AeroSafety WORLD CRIMINALIZATION CONFLICT Presenting a united front MU-2B EXAMINED, AGAIN Training, operating rules proposed SafetY RoadmaP strategY Implementation details FEATHERED RISKS Bird strikes soar 737 PRESSURIZATION CRASH HELIOS CREW MISSED OPPORTUNITIES FlightTHE JOURNAL Safety OF FoundationFLIGHT SAFETY FOUNDATION JANUARY 2007 What can you do to improve aviation safety? Join Flight Safety Foundation. Your organization on the FSF membership list and Internet site presents your commitment to safety to the world. • Receive AeroSafety World, a new magazine developed from decades of award-winning publications. • Receive discounts to attend well-established safety seminars for airline and corporate aviation managers. • Receive member-only mailings of special reports on important safety issues such as controlled flight into terrain (CFIT), approach-and-landing accidents, human factors, and fatigue countermeasures. • Receive discounts on Safety Services including operational safety audits. An independent, industry-supported, nonprofit organization for the exchange of safety information for more than 50 years Wright Flyer photo/source: U.S. National Aeronautics and Space Administration If your organization is interested in joining Flight Safety Foundation, we will be pleased to send you a free membership kit. Send your request to: Flight Safety Foundation 601 Madison Street, Suite 300, Alexandria, VA 22314 USA Telephone: +1 703.739.6700; Fax: +1 703.739.6708 E-mail: [email protected] Visit our Internet site at www.flightsafety.org PRESIDENT’sMEssaGE Connections s a young man, I dreamed of being the pilot It doesn’t do much good to talk about a who saves the day with his spectacular new system of connections if you don’t have airmanship, the controller with the bril- a plan to get there. That is what the ICAO/ liant flight assist or the mechanic who Industry Global Aviation Safety Roadmap is Adiscovers a hidden defect and saves hundreds of about. You can read more about the Roadmap lives. In those days, we never talked about systems; in this issue of AeroSafety World (see page safety was all about the individual or the latest 28). Let me tell you about the philosophy that safety technology. drove its creation. But our industry has grown up, and we now A large cross section of the aviation industry understand, more than ever, the importance of realized that progress in terms of safety systems and systems. I’ve outgrown the idea of the spectacular connections depends on all of us working together. individual save and realize that the best shot at So we wrote a plan that shows how to systematically improving safety today is to plug a few gaps by con- develop implementation strategies for regions, op- necting people and systems together. That is why I erators and governments in a way that finally will want to talk about the importance of connections. bring together all the pieces and forge lasting con- There are many important connections in nections that will serve safety for decades. our industry, but this month I am going to focus Not only did this broad cross section of in- on the connection between the regulator and the dustry devote considerable time and resources to operator. the creation of this plan, they actually committed A safety management system (SMS) deals with to follow it. It will become the guiding document critical connections between operators, manage- that ICAO and the aviation industry refer to when ment systems and production systems, but it doesn’t safety improvements are contemplated. The first deal with the new relationship that must exist priorities for the industry will be those invest- between the regulator and the operator. That new ments and activities that support the coordinated relationship is one of the major motivations behind development of safety systems around the world, the creation of the new International Civil Aviation as outlined in this plan. This is a big step. Historic Organization Standards and Guidance material. competitors and groups with diverse interests have Under those standards, which are now in ef- put aside old differences to make real commit- fect, it is not good enough just to say, “My airline ments to act as one. They are doing this to create has an SMS.” The regulator and the airline have the connections that will define our future. to be able to stand together and talk about how their systems connect from the regulator, through management, to the operation. I was responsible for those standards when I was with ICAO, so I can tell you firsthand that was the intent. It is a change for all of us and a big opportunity for lasting prog- William R. Voss ress. Those standards can be found at <www.icao. President and CEO int/anb/safetyManagement/Documents.html>. Flight Safety Foundation WWW.FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JANUARY 2007 | 1 AeroSafetyWORLD contents January2007 Vol 2 Issue 1 features 11 StrategicIssues | Accident Criminalization 15 AuditReview | Auditing for Best Practices 11 18 CoverStory | Missed Opportunities 25 SeminarsIASS | Committing to Automation 28 StrategicIssues | Safety Roadmap Details 32 FlightTraining | MU-2B — Just Different? 37 AirportOps | Collision Risks on Feathered Wings 42 ThreatAnalysis | TAWS — Last Line of Defense 18 46 CabinSafety | A380 Evacuation ‘Over in a Flash’ departments 1 President’sMessage | Connections 5 EditorialPage | A Slight Adjustment 28 6 AirMail | Letters From Our Readers 2 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JANUARY 2007 37 contents 32 46 AeroSafetyWORLD William R. Voss, publisher, 7 SafetyCalendar | Industry Events FSF president and CEO [email protected], ext. 108 8 InBrief | Safety News J.A. Donoghue, editor-in-chief, FSF director of publications [email protected], ext. 116 50 DataLink | Swiss Watch Mark Lacagnina, senior editor [email protected], ext. 114 53 InfoScan | Pilot Project Wayne Rosenkrans, senior editor [email protected], ext. 115 Linda Werfelman, senior editor 57 OnRecord | Recent Accidents and Incidents [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, production designer [email protected], ext. 120 Susan D. Reed, production specialist [email protected], ext. 123 Patricia Setze, librarian [email protected], ext. 103 Editorial Advisory Board David North, EAB chairman, consultant About the Cover Misset controls doomed a Helios 737. William R. Voss, president and CEO © Chris Sorensen Flight Safety Foundation J.A. Donoghue, EAB executive secretary We Encourage Reprints (For permissions, go to <www.flightsafety.org/asw_home.html>) Flight Safety Foundation Share Your Knowledge J. Randolph Babbitt, president and CEO If you have an article proposal, manuscript or technical paper that you believe would make a useful contribution to the ongoing dialogue about aviation safety, we will be Eclat Consulting 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]>. Steven J. Brown, senior vice president–operations 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 payment is made to the author upon publication. National Business Aviation Association Subscriptions: Subscribe to AeroSafety World and become an individual member of Flight Safety Foundation. One year subscription for 12 issues Barry Eccleston, president and CEO includes postage and handling — US$350. Special Introductory Rate — $280. Single issues are available for $30 for members, $45 for nonmembers. Airbus North America For more information, please contact the membership department, Flight Safety Foundation, 601 Madison Street, Suite 300, Alexandria, VA 22314-1756 USA, +1 703.739.6700 or <[email protected]>. Don Phillips, transportation reporter International Herald Tribune AeroSafety World © Copyright 2007 by Flight Safety Foundation Inc. All rights reserved. ISSN 1934-4015 Suggestions and opinions expressed in AeroSafety World are not necessarily endorsed by Flight Safety Foundation. Russell B. Rayman, M.D., executive director Nothing in these pages is intended to supersede operators’ or manufacturers’ policies, practices or requirements, or to supersede government regulations. Aerospace Medical Association www.FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JANUARY 2007 | 3 Serving Aviation Safety Interests for More Than 50 Years OFFICERS AND STAFF Chairman, light Safety Foundation is an international membership organization dedicated to Board of Governors Amb. Edward W. the continuous improvement of aviation safety. Nonprofit and independent, the Stimpson President and CEO William R. Voss FFoundation was launched officially in 1947 in response to the aviation industry’s need Executive Vice President Robert H. Vandel 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. Treasurer David J. Barger recommend practical solutions to them. Since its beginning, the Foundation has acted in the public interest to produce positive influence on aviation safety. Today, the Foundation ADMINIstRATIVE provides leadership to more than 1,000