analysis of Medical Conditions Affecting The report said that safety was seri- assistance. Pilots Involved in Accidents and Incidents, ously threatened in seven events: 1 January 1975 to 31 March 2006. ATSB. B2006/0170. January 2007. • A Boeing 737 first officer suffer- • A McDonnell Douglas MD-88 ing a grand mal seizure related captain wearing monovision 4. ATSB Aviation Safety Report to alcohol withdrawal “suddenly contact lenses — which correct for BO/200003771. near vision in one eye and distant screamed, extended his arms up 5. DeJohn, C.A.; Wolbrink, A.M.; Larcher, rigidly, pushed full right rudder vision in the other eye — per- J.G. In-Flight Medical Incapacitation and and slumped over the yoke dur- ceived the airplane to be higher Impairment of U.S. Airline Pilots: 1993 to ing an approach,” the report said. than it was during an overwater 1998. Civil Aerospace Medical Institute. DOT/FAA/AM/04/16. October 2004. “The captain regained control approach in rain and fog. “This resulted in a steeper-than-normal Reprinted in Flight Safety Digest Volume after flight attendants pulled the 24 (January 2005): 1–23. first officer off the controls.” final approach, causing the aircraft to strike the approach lights,” the Further Reading • A Douglas DC-9 first officer’s report said. Three passengers sus- foot lodged against a rudder pedal tained minor injuries during the Snyder, Quay. “Missing Perspectives.” ASW Volume 2 (October 2007): 22–23. when he stiffened during a heart subsequent evacuation. attack. “The captain had to apply Rosenkrans, Wayne. “Cabin Fever.” ASW full opposite rudder to control • The captain and first officer Volume 2 (August 2007): 22–26. the aircraft until the foot could be were impaired by fatigue when a Werfelman, Linda. “Too Old to Fly?” ASW dislodged,” the report said. Douglas DC-8 freighter stalled Volume 2 (February 2007): 11–15.
16 | flight safety foundation | AeroSafetyWorld | January 2009 For over 60 years, the business aviation community has looked to the National Business Aviation Association (NBAA) as its leader in enhancing safety and security, shaping public policy, providing world-renowned industry events, and advancing the goals of more than 8,000 Member Companies worldwide. Discover how NBAA Membership can help you succeed.
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ell-trained and well-equipped dispatchers who can help attend to the myriad details of planning and conducting flights are a boon to any busy flight department. Most ASW readers are probably familiar with the airline model of operational control, which com- prises dispatchers, schedulers, maintenance controllers and pilots working together to Wdirect the intricate ballet of a day’s flying. In a tightly scheduled airline hub system, even the good days can be a running battle against dis- ruption. Besides keeping the system on time, safety and compliance must remain as paramount goals. The same basic issues apply to a similar operation without a fixed schedule, like a large fractional ownership or charter company.
BY PATRICK CHILES A good dispatch team enhances safety and efficiency while reducing disruptions. ground support
| | 18 | flight safety foundation AeroSafetyWorld January 2009 © Chris Photography Sorensen Flight control center personnel ground support provide a ‘second set of eyes’ for flight crews in NetJets’ worldwide operations.
© NetJets
NetJets’ U.S.-based operation, for example, has a fleet of more than 400 aircraft in worldwide service. Each day’s schedule is shaped not by an economic analysis of demand between city pairs, but by the personal demands of thousands of individual share owners and charter clients. So, imagine having a route system the size of a major international airline’s — and taking a big eraser to the schedule every day, if not every few hours. This creates enormous challenges across the system. Scheduling, logistics, safety and compliance are put to the test by a constantly evolv- ing demand structure. And the end result — safely delivering exceptional service — has to be as transparent as possible to the passengers. Although passengers generally accept uncontrollable disruptions like weather, ev- erything else is expected to run like clockwork. To stretch the analogy a bit further: How does this happen when nobody knows exactly what the clock may look like from one day to the next? And how is it managed without © NetJets compromising safety?
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Andrew Wuertzer, dispatch tactical manager, and Aaron Chamberlain, ATC specialist, work out details for an upcoming flight.
© NetJets
Early Challenges 1990s, any major new programs were likened to Early in the program’s history, many arrangements changing tires on a moving car. were delegated to the flight crew. Fleet chief pilots were always available to help with problem solving, Shared Responsibility a practice that continues today. But, while em- As Peter V. Agur Jr. pointed out in a previous is- ployees at the Columbus, Ohio, operations center sue of ASW (3/08), one of the biggest hurdles in managed schedules and logistics, most operational developing the needed ground support system and safety decisions were left to the pilots. was indeed “people-related” — the necessary Route planning and the related calculations cultural change was not to be taken lightly. With were accomplished by individual flight crew- so many pilots coming from corporate or char- members before each leg, while the operations ter aviation, some were reluctant to accept the center could provide computerized weight- shared-responsibility concept — as some would and-balance data and field-length performance say, “No one is about to tell me how much fuel calculations. It remained the flight crew’s to carry!” responsibility to check the numbers, in addition Moving beyond this required demonstrable to preparing and filing their own flight plans. expertise, while making clear that the pilots As the fractional program grew and daily flight were getting help and not another layer of man- counts continued to rise, it became clear that pilots agement. Having round-the-clock access to chief needed to be unburdened from dispatch-related pilots for each aircraft type helped everyone tasks. The type and quality of ground support had through this growing pain. to improve. Implementing an airline-style flight To be fair, it was not merely an ego clash. dispatch organization was seen as the best way to Responsibilities in the airline world are clearly simultaneously improve fleet utility and safety. defined and supported by decades of organiza- There were, and still are, many challenges to tional experience. Beyond any legal requirement, this approach. Figuring out personnel, licens- airlines see this relationship as an accepted best ing and equipment needs was comparatively practice for managing complex systems, and straightforward — the more amorphous ques- their crewmembers are generally more amenable tions of “how” would take years to work out. toward it. But tailoring this model to fit a general
At the rate the company expanded during the aviation environment created as many questions as © Chris Photography Sorensen
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it answered. For example: How do you grant nearly every flight, licensed dispatchers create a release 50 dispatchers, who technically are not required, package that contains weight-and-balance data, the authority to be effective without simultane- takeoff and landing performance calculations, a ously undermining the captain’s authority? computerized flight plan, weather information Ultimately, the pilot-in-command still has and notices to airmen (NOTAMs). final authority to conduct, cancel or change a As mentioned, crewmembers are still re- Ultimately, the flight. How does that work in practice? In our quired to check relevant details and calculations case, decisions to release flights and requests by before accepting a release, but they no longer pilot-in-command scheduling or customers for operational diver- have to work it out on the run. This means turn sions must also go through the dispatchers. Any times are more productively spent actually get- still has final diversions for such matters as aircraft malfunc- ting the airplane ready to fly. For an operation authority to tions, equipment problems or weather are deci- that is governed by the regulatory requirements sions that remain with the crew. for fractional ownership operations, charter op- conduct, cancel Over time, the dispatcher’s second set of erations and supplemental air carrier operations, eyes has undoubtedly enhanced safety. For this has become an absolute necessity. or change a flight.
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view to develop options for trips with go/no-go challenges. This makes the outright canceling of trips a rare occurrence.
Collective Knowledge Work on an individual flight typically begins several hours ahead of departure. While prepar- ing a flight plan and release, dispatchers are not entirely on their own — supporting them are teams of meteorologists, air traffic control (ATC) coordinators and Jeppesen international handlers. NetJets participates in the U.S. Federal Aviation Administration’s Air Traffic Control System Command Center collaborative deci- sion making program, and most company ATC specialists are former controllers. This enables Patrick Chiles the dispatchers to have a complete picture of With weather, Pieces in Place national flow control programs, in addition to weight-and-balance The big picture is managed through a propri- access to the company’s internal route data- and scheduling etary reservation and flight-following program base. Built over several years of experience, the information at his called IntelliJet II. Anyone in the company with database includes thousands of preferred routes fingertips, Mike a hand in creating or managing trips uses this between common city pairs. Olson prepares a as their access point. Every flight goes from This advance coordination and collec- BBJ flight release. initial booking to crew and aircraft scheduling, tive knowledge gives dispatchers the ability to through airport review, feasibility and logistics, quickly create more accurate flight plans. There and finally to dispatch and flight following. are obvious benefits — for example, routes that The program is also integrated with Jeppesen’s ATC is more likely to clear as filed mean more flight planning software and UltraNav’s takeoff predictable arrival times and fuel burns. performance tool. Other tools, like Flight Ex- While accurate flight plans are the goal, tools plorer and Jeppview electronic charts, round out like the route database are crucial in enabling dis- the information at the dispatcher’s fingertips. patchers to manage their workload. And that load Different teams of specialists have a hand in can be considerable. Customer demand, crew dis- each trip at different steps along the way. Initial connects, broken airplanes and bad weather may booking of a new flight immediately generates converge — often all at once — to make the flight activity through airfield analysis and trip feasibil- schedule a constantly moving target. The rapid ity. Analysts review airport suitability and look pace can be both frustrating and exhilarating, for any potential show-stoppers on each trip. By testing even the most three-dimensional thinker. the time a flight makes it to the dispatcher for One dispatcher can easily release up to 50 flights release, there is usually little question remaining on a shift, not counting those that end up in the as to whether it can run as planned. trash bin because of schedule changes. This is not to say that problems never ap- After the final flight plan is filed and uplinked pear — some things just cannot be known until to the airplane, centers of gravity are checked via it’s time for the rubber to meet the road. NetJets a weight-and-balance tool integrated with the dispatchers have unique value in the customer flight release program. It is a relatively simple service arena as creative problem solvers. Co- calculation using standard average weights by ordinating among multiple departments, they seat location. A more complex application is the have the technical expertise and big-picture UltraNav takeoff performance tool, which uses
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airplane flight manual performance data to deter- to Hawaii while keeping a generous reserve mine field-length limits and climb capability. margin. A similar fuel-burn study enabled The dispatcher can input the published climb reliable scheduling of nonstop trips between gradient and minimum safe altitude from a pub- New York and London by the Cessna Citation lished standard instrument departure, or a con- X with similar safety margins. Actual burns trolling obstacle if there is a published departure regularly end up well within 1 percent of the procedure for avoidance. The exception to this flight plan estimates. practice is with the Boeing Business Jet fleet, which relies on Boeing’s Onboard Performance Tool. In- Safety Firewall stead of using charted procedures, this tool directly Ultimately, fuel-burn management is not why calculates regulatory takeoff performance against this program was started. When the fractional- a runway and obstacle database. This real-time ownership program took off in the 1990s, flight runway analysis generally allows higher maximum dispatch was created as a way to deal safely with takeoff weights for a given condition. the increased operating tempo. The shared responsibility concept creates Off to the Races a firewall against rushed decision making in a Once the flight is airborne, dispatchers are able rapidly changing environment. These benefits to monitor its progress using Flight Explorer, a are more difficult to quantify, but anecdotal commercially available product. It enables them evidence from employees on both sides of the to view flight plan tracks layered with any num- process have cemented the belief that this model ber of informational displays. Satellite views, has successfully cut off any number of potential prognostic charts, icing reports and temporary hazards before they could materialize. flight restrictions are most commonly used. Threat and error management has been Communications are maintained with sev- getting more deserved attention of late, and it is eral tools, including the airborne flight informa- clear that a robust, well-qualified dispatch team tion system (AFIS), aircraft communications mitigates numerous threats before airplanes addressing and reporting system (ACARS), even leave the ramps. Any flight department satellite phones and sometimes even a good old- with a heavy operational tempo or complex fashioned ARINC phone patch. scheduling would be well served to consider the As mentioned before, non-emergency diver- benefits of similar practices. sions are coordinated through the dispatch team. Patrick Chiles is manager of technical operations for the Many diversions are “self-inflicted,” resulting NetJets Large Aircraft program. He is a member of the Flight from owners’ needs changing in flight. Pilots Safety Foundation Corporate Advisory Committee and the would agree that dedicated specialists on the Society of Aircraft Performance and Operations Engineers. ground, evaluating each diversion as it happens, are worth their weight in gold. Further Reading The dispatch team also has enabled the Agur, Peter V. Jr. “Real Time Risk Management.” ASW company to better manage fuel consumption Volume 3 (March 2008): 19–22. by using computerized flight planning and Chiles, Patrick. “VFR in the Himalayas.” ASW Volume 3 by tankering fuel through high-cost locations. (April 2008): 22–26. Beyond saving money, tracking planned versus actual fuel burn has improved safety by enabling Chiles, Patrick. “Planning the Departure.” ASW Volume 2 (July 2007): 26–32. the company to accurately fine-tune the airplane cruise databases. Snyder, George H. Jr.; Agur, Peter V. Jr. “High Culture.” For example, a thorough analysis of Das- ASW Volume 2 (June 2007): 12–21. sault Falcon 2000 fuel consumption was a key Chiles, Patrick. “ETOPS Redefined.” ASW Volume 2 factor in increasing payload on winter flights (March 2007): 12–16. www.flightsafety.org | AeroSafetyWorld | January 2009 | 23 safetyculture
Mainstream
Although many operators will miss ICAO’s January deadline for implementation ofInto a safety management the system, the SMS concept is gaining ground.
BY LINDA WERFELMAN
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ropelled into more widespread existence civil aviation authorities for the development of by a 2009 deadline, safety management the regulatory framework for SMS, to service systems (SMSs) — the subject of years of providers for the implementation of SMS, and discussion and planning — are taking hold to ICAO member states for the establishment of Pwithin airlines and aviation maintenance organiza- SSPs — all in greater detail than the first edition, tions worldwide. But implementation cannot be published in 2006. completed without the adoption of state safety pro- “That doesn’t mean that the guidance mate- grams (SSPs) by national governments worldwide. rial will be perfect for everything and everyone,” By mid-December 2008, the number of Ramos said. “Everything that’s in there, people airlines with an SMS in place or under develop- have to adapt to their own operations.” ment had increased dramatically from the 10 The SMM describes an SMS as similar to “a percent estimated one year earlier, according to toolbox that contains the tools that an aviation Miguel Ramos, technical officer in the Integrat- organization needs to be able to control the ed Safety Management Section of the Interna- safety risks of the consequences of the hazards tional Civil Aviation Organization’s (ICAO’s) Air it must face during the delivery of the services Navigation Bureau. Ramos said, however, that that are the reason why the organization is in ICAO lacks a precise count of how many airlines business. … and aviation maintenance organizations are “SMS simply is a protective shell that ensures developing an SMS — or exactly how many had proper and timely storage, availability and one in place as the organization’s January 2009 utilization of the tools needed to deliver specific deadline neared. safety management processes in the organiza- Even without knowing exact numbers, Ramos tion. Without the proper tools inside, SMS is said, it is clear that “SMS has really evolved.” only an empty shell.” He noted that airlines and other service The SMM describes how airlines and other providers — including airports, maintenance service providers might fill those empty shells — organizations, regulators and air traffic manage- for example, with safety audits, surveys, safety li- ment organizations — are moving away from braries, flight data analysis and other safety tools the reactive mode of managing safety in which — and how safety management must permeate a safety advances typically follow accident inves- service provider’s organizational chart. tigations and the resulting investigations, and toward the more predictive mode of managing ‘Complex’ Implementation safety in which data collection and analysis en- One of the first civil aviation authorities to start able risks to be identified and addressed before work on SMS regulations was Transport Canada they cause an accident or serious incident. (TC), which began its SMS efforts in 1999. “That’s a major improvement,” Ramos said. “On the surface, it appeared quite a simple “SMS is now being considered a major system task: Develop a set of regulatory instruments involved in running an airline or another avia- and the supporting tools to facilitate the imple- tion service provider.” mentation of SMS in Canadian aviation,” said In recent months, in response to complaints Jacqueline Booth-Bourdeau, chief of technical about vague requirements for SMS — defined program evaluation and coordination in the by ICAO as “a systematic approach to managing TC Standards Branch. “SMS regulation and safety, including the necessary organizational implementation in Canada were infinitely more structures, accountabilities, policies and proce- complex than we had first imagined.”2 dures” — ICAO overhauled its Safety Manage- In a presentation to Flight Safety Founda- ment Manual (SMM).1 tion’s October 2008 International Air Safety The second edition, still in the final edit- Seminar in Honolulu (see “SMS Implementation
© Tobiasjo/iStockphoto © ing process in late 2008, provides guidance to Experiences,” p. 28), Booth-Bourdeau said that
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to ensure aviation safety or the procedures and processes for SMS safety of the public.” implementation and made efforts to Booth-Bourdeau said that, apply them consistently.”3 “from a practical perspective, The auditor general’s report also not- this means that an organiza- ed “several weaknesses” in TC’s manage- tion must develop, maintain ment of the transition to SMS and issued and integrate a management nine recommendations — including calls system comprised of six basic for improved transition planning, a better components: a safety manage- defined standard for an acceptable level of ment plan, training, safety oversight and establishment of perfor- oversight (reactive and proac- mance indicators to evaluate the extent tive), documentation, quality to which SMS and other programs are assurance and emergency contributing to TC’s long-term objectives. response preparedness.” TC accepted all nine recommendations. In recent years, critics have Booth-Bourdeau challenged TC’s approach to Phased Implementation the implementation of SMS required SMS as a form of deregulation or industry At press time, the Australian Civil organizations to change the ways they self-regulation. Aviation Safety Authority (CASA) was manage safety and to enhance their “None of these things is true,” reviewing aviation industry comments
Wayne Rosenkrans Wayne internal safety culture. Booth-Bourdeau said. She cited a May on proposals to require SMS for all Canadian Aviation Regulations define 2008 report by the Office of the Auditor regular public transport operations. an SMS as “a documented process for General of Canada, noting the office’s CASA planned to adopt the proposals managing risks that integrates operations finding that TC, the first civil aviation as amendments to the Civil Aviation and technical systems with the manage- authority in the world to produce SMS Orders on Jan. 1, 2009, with a phased ment of financial and human resources regulations, had “developed appropriate implementation schedule “to assist
Canada was an early SMS adopter. Shown here is Toronto Pearson International Airport.
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the aviation industry [in managing] specific SMS requirements. The FAA of their internal safety management ap- the work and costs of developing and planned to file a difference with ICAO to paratus — the SSP. putting in place safety management explain that, although the agency intends Few regulatory authorities have systems, human factors training and eventually to develop SMS regulations a fully functioning SSP, Ramos said, non-technical skills assessment.” and policies, they would not be ready in noting that the SMM devotes separate CASA’s proposed schedule would time to meet the Jan. 1 deadline.5 guidance to the regulators responsible give operators six months to develop an In a memo to operators, the FAA said for that program, defined by ICAO as SMS implementation plan and up to two that, although it has not developed SMS “a management system for the manage- years to complete the implementation. regulations, it has encouraged adop- ment of safety by the state.” The agency said that the changes tion of SMS within the industry and An SSP has four components: state eventually would be incorporated into has published Advisory Circular 120- safety policy and objectives, including Civil Aviation Safety Regulations.4 92, Introduction to Safety Management a legislative framework, accident and “At that time, the requirements will Systems for Air Operators, which contains incident investigation and enforcement be extended to cover all air transport information on the development and policy; state safety risk management, in- operations, including charter flights,” implementation of SMS on a voluntary cluding safety requirements for the SMSs CASA said. Many major airlines, basis. Additional supporting material is operated by service providers; state safety including Qantas, and smaller opera- being developed, the FAA said. assurance, including safety data collec- tors already have implemented SMS, in tion, analysis and exchange; and state advance of the regulatory requirements. Management for Managers safety promotion, including internal and As airlines and other service providers external training, communication and Missed Deadline have moved ahead, Ramos said, it has dissemination of safety information. A number of operators also have imple- become clear that they have made con- ICAO considers implementation mented SMS in the United States, where siderably more progress with SMS than of an SSP a prerequisite for the imple- the Federal Aviation Administration most regulatory authorities have made mentation of effective SMSs by service (FAA) is continuing its efforts to develop with development and implementation providers.
© Marcus Obal/Wikimedia.org
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SMS Implementation Experiences
n addition to the presentation by difficult.” A more positive and productive the way they feed back on each other Jacqueline Booth-Bourdeau of approach is to recognize existing capabili- and the way they work,” he said. “Safety ITransport Canada (see “Into The ties and simplify implementation from the management is done by line managers, Mainstream,” p. 24), three other panel- existing elements: “There is no airline or people who control resources, not by ists described their experiences with other organization in aviation that has to safety departments. Those line manag- safety management system (SMS) start from scratch,” Simpson said. “If your ers have lots of other things to do; they implementation during the Joint organization has passed the International don’t just know how to manage safety. Meeting of the Flight Safety Foundation Air Transport Association Operational There aren’t a lot of resources [or] time, 61st annual International Air Safety Safety Audit [IOSA], and has IOSA accredi- and we can’t expect managers to turn Seminar, International Federation tation, that also implies that you’ve got the themselves into safety experts overnight. of Airworthiness 38th International building blocks, the basic components of If they have a comfort level with certain Conference and International Air the SMS. The real challenge is to make that aspects of existing systems or reporting, Transport Association in Honolulu. SMS effective. Assessing risk is perhaps the you need to build on that. You’re not Moderator David Mawdsley, aviation most complex or over-complicated part. trying to make SMS work for the safety safety adviser for Super Structure Group It is quite misunderstood, but it doesn’t manager, you are trying to make it work and an instructor at Cranfield University, need to be.” for the line manager.” said that many aviation organizations Extensive guidance resources, tem- Integrated safety data from mul- find change management to be the plates and examples — many already tiple sources — such as safety reports, greatest implementation challenge. compiled in one place by Eurocontrol’s telephone calls and line operations “An airline or other enterprise is SKYbrary Web site
Wayne Rosenkrans Wayne Robert Dodd, the airline’s against the plan? A large number of general manager, group organizations go part way through the safety. “For an SMS to [SMS] process. They collect enough be effective, it has to be information to adequately describe the like any other element nature of a problem. What they don’t in aviation engineering; do is put as much energy into making you cannot just throw all sure that they actually have fixed it.” these elements together Since 2005, airports worldwide have Simpson and not think about discovered advantages during SMS
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implementations, said Gerhard Gruber, and safety interface with contractors, turn, 140 degrees. This turn was not manager, rescue and airport operations, such as ramp service companies and designed for aircraft [crews] taxiing Vienna (Austria) International Airport. other third parties. without a yellow centerline, however, Regardless of the wide diversity among A special challenge for airports has and the inner gear of this aircraft flat- airport implementations, the SMS has been some airside employees’ low level tened the edge lights of the taxiway, helped many of them to cope with of education, sometimes coupled with then the crew completed the takeoff. difficult operational pressures linked to low personal motivation, compared “This was observed by a marshaller rapid traffic growth, airport privatiza- with the personnel in areas like flight from a distance of 1.5 km [0.8 nm]. The tion and compliance with harmonized operations and air traffic control (ATC), marshaller reported to the operations international standards. Gruber said. Awareness, data presenta- officer that he saw the [aircraft wheels “The optimum use of existing tions and training therefore have to crush the] edge lights. The operations infrastructure is a challenge,” Gruber be tailored to what each individual officer informed ATC, and ATC informed said. “You have airports that already needs to know — including simplified the pilot that there might be tire have a safety system in place — they SMS theory — in order to do their part. damage and [risk of] an unsafe land- just name it ‘SMS’ and [other] airports “Everyone should understand what ing. [Using SMS practices,] we had a do not have a single element of SMS. SMS means to be able to follow the discussion with Vienna ATC and found … Any inconsistency, carelessness or ideas and the policies,” he said. out that ATC was not aware that there deviation from safety standards [such When people see themselves as was no yellow centerline and that the as snow-covered runways, low visibility elements of a larger system beyond routing assigned should not have been or missing/misleading visual aids] their immediate job, the level of safety used. … The pilot involved had never may result in a disaster.” The airport increases. “For example, an aircraft had training for a taxi turn more than operator’s scope of responsibility for an taxiing out for departure [at Vienna] 90 degrees, so his company subse- SMS includes a comprehensive safety missed an intersection,” Gruber said. quently implemented that training.” policy; a person dedicated to running “ATC gave alternative instructions and, the SMS; staff awareness and training; finally, the aircraft had to make a sharp — Wayne Rosenkrans
“One of the objectives of an SSP is to gener- employees of regulatory authorities to ensure “The service ate a context that supports the implementation that they understand safety management of SMS by service providers,” the SMM said. concepts and related ICAO standards and rec- providers’ SMS “The service providers’ SMS cannot effectively ommended practices (SARPs), and to ensure cannot effectively perform either in a regulatory vacuum or in an that they have the knowledge to “accept and exclusively compliance-oriented environment. oversee” implementation of the key compo- perform either in a In such environments, service providers will nents of an SMS, in compliance with national only implement and demonstrate, and the state regulations and ICAO SARPs. regulatory vacuum authorities will only assess, the tokens of SMS. In order for an SSP to specifically sup- or in an exclusively [Effective performance of] SMS by service pro- port SMS implementation, additional steps are viders can only flourish under the enabling um- required — the development of SMS require- compliance-oriented brella provided by an SSP. The SSP is therefore a ments for service providers and related guidance fundamental enabler for the implementation of materials, and the revision of the civil aviation environment.” effective SMS by service providers.” oversight authority’s enforcement policy. The SMM laid out several steps to imple- “During the course of normal safety manage- menting an SSP. First, a “gap analysis” should be ment activities under the respective SSP and SMS, conducted to assess the status of existing programs the state and the service providers will exchange that might constitute elements of an SSP. The safety data,” the SMM said. “The service providers’ analysis should be followed by development of safety data received by the state will be [propri- legislation and operating regulations for the SSP. etary] data, a part of which the state will convert Early in the implementation process, a into aggregate data. A significant amount of all training program should be developed for these data will reasonably refer to safety concerns www.flightsafety.org | AeroSafetyWorld | January 2009 | 29 safetyculture
identified through the normal course of aviation in the U.K. and the need to ac- SMS already are being realized, “not the service providers’ SMS processes. If commodate the U.K.’s relationships with only in terms of safety, but [SMS] has the response to this data by the civil avia- its territories and dependencies overseas. given greater clarity to air transport tion oversight authority is enforcement In addition, because military aircraft are organizations and resulted in enhanced action, the safety management process in so active within U.K. airspace, the CAA operational efficiency.” the state will grind to a halt.” decided that the SSP would address both Nevertheless, the IAC said, “SMS To prevent such situations, the civil and military aviation. implementation is proving to be a SMM said, revision of enforcement Details of the roles to be played by tougher road than expected.” policies is required “to ensure continu- EASA and the European Community Notes ing flow and exchange of proactive and will be described in the Community predictive safety management data with Safety Programme (CSP) being devel- 1. ICAO. Safety Management Manual, second edition, unedited draft. Montreal, 2008. service providers who operate under an oped by EASA. The CSP, which will be SMS environment.” EASA’s version of an SSP, is expected to 2. Booth-Bourdeau, Jacqueline. “Assessing Compliance in a SMS Environment: The SMM recommended that the be issued in 2009. A Systems Approach to Oversight.” In SSP include provisions to ensure that, The gap analysis found that al- Proceedings of the 61st annual International although “gross negligence, reckless though “most essential elements of the Air Safety Seminar. Alexandria, Virginia, conduct and willful deviations should be safety framework are well established,” U.S.: Flight Safety Foundation, 2008. dealt [with] through established enforce- some items were identified for im- 3. Office of the Auditor General of Canada. ment procedures,” some specific safety provement, Griffiths said. 2008 May Report of the Auditor General of concerns should be handled internally by Canada, “Chapter 3 — Oversight of Air airlines and other service providers and Training Sessions Transportation Safety — Transport Canada.” within the context of the provider’s SMS. For regulatory authorities still without
30 | flight safety foundation | AeroSafetyWorld | January 2009 smokefirefumes
hen the Royal Aeronautical Society Everyone in the industry remembers well the published its Specialist Document tragic loss of Swissair Flight 111, a McDonnell “Smoke and Fire in Transport Air- Douglas MD-11 that crashed near Halifax, Nova craft” (SAFITA) in February 2007, Scotia, on Sept. 2, 1998. The Transportation Safety theW document said that in the United States an Board of Canada (TSB) investigated the accident average of one airplane each day diverts due to and wrote a comprehensive report that detailed the a smoke event. However, new information from ways in which this accident was an example of the the FAA now puts that average at more than two potential extreme consequences of a smoke/fire/ diversions daily. Improved reporting of events fumes event in an aircraft. Following the recom- accounts for much of the increase, but it is clear mendation of the TSB, improvements were made that the problem of smoke in aircraft is not in the MD-11’s thermal acoustic blankets. While improving across the industry. Continued on page 34
It’s time to implement recommendations for mitigating smoke/fire/fumes events.
NO SMOKING BY JOHN COX in the Cockpit © Chris Photography Sorensen
www.flightsafety.org | AeroSafetyWorld | January 2009 | 31 smokeFirefumes
Smoke, Fire and Fumes Events in the United States and Canada, October–November 2008
Flight Event Event Date Phase Event Airport Event Classification Sub-classification Aircraft Model Operator Name La Guardia, Oct. 8, 2008 Climb New York (LGA) Return to airport Smoke alert EMB-145LR Chautauqua Airlines After takeoff from LGA, flight crew received an EICAS lavatory smoke indication. Return to airport, Oct. 7, 2008 Climb Portland, Oregon (PDX) unscheduled landing Smoke in cockpit A320 Allegheny Airlines 5 minutes after takeoff, smoke started coming out of center glareshield panel. Oct. 7, 2008 En route Denver, Colorado (DEN) Diversion, unscheduled landing Fumes in cabin DC-9 American Airlines Crew reported strong electrical smell in aft cabin. Flight attendant and passengers nauseous. Oct. 30, 2008 En route Diversion, unscheduled landing Fumes in cabin A320 United Air Lines Flight diverted after electrical smell in cabin. American Oct. 3, 2008 Descent Emergency landing Smoke in cabin EMB-145LR Eagle Airlines On approach, cabin started filling with hazy smoke. Emergency descent to landing initiated. Memphis, Oct. 29, 2008 En route Tennessee (MEM) Emergnecy landing Smoke in cockpit 727 Federal Express
At FL350, electrical odor was noted; donned O2 masks and ran "Smoke" checklist. Smoke visible near first officer's LIDO bag. Smoke in cockpit, Oct. 29, 2008 En route Diversion fire in cockpit Beech 58 Corporate Pilot smelled smoke and saw flames coming out of propeller heat circuit breaker switch. Charlotte, Return to airport, Oct. 28, 2008 Climb North Carolina (CLT) emergency landing Smoke in cabin ERJ190 Allegheny Airlines Smoke/fumes in aft galley. Captain requested emergency equipment upon return to airport. Return to airport, Smoke alert, Oct. 27, 2008 Climb Dallas, Texas (DAL) emergency landing smoke in cabin 737 Southwest Airlines Both lavatory smoke alarms sounded; flight attendants reported haze in cabin. Oct. 24, 2008 Descent None Smoke in cockpit Saab 340 Colgan Airways Smoke in cockpit during descent. Return to airport, Oct. 24, 2008 Climb unscheduled landing Smoke in cockpit EMB-120ER Sky West Airlines After takeoff, smell of smoke in flight deck, lavatory smoke detector activated. Return to airport, Smoke in cockpit, American Oct. 23, 2008 En route Columbus, Ohio (CMH) unscheduled landing smoke in cabin EMB-145LR Eagle Airlines On climbout, flight crew observed smoke in the cockpit and cabin. Odor in cockpit, Oct. 23, 2008 Climb Jamaica, New York (JFK) Return to airport odor in cabin ERJ190 JetBlue Airways Burning odor detected in cockpit and cabin. Oct. 2, 2008 Climb Unscheduled landing Smoke in cockpit Lear 60 Corporate Upon leveling off at FL410, flight crew observed smoke in the area of the copilot’s control yoke. Return to airport, Oct. 19, 2008 Climb emergency landing Fumes in cockpit A320 Allegheny Airlines
Captain donned O2 mask and declared emergency after fumes in cockpit. Kansas City, Return to airport, Oct. 17, 2008 Climb Missouri (MCI) unscheduled landing Smoke in cabin EMB-145XR Continental Express Flight crew reported smoke in the cabin shortly after takeoff. Return to airport, Oct. 17, 2008 Climb Atlanta, Georgia (ATL) unscheduled landing Smoke in cabin DC-9 American Airlines During climbout, flight attendant reported white smoke in cabin. Return to airport, Oct. 17, 2008 Climb Jamaica, New York (JFK) unscheduled landing Smoke in cabin 767 American Airlines Crew reported smoke in cabin. Return to airport, Smoke in cockpit, Oct. 16, 2008 Climb unscheduled landing smoke in cabin CL600 Sky West Airlines After takeoff, aircraft filled with smoke. Toilet smoke caution received.
32 | flight safety foundation | AeroSafetyWorld | January 2009 smokefirefumes
Smoke, Fire and Fumes Events in the United States and Canada, October–November 2008
Flight Event Event Date Phase Event Airport Event Classification Sub-classification Aircraft Model Operator Name Florence, Oct. 10, 2008 En route South Carolina (FLO) Diversion, emergency landing Smoke in cockpit Dash 8 Henson Aviation Flight crew diverted to FLO with smoke in the cockpit and burning smell in cabin. Managua, Nov. 30, 2008 En route Nicaragua (MGA) Diversion, emergency landing Smoke in cabin 737 Continental Airlines Crew declared an emergency following engine problems. During diversion the cabin started to fill with smoke. Nov. 28, 2008 En route Diversion, emergency landing Smoke in cabin 737 Southwest Airlines Declared an emergency with smoke in the cabin. Charleston, Atlantic Nov. 28, 2008 En route West Virginia (CRW) Diversion Smoke in cockpit CRJ-200 Southeast Airlines Diverted after the crew smelled smoke in the cockpit. Landed approximately 15 minutes later. Minneapolis, Return to airport, Smoke alarm, Nov. 26, 2008 Climb Minnesota (MSP) unscheduled landing fumes in cabin CL600 Mesaba Aviation Amber caution smoke in lavatory. Flight attendant reported fire odor. Aircraft landed overweight. Return to airport, Nov. 25, 2008 Climb unscheduled landing Smoke in cabin EMB-135BJ Corporate Immediately after departure crew noted the cabin filling with smoke. American Nov. 25, 2008 Takeoff Aborted takeoff Smoke in cockpit EMB-135KL Eagle Airlines At 80 kt on takeoff roll, cockpit became hazy with smoke accompanied by odor. Return to airport, Smoke in cockpit, Nov. 25, 2008 Climb Jamaica, New York (JFK) emergency landing smoke in cabin ERJ190 JetBlue Airways Smoke in cabin and cockpit. Nov. 24, 2008 Descent Emergency landing Smoke in cabin MD-88 Delta Air Lines Smoke in cabin, both aft lavatory smoke detectors alarmed. Return to airport, Nov. 24, 2008 Climb Houston, Texas (IAH) unscheduled landing Smoke in cabin CL600 Chautauqua Airlines Flight attendant reported smoke rising from the floor distribution ducts. Nov. 23, 2008 En route Buffalo, New York (BUF) Diversion, emergency landing Smoke in cockpit ERJ190 JetBlue Airways Cockpit smoke smell at FL380, EICAS failure, multiple faults. Return to airport, Nov. 20, 2008 Climb Fort Myers, Florida (RSW) unscheduled landing Smoke in cabin EMB-145LR Continental Express Flight attendant reported smoke in the cabin. Return to airport, Smoke in cockpit, Nov. 17, 2008 Climb emergency landing smoke in cabin Lear 35A Corporate On takeoff, crew noted smoke and fumes in aircraft, aircraft pressurization was in emergency. Nov. 17, 2008 Takeoff Burbank, California (BUR) Aborted takeoff Smoke in cockpit CL600 Mesa Air Group Flight crew aborted takeoff and returned to gate due to smoke in the cockpit. Return to airport, Smoke in cockpit, American Nov. 15, 2008 Climb emergency landing smoke in cabin Emb135KL Eagle Airlines Crew reported smoke detected in cabin and cockpit 30 seconds after takeoff. Smoke in cockpit, Nov. 12, 2008 Climb Unscheduled landing smoke in cabin MD-88 Delta Air Lines Smoke in cabin and cockpit. Nov. 11, 2008 En route Jacksonville, Florida (JAX) Diversion, emergency landing Smoke in cabin 717 AirTran Airways Crew declared an emergency due to smoke in the cabin. Nov. 11, 2008 Takeoff Winnipeg, Canada (YWG) Aborted takeoff Smoke in cabin CRJ-200 Sky West Airlines Rejected takeoff due to fire alert in rear lavatory, with smoke. Two hours later, the same aircraft attempted takeoff again with the same warning.
EICAS = engine indicating and crew alerting system
Source: FAA, SDR (Service Difficulty Reports) data compiled by Safety Operating Systems
www.flightsafety.org | AeroSafetyWorld | January 2009 | 33 smokeFirefumes
this was a needed improvement, it was This Florida diversion reminds us each recommend steps we can take to not all that needed to be done. of the needs pilots have for oxygen to lower the risk. By reviewing and imple- In February 2006, a McDonnell breathe, to keep smoke out of their menting these recommendations we Douglas DC-8 freighter landed in eyes and to see the flight instruments. can reduce the chance of a fire and the Philadelphia with a cargo fire. The U.S. Pilots must be able to fly the aircraft, impact on the flight, and increase the National Transportation Safety Board accomplish the checklist, set up the probability of a successful outcome. (NTSB) investigated the accident. In approach procedure and successfully Aircraft are one of the worst places its report, the NTSB cited the need for land the aircraft. Reinforcing the im- a fire can break out. In flight, a fire improved “Smoke/Fire/Fumes” check- portance of protecting a pilot’s ability must be extinguished with the items lists and recommended widespread to perform, the International Federa- on board; expert training and good adoption of a new checklist developed tion of Air Line Pilots’ Associations equipment are essential. Operators by industry initiative, concurring with a (IFALPA) considers a pilot who cannot should improve maintenance practices recommendation made by the TSB. see his or her flight instruments to be to inspect thermal acoustic blankets, Flight Safety Foundation led an incapacitated. which can provide fuel if a fire breaks industry group to develop an improved Improved flight crew training can out. Each of the multiple layers of checklist used by flight crews facing make a significant difference in the mitigation is a step to risk reduction. an in-flight smoke/fire/fumes event. outcome of a smoke/fire/fumes event. It is time to implement the recommen- Boeing, Airbus, Embraer and Bom- Many newer flight simulators use dations made by the NTSB, TSB and bardier have agreed to begin using this theater smoke to realistically simulate a SAFITA. improved checklist, an agreement that smoke event. This more realistic simu- Flight Safety Foundation is work- is a step forward in helping flight crews lation shows the challenges in com- ing with the Royal Aeronautical Society to successfully deal with in-flight fires. munications between the crewmembers and others to enlighten the industry The incorporation of the new and with air traffic control, and the dif- about this issue’s importance. By work- checklist is one of 18 recommenda- ficulty of programming flight manage- ing together, successful cost-effective tions in SAFITA. SAFITA, like the ment computers under such conditions. mitigations can and should be imple- TSB and NTSB reports, recommends Improved training is one of the SAFITA mented. The Swissair Flight 111 tragedy specific improvements to reduce the recommendations. happened more than 10 years ago — we likelihood and severity of a fire aboard While it is tempting to look back must not let time dim the memory of an airplane. The U.S. Federal Aviation and believe that we have not had a seri- the importance of that accident. We Administration (FAA) recently adopted ous fire event since 1998, investigation have analyzed accidents and incidents another of the recommendations by proves otherwise. In 2007, a widebody involving in-flight smoke/fire/fumes. It requiring improved maintenance pro- jet experienced a serious fire just after is now time to act and implement the grams for aircraft wiring. This is a good engine start. The crew only became recommendations. step to reduce the source of ignition. aware of electrical anomalies following Capt. John Cox is chief executive officer, Safety Have we done enough? Based on the second engine start. Maintenance Operating Systems. He is a 25-year veteran of the recent experience of a flight crew technicians found evidence of a consid- flying for a major U.S. airline. He served as that diverted to South Florida because erable fire in the electronics bay. executive air safety chairman for the Air Line of a smoke event, more needs to be The FAA said in November 2005 in Pilots Association and participated in accident done. This flight crew suddenly had a notice of proposed rulemaking, “We investigations, including USAir 427. dense smoke in the flight deck, fol- have concluded we are unlikely ever (Editor’s note — This article and chart intro- lowed by a windshield beginning to to identify and eradicate all possible duces a new feature in AeroSafety World, a crack. The inner pane of the windshield sources of ignition.” quarterly chart that is intended to focus atten- shattered. Fortunately, the source of the Accepting that aircraft will continue tion on a continuing risk factor: significant smoke, fire and fumes events in the U.S. This smoke was located and electrical power to have smoke events, the industry information is drawn from available U.S. removed. A successful unscheduled must develop multiple layers of mitiga- sources. However, should information from landing followed, just one of that day’s tion to reduce the hazard to an accept- other nations or regions become available we several smoke-caused diversions. able level. The NTSB, TSB and SAFITA will endeavor to use it.)
34 | flight safety foundation | AeroSafetyWorld | January 2009 LEADERSLOG
BY NICHOLAS A. SABATINI Managing Safety From the Inside Out
hen Jerry Lederer started Flight discusses the importance of such an and to have a safety culture. It is es- Safety Foundation in 1947, U.S. inside-out approach. He says you must sential that the FAA hold itself to the Wair carriers averaged a major manage risks from inside because an same high standards to which it holds accident every 16 days, for a fatality organization, such as the FAA, could industry. The FAA’s Aviation Safety rate that approached 2,000 fatalities per unwittingly contribute to an unsafe Organization — with its nearly 7,000 100 million people flown. Today, that condition or unsafe practices. employees and many more designees rate is down dramatically to an average Organizational risk is not new who act on behalf of the FAA ad- of 2.5 fatalities per 100 million people in aviation. It was present at Kitty ministrator — is moving to an SMS. flown. While the overall rate is higher Hawk with Orville and Wilbur Wright The organization developed an SMS on a global scale, the strong safety and machinist Charlie Taylor. It was doctrine in concert with industry and record in most regions of the world is a present in the 1940s with accidents remarkable achievement. every 16 days. Yet, organizational risk Yet, we can never rest. With aviation’s was largely undetected because it was vital importance, we must build on this overshadowed by greater risks — such achievement. The U.S. Federal Avia- as engine failure, controlled flight into tion Administration (FAA) is taking a terrain, loss of control, and approach two-pronged approach to manage risks and landing accidents. Now that we and keep improving safety. To begin, the have fundamentally addressed those FAA is managing risk from the “inside common causes, we need to identify out.” The FAA’s Aviation Safety Organi- and address other vulnerabilities, zation has been undergoing a rigorous including organizational risk, which self-examination — looking at how it is now may pose greater concern. Meta- organized, at processes, and at internal phorically, organizational risk is taller measures and accountability. At the same due to the flatness of the surrounding time, the FAA must focus outward on the terrain. entities and individuals that it regulates. As a regulator, the FAA requires In his book, Managing the Risks of regulated organizations to operate with Nicholas A. Sabatini recently retired as FAA Organizational Accidents, James Reason a safety management system (SMS) associate administrator for aviation safety. www.flightsafety.org | AEROSafetyWorld | January 2009 | 35 LEADERSLOG
is moving ahead with an implementation plan That was one data point: the finding that for an integrated system safety approach across several airlines received TAWS warnings in the the organization. same area. ASIAS analysts reviewed multiple SMS is built on the foundation of a quality data sources to get a clearer and fuller picture of management system (QMS), which the Aviation the problem. They analyzed minimum vector- Safety Organization implemented through ISO ing altitudes (MVAs), plotted TAWS warning 9001 standards in 2006. QMS addresses processes locations in relationship to these MVAs and — their standardization and consistency — as well overlaid radar track data from arriving flights to as continuous improvement. It is essential to add reveal a relationship. Then, they overlaid the ter- safety management to assure that risk manage- rain database combining, or fusing, it with the ment is incorporated into key processes. Yet, both MVA and TAWS data. QMS and SMS are processes executed by humans. With all of this, the analysts were able to see For safety’s sake, processes must exist in a safety a causal relationship that could not be seen from culture. Getting the culture right is more impor- any one data source. The experts call what they tant than the systems used. This is what is most did “fusion.” The single data point — the TAWS important about managing from the inside out. warnings — was just that: a single piece of infor- What about the second prong — the regula- mation. But fusing the data sources, including tor’s essential external focus? What can we do the MVAs, radar track data and more, provided For safety’s sake, to manage risk more effectively across civil a larger picture, a more complete understanding processes must aviation? With an air carrier fatality rate of 2.5 of the issues, and enabled the FAA Air Traffic per 100 million people flown, some might think Organization and Aviation Safety Organiza- exist in a safety the accident rate has reached such a low level tion to work together based on solid objective that we should no longer expect sudden and information. culture. Getting the sustained breakthroughs in future rates. From those TAWS warnings in Northern
culture right is more I disagree. The aviation community is on California airspace, thanks to data gathering, the threshold of the next level in aviation safety. sharing and analysis, FAA is making flying important than the This will be possible by managing risk far more safer — in the way it designs MVAs, how it effectively. The way to do this is through gather- vectors traffic, the design of TAWS software systems used. ing and sharing key safety data, using sophis- and much more. ticated data analysis to identify precursors and With ASIAS, we are making a game- detect emerging risks, and prioritizing and changing move from gathering data after measuring mitigations. accidents, in what has been termed a “forensics” Today, with the Aviation Safety Information approach, to preempting accidents. The more Analysis and Sharing (ASIAS) initiative, the FAA complete data, coupled with advanced analy- is gathering crucial safety information from sis, help us find emerging threats and identify a number of data sources. Furthermore, with precursors — precursors that could be buried sophisticated analysis tools, we are detecting in terabytes of safety data. This gives us advance trends, identifying precursors and assessing — warning and a tremendous advantage in pre- and addressing — risks. emptively managing risk. Here’s an example of how data analysis and Years ago, Jerry Lederer said, “Risks are ever- sharing can make a big safety difference. In 2007, present, must be identified, analyzed, evaluated several airlines reported that their digital recorder and controlled.” In today’s interconnected world data, or flight operational quality assurance data, — with far greater demand and vastly increased showed that they were getting warnings from complexity — Lederer’s guidance is more pre- their terrain awareness and warning systems scient than ever. The aviation community must (TAWS) at several airports with adjacent moun- manage risk. It is imperative that we manage tainous terrain in Northern California. risk together.
36 | flight safety foundation | AEROSafetyWorld | January 2009 FoundationFocus
Donoghue Recognized for Career Achievements in Aviation Journalism
.A. Donoghue, Flight Safety Foun- speech. “As Air Transport World’s third UTC is the long-time sponsor of the dation director of publications and editor-in-chief in its 45-year history, award. editor-in-chief of the Foundation’s I’m especially pleased to join the Lyman “I find the mission of the Founda- monthly magazine AeroSafety list with Jim Woolsey, the man who tion to be highly motivating and the WorldJ , has received the 2008 Lauren D. hired me and taught me much, espe- quality of what is done there to be in- Lyman Award for outstanding achieve- cially about the use of photography and spiring,” Donoghue said. “I couldn’t be ment in aviation journalism. graphics in the magazine, and ATW’s having more fun and still get paid for it. “Jay’s contribution to the aviation founder, the late and unquestionably “In the end, I’ve always felt honored industry spans three decades,” said Jay great Joe Murphy. Also, ATW’s long- to be a member of the aviation trade DeFrank, vice president–communi- time London correspondent, Arthur press and to be a small part of this in- cations for Pratt & Whitney, part of Reed, now departed.” credibly exciting aerospace community. United Technologies Corp. (UTC). Donoghue has won numerous The quality of that industry’s journalism “His stories on air safety and technical- awards for excellence in aviation makes any award presented by our related developments truly exemplify journalism, including the Royal peers special, and none the standards and skills by which Deac Aeronautical Society Journalist of more than this Lyman lived and worked.” the Year recognition in 2004. A former on e .” The award is named after Lauren U.S. Army helicopter pilot, his service “Deac” Lyman, a Pulitzer-prize winning included a year in Vietnam with the aviation reporter for the New York 4th Infantry Division flying Bell UH-1 Times who later had a distinguished ca- “Hueys” and Huey gunships. His com- reer as a public relations executive with mercial pilot license includes ratings for United Aircraft, a predecessor to UTC. helicopters, airplanes and gliders, and he Donoghue, who has more than 30 remains an active glider pilot. years experience covering aviation and Joining Flight Safety Foundation in 3,500 flight hours as a pilot, began his 2006, he oversaw the transition from career in aviation journalism in 1976 as a seven monthly and bi-monthly newslet- staff reporter for Aviation Daily. Moving ters to a new monthly four-color maga- to Air Transport World in 1980, he held zine, AeroSafety World, which currently a number of positions before becoming has a circulation of 40,000 hard copies editor-in-chief in 1991 and editorial di- and Web downloads per issue. rector of the ATW Media Group in 2002. First presented in 1972, the award “I am overwhelmed to be included goes to a journalist or public relations in the ranks of past Lyman award win- professional in aviation who exhibits ners,” Donoghue said in his acceptance Lyman’s high standard of excellence. www.flightsafety.org | AeroSafetyWorld | January 2009 | 37 HelicopterSafety
he crew of a CHC Scotia Aérospa- “The commander’s initial actions to support for gas operations in the East tiale SA 365N Dauphin 2 lost control recover the helicopter were correct, but Irish Sea, for a planned eight-segment during a nighttime approach to a gas the helicopter subsequently descended flight to offshore gas production platform in the Irish Sea, overflying into the sea,” the report said. platforms operated by Hydrocarbon
Tthe landing site and striking the water. The AAIB also cited “the approach Resources Limited (HRL). © Elnur/Dreamstime.coom The helicopter disintegrated on impact profile flown by the copilot, [which] The crew had flown a similar multi- and sank in the Dec. 27, 2006, crash, kill- suggests a problem in assessing the cor- segment flight earlier in the day and ing the two pilots and all five passengers. rect approach descent angle, probably had completed the first two segments The U.K. Air Accidents Investiga- … because of the limited visual cues of the accident flight without inci- tion Branch (AAIB), in its final report available to him.” dent. As they began the third segment, on the accident, cited three contribu- The third contributing factor was from the Millom West platform, five tory factors, including the lack of a the company’s failure to use “an ap- passengers boarded. Plans called for a “precise” transfer of control from the propriate synthetic training device,” seven-minute flight to the North More- copilot to the commander after the although one was available, the report cambe platform to pick up a passenger copilot lost control of the helicopter said. “The extensive benefits of con- and some freight before continuing to during the approach in poor weather ducting training and checking in such another platform. conditions. Four seconds elapsed after an environment were therefore missed.” The helicopter left Millom West at the copilot’s request for help before the The report said that the helicopter 1826, climbed to 500 ft and accelerated commander took control of the heli- had departed at 1800 local time from to 125 kt. The automatic flight control copter, the report said. Blackpool Airport, a base for helicopter system was engaged, and the helicopter
Investigators said that a lack of visual cues likely led the pilots of an SA 365N to lose control during a nighttime approach to an Irish Sea gas platform.
BY LINDA WERFELMAN ‘Flying Into the Sea’
38 | flight safety foundation | AeroSafetyWorld | January 2009 HelicopterSafety
his sighting of the Route of Accident Flight platform but climbed to just over 400 ft and Rigs
1 then began another Helicopter track Millom West 0 2.5 5 10 15 20 km descent. The helicopter’s 2.5 5 7.5 10 nm Last recording combined voice and 1832 hours flight data recorder Departure (CVFDR), which 1826 hours North Morecambe records five hours of Fleetwood data and one hour of Irish Sea audio from the com- Departure mander’s, copilot’s 1814 hours and cockpit area mi- crophones, at 1832:21, AP1 recorded the com- Departure Blackpool mander saying, “You 1800 hours get no depth percep- tion, do you?” The copilot replied, “Yeah, not on Note: this one, not tonight, 1. The helicopter’s track was derived from its combined voice and flight data recorder. no.” During this part Source: U.K. Air Accidents Investigation Branch of the approach, there were “steady increases Figure 1 in the collective, tail rotor input, cyclic was in the normal stabilization pitch and cyclic roll input,” and mode for flight, the report said. radio height decreased, then in- The commander, the pilot not fly- creased, the report said. ing, confirmed that lights on the At 1832:33 — with cyclic pitch North Morecambe platform were and roll inputs increasing and properly illuminated. oscillating, the collective increas- “Shortly after the 4 nm [7 km] ing at an escalating rate and the GPS [global positioning system] helicopter pitching nose down and call made by the commander, the rolling right — the commander crew became visual with the rig, asked, “You all right?” and the
BY LINDA WERFELMAN and the copilot said, ‘I got the deck copilot answered, “No, I’m not now,’” the report said. “Allowing for happy, mate.” the speed of the helicopter at the As the combined engine time, this equates to a visual range torques exceeded 100 percent, the of about 6,800 m [4 mi]. The com- commander asked, “We going mander then completed before- round?” and the copilot replied, landing checks, which included “Yeah, take … help us out.” arming the floats.” The report said, “This request The helicopter was at about was not initially understood by 270 ft when the copilot announced the commander, and the copilot
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reiterated his request, saying, ‘Help us normal,” the report said. The helicopter that related to the crash. A routine out.’ The commander took control ap- then banked right and disappeared into 50-hour maintenance check had been proximately four seconds after the initial darkness before the witnesses heard an performed the day of the accident, and request for help and said, ‘I’ve got it, I’ve impact with the water. no problems were reported. got it, I have got it, I have control, I have The fuselage broke apart on impact, control.’” At the time, the helicopter’s and most sections of the helicopter sank. ‘A Particularly Dark Night’ right bank angle increased to 38 degrees, Rescue boats arrived 16 minutes after Weather at the time of the accident its nose was about 38 degrees down, the crash from a multipurpose standby included visibility of 3 to 7 km (2 to indicated airspeed (IAS) was 90 kt and vessel that was near the platform. Bodies 4 mi) in mist and light rain or drizzle, increasing, and radio altitude was 290 ft, of six of those in the helicopter were re- scattered to broken clouds with a base with a descent rate of 2,000 fpm. covered, but the seventh was not found. at 700 ft, broken to overcast clouds A second after the commander took The commander, who had flown with a base at 1,200 to 1,500 ft and control, the report said, “a large left helicopters in the Morecambe Bay gas surface wind from 130 degrees at 15 kt. cyclic roll input was made, followed one field for 20 years, was the base chief A weather observer on a platform near second later by an aft cyclic pitch input.” pilot, a line training captain and a crew the accident site said that conditions The helicopter’s bank angle shifted to 7 resource management instructor. He about 90 minutes before the accident degrees left, and pitch attitude shifted to had an airline transport pilot license included 4,000 m (2.5 mi) visibility in 13 degrees nose-down; as the helicopter and an instrument rating, and had ac- rain and skies obscured; an accurate as- descended through 180 ft, IAS increased cumulated 8,856 flight hours, including sessment of the cloud base was not pos- through 100 kt. Over the next six sec- 6,156 hours in type. Records showed sible because the observer did not have onds, IAS continued to increase; vertical he had completed 34 instrument ap- appropriate equipment to measure it. speed, which initially had been reduced proaches and 37 night deck landings in The report said that, although there to 1,320 fpm, increased to 1,690 fpm. the 90 days before the crash. was a half moon, the clouds completely The copilot had received helicopter obscured any light from the moon, and ‘You All Right?’ flight training in the British Army and “it was a particularly dark night.” “At 1832:45, the copilot uttered an had flown emergency medical services Data from the helicopter’s inte- expletive, as though disappointed, helicopters for 2 ½ years. He had been grated health and usage monitoring and the commander asked, ‘You all working for CHC Scotia for 13 months system (IHUMS), which incorporated right?’; the copilot said, ‘Yep … no,’ in at the time of the accident and had the CVFDR, showed that no system a resigned manner,” the report said. At 3,565 flight hours, including 377 hours fault warnings were activated during 1832:47, the automatic voice alert de- in type. He had 467 hours of night the accident flight. Two main gearbox vice, which provided audio warnings of flight — three of which were recorded exceedances were recorded — the first, the helicopter’s height above the surface, in the three months prior to the ac- when the combined engine torque sounded a “100 feet” call. cident. He had completed nine instru- exceeded 100 percent at an airspeed The report described cockpit com- ment approaches and seven night deck below 75 kt, and the second, after the munications as “calm” and said that landings in the 90 days before the crash. commander took the flight controls, there were no indications of other prob- The helicopter was manufactured by when the torque exceeded 94 percent lems. The helicopter was last recorded at Aérospatiale (now Eurocopter) in 1985 with the airspeed above 75 kt. 30 ft in a 12-degree nose-down attitude, and had accumulated 20,469 airframe Data also showed that, during the a 20-degree right bank and an IAS of hours and 13,038 cycles. Records accident segment of the flight, the 126 kt. The recording ended at 1832:50. showed that it had been maintained in autopilot heading hold, IAS hold, alti- Witnesses on the North Morecambe accordance with an approved main- tude hold and area navigation (RNAV) platform told investigators that the tenance schedule and was in compli- modes were not used. helicopter appeared to be on a standard ance with all applicable airworthiness approach until it “appeared to initi- directives. Maintenance records for Two Distinct Phases ate a go-around, although it seemed the 12 months preceding the accident The report said that, because there was faster and closer to the platform than showed no defects had been reported no evidence of any technical problem,
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investigators focused on human factors issues Aviation Organization beginning in 2009 — call “to understand why two experienced pilots were for installing green lights instead of yellow lights unable to stop a serviceable helicopter [from] on helideck perimeters as a means of enhancing flying into the sea.” pilot situational awareness. Further trials by the Investigators identified “two distinct phases” U.K. Civil Aviation Authority (CAA) have led to of the final approach. The first involved a the development of other helideck lighting pat- “steady reduction in collective demand and a terns now being tested on offshore platforms.1 steady, positive change in pitch attitude,” the The report said that judging the approach report said. The second — which began after angle apparently had presented the crew with a the commander’s callout of “fifty-five,” a refer- significant challenge that might have been met by ence to airspeed — involved a steady increase minimizing the number of variables involved — in collective demand as the helicopter began to “by commencing the descent at a specified height climb, suggesting “a change in the appreciation and range, and maintaining a stable pitch attitude of the helicopter’s position or motion relative to and a fixed relationship to the intended landing the deck,” the report said. area” — or by using instrument references in “The approach was flown essentially by reference to visual Aérospatiale SA 365N Dauphin 2 cues. In dark, overcast conditions, it is likely that some cues were degraded or absent. For example, without a distinct horizon, the assessment of pitch attitude and approach angle (by reference to the depression of the deck below the horizon) would be compromised.” The report noted that if recommended changes in helideck lighting had been implemented, better visual cues might have been available, © Darren Wilson/Airliners.net © Darren perhaps enabling the crew to determine he Aérospatiale (now Eurocopter) SA 365N, first flown in 1979, is a twin-engine helicopter earlier in their ap- designed to carry two pilots and up to eight passengers. It is equipped with Turbomeca Arriel proach that they had T1C gas turbine engines, each rated at 530 kW (710 shp). Empty weight is 2,017 kg (4,447 lb) and maximum takeoff weight is 4,000 kg (8,818 lb). deviated from a safe Maximum cruising speed at sea level is 140 kt, maximum rate of climb is 1,515 fpm, and service approach path. The ceiling is 15,000 ft. Maximum range, with standard fuel at sea level, is 475 nm (880 km). recommendations — Source: Jane’s All the World’s Aircraft, U.K. Air Accidents Investigation Branch to be mandated by the International Civil www.flightsafety.org | AeroSafetyWorld | January 2009 | 41 HelicopterSafety
addition to the limited visual cues. However, the helideck approaches flown by all of its types radio altimeter was not in a location that enabled “with the aim of ensuring safe operations.” it to be conveniently included in the copilot’s Another recommendation called on the instrument scan, the report said, and the cockpit European Aviation Safety Agency (EASA) to voice recorder indicated that the crew was not ensure the prompt completion of research into “using range information to determine the initia- instrument landing systems that would aid heli- tion of the descent or cross-checking with height, copter crews in monitoring approaches in poor and except for the ‘fifty-five’ call and one height visual conditions to oil and gas platforms. call at 400 ft, the commander did not provide any A second recommendation to the EASA information that may have assisted the copilot. said the agency should investigate methods of “The nature of the copilot’s difficulty is open increasing the conspicuity of immersion suits to conjecture; he may have commenced the worn by flight crewmembers. Rescuers had told descent too early or initially too steeply; or he accident investigators that the yellow immer- may have used an inappropriate control strategy sion suits worn by passengers of the accident or inadvertently changed the pitch attitude. The helicopter were easier to see than the blue suits underlying causes, however, most likely stem worn by the pilots. from the limited visual cues available and the The AAIB also recommended that the CAA paucity of instrument checks. Inadequate moni- ensure that recurrent training and checking of toring of the approach by the commander must JAR-OPS (Joint Aviation Requirements–Opera- also be regarded as a contributory factor.” tions), Part 3 approved operators be conducted The report also said that the commander ap- in an approved synthetic training device. peared “ill-prepared” to take control of the helicop- A second recommendation to the CAA ter and that both the go-around decision and the called on the agency to ensure that person- subsequent transfer of control to the commander nel who conduct weather observations from appeared to have been handled inappropriately. offshore facilities are “suitably trained, qualified “It is possible that more positive crew interac- and provided with equipment than can accu- tion and a more active participation in approach rately measure the cloud base and visibility.” The profile monitoring by the non-handling pilot report noted that the employee who compiled may have resulted in a positive outcome,” the weather data on the evening of the accident had report said. not received formal training and had no equip- ment to aid in his observations. Monitoring the Approach After the accident, the operator provided The report included a safety recommendation more specific procedures and guidance for that CHC Scotia review its standard operating actions to be taken in the event of pilot disori- procedures (SOPs) for helideck approaches “to entation or incapacitation; developed go-around ensure that the non-handling pilot actively procedures that included use of the autopilot monitors the approach and announces range to coupler; developed and published a night circuit touchdown and height information to assist the pattern; and continued development of its policy flying pilot with his execution of the approach to train all pilots in synthetic training devices. profile.” This article is based on AAIB Accident Report No. The recommendation said that the non-han- 7/2008: Report on the Accident to Aerospatiale SA 365N, dling pilot’s assistance is especially important Registration G-BLUN, Near the North Morecambe Gas when an SA 365N copilot is flying an approach Platform, Morecambe Bay, on 27 December 2006. in poor visual conditions “and cannot easily monitor a poorly positioned radio altimeter.” Note A second recommendation to the opera- 1. CAA. Enhancing Offshore Helideck Lighting, CAA tor called for a review of all SOPs concerning Paper 2004/01.
42 | flight safety foundation | AeroSafetyWorld | January 2009 Strategicissues Fairly Disciplined Shanghai Airlines reports positive results after launching By Wayne Rosenkrans China’s first conditional nonpunitive FOQA program.
irlines, pilots and civil aviation procedures (SOPs) and cooperate in Transport Association in Honolulu. Some authorities worldwide have analysis of flight parameter exceedances. could replicate the approach of Shanghai struggled for decades to recon- Airlines in China, as in most coun- Airlines, which decided that nonpunitive cile their conflicting interests to tries, this year will redouble efforts to FOQA policies stand a greater chance of Aobtain maximum benefits from flight integrate existing FOQA programs into success than punitive policies of the past. operational quality assurance (FOQA) their implementation of safety manage- Because of culturally ingrained beliefs programs, also known as flight data ment systems (SMSs), according to a about individual accountability for com- monitoring. They all want to be suc- presentation and ASW interviews during plying with safety rules, however, some cessful in detecting accident precursors the Joint Meeting of the Flight Safety aspects of Shanghai Airlines’ policies have and unsafe trends in routine flight data. Foundation 61st annual International caught off-guard aviation safety profes- They also want to foster a work environ- Air Safety Seminar, International Fed- sionals in North America and Europe. ment in which flight crews readily report eration of Airworthiness 38th Interna- Unlike the 20 U.S. airlines — out deviations from standard operating tional Conference and International Air of 681 — that voluntarily analyze © Florian Trojer/AirTeamImages © Florian
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is a 90 percent–plus QAR installa- the digital flight data recorder, which tion rate for all Chinese airlines,” says primarily is designed for crash inves- Fang Jun, coordinator for interna- tigations, and leaving it at a laboratory
Wayne Rosenkrans Wayne tional safety programs at CAAC for several days of data readout and headquarters. “FOQA is not so new analysis had proved too cumbersome. for Chinese airlines, but SMS is. Since “Today, if the airline doesn’t have the we are advocating and pushing the QAR or equivalent equipment on a implementation of SMS, the FOQA technically compatible airplane, the programs are essential.” airplane is not airworthy,” Fan said. His airline’s effort to introduce Early Adoption of QARs FOQA, and overhaul initial assump- In 1997, CAAC issued an airworthiness tions and policy, has been singled out by Fan directive requiring all Chinese airlines to CAAC as a benchmark for all Chinese parameters of daily airplane operations equip their aircraft with QARs or equiva- airlines. “Shortly after issuing the captured by quick access recorders lent equipment. Policy details for routine airworthiness directive, CAAC realized (QARs), all airlines in China for about flight data monitoring and analysis, that having QARs on airplanes was not 12 years have been required to install however, were left to each airline. enough,” Fan said. QARs on their airplanes, except those Data collection with QARs was An unintended consequence of that are technically incompatible, and seen as a way for CAAC and airlines sparse QAR and FOQA requirements to conduct a FOQA program. to reduce delays in obtaining recorded was free rein for airlines to discipline Encouraging China’s airlines parameters to conduct aircraft incident pilots for any exceedances of aircraft to also adopt a nonpunitive FOQA investigations, recalls Fan Hai-xiang parameters deemed to indicate non- policy has become a strategic priority (Steven), deputy general manager, flight adherence to SOPs (Table 1). This of the Civil Aviation Administration technical, and director, Flight Training soon caused resentment and resis- of China (CAAC). “Right now, there Center, at Shanghai Airlines. Removing tance among flight crews rather than © The Boeing Co. The ©
44 | flight safety foundation | AeroSafetyWorld | January 2009 Strategicissues
Consequences of Hard Landings for Flight Crews in China
Normal Operations Airline FOQA Program Monitors QAR Data and Interacts With Crews CAAC Investigates Landing Event Hard Landing Severity +1.4 g or less +1.6 g +1.8 g +2.0 g >+2.0 g or <+1.1 g Minor Moderate Severe Severe hard incident Normal landing exceedance exceedance exceedance landing (damage) Accident Typical FOQA Program in China No monitoring/ Crew counseled Discipline for these FOQA exceedances, at discretion of Consequences determined outside of actions airline mid-management, may include fine, suspension and FOQA program crew identification in notice to fleet Conditional Nonpunitive FOQA Program at Shanghai Airlines No monitoring/ Only trend Crews counseled Crew disciplined Crew suspended, Consequences determined outside of actions monitoring if but not identified but any notice possibly fined, FOQA program event reported to mid- to fleet will not retrained and within 48 hours, management identify them identified in validated by data unless they failed unless event notice to fleet and not repeated to report event recurs or they fail regardless of in 12 months within 48 hours to report it within event report 48 hours FOQA = flight operational quality assurance; CAAC = Civil Aviation Administration of China; g = 1.0 times acceleration of gravity; QAR = quick access recorder
Source: Shanghai Airlines Table 1
cooperation in the analysis of events flagged by FOQA program in 2000, somewhat later than analytical software. other large airlines in China. Because of the ex- “The CAAC began to realize there was some- tended implementation time, the company was thing not quite right,” Fan said. “Airline manag- less vested in the industry’s prevailing orienta- ers would talk to the crew and ask them what tion toward punitive FOQA programs. happened, then the pilots would be punished. “From 2000 to 2004, we did parameter devel- This was something that should not happen, and opment with emphasis on hard landings; sink rate CAAC in 2003 called on the airlines to start creat- warnings and high speed at low altitudes; landing ing nonpunitive FOQA programs.” The regulator long; and unstabilized approaches,” Fan said. also invited airlines, pilots, airframe manufacturers “The event reports were very few, not enough, and FOQA-related vendors to take part in annual so we fine-tuned the parameters and the trigger FOQA seminars in different regions of China. conditions. We analyzed the event and inter- “Some cultures have approached FOQA viewed the crew. The pilots also got called in by programs by using data obtained from flight data their mid-manager and got punished … we then recorders to punish the pilots for even minor issued notices to the fleet with pilot identifica- exceedances of parameters,” said Frank M. Han- tions. A lot of pilots felt hurt; they did not want to kins, a training captain in China for The Boeing be identified. When we tried to talk to the crews, Co. and Fan’s co-author of the IASS presentation. they would try to keep quiet, saying as little as “Such is the case in most of mainland China and possible so they would not make trouble for some other countries in Asia. The pressure on themselves or colleagues. When we could get in- flight crews to fly by the book — knowing that formation, it probably was two or three weeks old the ‘QAR police’ are looking over their shoulders … or not enough. Another negative aspect was — has a very debilitating effect on … their judg- that the captains started to fly the airplane more; ments, which jeopardizes the safety of flight.” they would not let the first officers fly because if Shanghai Airlines had chosen hardware and the first officer made a mistake, the captain also software vendors in 1998, but implemented its got punished. I felt that this was not conducive to
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effective crew resource management and system would treat them fairly and/or minor and moderate exceedances of diminished safety.” embarrassment. Policy changes would FOQA parameters; and strong incentives/ Seeds of a major change were sown have to address every concern. reduced discipline for crews to report when Fan approached the airline’s se- “Throughout much of Asian culture, non-normal operational events. A few nior management about trying some- including in China, people believe that if exceptions made the nonpunitive policy thing different, drawing from his own you make a mistake, it is right to disci- “conditional,” and the concept still falls safety literature review and visits to pline and to administer some punish- within the bounds of just culture used in nonpunitive FOQA programs in several ment,” Fan said. “It is acceptable, expected international aviation, Fan believes. Western countries. The airline’s original and part of who we are as a people. Even “It’s conditional — that’s the magic FOQA program had failed to live up to pilots who have made big mistakes tell us, word; our own way of designing a expectations, and Fan and his staff were ‘Punishment is OK, no problem. It’s right. nonpunitive reporting system is prob- anxious to devise a new nonpunitive I was wrong. I am sorry for that.’ But ably not the same as that of others,” Fan reporting policy. when pilots did not have good protec- said. Conditional means that there are In his pitch to senior management, tion, or we punished them for minor prerequisites for deidentified, nonpuni- Fan argued that unjustifiably disclosing exceedances, they would say, ‘No, this is tive handling of a minor or moderate flight crew names in notices to the fleet not fair — why should I be disciplined?’ exceedance: The crew must report the undercut corporate values of fairness and then they would stay quiet.” event within 48 hours (Figure 1), the and objectivity. “You usually must Early advocacy of nonpunitive report has to be validated by cor- deidentify them in order to have a fair FOQA could not budge senior manage- responding QAR data, and the crew solution,” he said. ment from one fixed position. For the must not have had a related exceedance One factor in his favor was peer most serious FOQA exceedances, a within the previous 12 months. scrutiny of his initial ideas outside notice to the fleet about each event was Even with high-level support, Fan China — including at a 2004 regional considered warranted, including disclo- and other safety professionals soon safety seminar organized by the Inter- sure of the names of the pilots involved. encountered opposition at the mid- national Civil Aviation Organization. Senior management was willing, management level. He attributes this The audience questioned his reasoning however, to require all mid-managers resistance to mid-managers’ perceived when they heard him propose limited to shift their focus from disciplining in- loss of a management tool/control disciplinary measures within Chinese dividuals to solving systemic problems. and to traditional cultural concepts of FOQA programs. “I told senior management that the “father-to-son discipline” that spill over Some people who heard him speak, situation was like having one window into professional relationships. for example, asked him to catego- in a room,” Fan said. “If this window “In the past, the mid-managers knew rize his proposal as either punitive were open, mid-management only that when they received a FOQA notice or nonpunitive. Fan answered, “Our would look out, they would not look at to the fleet, they would know who had system will be less punitive.” Similarly, things happening inside the room. But the problem, who made the mistake, who they asked why airlines ever should if we shut the window, then they would had the exceedances,” Fan said. “Now, the disclose the names of flight crews to have to look in other directions for how typical report to the fleet just says what mid-managers and/or all the fleet to solve the problem. That’s why I got happened and how the event happened, pilots. “I admitted that identifying the senior management support.” but not who did it. During the trial run of crew is a punishment,” he recalls. “I The company in 2005 had a success- conditional nonpunitive FOQA in 2005, said, ‘Changing that is difficult, but we ful trial run of its revised policy, calling it the majority of pilots were delighted, but will try.’ Their input really inspired me a conditional nonpunitive FOQA program; not all of them agreed.” toward turning my airline’s system in a the program was fully implemented in The logic of the new policy still nonpunitive direction.” 2006. It includes objective validation with escapes mid-managers who adhere to Shanghai Airlines began with an as- data of non-normal operational events in traditional cultural values. “When we sumption that flight crews are tempted the interest of accuracy, consistency and issued the first notice to the fleet with to conceal mistakes for fear of disciplin- fairness; elimination of disciplinary action no crew identification on it, the mid- ary action, lack of confidence that the — including crew identification — for manager responsible for two Boeing 737
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fleets asked me, ‘Can you tell me who made this to be identified or not,” Fan said. Exceedances mistake?’ I said, ‘Why do you want to know?’ He can be minor, moderate or severe. Only severe said, ‘If it’s another mid-manager’s fleet, then it exceedances trigger automatic notification is his problem — I am not going to do anything of the fleet and disclosure of the crew names. within my fleets.’” When told that the exceedance Consequences for a pilot responsible for a severe had involved a 737, the mid-manager insisted on exceedance include a monetary fine, 30-day knowing the crew names and whether the captain suspension from flight or first officer should be held responsible. Fan duty and counsel- Predominant Flight Crew Event Reports, told him, “This is why I don’t want you to tackle ing/retraining in a February 2005–December 2007 the problem by finding a person — I want you to simulator but do not Others Flap speed limit solve this problem in your fleet.” include termination (including 1% Conditional nonpunitive FOQA offers greater of employment. For suggestions) 8% objectivity and fairness than in the past, when events other than a disciplinary action varied for the same exceedance severe exceedance, the severity. The key reason is that mid-managers now program’s conditions Landing long Bank angle have significantly reduced jurisdiction and discre- come into play. 13% 25% tion. “By deidentifying pilots if the event was just a Among disciplin- minor exceedance of the set parameters, mid- ary actions, disclosure managers cannot apply any punishment,” Fan said. of names to peers is Sink rate Hard landing 24% 29% As in many countries, the Shanghai Airlines considered personally personnel handling FOQA data adhere to embarrassing yet ac- internal rules of strict confidentiality. No flight ceptable to most pilots. crew’s identity is disclosed in connection with a “If we are announcing FOQA event except by an independent quality that somebody made Source: Shanghai Airlines supervisor in flight operations. a mistake … every- body knows,” Fan Figure 1 Reports Pour In The company said that from February 2005 Flight Crew Event Reports Increase through December 2007, flight crews submitted Annual totals 1,518 reports — most pertaining to what pilots Web reports 716 suspected were hard landings, landing long Paper reports Telephone reports or other misconceptions of what constituted a 540 “QAR” event (Figure 2). “Although the reports kept growing, the exceedances rate did not go 377 404 up,” Fan said. These events led to a total of 77 262 notices to the fleet, in which the names of flight Number of reports crews were disclosed nine times. 163 153 159 The FOQA office staff analyzes all flight data 132 130 and also cross-checks the required flight crew 4 0 4 0 0 0 event reports to see if an exceedance of param- 2004 2005 2006 2007 eters occurred and determine the significance Original Conditional Conditional of any confirmed event. If not confirmed, no FOQA program nonpunitive nonpunitive FOQA trial FOQA further action is required. Year “If there is an exceedance, the FOQA office FOQA = flight operational quality assurance sends it to the quality supervisor, who talks to Source: Shanghai Airlines the crew and decides whether the fleet needs to be notified or not, and whether the crew needs Figure 2 www.flightsafety.org | AeroSafetyWorld | January 2009 | 47 Strategicissues
said. “Identifying all flight crew names, nonpunitive program … but that’s not to improve safety. It cannot be used including who was the captain, who was enough,” Fan said. “We want to increase for other than that purpose. Corporate the pilot flying, who was pilot monitor- the depth and breadth of the trend safety is more important than the indi- ing is a form of punishment.” analysis program to establish the SMS vidual saving face.” He draws a distinction between pun- within Shanghai Airlines, and design a Unlike the European Aviation Safety ishment, a matter of justice, and motivat- vehicle for incorporating trend analysis Agency and the U.S. Federal Aviation ing an aviation professional to improve data into the SMS. We also need to ap- Administration, CAAC does not collect his or her performance. “If we publish ply the lessons learned to enhance flight Chinese airlines’ FOQA aggregate data the pilots’ names in the notice to the fleet, operations processes and pilot skills at headquarters and conduct trend anal- that is not for encouragement or motiva- training — especially during flight ysis. “I think that is our future direction, tion — it is just a lesson for them, a kind simulator sessions.” however,” Fang said. “FOQA data are of criticism of the crew,” Fan said. All airlines send to CAAC regional fundamental to improve safety … foster Another reason why these pilots offices monthly reports of deidentified a positive safety culture, and provide a have accepted the idea of conditions is trend data. The regulator usually does forum or channel for pilots to communi- that line pilot representatives had a voice not look at FOQA parameter ex- cate with each other, find problems and in determining which of thousands of ceedances of a specific flight but retains correct them in a timely manner.” flight parameters are recorded and what the right to obtain that data. As more airlines decide how to constitutes an exceedance during data evolve toward nonpunitive FOQA poli- analysis. “It’s quite an extensive com- FOQA Benefits CAAC cies, CAAC remains optimistic. “Before munication between our office and CAAC oversees the safety of aviation launching nonpunitive FOQA, an agree- the pilots,” Fan said. “We had wanted from headquarters in Beijing through ment on conditions should be reached to identify flight crews for one type of regional administrations and local field between the management and the line exceedance, but the pilots said, ‘We don’t offices within each region. Its primary in- pilots, especially on the nonpunitive want to be identified for that.’” volvement in FOQA programs is inspec- policy,” Fang said. “I am not sure about tions for QAR compliance and existence other world regions, but in Asia, it is hard Secure Web Site Access of a FOQA program, and safety guidance. — but not impossible — to adopt even Shanghai Airlines prefers input of flight “We still have a lot of work to do to a conditional program because of the crew event reports via a secure Web be more successful with FOQA pro- culture. It is possible because if the airline site but also accepts reports on paper grams in China,” said CAAC’s Fang. leaders, the top management, realize the and by telephone. Deidentified FOQA “We leave this job to the CAAC regional significance, they will be supportive.” information on this special Web site level. The regional administrations is accessible only by company pilots. oversee the installation of the QARs and Note
They can retrieve, for any listed event, also the FOQA program of the airlines 1. FAA. “Statement of Nicholas A. Sabatini, the report title, airplane type, phase of within each respective region. CAAC Associate Administrator for Aviation flight, crew narrative of what occurred has given airlines a lot of freedom to do Safety, Before the Committee on and lessons learned. these programs. The Shanghai Airlines Transportation and Infrastructure on Beyond increased event reporting — program is a benchmark.” CAAC in the ‘Critical Lapses in FAA Safety Oversight of Airlines: Abuses of Regulatory which enables timely safety actions by near future will issue to airlines a second ‘Partnership Programs.’” April 3, 2008. the company — the conditional nonpu- management document that is more ex- Air carriers with annual operating nitive FOQA program has been success- plicit about its expectations of nonpuni- revenue greater than US$20 million as of ful in other respects, he said. “The pilots tive FOQA programs, he said. December 2008 included 44 major/region- are now comfortable about reporting “We have realized that programs al passenger air carriers and 24 cargo air deviations, and they feel comfortable let- using FOQA data mainly to punish the carriers, according to the U.S. Bureau of Transportation Statistics. Smaller airlines ting the first officers fly,” Fan said. pilots still exist in some of the airlines,” also may qualify to operate FAA-approved Whether other airlines follow this Fang said. “The next management FOQA programs but typical participants evolving model remains to be seen. “We document will have a statement that a come from the same categories as these 68 have established a CAAC-approved FOQA program should be used only air carriers.
48 | flight safety foundation | AeroSafetyWorld | January 2009 DataLink
Disparate Measures Continuing a long-term trend, charter operations had higher accident, fatal accident and fatality rates than scheduled flights in Australia.
BY RICK DARBY
he Australian fatal accident rate for lower than the average of 0.34 in the previous chartered flights increased in 2007 from nine years. the previous three years and continues at The 2007 low capacity accident rate, at 0.63, a higher rate than for scheduled opera- compared with zero in 2006. The 2007 rate was tions,T the Australian Transport Safety Bureau still lower than the average for the previous nine (ATSB) reported.1 The rate for all air transport years, which was 0.94. accidents increased year-over-year (Figure 1). Throughout the study period, the accident All rates were calculated per 100,000 flight rate for charter operations ranged from about hours. four to 60 times higher than for high-capacity Australian scheduled aviation — called regular public transport. The disparity also fell regular public transport — is subdivided into into that range in 2007, with an accident rate of high capacity and low capacity.2 The high capac- 2.94 and a fatal accident rate of 0.37. ity accident rate in 2007 was 0.30, a 43 percent The accident rate for charters, although 40 increase from the rate of 0.21 in 2006 (Table 1, percent higher than the previous year’s, was 38 p. 50). The 2007 rate was, however, 13 percent percent lower than the 1998–2006 average of
Australian Air Transport Accident and Fatality Rates, 1998–2007
4.0 Accidents Fatal accidents Fatalities 3.0
2.0
1.0 Rate per 100,00 ight hours
0.0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year
Source: Australian Transport Safety Bureau
Figure 1 www.flightsafety.org | AeroSafetyWorld | January 2009 | 49 DataLink
4.78. The fatal accident rate, a 76 percent jump After two years in which there were no from that of 2006, was 23 percent down from business aviation accidents, the 2007 rate was the previous nine-year average of 0.48. 2.57, with a fatal accident rate of 0.64 (Table 2). In total, the 2007 air transport accident rate The accident rate was an improvement on the of 1.16 was the highest since 2003 but lower 1998–2006 average of 2.0, but the fatal accident than in any of the first six years in the study pe- rate was higher than the nine-year fatal accident riod. The fatal accident rate, double the rate for rate of 0.42, which notably included six years 2006, was 25 percent lower than the 1998–2006 without any fatal accidents. average of 0.16. The fatality rate held steady at For general aviation — which includes 0.12, with only 2004 having a lower rate during aerial work, flight training and private flying in the study period. addition to business operations — in 2007, the
Australian Air Transport Accident and Fatality Rates, by Category, 1998–2007
Category 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 High capacity Accidents 0.14 1.13 0.39 0.38 0.42 0.13 0.11 0.11 0.21 0.30 Fatal accidents 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Fatalities 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 Low capacity Accidents 0.70 1.05 1.05 1.20 1.92 1.52 0.00 1.00 0.00 0.63 Fatal accidents 0.00 0.00 0.35 0.00 0.00 0.00 0.00 0.50 0.00 0.00 Fatalities 0.00 0.00 2.80 0.00 0.00 0.00 0.00 7.53 0.00 0.00 Charter Accidents 8.29 4.17 5.68 6.92 4.53 6.33 3.13 1.87 2.10 2.94 Fatal accidents 0.40 0.60 0.63 0.86 0.91 0.47 0.00 0.21 0.21 0.37 Fatalities 1.42 1.98 2.31 2.16 2.72 1.88 0.00 0.62 0.42 0.37 Total Accidents 2.96 2.13 2.15 2.52 1.97 2.24 1.03 0.75 0.75 1.16 Fatal accidents 0.13 0.20 0.26 0.26 0.29 0.14 0.00 0.12 0.06 0.12 Fatalities 0.47 0.67 1.24 0.66 0.88 0.58 0.00 1.12 0.12 0.12
Note: Rates are per 100,000 flight hours.
Source: Australian Transport Safety Bureau
Table 1
Australian Business Aviation Accident and Fatality Rates, 1998–2007
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Accidents 7.23 3.86 2.16 2.73 0.69 0.00 1.38 0.00 0.00 2.57 Fatal accidents 1.81 1.29 0.00 0.00 0.00 0.00 0.69 0.00 0.00 0.64 Fatalities 3.62 1.29 0.00 0.00 0.00 0.00 4.14 0.00 0.00 1.29
Note: Rates are per 100,000 flight hours.
Source: Australian Transport Safety Bureau
Table 2
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Australian Accidents, Serious Incidents and Incidents, 1998–Sept. 30, 2008
Category 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Total Accident 230 196 224 203 164 157 167 133 103 153 131 1,861 Serious incident 1 7 9 9 8 6 20 28 24 40 37 189 Incident 4,991 5,377 5,764 5,491 5,841 4,856 5,129 6,712 7,483 7,780 5,990 65,414 Total 5,222 5,580 5,997 5,703 6,013 5,019 5,316 6,873 7,610 7,973 6,158 67,464
Source: Australian Transport Safety Bureau
Table 3 accident rate was up but the fatal accident Australian General Aviation Accident and Fatality Rates, 1998–2007 rate and fatality rate 15.0 Accidents were down (Figure 2). Fatal accidents Fatalities The numbers of 12.0 accidents, serious incidents and inci- 9.0 dents all increased year-over-year in 6.0 2007 (Table 3).3 The report noted 3.0 Rate per 100,00 ight hours that “the significant increase in incident 0.0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 numbers from 2003 Year [is] likely to be the combined result Note: General aviation includes aerial work, business, flying training and private flying. of an increase in Source: Australian Transport Safety Bureau activity and healthy Figure 2 reporting culture in Australia, sup- payload of more than 4,200 kg (9,259 lb). Less than ported by the introduction of the Transport either measurement is considered low capacity. Safety Investigation Act 2003 and Transport 3. An accident is defined as an event in which any Safety Investigation Regulations in mid-2003, person suffers death or serious injury, or the aircraft which better specified a comprehensive range incurs substantial damage or structural failure, or the aircraft is missing or inaccessible. A serious incident is of specified incidents that are required to be defined as an occurrence associated with the opera- reported to the ATSB.” tion of an aircraft that affects or could affect the safety of the aircraft or that involves circumstances indicat- Notes ing that an accident nearly occurred. An incident is 1. Aviation Statistics: 1 January 1998 to 30 September defined as an occurrence, other than an accident or 2008, report AR-2008-057, published November serious incident, associated with the operation of an 2008. Available via the Internet at
www.flightsafety.org | AeroSafetyWorld | January 2009 | 51 InfoScan Picture This Illustrated safety briefing cards score poorly for comprehension.
REPORTS In a further effort to test passenger compre- hension of pictorial instructions, this study’s Cabin Safety’s Image researchers recruited 785 participants from Effective Presentation Media for Passenger Safety I: high schools, government offices, cabin safety Comprehension of Briefing Card Pictorials and Pictograms workshops and the SAE Cabin Safety Provisions Corbett, Cynthia L.; McLean, Garnet A.; Cosper, Donna K. U.S. Federal Committee. The participants were about evenly Aviation Administration (FAA) Office of Aerospace Medicine. DOT/ FAA/AM-08/20. Final report. September 2008. 58 pp. Figures, tables, distributed by gender and ranged in age from references, appendixes. Available via the Internet at
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was “don’t know” — and “blank” — no response. by those who were not the main focus of the “Categorized responses were then transformed, intended message.” using a weighting algorithm, to yield pictorial/ Cabin safety specialists are, thus, faced with pictogram comprehension scores,” the report a paradox: Illustrated briefing cards are best says. “Pictorial/pictogram comprehension scores understood by frequent fliers who have the least were further analyzed with respect to subject need for them. The report says, “The results demographics, particularly gender, flight his- indicate that safety briefing card pictorials/pic- tory, and cabin safety procedures knowledge and tograms need to be designed and implemented experience.” with respect to novice passengers, i.e., those The results confirmed those of the earlier who do not have [greater] understanding of the studies cited. Comprehension scores ranged design and operation of transport aircraft, emer- from 28.8 percent to 96.3 percent, averaging 65 gency equipment and/or aircraft emergency percent. Two international organizations with procedures.” acceptability criteria for pictorial/pictogram Safety briefing cards would benefit from information are the International Association “well-known educational principles and in- for Standardization (ISO) and ANSI. Even with structional techniques from outside aviation, experienced travelers and aviation profession- whether produced by professional graphics als among the participants, 45.8 percent of the designers or in-house airline cabin safety pro- scores satisfied the ISO acceptability standard fessionals,” the report says. It also warns against and only 8.3 percent met the ANSI criteria. In a problem familiar to anyone who has tried comparison, the average “symbol literacy index” to puzzle out furniture assembly or advanced Illustrated briefing was 75 percent. audio and video equipment instructions, cards are best “Comprehension scores based on the indi- produced by an “expert system” in which the vidual question(s) for each pictorial/pictogram designers cannot put themselves in the place of understood by ranged from 28.8 percent [for ‘flotation device the non-expert. usage’] to 96.3 percent [for ‘no smoking in the “Excessive graphical clutter, overly complex frequent fliers who lavatory’],” the report says. Composite scores, drawings and overly simplistic illustrations derived from a combination of the responses considered unrealistic or unclear suggest a reli- have the least to individual questions about the particular ance on briefing card designers who know the need for them. pictorial/pictogram, ranged from 39.8 per- information so well that their attention naturally cent (“warning”) to 85.3 percent (for “seat belt focuses on the elements that best portray the usage”). message and disregards information or structure Correlations among demographic variables that detracts,” the report says. “Failure to test were related to the “progressive expertise associ- the comprehension of briefing card materials ated with advancing age, education and number adequately obscures such shortcomings.” of flights,” the report says. No gender differences Although briefing cards are designed to be were found. understood without reference to any particu- “The test booklet questions … received a lar language, the report says that some ad- wide range of responses, especially for pictori- ditional text would “focus attention, highlight als that contained multiple elements and/or concepts and simplify complex pictorials/ multiple actions,” the report says. “The variety pictograms.” In addition, “standardization of of responses was also greater for pictograms in validated safety briefing card information and which serial actions were not tightly linked pic- presentation methods across the airline indus- torially. Participants also missed specific details try would provide not only a well-founded, in certain pictorials, especially when the details consistent safety message, but also a degree were not the main focus of the intended mes- of familiarity and, therefore, comprehension sage. Often such details would only be identified never before seen.” www.flightsafety.org | AEROSafetyWorld | January 2009 | 53 InfoScan
The Long and the Short of It as “anomalies,” were categorized as aircraft Analysis of Aircraft Overruns and system fault; wildlife hazards; weather condi- Undershoots for Runway Safety Areas tions; human errors; runway surface conditions; Hall, Jim; Ayres, Manuel Jr.; Wong, Derek; et al. Washington, D.C.: and approach/takeoff procedures. These basic Transportation Research Board of the National Academies, Airport Cooperative Research Program (ACRP) Report 3. 59 pp. Figures, categories were themselves subdivided. tables, references, list of abbreviations. Available via the Internet at It was found that for landing overruns, the
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Using mathematical models, the report Pilot: “Be back, uh, [Name] fifty heavy.” “introduces a more comprehensive approach to ATC: “[Name] fifty heavy, I’m sorry, was evaluate the degree of protection offered by a that affirmative or negative for two seven specific RSA, and provides a risk-based assess- right full length?” ment procedure that is rational and accounts [Pilot] “Negative, [Name] fifty heavy.” for the variability of several risk factors associ- [ATC] “Okay, uh, one more time, sir, af- ated with aircraft overruns and undershoots. In firmative or negative, I’m missing part of addition, this study provides risk models that your transmission.” are based on comprehensive evidence gathered [Pilot] “Negative, [Name] fifty heavy, we from aircraft accidents and incidents in the cannot accept.” United States and other countries. Information [ATC] “You cannot accept, negative, okay, gathered from these events has been organized thank you.” into a database that may be used for future stud- This exchange required seven transmis- ies on airport risk assessment.” sions in total during the busy approach phase of flight and while the controller might have been Say Again arranging the arrival of several aircraft. Nei- Pilot English Language Proficiency and the ther the question nor the answer was especially Prevalence of Communication Problems at Five U.S. Air Route Traffic Control Centers complex; the extraneous effort resulted from Prinzo, Veronika O.; Hendrix, Alfred M.; Hendrix, Ruby. DOT/FAA/AM- poor understanding of the other’s speech by one 08/21. Final report. October 2008. 32 pp. Figures, tables, references, or both parties. appendixes. Available via the Internet at
transactions involving policy will be added to the online library a breakdown in com- annually. munication, runway The Web site’s introduction explains that assignment and route accidents are arranged in predefined groups or clearance transactions “perspectives” to “illustrate the complex inter- were especially prob- relationship of accident causes” — airplane life lematic for the pilots of cycle, accident threats and accident common [non-U.S.]-other regis- themes. For example, the “accident common try aircraft,” the report themes” group identifies accidents by human says. “The problem error, flawed assumptions, unintended effects, may be partially due to pre-existing failures and organizational lapses. controllers’ and pilots’ Each accident entry contains links that open use of plain language and the pilots’ pronuncia- windows to specifics: an overview; a summary of tion and fluency. Notably, accent affected the in- the accident investigation report and a link to the telligibility of 40 percent of the pilots’ messages.” full report; the accident report’s recommendations; The report says that “when the registry of relevant regulations; cultural and organizational an aircraft was [non-U.S.] and its primary or factors; unsafe conditions; safety assumptions; pre- official language was not English, not only did cursors; resulting regulatory and policy changes; pilots spend more time communicating with resulting airworthiness directives; lessons learned; ATC, they also exchanged more transmissions common themes; and a list of related accidents. En- and had more communication problems in their tries may contain graphics, photographs and links transmissions. The additional pilot messages to Internet sites with additional information. may have resulted from attempts to resolve some Researchers can locate accidents by review- of the communication problems. In these situ- ing the predefined groups, using the Web site’s ations, a pilot’s English language proficiency — search/sort feature or selecting from lists on the especially his/her accent — often resulted in the site map. In addition to a list of all accidents in the controller not being able to completely under- database, the site map contains a list of videos and stand what the pilot was attempting to say.” animations of accidents. Videos and animations Proficiency in English beyond the minimum with audio and audio transcripts explain causes specifications in the ICAO language proficiency and contributors. Two examples are an animation scales “must be realized if communication prob- comparing the Air Florida Flight 90 takeoff in lems are to decline,” the report says. icing conditions from National Airport, Washing- ton, D.C., to a normal takeoff on the same runway; WEB SITES and an animation and explanation of the fire that The School of Experience developed and spread on British Airtours Flight Lessons Learned From Aviation Accidents Library, KT28M at Manchester Airport, England.
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‘Don’t Say Anything’ Unreported ground accident causes cabin depressurization.
BY MARK LACAGNINA
The following information provides an aware- forward cargo door on the right side of the air- ness of problems in the hope that they can be plane. “Further inspection revealed that a crease avoided in the future. The information is based in the skin of the fuselage existed forward of the on final reports by official investigative authori- tear, consistent with the skin being damaged by ties on aircraft accidents and incidents. a foreign object,” the report said. Airline personnel and FAA inspectors found JETS metal shavings on the ramp where the DC-9 had been parked at Syracuse Hancock International Fuselage Skin Torn Near Cargo Door Airport. “Examination of the belt loader used McDonnell Douglas DC-9-30. Substantial damage. No injuries. during the loading process revealed that [it] had fter departing from Syracuse, New York, U.S., red paint flakes adhering to the front right-hand for a scheduled flight to Detroit on May 18, corner, which matched the height of red paint A2007, the DC-9 was climbing through 20,000 scrape marks on the front left bumper of a lug- ft when the flight crew heard a loud pop and the gage tug. The top right-hand forward corner of cabin depressurized. “The flight crew donned their the luggage tug exhibited scrape marks, missing oxygen masks and initiated an emergency descent paint and exposed metal.” to 10,000 ft,” said the report by the U.S. National The airline’s station manager and ground Transportation Safety Board (NTSB). agents for the contracted ramp-service com- After reaching 10,000 ft, the crew diverted pany told investigators that the belt loader’s to the closest suitable airport, Buffalo Niagara engine had failed either while luggage was being (New York) International, where the airplane off-loaded or loaded before the accident flight. was landed without further incident. None “Three of the contractor’s ground agents at- of the 95 passengers and four crewmembers tempted to manually push the belt loader away was injured. “After landing, the airplane was from the airplane but were unable to do so,” the inspected by airport emergency personnel and report said. “The senior of the three decided to taxied to the gate,” the report said. use the luggage tug to push the belt loader away A postflight examination by a U.S. Federal from the airplane.” Aviation Administration (FAA) inspector re- The senior ground agent positioned the lug- vealed a 12-in by 5-in (30-cm by 13-cm) tear in gage tug parallel to the airplane’s fuselage and the fuselage skin about 6 ft (2 m) forward of the within the designated safety zone in which www.flightsafety.org | AEROSafetyWorld | January 2009 | 57 OnRecord
luggage-tug operations are prohibited. “At some causal factors are: airspeeds below the target point during or immediately after pushing the landing reference speed (Vref); high rates of belt loader away from the airplane, the upper descent leading to higher pitch attitudes in the right-hand side of the tug’s cab contacted the flare; and excess speed causing the aircraft to fuselage,” the report said. “The senior ground float and touch down with a high pitch attitude. agent then advised ‘don’t say anything’ to one of London City’s Runway 28 has an available the other ground agents who was working the landing distance of 1,508 m (4,948 ft), and the “The upper right- flight with him.” ILS glideslope angle is 5.5 degrees. “For a NTSB determined that the probable cause successful steep approach onto the relatively hand side of the of the accident was “the senior ground agent’s short runway, a high degree of accuracy needs to tug’s cab contacted failure to follow written procedures and direc- be achieved,” the report said, noting that thrust tives.” The report said that among actions settings typically are lower than normal during the fuselage.” taken by the contractor after the accident was such an approach. publication of a memo to station personnel The Avro had encountered turbulence that stated: “It is imperative that when a piece during the approach, and recorded flight data of equipment comes in contact with an aircraft, showed that airspeed was 4 kt below Vref when leaving a scratch, dent, hole, etc., the incident the slight, variable headwind sheared to a slight must be reported immediately. … It is beyond tailwind about 50 ft above ground level (AGL) at a concern of potential discipline; it is the ulti- the same time the commander moved the thrust mate significance of ensuring there is no risk to levers to flight idle. the safety of flight.” “The aircraft was already in a low energy state; then thrust was reduced,” the report said. Low Energy, Wind Shear Lead to Tail Strike “A combination of these factors reduced the Avro RJ100. Substantial damage. No injuries. energy of the aircraft, which was felt as a ‘sink’ nbound from Zurich, Switzerland, the flight by the pilots.” The commander’s instinctive crew was conducting an instrument landing movement of the control column caused pitch Isystem (ILS) approach to Runway 28 at London attitude to increase above the tail-strike attitude City Airport the morning of Aug. 18, 2007. Visual of 7 degrees. Vertical acceleration was 2.3 g meteorological conditions (VMC) prevailed, and when the tail struck the runway. surface winds were from 190 degrees at 10 kt. “At between 50 and 30 ft above the runway, Incorrect Stabilizer Trim Cited in Overrun the pilots felt the aircraft ‘dropping,’ and the Dassault Falcon 900. Substantial damage. No injuries. commander … pulled back on the control col- hile preparing for a flight from Santa umn to prevent a hard landing,” said the report Barbara, California, U.S., to Tampa, by the U.K. Air Accidents Investigation Branch WFlorida, the afternoon of June 10, 2007, (AAIB). The Avro’s pitch attitude increased to the first officer calculated a gross takeoff weight 9.3 degrees, and the lower aft fuselage struck the of 45,400 lb (20,593 kg) and entered a rota- runway before the aircraft touched down on the tion speed of 129 kt on the takeoff and landing main landing gear. distance (TOLD) card. He did not calculate the There were no injuries among the 88 pas- center of gravity (CG) location. sengers and five crewmembers. “Neither the Before takeoff, the flight crew set the sta- pilots nor the cabin crew were aware that there bilizer trim at minus 5.5 degrees, which cor- had been a tail strike, although the rear cabin responds with an aft CG. The takeoff range for crewmember reported that there had been a stabilizer trim is minus 4.5 degrees to minus 7.5 loud noise on touchdown,” the report said. degrees, according to the NTSB report. An analysis of RJ100 and BAe 146 tail-strike The captain, the pilot flying, told investiga- events by British Aerospace showed that key tors that the takeoff roll was normal until the
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first officer called “rotate.” The captain pulled its right wing tip struck the nose of another back on the control column (yoke), but the Fal- Global Express that was parked on the runway. con did not respond. “When the speed was well The towed aircraft’s right wing pushed the into the upper 130-kt range, he relaxed the yoke, parked aircraft’s nose sideways and onto the roof then pulled aft again; and, again, there was no of a crew van. Both aircraft and the van were response from the airplane,” the report said. substantially damaged, but no one was injured, The captain said that the airplane “did not said the report by the Irish Air Accident Investi- even try to lift off” and, with the runway end gation Unit. approaching rapidly, he decided to reject the The tug driver told investigators that before takeoff because “the odds of a possible airborne he had attached the towbar to the aircraft, the crash were greater than a runway/clearway type tug’s windshield had cracked and fallen into of incursion.” the cab. “He secured the windscreen alongside He pulled the thrust levers back to the stops himself in the cab and decided to undertake the and applied maximum brake pressure and full tow,” the report said. “There was no radio on the forward pressure on the control column. He tug, so ATC [air traffic control] clearance was also told the first officer and passengers to brace coordinated by a marshaller who was driving themselves. The airplane overran the 6,055-ft [the] crew van.” (1,846-m) runway, struck a berm and came to a The parked aircraft had been correctly stop 580 ft (177 m) beyond the threshold. positioned behind a red line on the runway The nosegear separated during the overrun, that designated the parking-area boundary. and the forward section of the Falcon’s pressure The report noted, however, that there were “a vessel was damaged substantially. There were no significant number of lines or markings on the injuries among the 15 people aboard the airplane. disused runway, [including] old runway mark- Investigators determined that the Falcon’s ings, roadway markings …, old taxiway lines takeoff weight was 1,081 lb (490 kg) heavier and new taxi lines.” than the first officer had calculated, the correct The tug driver told investigators that he was rotation speed was 131 kt and the CG was at confused by two taxi lines on the runway. “The The tug driver told minus 15.73 percent mean aerodynamic chord. driver did not follow either but went to some “The right setting for the stabilizer trim should extent between them,” the report said. “He kept investigators that have been between minus 7.0 and minus 7.5 to the right of the new … taxi line and to the he was confused by degrees,” the report said. left of the old taxi line, which led directly up the Tests in a Falcon 900 flight simulator showed white centerline of the runway.” two taxi lines on that at the accident airplane’s gross weight, stabi- The marshaller drove the crew van ahead lizer setting and calculated rotation speed, there of the tug. After passing the parked Global the runway. is a delay of 2 to 4 seconds between up-elevator Express, she stopped the van beside it, got out input and the airplane’s reaction to the control and removed chocks that were in the intended input. “When the simulator was configured with parking space for the towed aircraft. The tug the stabilizer trim set to minus 7.0 degrees and driver said that he “knew she wanted him to the V-speeds set for 46,480 lb [21,083 kg], there go past the [parked] aircraft and reverse in,” was no delay in airplane response to elevator the report said. “He slowed down [and] saw input,” the report said. the marshaller standing on the red line, but she did not signal any warning. He then felt a Towing Error Damages Two Aircraft bu mp.” Bombardier Global Express. Substantial damage. No injuries. The marshaller said that after removing the he aircraft was being towed to a parking chocks, she “moved back to wing-mark [the area on a closed runway at Dublin (Ireland) towed aircraft] into place [but] had not reached TAirport the afternoon of July 4, 2007, when the van when the impact occurred.” www.flightsafety.org | AEROSafetyWorld | January 2009 | 59 OnRecord
“Though there was no disagreement underinflation and/or overloading during use between the statements of the tug driver and in service.” the marshaller regarding the position of the marshaller at the time of the incident; both Dual Flameout Remains a Mystery stated that no wing-marker [wing-walker] was Gates Learjet 25B. Substantial damage. No injuries. in position,” the report said. “However, the he flight crew was conducting a position- driver should have stopped and either waited ing flight to St. Augustine (Florida, U.S.) until the marshaller was in a position to act as TAirport in VMC the afternoon of July 21, wing-marker or otherwise communicated to the 2007. The Learjet was at 5,000 ft, about marshaller that one was required in position in 5 nm (9 km) from the destination, when accordance with the aerodrome procedures in both engines flamed out after the first officer, force at the time.” the pilot flying, moved the power levers back to begin the descent, the NTSB report Delaminated Tire Bursts on Takeoff said. Boeing 737-800. Minor damage. No injuries. The captain attempted unsuccessfully he 737 was accelerating though 100 kt on to restart the engines. He then took control takeoff from Phoenix Sky Harbor Interna- and landed the airplane on St. Augustine’s Ttional Airport the night of Nov. 25, 2007, Runway 13. After touching down hard just when the “ANTISKID INOP” warning light past the threshold of the 7,996-ft (2,437-m) illuminated. “The takeoff was continued, and runway, both main landing gear tires burst. no other anomalies were noted,” the NTSB “A postaccident inspection by an FAA inspec- report said. “Soon after leveling at [Flight tor revealed that the airplane had incurred Level] 330, the crew was advised by ATC that substantial damage to the wings and fuselage tire fragments had been found on the runway during the landing,” the report said. and that they had possibly had a tire failure The investigation failed to determine conclu- on takeoff.” sively why the engines had flamed out. “Both The flight crew then noticed that hydrau- engines were test-run following the accident at lic system A was losing fluid and decided to full and idle power with no anomalies noted,” land at the nearest suitable airport, Denver the report said. “Tread on the right International. “After declaring an emergency, However, the report noted some “issues” the crew made an overweight landing using found in the Learjet’s aftermarket throttle quad- outboard tire had 40 degrees of flap,” the report said. “The crew rant: “The power lever locking mechanism pins,
come off and had allowed the airplane to roll almost the full as well as the throttle quadrant idle stops for length of the runway and stopped on a taxi- both engines, were worn. The power lever lock- struck the inboard way. The airplane was then towed to the gate.” ing mechanism internal springs for both the left None of the 160 passengers and six crewmem- and right power levers were worn and broken. and mid-span flaps.” bers was injured. Additionally, it was possible to repeatedly move “Postaccident inspection revealed the tread the left engine’s power lever directly into cutoff on the right outboard tire had come off and had without first releasing its power lever locking struck the inboard and mid-span flaps, neces- mechanism; however, the right engine’s power sitating their replacement,” the report said. “In lever could not be moved to the cutoff position addition, the leading edge of the right hori- without first releasing its associated locking zontal stabilizer had been struck and required mechanism. replacement.” “Other than the throttle quadrant issues, NTSB determined that the probable cause no other issues were identified with either the of the incident was “delamination of the right engines or airframe that could be [attributed] to outboard tire during the takeoff roll due to both engines losing power simultaneously.”
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TURBOPROPS m] down the runway. The winds, combined with the prop wash from the aircraft [and] the blowing Close Call in Blowing Snow snow, had caused it to be obscured and out of Swearingen Metroliner. No damage. No injuries. sight. I immediately commenced a go-around.” eather conditions at Denver Interna- The A319 crew already had initiated the go- tional Airport the morning of Jan. 5, around when the airport movement area safety W2007, included 1/2-mi (800-m) visibility system (AMASS) generated an aural and visual in light snow and mist, a 600-ft overcast and alert in the control tower. “Four seconds later, surface winds from 030 degrees at 12 kt. The the [local] controller instructed [the A319 crew] Metroliner pilot received instructions from the to go around,” the report said. “The aircraft airport ground traffic controller to taxi from missed colliding by approximately 50 ft.” the cargo area, which is on the south side of the NTSB concluded that the probable cause of airport, to Runway 34R for takeoff. the incident was the Metroliner pilot’s inadvertent The instructions called for the pilot to taxi entry onto the active runway. “A contributing fac- north on a taxiway that parallels Runway 35L, tor to the incident was the failure of the Denver which is on the east side of the airport, and then tower ground and local controllers to detect the turn left on a taxiway leading to Runway 34R, aircraft on the [AMASS] display and issue a go- which is on the west side of the airport. around instruction to the arrival flight crew.” The pilot told investigators that the blowing snow reduced his visibility and that snow cover- Flight Continued With Open Door ing the taxiway leading from the cargo area pre- Let L410. Minor damage. No injuries. vented him from seeing the taxiway-centerline he unpressurized twin-turboprop aircraft was lighting. “As he attempted to find the centerline departing with 16 passengers from Belfast City lighting, he saw blue taxi lights, followed them T(Northern Ireland) Airport the morning of and turned onto Runway 35L,” said the NTSB April 28, 2008, when the right nose baggage door report. The Metroliner entered Runway 35L opened. “The crew reduced speed to 120 kt and, as near the approach threshold, and the pilot began there was no vibration and the door appeared to be to taxi north on the runway. stabilized in the open position, decided to continue About one minute later, the ground controller to their destination [Ronaldsway, Isle of Man],” asked the pilot for the airplane’s position. The pi- said the AAIB report. lot replied that he was abeam the general aviation The commander, who was a company line fixed-base operator. “According to the pilot, once training captain, told ATC that the baggage door the controller asked for his location, he noticed had opened, but he did not declare an emergen- that he was on a runway,” the report said. cy. “On the approach to Ronaldsway, the crew Meanwhile, the flight crew of an Airbus requested, and were given, wide vectoring for a A319, inbound from St. Louis with 50 people long final,” the report said. The L410 was landed aboard, was conducting an ILS approach to without further incident. The baggage door had Runway 35L and had been cleared to land by the buckled and was torn near the latching mechan- local traffic controller. ism, and one piece of baggage was missing. The A319 first officer, the pilot flying, told “The incident occurred because the right investigators that the airplane broke out of the nose baggage door had probably been incorrectly clouds at about 600 ft AGL. “[The captain and I] closed prior to departure,” the AAIB said. The re- looked down the runway and confirmed verbally port noted that the latch can be placed flush with to each other that the runway was clear,” he said. the door, giving the appearance that the door “We didn’t see the [Metroliner] until we were is locked, even though the inner hook has not about 100 to 50 ft or so above the deck. When it engaged the catch. “A modification is available to did come into sight, it was at least 2,000 ft [610 fit a physical indicator to the front door locking www.flightsafety.org | AEROSafetyWorld | January 2009 | 61 OnRecord
mechanism, but the modification had not been about 250 ft thick, the NTSB report said. The un- incorporated on this aircraft,” the report said. controlled airport had no instrument approaches. “Witnesses reported that the pilot flew at Bad Weather in a Mountain Pass low level up the valley and eventually entered Cessna 208B Caravan. Destroyed. Two fatalities. the fog,” the report said. “About one mile prior fter a sales-demonstration flight in Ther- to reaching the airport, the pilot attempted to mal, California, U.S., on March 28, 2006, climb out of the valley, but the airplane began Athe pilots were conducting a positioning impacting trees on the rising terrain [about flight over mountainous terrain to Ontario, 0.25 mi (0.40 km) from the airport]. All of the California. “One of the two pilots requested, and witnesses stated that the engines ran strong and received, an abbreviated weather briefing prior smooth until the final impact.” to departure … and filed an instrument flight rules (IFR) flight plan,” the NTSB report said. Engine Failure Leads to Ditching Nevertheless, the departure was conducted Piper Cherokee Six. Destroyed. Four minor injuries. under visual flight rules (VFR), and the pilots he pilot of the single-engine aircraft was told an air traffic controller that they would conducting a VFR charter flight from Horn continue under VFR and open their IFR flight TIsland to Warraber Island, both in Queens- plan after exiting a mountain pass. “The flight land, Australia, the morning of May 23, 2007. was likely in at least intermittent, if not mostly Before boarding the three passengers, he briefed solid, instrument meteorological conditions as it them on the Cherokee’s emergency equipment, flew through the pass,” the report said. including the life jackets, said the report by the The Caravan was nearing the end of the pass Australian Transport Safety Bureau. when the controller told the pilots that ATC The islands are about 75 nm (139 km) apart radar showed they were heading toward rising in Torres Strait. “The planned cruise altitude terrain. The controller asked if they had the was 1,500 ft, but, due to some cloud and turbu- terrain in sight, and one pilot responded, “We’re lence at that altitude, the pilot revised the cruise maneuvering away from the terrain right now.” altitude to 3,500 ft,” the report said. A review of ATC radar data indicated that The Cherokee was about 25 nm (46 km) the Caravan was in a steep climbing turn when from the destination when the pilot attempted it apparently stalled at about 8,800 ft, descended to reduce power to begin the descent. However, rapidly and struck terrain at 6,073 ft near Oak propeller speed momentarily increased to 3,000 Glen, California. Witnesses said that they rpm before a total power loss occurred and the had seen the airplane emerge from the clouds constant-speed propeller “began slowly wind- “almost straight nose-down.” Examination of milling in a shuddering manner,” the report said. the wreckage revealed no sign of mechanical The pilot attempted unsuccessfully to restart malfunction or failure, the report said. the engine. He radioed the company that the flight was “going down,” then told the passen- PISTON AIRPLANES gers to don their life jackets but not to inflate them. “He then donned his own life jacket and Valley Airport Blanketed by Fog prepared the aircraft for ditching,” the report Cessna 340. Destroyed. Three fatalities. said. “When the aircraft impacted the water, it ost of the area near the business flight’s pitched steeply nose-down, then settled back destination had VMC, with clear skies and into a near-level attitude.” All the occupants Malmost unlimited visibility, the morning of sustained minor injuries but were able to exit Nov. 6, 2007. However, the destination, Garberville the Cherokee before it sank. (California, U.S.) Airport is located in a narrow A search-and-rescue helicopter crew river valley and was covered with a layer of fog dropped two life rafts, but the survivors did
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not know how to inflate them. After spending The previous owner told investigators that nearly an hour in the water, the survivors were the preflight preparations were rushed, “as if the winched aboard a rescue helicopter. pilot was in a hurry.” The report said that the The Cherokee was not recovered, and inves- helicopter had less than 50 L (13 gal) of fuel and tigators could not determine conclusively what that the low-fuel warning lights likely illumi- caused the engine failure. However, the report nated before takeoff from a farm field. said that it likely was caused by a problem with The previous owner and another witness the forward crankshaft bearing. saw the Gazelle hover over the field for several minutes before flying a circuit around the field, Corrosion Cited in Wing Separation landing, lifting off and beginning another circuit Helio Super Courier. Substantial damage. Four fatalities. of the field. They said that the Gazelle was at he float-equipped airplane was being used about 500 ft AGL when the engine failed. “This to transport sport fishermen from a remote caused no immediate alarm, as extensive open Tlake to a lodge near King Salmon, Alaska, fields were available to the pilot to make a con- U.S., on Sept. 30, 2007. “The pilot contacted trolled landing,” the report said. lodge personnel while en route and estimated As the witnesses drove toward the assumed his arrival time in about three minutes,” the landing site, however, they saw the pilots walk- NTSB report said. “When the airplane failed to ing toward them and the helicopter on its side, arrive, an aerial search discovered the wreckage badly damaged. “The fact that the helicopter was about 10 miles [16 km] from the lodge.” equipped with safety [harnesses] of four-point Examination of the wreckage showed that a type may explain why those on board were not corrosion-induced fatigue fracture had caused seriously injured,” the report said. an attachment fitting in the left wing to fail. The Estimating that the helicopter had used 43 L report said that this resulted in an uncontrolled (11 gal) of fuel during the 11-minute flight, the descent when the left wing partially separated report said that the cause of the accident was from the fuselage. “engine failure because of a lack of fuel due to The Courier had accumulated about 8,700 inadequate preflight preparations.” flight hours, including about 1,800 hours since the wings were replaced following an accident in Pilot Struck by Turning Rotor Blades October 2000. The new wings had been ac- Bell 407. No damage. One fatality. quired from a salvage dealer that closed in 2006 he pilot shut down the engine after landing and retained no records of the transaction. at Morristown, Tennessee, U.S., on Nov. 9, T2007, but did not tighten the cyclic fric- HELICOPTERS tion lock. After escorting the passengers to the fixed-base operator, the pilot was walking back Test Flight Ends With Fuel Exhaustion toward the helicopter when he was struck by the Aerospatiale AS 342J Gazelle. Destroyed. Two minor injuries. still-moving main rotor. n March 22, 2007 — the day before the A witness said that the rotor blades were helicopter was to be delivered to its new tilted forward and that the blade tip path was Oowner, a company based in Italy — two about 5 1/2 ft (2 m) off the ground. ferry pilots arrived in Broby, Sweden, to “The flight manual did not describe a pro- conduct a brief test flight. “One of the pilots cedure for the pilot to exit the helicopter while was trained on the type and was to be the the engine and rotor continued to operate commander, while the other, without training but did state that during shutdown, the pilot on the type, was to be a passenger,” said the should ‘remain on the flight controls until the report by the Swedish Accident Investigation rotor has come to a complete stop,’” the NTSB Board. report said. www.flightsafety.org | AEROSafetyWorld | January 2009 | 63 OnRecord
Preliminary Reports Date Location Aircraft Type Aircraft Damage Injuries Nov. 1, 2008 Western Guyana Beech King Air A90 NA 3 NA The King Air was reported missing during a survey flight over a remote area and was not found during a five-day search. Nov. 1, 2008 Near Vaalwater, South Africa Cessna 208B destroyed 1 serious, 5 none After touching down in a game preserve, the pilot realized that he was on the wrong runway and initiated a go-around. The Caravan overran the runway at 80 kt and burst into flames. Nov. 1, 2008 Toksook Bay, Alaska, U.S. CASA 212-200 substantial 2 minor The right engine did not respond when the copilot attempted to increase power while turning onto final approach. The pilot initiated a go- around, but the cargo airplane yawed right and descended rapidly. The linkage between the right power lever and the propeller pitch control was found disconnected. Nov. 2, 2008 Graz-Thalerhof, Austria Piper Seneca III destroyed 3 fatal The Seneca was completing a charter flight from Salzburg when it crashed in a wooded area during approach. Nov. 3, 2008 Punta Chivato, Mexico Beech Super King Air 200 destroyed 1 fatal Witnesses said that the airplane stalled and crashed after barely clearing a small hill on departure. Nov. 4, 2008 Mexico City, Mexico Learjet 45 destroyed 8 fatal The Learjet may have encountered wake turbulence from a preceding Boeing 767 before it crashed in an industrial/residential area during approach. Several people on the ground also were killed or injured. Nov. 6, 2008 Fakfak, Indonesia Dornier 328 substantial 36 none The landing gear separated and the left wing was damaged when the Dornier touched down 3 m (10 ft) short of the runway and then struck the raised threshold. Nov. 7, 2008 Bathurst, Australia Piper Chieftain destroyed 4 fatal During departure, the Chieftain struck a hill about 3 nm (6 km) from the airport. Nov. 8, 2008 Mount Kilimanjaro, Tanzania Cessna U206F destroyed 4 fatal, 1 serious The airplane crashed at 14,200 ft on Mawenzi Peak during a sightseeing flight. The pilot was the sole survivor. Nov. 10, 2008 Rome Boeing 737-800 substantial 172 none Multiple bird strikes to the nose, wings and engines occurred during approach, and the left main landing gear collapsed on touchdown. Nov. 13, 2008 Detroit Bombardier CRJ200 substantial 24 none The airplane collided with a tug on a taxiway at Detroit Metropolitan Wayne County Airport. The tug driver sustained a minor head injury. Firefighters sprayed foam on fuel that leaked from a punctured tank. Nov. 13, 2008 Al Asad, Iraq Antonov An-12B destroyed 7 fatal The airplane crashed shortly after departing from a U.S. air base for a cargo flight to Baghdad. Nov. 16, 2008 Thormanby Island, Canada Grumman G-21A Goose destroyed 7 fatal, 1 serious The airplane struck a hill during a charter flight from Vancouver to a work site at Powell River. Nov. 18, 2008 Göteborg, Sweden British Aerospace Avro RJ100 minor 63 none The airplane was en route from Stockholm to Brussels, Belgium, when an unidentified object struck the windshield and the cabin began to depressurize. The flight crew conducted an emergency landing at Landvetter Airport. Nov. 22, 2008 God’s Lake Narrows, Canada Beech King Air A100 destroyed 5 minor The King Air struck terrain while returning to the airport after a cockpit fire erupted during departure for an air ambulance flight. Nov. 23, 2008 Recife, Brazil Beech Super King Air 200 destroyed 2 fatal, 8 NA The airplane stalled and crashed in a residential area after both engines failed due to fuel exhaustion on approach to Guarapes Airport. No one on the ground was hurt. Nov. 27, 2008 Perpignan, France Airbus A320-200 destroyed 7 fatal The A320 was on a postmaintenance test flight when it struck the Mediterranean Sea on approach to Perpignan Airport.
NA = not available This information, gathered from various government and media sources, is subject to change as the investigations of the accidents and incidents are completed.
64 | flight safety foundation | AEROSafetyWorld | January 2009 Corporate Flight Operational Quality Assurance C-FOQA
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Using actual performance data to improve safety • Appropriate use of stabilized-approach procedures; by identifying: and
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Jim Burin Director of Technical Programs E-mail: [email protected] Tel: +1 703.739.6700, ext. 106 EASS 21st annual European Aviation Safety Seminar Ni c o s i a , Cy p r u s March 16–18, 2009
To receive agenda and registration information, contact Namratha Apparao, tel: +1 703.739.6700, ext. 101; e-mail: [email protected]. To sponsor an event, or to exhibit at the seminar, contact Ann Hill, ext. 105; e-mail: [email protected]. © Dainis Derics/iStockphoto© Dainis