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Aerosafety World February 2011

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AeroSafety WORLD COCKPIT INTERFERENCE Deadly consequences in Tu-154 TOO HEAVY TO FLY? S-61 crash cause disputed PROTECTED AIRSPACE Position monitoring essential HELICOPTER EMS RULES Proposals tighten operations LEVELING OFF IN 2010 SAFETY NO BETTER, NO WORSE THE JOURNAL OF FLIGHT SAFETY FOUNDATION FEBRUARY 2011 APPROACH-AND-LANDING ACCIDENT REDUCTION TOOL KIT UPDATE More than 40,000 copies of the FSF Approach and Landing Accident Reduction (ALAR) Tool Kit have been distributed around the world since this comprehensive CD was first produced in 2001, the product of the Flight Safety Foundation ALAR Task Force. The task force’s work, and the subsequent safety products and international workshops on the subject, have helped reduce the risk of approach and landing accidents — but the accidents still occur. In 2008, of 19 major accidents, eight were ALAs, compared with 12 of 17 major accidents the previous year. This revision contains updated information and graphics. New material has been added, including fresh data on approach and landing accidents, as well as the results of the FSF Runway Safety Initiative’s recent efforts to prevent runway excursion accidents. The revisions incorporated in this version were designed to ensure that the ALAR Tool Kit will remain a comprehensive resource in the fight against what continues to be a leading cause of aviation accidents. AVAILABLE NOW. FSF MEMBER/ACADEMIA US$95| NON-MEMBER US$200 Special pricing available for bulk sales. Order online at FLIGHTSAFETY.ORG or contact Namratha Apparao, tel.: +1 703.739.6700, ext.101; e-mail: apparao @flightsafety.org. EXECUTIVE’sMESSAGE The System Works uring a recent trip to Africa and the Middle export of oil and minerals. The government will East, I found myself in some situations not be able to wait for a regulatory agency to be that reminded me how important it is for staffed up and audited before the geologists and each airline, and this industry, to really miners start flying around. Those big resource Dhold itself accountable for its safety performance. companies will have to ensure that their people Sometimes stuff happens that distracts govern- can travel safely from the very first day. That means ments from oversight and enforcement, yet that they will have to publish and enforce the standards show must still go on. on those operators just like a regulator would, if I was in Beirut visiting the Arab Air Carrier there was one. That is just another extreme ex- Organization and talking with Lebanon’s director ample of companies and industries owning their general of civil aviation, an old friend. My timing own safety performance without a state agency wasn’t great. When I arrived, it was clear that the forcing compliance. volatile state of domestic politics was taking a toll A couple days after I got home from Cairo, on civil aviation oversight; by the time I left the I followed closely the historic events in Tahrir next morning, the government had collapsed. Square. The top aviation safety guy became the Like everybody, I felt a little nervous as I acting prime minister, and clearly he was instantly headed to the airport that morning, but it wasn’t busy with non-aviation priorities. But I knew because I was afraid to get on the airplane. The the system would carry on, at least for a while. airline personnel were sticking to their safety EgyptAir and others were not waiting for the routine, and the airport operators were doing their regulator to turn its back so they could do stuff jobs. And they were doing their jobs not because wrong. They had to maintain International Air somebody was looking, because they weren’t, Transport Association audit standards for their but because being safe is built into their jobs and code-share partners, and they were committed to into their psyche. These people also know that in-house safety programs for each other and for when the world gets crazy, aviation matters. They their customers. learned that the hard way when their airport was So the next time you try to justify something to blown up, most recently in 2006. They kept it safe your CFO, and the answer is “no” because it is not then, and I knew they would keep it safe now. a regulatory requirement, remind that person that My next stop was Cairo, Egypt, and on the isn’t the way this industry really works. If we all day I arrived, neighboring Sudan was taking an waited for a regulator to force us to act, the world important vote. It was a vote that will lead to the would be a very different place. birth of a new nation. As I talked to my Egyptian colleagues about this remarkable event, it became clear that this new nation, essentially the southern half of Sudan, will be dependent on aviation from the moment it is born. It will be a largely land- William R. Voss locked state with almost no surface transportation President and CEO infrastructure and a future that depends on the Flight Safety Foundation WWW.FLIGHTSAFETY.ORG | AEROSAFETYWORLD | FEBRUARY 2011 | 1 AeroSafetyWORLD contents February 2011 Vol 6 Issue 1 features 13 FlightTech | Undesired TCAS RAs 184° 16 CoverStory | Review of 2010 Accidents 004° 13 20 CausalFactors | Tu-154 Crash at Smolensk 25 SafetyManagement | SMS Swiss Style 170° 27 SafetyCulture | Do the Right Thing 30 HelicopterSafety | Weighty Issues 35 FlightOps | Wildfires Make Their Own Weather 38 ThreatAnalysis | Dangerous Approaches 16 44 SafetyRegulation | Changing the HEMS Rules 25 48 RunwaySafety | Italian Incursion Focus departments 1 Executive’sMessage | The System Works 5 EditorialPage | A Grain of Salt 7 SafetyCalendar | Industry Events 2 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | FEBRUARY 2011 27 35 44 AeroSafetyWORLD telephone: +1 703.739.6700 10 InBrief | Safety News William R. Voss, publisher, FSF president and CEO [email protected] 50 DataLink | Re-Examining the Rudder J.A. Donoghue, editor-in-chief, FSF director of publications 53 InfoScan | When Worlds Collide [email protected], ext. 116 Mark Lacagnina, senior editor 57 OnRecord | Fire Erupts During Maintenance Test [email protected], ext. 114 Wayne Rosenkrans, senior editor [email protected], ext. 115 Linda Werfelman, senior editor [email protected], ext. 122 Rick Darby, associate editor [email protected], ext. 113 Karen K. Ehrlich, webmaster and production coordinator [email protected], ext. 117 Ann L. Mullikin, art director and designer About the Cover [email protected], ext. 120 The global commercial jet accident rate has only budged in five years. Susan D. Reed, production specialist © Jim Glab [email protected], ext. 123 Editorial Advisory Board We Encourage Reprints (For permissions, go to <flightsafety.org/aerosafety-world-magazine>) David North, EAB chairman, consultant Share Your Knowledge If you have an article proposal, manuscript or technical paper that you believe would make a useful contribution to the ongoing dialogue about aviation safety, we will be William R. Voss, president and CEO glad to consider it. Send it to Director of Publications J.A. Donoghue, 801 N. Fairfax St., Suite 400, Alexandria, VA 22314-1774 USA or [email protected]. Flight Safety Foundation The publications staff reserves the right to edit all submissions for publication. Copyright must be transferred to the Foundation for a contribution to be published, and J.A. Donoghue, EAB executive secretary payment is made to the author upon publication. Flight Safety Foundation Sales Contacts Europe, Central USA, Latin America Asia Pacific, Western USA Steven J. Brown, senior vice president–operations Joan Daly, [email protected], tel. +1.703.983.5907 Pat Walker, [email protected], tel. +1.415.387.7593 National Business Aviation Association Northeast USA and Canada Regional Advertising Manager Barry Eccleston, president and CEO Tony Calamaro, [email protected], tel. +1.610.449.3490 Arlene Braithwaite, [email protected], tel. +1.410.772.0820 Airbus North America Subscriptions: Subscribe to AeroSafety World and become an individual member of Flight Safety Foundation. One year subscription for 12 issues includes postage and handling — US$350. Special Introductory Rate — $310. Single issues are available for $30 for members, $50 for nonmembers. Don Phillips, freelance transportation For more information, please contact the membership department, Flight Safety Foundation, 801 N. Fairfax St., Suite 400, Alexandria, VA 22314-1774 USA, reporter +1 703.739.6700 or [email protected]. Russell B. Rayman, M.D., executive director AeroSafety World © Copyright 2011 by Flight Safety Foundation Inc. All rights reserved. ISSN 1934-4015 (print)/ ISSN 1937-0830 (digital). Published 11 times a year. Suggestions and opinions expressed in AeroSafety World are not necessarily endorsed by Flight Safety Foundation. Aerospace Medical Association Nothing in these pages is intended to supersede operators’ or manufacturers’ policies, practices or requirements, or to supersede government regulations. WWW.FLIGHTSAFETY.ORG | AEROSAFETYWORLD | FEBRUARY 2011 | 3 Select the Integrated Air Safety Management Software Solution... SMS IAMS FAA Airline Quality JSA IOSA Flight Control Safety Audits Risk Matrix Safety Integrated JSA Aviation Security IAMS SMS IOSA Environmental JSA FAA Risk Management IAMS SMS SMS IATA Operational Safety Audit Flight Control Job Safety Analysis IATA Risk Matrix Safety Management System Job Safety Analysis FAA IOSA Risk Assessment JSA Integrated Airline Management System IATA JSA Environmental Federal Aviation
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