AeroSafety WORLD DOUSING THE FLAMES FedEx’s automatic system CRM FAILURE Black hole approach UPSET TRAINING Airplane beats simulators IASS REPORT 777 power rollback, more TRAGEDY AS INSPIRATION JAPAN Airlines’ safeTY CENTER THE JOURNAL OF FLIGHT SAFETY FOUNDATION NOVEMBER 2009 “Cessna is committed to providing the latest safety information to our customers, and that’s why we provide each new Citation owner with an FSF Aviation Department Tool Kit.” — Will Dirks, VP Flight Operations, Cessna Aircraft Co. afety tools developed through years of FSF aviation safety audits have been conveniently packaged for your flight crews and operations personnel. These tools should be on your minimum equipment list. The FSF Aviation Department Tool Kit is such a valuable resource that Cessna Aircraft Co. provides each new Citation owner with a copy. One look at the contents tells you why. 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For more information, contact: Namratha Apparao, + 1 703 739-6700, ext. 101 e-mail: [email protected] PRESIDENT’sMESSAGE REGULATING Fatigue had the honor of testifying recently before the and the politicians want the industry and the regula- U.S. Senate Committee on Commerce, Science tor to take on the issue of commuting long distances and Transportation’s subcommittee on aviation, to flight assignments. That is a problem that may be which conducted a hearing on fatigue regulation too tough for regulation to solve. Market demands Iin commercial aviation. It reminded me what a tough force airlines to move domiciles quickly, and pilots job it is to write decent regulations in the middle of a like to have a stable home, living where they like and public debate. Right now, fatigue rules are undergo- commuting to work. Many of us in the industry ing a fundamental rewrite by both the U.S. Federal would like to leave that issue up to professionalism Aviation Administration (FAA) and the European and trust pilots to show up rested. But I have to tell Aviation Safety Agency. This effort is long overdue. you, that is not an easy position to defend when Researchers have been telling us for at least 15 years the parents of a Colgan victim are sitting two rows that our fatigue regulations are out of date. behind you. They don’t want to hear “trust us.” For most of those 15 years, the problem has Another tough balance is choosing between solid been special interests and an extreme lack of trust. prescriptive regulations and fatigue risk management On both sides of the Atlantic, there has been a systems. A modern regulation needs to address both. great deal of concern that labor or management It looks like the FAA process will result in the adop- or both would take advantage of fundamental tion of prescriptive regulations, based on science, that changes in flight and duty-time rules. Nobody are similar to those from the U.K. That is an essential wanted to make the first move, because no one start, but there also has to be room for sophisticated knew what the result would be. The thinking was operators to use a fatigue risk management system to that it is easier to live with rules that are known continuously optimize the safety of their operation. to be flawed rather than risk letting the other side This is easy to write but hard to sell to a public that win. I don’t think anybody was proud of this epic doesn’t want to hear anything that sounds like there standoff, but few things are more important than is more than one acceptable way to fly safely. working conditions. Sometimes even the best of us There is a lot of momentum behind the current tend to put less important things ahead of safety. regulatory initiative in the U.S., and there is a lot of It seems that the gridlock has at least ended in agreement among many traditional adversaries. My the U.S. There is now enough science on the table biggest concern is that the FAA finds a way to sell for people to trust that the possible outcomes will be the right answer to the public. fair and reasonable. In addition, the tragedy of the Feb. 12, 2009, Colgan Air crash in Buffalo, New York, made inaction unacceptable, and a dynamic new FAA administrator is ready to serve as a tiebreaker on those issues where the answers are not obvious. William R. Voss Even with all of this new momentum in the U.S., President and CEO the problem is still difficult. First of all, the public Flight Safety Foundation WWW.FLIGHTSAFETY.ORG | AEROSAFETYWORLD | NOVEMBER 2009 | 1 AeroSafetyWORLD contents November2009 Vol 4 Issue 11 features 12 CoverStory | Precious Lives 17 TrafficControl | ATC Crisis Management 12 20 HumanFactors | Topsy Turvy 24 HumanFactors | OGHFA on SKYbrary 17 26 SeminarsIASS | Grappling With the Unexpected 32 CausalFactors | Teamwork Fades in a Black Hole 39 CargoSafety | Dousing the Flames departments 20 1 President’sMessage | Regulating Fatigue 5 EditorialPage | Delicate Balance 6 AirMail | Letters From Our Readers 7 SafetyCalendar | Industry Events 9 InBrief | Safety News 38 FoundationFocus | ERA Applauds ASW 2 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | NOVEMBER 2009 24 32 39 AeroSafetyWORLD telephone: +1 703.739.6700 44 FoundationFocus | FSF Members William R. Voss, publisher, FSF president and CEO [email protected] 49 DataLink | Madrid Accident Overshadows EASA Data J.A. Donoghue, editor-in-chief, FSF director of publications 53 InfoScan | Sample Case [email protected], ext. 116 Mark Lacagnina, senior editor 57 OnRecord | MD-83 Clips Approach Lights on Departure [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 [email protected], ext. 120 About the Cover Susan D. Reed, production specialist Japan Airlines uses its 747SR crash to foster employees’ safety consciousness. [email protected], ext. 123 Wayne Rosenkrans Patricia Setze, librarian [email protected], ext. 103 We Encourage Reprints (For permissions, go to <www.flightsafety.org/aerosafety-world-magazine>) Editorial Advisory Board Share Your Knowledge David North, EAB chairman, consultant If you have an article proposal, manuscript or technical paper that you believe would make a useful contribution to the ongoing dialogue about aviation safety, we will be glad to consider it. Send it to Director of Publications J.A. Donoghue, 601 Madison St., Suite 300, Alexandria, VA 22314-1756 USA or [email protected]. William R. Voss, president and CEO 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 Flight Safety Foundation payment is made to the author upon publication. J.A. 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For more information, please contact the membership department, Flight Safety Foundation, 601 Madison St., Suite 300, Alexandria, VA 22314-1756 USA, Don Phillips, freelance transportation +1 703.739.6700 or [email protected]. reporter AeroSafety World © Copyright 2009 by Flight Safety Foundation Inc. All rights reserved. ISSN 1934-4015 (print)/ ISSN 1937-0830 (digital). Published 12 times a year. Suggestions and opinions expressed in AeroSafety World are not necessarily endorsed by Flight Safety Foundation. Russell B. Rayman, M.D., executive director Nothing in these pages is intended to supersede operators’ or manufacturers’ policies, practices or requirements, or to supersede government regulations. Aerospace Medical Association WWW.FLIGHTSAFETY.ORG | AEROSAFETYWORLD | NOVEMBER 2009 | 3 Hosted by Dallas/Fort Worth International Airport May 16-19, 2010 aaae.org/meetings/annual2010 For registration details, contact the AAAE Meetings Department: [email protected] For exhibit and sponsorship details, contact the AAAE Sales and Marketing Department: [email protected] (703) 824-0504 EDITORIALPAGE DELICATE Balance erhaps the most difficult part of they advanced the throttles and felt that aircraft entering the pattern would ap- flying any aircraft is maintaining settling in the seat of their pants, so the pear. With difficult forward visibility, I that balance of vigilance, that hap- airplane must be climbing, right? wasn’t looking straight ahead, but the py area between hyper-alertness Considering the words “standard pilot flying was, and he picked up an er- Pand complacency.