AeroSafety w o r l d
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
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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
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
| 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 | AeroSafetyWorld | January 2007 | 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 member organizations in 143 countries. Manager, Support Services Linda Crowley Horger Financial MemberGuide Chief Financial Officer Penny Young Flight Safety Foundation Staff Accountant Maya Barbee 601 Madison Street, Suite 300, Alexandria, VA, 22314-1756 USA tel: +1 703.739.6700 fax: +1 703.739.6708 Membership www.flightsafety.org Director, Membership and Development Ann Hill Membership Manager David Chu Membership Services Coordinator Namratha Apparao
Communications Director of Communications Emily McGee
Technical Director of Technical Programs James M. Burin Technical Programs Specialist Millicent Wheeler Managing Director of Air Member enrollment ext. 105 Transport Safety Services Louis A. Sorrentino III Ann Hill, director, membership and development [email protected] Technical Specialist/ Safety Auditor Robert Feeler Seminar registration ext. 101 Namratha Apparao, membership services coordinator [email protected] Manager, Data Systems and Analysis Robert Dodd, Ph.D. Seminar/AeroSafety World sponsorships ext. 105 Manager of Ann Hill, director, membership and development [email protected] Aviation Safety Audits Darol V. Holsman Exhibitor opportunities ext. 105 Ann Hill, director, membership and development [email protected] Past President Stuart Matthews AeroSafety World orders ext. 102 Founder Jerome Lederer David Chu, membership manager [email protected] 1902–2004 Technical product orders ext. 101 Namratha Apparao, membership services coordinator [email protected] Library services/seminar proceedings ext. 103 Patricia Setze, librarian [email protected] Web Site ext. 117 Karen Ehrlich, web and print production coordinator [email protected]
| SINCE 1947 flight safety foundation | AeroSafetyWorld | January 2007 Editorialpage a SLIGHT Adjustment
hen Aviation Safety World looking for a new name. Thanks to the This new year will bring more chang- debuted in July, I predicted generosity of the name’s owners we were es to ASW as we seek an audience beyond the publication would evolve able to continue publishing for several the FSF membership base. Probably the as we learned how to handle months under the original title while we first such change will be the launch of an Wthe new format. Now, seven months down conducted a proper search, with legal electronic version of the journal, allow- the road, you might have noticed a change vetting, to make sure the new title was ing us to expand readership at minimal when you picked up this journal: We have conflict-free. cost. This expansion will bring ASW’s a new name, AeroSafety World. This isn’t From its earliest days Flight Safety safety messages to a larger number of the sort of change I had in mind. Foundation was very much a cockpit and readers, a good thing in its own right, In many ways the situation that cre- aircraft-focused organization. However, while making the publication more at- ated our need to alter the name was as our understanding grew about aviation tractive to advertisers wishing to reach an similar to a classic accident scenario, the system impact on safety, the Foundation operations-focused aviation community one that begins with the crew becoming has given increased attention to issues around the world. distracted by a minor problem that takes outside the cockpit. This is one of the Now that the magazine is up and run- up more and more of the crew’s attention reasons that Flight Safety Digest did not ning we must turn our attention to selling until there isn’t enough left over to fly morph into Flight Safety World. “Flight” and servicing advertisements, generating the airplane. has a strong association with aircraft and revenue to offset the cost of producing a In our case so much effort was put the operation of aircraft. We looked at publication of ASW’s quality. However, into creating a title that had wide accep- “aviation” as having a wider scope than our intention is to maintain advertising tance that when consensus finally was “flight,” to include air traffic control, air- opportunities at a level below that com- achieved everyone relaxed and consid- ports and the whole aviation system. On monly seen in commercial publications, ered the job done. this count, we believe “aero” to be nearly where ads often outnumber the editorial Several months after we began pub- synonymous with “aviation.” pages. In AeroSafety World, the safety lishing the journal, we received a short An additional attribute of the word message will always take precedence over letter from a publishing firm informing “aero” is its international flavor. The commercial considerations. us that they owned a registered trademark Foundation has had a global view of on the name “Aviation Safety” and that we aviation safety for many decades, yet were violating that trademark. And, oh, the perception persists that it is a North yes, please stop using that title. American-centric organization. This is A quick check with legal minds expert simply not true, and we hope that the in the arcane ways of the trademark world story mix in ASW helps us drive that confirmed their claim and we started fact home. www.flightsafety.org | AeroSafetyWorld | January 2007 | AirMail
Feline Graphics information sequence, whether live or or card. Who would have just love your new magazine. From video, and the safety briefing/features the internal final say on the developed a graphics standpoint, it’s the “cat’s card. product or procedure? One would I meow.” From cover to cover, this is I’m talking about the sequence of expect it to be flight operations/cabin the best aviation safety magazine out what is being said or demonstrated service, but why then does this unsatis- there! Every article is great and chock- versus the flow of information on the factory situation exist in most airlines? full of valuable information. Your card. Cards are one page with usu- article “Chilling Effects” [September, ally one or two folds with information Bart Crotty page 26] — excellent! on both sides. Passenger attention is Aviation safety/security consultant My compliments to your graphic usually directed to the card by a flight (Former FSF director of aviation safety services) designer for highest quality product. I attendant at the start of the briefing and don’t see how you can improve on it, passengers are asked to follow along. but I will be reading every issue just I have yet to find a perfect match, watching to see it evolve. to say the least, and in most cases one has to several times quickly search the Vicki Grimmett card for the item being described in the Aviation Graphics briefing, scanning among the folds of Seattle the card or turning it over and invari- ably losing the synchronization with Sight and Sound in the briefing flow. Passenger Safety Briefings The result is understandable pas- fine piece on the question of senger frustration with the whole brief- AeroSafety World encourages the effectiveness of cabin safety ing procedure, a definite turn-off for comments from readers, and will briefings and passenger atten- giving future attention to safety briefing assume that letters and e-mails A are meant for publication unless tion as reported by Rick Darby based presentations. on the Australian Transport Safety Yes, there could be some graphic otherwise stated. Correspondence Bureau (ATSB) study [November, page difficulty in fitting the ideographs or is subject to editing for length and 25]. All of us in our air travel no doubt diagrams in lock-step progression with clarity. have second-guessed what can be done the briefing but nothing that can’t be Write to J.A. Donoghue, director to get more passengers to pay more handled. of publications, Flight Safety attention to briefings and what could The problem could lie in a further Foundation, 601 Madison St., enhance them. disconnect within the airline between Suite 300, Alexandria, VA © 2006 iStock International© 2006 iStock Inc. An area the study surprisingly the flight operations/cabin service 22314-1756 USA, or e-mail does not touch is my pet peeve — the department and the media support
disconnect between the safety briefing group or contractor producing a video Copyright Photos:
| flight safety foundation | AerosafetyWorld | January 2007 ➤ safetycalendar
Feb. 6–7 (Hong Kong), Feb. 9 (Nagoya, March 12–14 ➤ 19th annual European April 15–18 ➤ FAA Tech Transfer Japan) ➤ Asian Business Aviation Conference Aviation Safety Seminar (EASS): “Staying Conference and Exposition. American & Exhibition (ABACE). National Business Aviation Safe in Times of Change.” Flight Safety Association of Airport Executives, U.S. Federal Organization.
www.flightsafety.org | AeroSafetyWorld | January 2007 | inBrief Safety News Coping With ‘Core Lock’
he U.S. National Transportation engines, “require manufacturers to other turbine engines to check for Safety Board (NTSB), citing its perform high-power, high-altitude susceptibility to core lock. If engines Tcontinuing investigation of a 2004 sudden engine shutdowns; determine are found to be susceptible, tests accident in which a Bombardier CRJ200 the minimum airspeed required to should be conducted to determine the crashed near Jefferson City, Missouri, maintain sufficient core rotation; minimum airspeeds required to main- U.S., has issued several safety recom- and demonstrate that all methods of tain sufficient core rotation to enable mendations regarding “core lock,” a rare in-flight restart can be accomplished an engine restart; the issue should be condition that can freeze an engine core when this airspeed is maintained.” discussed in airplane flight manuals, after an in-flight flameout and prevent NTSB also recommended that NTSB said. If restart is impossible a windmill restart (see Aviation Safety FAA ensure that the flight manuals for with a core rotation speed of zero, World, July 2006, p. 44). CRJ100, 200 and 440 models and for other design or operational means The captain and first officer — the other airplanes with CF34-1 or CF34-3 should be provided to enable flight only people in the airplane during the engines state the consequences of fail- crews to restart the engines. In addi- Oct. 14 Pinnacle Airlines (a subsidiary of ing to maintain the minimum airspeed tion, certification requirements should Northwest Airlines) repositioning flight required for engine core rotation after be established to “place upper limits from Little Rock, Arkansas, to Minne- a high-power, high-altitude sudden on the value of the minimum airspeed apolis — were killed, and the airplane engine shutdown. required and the amount of altitude was destroyed. Other NTSB recommendations loss permitted for windmill restarts,” The NTSB investigation has deter- called for a review of the design of NTSB said. mined that the pilots triedunsuccessfully to restart the General Electric (GE) CF34-3 turbofan engines after a stall and dual-engine flameout at 41,000 ft. The flight crew attempted a windmill restart, which requires airspeed of at least 300 kt; recorded flight data showed that the maximum airspeed during the restart at- tempt was 236 kt. The core engine speed remained at zero during the attempted windmill restart and during subsequent restart attempts at 13,000 ft using the auxiliary power unit. As a result of the investigation, NTSB said that the U.S. Federal Avia- tion Administration (FAA) should, for airplanes with CF34-1 or CF34-3 © Oktawian Kosiorek/Jetphotos.com
NTSB Seeks Expanded CRM Training
rew resource management (CRM) carrier either did not have a CRM pro- Other Most Wanted items af- training should be required for gram or the CRM program was much less fecting aviation deal with runway Con-demand operators that conduct comprehensive than would be required incursions, flammable fuel/air vapors dual-pilot operations, the U.S. National for a Part 121 [air carriers and commer- in fuel tanks, aircraft icing and the Transportation Safety Board (NTSB) said cial operators] program,” NTSB said. use of audio, data and video record- as it issued its annual “Most Wanted List NTSB said that although the U.S. ers to provide information to accident of Safety Improvements.” Federal Aviation Administration (FAA) investigators. “The [NTSB] has investigated several has agreed with the basic principles of The Most Wanted list was first issued fatal aviation accidents involving Part the recommendation, “no discernable in 1990; since then, it has been revised 135 on-demand operators … where the progress has been made.” annually.
| flight safety foundation | AeroSafetyWorld | January 2007 inBrief
Steps Taken to Improve Emergency Communications
he evacuation of a Boeing 717- ground crew and cabin crew … created that a briefing about the safety issues 200 following an engine fire that potential risk and [have] led to improved identified during the investigation Tbroke out as the crew prepared safety action for the future.” would be delivered to an operator that for departure from Hobart, Tasmania, As a result of the incident, the opera- was acquiring the fleet of 717s. Australia, prompted changes in training tor ordered several changes, including procedures intended to improve emer- “improved aircraft maintenance pro- gency communications, the Australian cedures relating to markings on door Transport Safety Bureau (ATSB) said. slide brackets, defined phraseology to The final ATSB report on the be used in emergency communications incident said that a starter on the right between aircraft dispatchers and pilots, engine had failed, resulting in smoke door closure procedures for engine starts, and sparks, and prompting the captain improved policy on cockpit discussion re- to order an evacuation of 26 passengers strictions after door closure and improved on May 17, 2005. Eleven people were cabin crew procedures and training.” injured during the evacuation, which ATSB said that copies of the was completed in 64 seconds. investigation report would be distrib- The report said that “problems with uted to all high-capacity regular public communication involving the pilots, transport operators in Australia and © Copyright iStockphoto© Copyright
Warnings Issued on Safeguards Urged to Limit Post-Impact Fires Fuel Filter Monitors ost-impact fires are a major suppress post-impact fires in time to ome older models of aircraft fuel cause of fatalities and injuries in prevent related injuries and deaths. filter monitors may be ineffective, Potherwise-survivable accidents “Considering the propensity for Swarned the Energy Institute, a involving aircraft weighing 5,700 rapid propagation and the catastrophic London-based organization represent- kg/12,500 lb or less, and actions should consequences of fuel-fed [post-impact ing individuals and businesses in the be taken to reduce related risks, the fire], the most effective defense … is energy industry. Transportation Safety Board of Canada to prevent the fire from occurring at The institute said that fuel filter (TSB) said in a 2006 report. impact, either by containing fuel or pre- monitors “qualified to IP 1583 fourth The report said that post-impact venting ignition or both,” the report said. edition or earlier editions cannot be fires present significant risks to oc- The report said that fuel system regarded as fail-safe devices for pre- cupants of small aircraft because of technologies have been developed in venting water [from] being delivered the volatility of aviation fuel and its land vehicles and helicopters to lessen to aircraft” during fueling operations. proximity to the occupants, limited the chances of post-impact fires and In addition, water-absorbent escape time, limited energy-absorption that a requirement for similar engi- polymers from the fuel filter monitors characteristics of the airframes, the neering changes in small aircraft could may migrate downstream into aircraft propensity for immobilizing injuries “significantly increase the rate of oc- fuel systems — a process that can clog and the inability of rescue workers to cupant survival.” fuel filters and can result in other related problems. The institute said that fuel filter monitors should always be used accord- Stockxchng ing to manufacturer instructions and should never be used in fuel containing any fuel system icing inhibitor — known as diethylene glycol monomethylether (DiEGME) or Prist — or in areas in which free water in the fuel may contain high concentrations of salt.
www.flightsafety.org | AeroSafetyWorld | January 2007 | inBrief
Runway Overrun Prompts Safety Recommendations
he U.S. National Transportation cause was the pilots’ “failure to ensure 135 (commuter and on-demand) Safety Board (NTSB) has issued four the airplane was loaded within weight- operators and principal inspec- Tsafety recommendations as a result and-balance limits, and their attempt tors to describe appropriate of its investigation of an accident in to take off with the center of gravity … methods by which a certificate which a Bombardier Challenger CL-600- well forward of the forward takeoff limit, holder can show that it has “ad- 1A11 overran a runway and continued which prevented the airplane from rotat- equate operational control over across a six-lane highway in Teterboro, ing at the intended rotation speed.” all on-demand charter flights New Jersey, U.S. The safety recommendations call on conducted under the authority of The airplane was destroyed in the the U.S. Federal Aviation Administra- its certificate”; Feb. 2, 2005, accident, and two pilots and tion to: • Review agreements between two people on the ground were seriously • Disseminate guidance to U.S. Part 135 certificate holders and injured. NTSB said that the probable Federal Aviation Regulations Part others to identify agreements that allow “a loss of operational control by the certificate holder” and to require revision of these agreements; • Require that Part 135 certificate holders “ensure that seatbelts at all seat positions are visible and ac- cessible to passengers before each flight”; and, • Require any Part 135 cabin per- sonnel who “could be perceived by passengers as equivalent to a qualified flight attendant” to un- dergo basic, FAA-approved train- ing in preflight briefing and safety checks, emergency exit operations and emergency equipment use. © Art Brett/Jetphotos.com
In Other News …
he Civil Air Navigation Ser- covering aircraft maintenance. The control training and procedures, vices Organisation (CANSO) proposed regulations are intended to and aviation safety standards and T is being added to the list of “achieve a better focus on safety out- regulations. organizations invited as observers comes,” CASA said. … The to meetings of the Council of the Directorate General for International Civil Aviation Organiza- Civil Aviation and the Air- tion (ICAO). ICAO President Roberto ports Authority of India Kobeh González said that CANSO’s have signed an agreement contributions would be vital in the with the U.S. Federal Avia- implementation of a comprehensive tion Administration for worldwide air traffic management help in modernizing India’s system. … The Civil Aviation Safety civil aviation infrastructure. Authority of Australia (CASA) has Among the first issues being proposed a new set of regulations considered are air traffic
Compiled and edited by Linda Werfelman.
10 | flight safety foundation | AeroSafetyWorld | January 2007 strategicissues Battling Accident
By Kenneth P. Quinn
Criminalizationhe Joint Resolution Regarding Criminal- We were assisted by an assortment of interna- ization of Aviation Accidents became fact tional experts, led by our new Foundation CEO Oct. 17, 2006, when Flight Safety Founda- and President William R. Voss, our past President tion (FSF) announced that it had achieved and CEO Stuart Matthews, RAeS CEO Keith Tconsensus with the Royal Aeronautical Society Mans, ANAE President Jean-Claude Bück, and (RAeS) in London, the Académie Nationale de CANSO Secretary General Alexander ter Kuile. l’Air et de l’Espace (ANAE) in Paris and the Civil Other members of the international aviation safety Air Navigation Services Organisation (CANSO) community also made important contributions.1 in Geneva (see page 13). This resolution was From the start we knew that many devasta- the culmination of a tremendous effort by many tions occur in a single aviation disaster. Most individuals in these organizations, based on importantly, lives are lost. Family members and consultation with leading experts in aviation friends of the victims mourn these losses; most accident investigation. seek answers, many seek change, and some seek That effort began at the May 18, 2006, revenge. Like the entire aviation industry, they meeting of the FSF Board of Governors. Board want to know what happened, and why. In time, members discussed a growing tendency of pros- and with hard work, many lessons are learned. ecutors and judges to seek criminal sanctions in Most accidents are the result of human errors the wake of aviation accidents, even when the and often arise in the context of a series of acts and facts do not appear to support findings of sabo- omissions. Aviation technology is imperfect still, tage, criminal negligence or willful misconduct. and individuals are even less perfect. Most of us In response, FSF Chairman Edward W. make mistakes in our everyday jobs. These mis- Stimpson formed the Criminalization Working takes normally go unnoticed and rarely result in Group to look into the matter and report find- real harm. Aviation, however, can be most unfor- ings and recommendations. As group chairman, giving. For decades, we have progressively elevated I quickly realized that the problem was quite the system to its current high level of safety, in part complex. The apparent increasing tendency because the industry has been permitted to con- to turn aviation accidents into potential crime duct thorough investigations and collect complete scenes is so widespread globally that no one information about the causes of accidents.
person or group could deal effectively with the In recent years, however, prosecutors and We recognized problem. We immediately saw an expanding net willing judges around the world have turned of potential defendants: air traffic controllers, the powerful weapons of criminal prosecution that in extreme regulators, pilots, designers, airport directors against what are simply tragic accidents, the result and corporate managers. Cases arose in Ath- of mistakes, not willful actions. In some cases, the cases … criminal ens, Greece; Milan, Italy; Zurich, Switzerland; prosecutions dragged on for more than a decade, investigation, and Miami; Colmar, France; and Sao Paulo, Brazil. causing enormous damage to reputations, careers For five months, we reviewed these cases and and finances. Prosecutions turned into persecu- even prosecution, the traditional legal standards associated with tions and chilled the free admission of mistakes “corporate manslaughter” and other charges. — even the direct testimony of witnesses or is appropriate.
www.flightsafety.org | AeroSafetyWorld | January 2007 | 11 strategicissues
participants. “Guilty by investigation” safety depends on unhindered commu- prosecutors to step back and see the wreaked unnecessary havoc on lives. nication between investigators, witness- wisdom in preserving an existing aviation We recognized that in extreme cases es and those involved in accidents. safety system that has worked remarkably — rising to the level of willful misconduct In several countries, individuals are well in reducing aviation accidents. or particularly egregious reckless con- being prosecuted in criminal courts As we stated, the paramount consid- duct, or intentional acts such as terrorism many years after an aviation accident. eration in a safety investigation should or sabotage — criminal investigation, and Several of these examples are outlined in be finding the facts and determining the even prosecution, are appropriate. the joint resolution. If those with infor- causal factors of the accident, not crimi- More often than not, however, we mation to explain the “what” and “why” nally punishing those who made errors found that criminal prosecutions occur- of an accident are discouraged from of judgment or mistakes that may have ring around the globe were not responses speaking openly to investigators because produced tragic consequences. We are to intentional, malicious acts. Instead, they fear the threat of criminal prosecu- very grateful to the many aviation pro- we saw verdict-hungry prosecutors tion, investigators may have difficulty fessionals who took part in the prepara- pursuing actions against members of the gathering pertinent facts. When deter- tion of this joint resolution and look aviation community based on nothing mining causation, complete disclosure is forward to engaging in a dialogue with more than their involvement in unfor- imperative to prevent future incidents. other groups and individuals on this tunate accidents. Without accountability The best way to honor victims of tragedy topic in the months and years ahead. ●
through administrative remedies, such as is to make sure we obtain all relevant Kenneth P. Quinn is general counsel and civil penalties and license suspensions or information that might prevent future secretary of Flight Safety Foundation. He is a revocations, or civil justice/tort remedies, accidents. If individuals are not helpful to partner at the law firm of Pillsbury Winthrop usually in the form of compensation, one investigators out of fear of being pros- Shaw Pittman LLP in Washington. He is edi- might argue that criminal prosecution ecuted and sentenced to jail, investigators tor-in-chief of TheAir & Space Lawyer of the American Bar Association, and former U.S. in some situations would be reasonable. may never discover the truth. Federal Aviation Administration chief counsel. However, administrative and civil rem- Stated differently, we found that the edies nearly always exist, and we found risk that the threat of criminal prosecu- Note almost no adequate basis, other than will- tion places on the future safety of air 1. The Criminalization Working Group, ful misconduct, for punishing individu- travel greatly outweighs any societal gathering facts and seeking ideas, turned als and companies further by subjecting benefit in satisfying the inherent hu- to FSF Board of Governors members: them to the risk of imprisonment or the man desire for revenge or punishment Robert T. Francis, former vice chairman equivalent of a corporate death sentence, in the wake of a terrible loss. of the U.S. National Transportation Safety particularly in an industry where safety Shortly after adoption of our joint Board; William G. Bozin, vice president of safety and technical affairs, Airbus; Steven reputations mean everything. resolution, the French court in the M. Atkins, vice president product integrity, Recognizing the value to interna- Air Inter crash cited in the resolution Boeing; Clay Foushee, formerly with FAA tional aviation safety of a complete and rendered its verdict: All six individuals and the U.S. National Aeronautics and thorough accident investigation, our were acquitted, but the aircraft manu- Space Administration; Carol Carmody, team rapidly reached consensus: “In- facturer and airline were required to former NTSB vice chairwoman; and Pierre creasing safety in the aviation industry is pay damages. Without expressing an Caussade, vice president of flight operations standards, support and development, Air a greater benefit to society than seeking opinion about whether the civil liability France. Also sought out for their knowledge criminal punishment for those ‘guilty’ of aspects of the case were right or wrong, were leading aviation and disaster law- human error or tragic mistakes.” we applaud the French court for at least yers: Gerard Forlin of Grays Inn Square in Certainly, it is human nature to seeing the wisdom of avoiding criminal London; Sean Gates of Gates and Partners, crave retribution when innocents are sanction and punishment in this case. in London; John Balfour of Beaumont & killed or seriously injured. However, Hopefully, this case represents a Son — Aviation at Clyde & Co. in London; and Daniel Soulez-Larivière and Simon when considering the chilling impact watershed event, after which prosecutors Foreman of Soulez Larivière & Associés in the threat of prosecution can and does and judges will exercise restraint about Paris. I consulted extensively with my RAeS have on safety investigations, it be- bringing criminal investigations. Perhaps counterpart, Charles Haddon-Cave, QC, comes clear that the future of aviation our joint resolution will persuade eager Chairman of the Air Law Group in London.
12 | flight safety foundation | AeroSafetyWorld | January 2007 strategicissues
Joint Resolution Regarding Criminalization of Aviation Accidents
ecognizing the importance in civil manslaughter charges and inter- f. an Italian court on July 7, 2006, aviation accident investigations in rogated pilots, while a magistrate affirmed the convictions for man- Rsecuring the free flow of informa- revoked the pilots’ passports; slaughter of five aviation officials, tion to determine the cause of accidents b. the French Supreme Court on including an air traffic controller, and incidents and to prevent future September 20, 2006, rejected a the former director of Milan Linate accidents and incidents; request to dismiss charges in the airport, and the chief executive Recognizing the actions taken re- July 2000 Air France Concorde and a former director-general of cently by the International Civil Aviation crash where three people, a for- ENAV, the Italian air traffic control Organization in promoting amendments mer French civil aviation authority agency, arising out of the October to Annex 13 – Aircraft Accident and official and two former aircraft 2001 runway accident between Incident Investigations to the Convention manufacturing officials, are cur- an SAS aircraft and Cessna jet in on International Civil Aviation, encour- rently under investigation for Milan, where authorities found an aging contracting states to adopt by criminal charges; inoperative ground radar system November 2006 certain actions to pro- contributed to the accident; c. a French court is expected to issue tect the sources of safety information; its verdict soon in the 1992 Air g. an ongoing Greek quasi-judicial Recognizing the importance of pre- Inter crash in Strasbourg, France, investigation exists of the 2005 venting the inappropriate use of safety wherein the designer of the Airbus Helios Boeing 737-300 crash near information, including the increasing A320, two retired Air Inter execu- Athens, Greece, wherein a draft use of such information in criminal pro- tives, the former director general accident report has been leaked ceedings against operational personnel, of civil aviation, the retired civil and authorities have indicated it managerial officers, and safety regula- servant who was national head will be used directly in a quasi- tory officials; of certification, and an air traffic judicial investigation to determine Recognizing that information given controller were investigated and criminal liability; voluntarily by persons interviewed dur- prosecuted 14 years after the h. U.S. federal and Florida state ing the course of safety investigations crash and face negligent homicide prosecutors brought criminal is valuable, and that such information, charges; charges, including 220 counts if used by criminal investigators or of murder and manslaughter, prosecutors for the purpose of assessing d. Swiss prosecutors in August 2006 against a maintenance company, guilt and punishment, could discour- charged eight Swiss Skyguide air several mechanics, and a main- age persons from providing accident traffic controllers with negligent tenance manager arising out of information, thereby adversely affecting homicide arising out of the DHL the 1996 ValuJet Flight 592 crash flight safety; Boeing 757 mid-air collision with in the Florida Everglades, with Recognizing that under certain a Bashkirian Tu-154 on July 1, nearly all charges later dismissed, circumstances, including acts of sabotage 2002, over Überlingen in Southern withdrawn, or dismissed on and willful or particularly egregious reck- Germany; appeal, and all tried individuals less conduct, criminal investigations and e. the Swiss Federal Prosecutor’s acquitted; and, prosecutions may be appropriate; Office has an ongoing crimi- Concerned with the growing trend nal investigation for negligent f. Greek prosecutors brought to criminalize acts and omissions of par- manslaughter of the former chief negligent manslaughter, negli- ties involved in aviation accidents and executive of Swiss International gent bodily injury, and disrupting incidents; Airlines, along with the head of the safety of air services charges Noting that: Switzerland’s Federal Office of against the captain and first of- a. law enforcement authorities in the Civil Aviation, and the operations ficer in connection with the 1979 September 29, 2006, mid-air colli- chief and chief trainer at Crossair Swissair crash in Athens, with the sion between an Embraer Legacy in connection with the November pilots receiving sentences of four 600 executive jet and a Gol Linhas 2001 Crossair plane crash near years imprisonment, which was Aéreas Inteligentes Boeing 737-800 Zurich, which the Swiss Aircraft later converted into a fine. have opened a criminal investiga- Investigation Bureau concluded Recognizing that the sole purpose tion and threatened involuntary was the result of pilot error; of protecting safety information from
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inappropriate use is to ensure its 2. Declare that, absent acts of criminal investigators the consid- continued availability to take proper sabotage and willful or particularly erable expense of conducting an and timely preventative actions and to egregious reckless misconduct entire separate investigation, a improve aviation safety; (including misuse of alcohol or considerable and serious risk exists Considering that numerous incen- substance abuse), criminalization of diverting these reports from tives, including disciplinary, civil and of aviation accidents is not an ef- their original purpose, as technical administrative penalties, already exist to fective deterrent or in the public in- causes often cannot be equated prevent and deter accidents without the terest. Professionals in the aviation to legal causes necessary when threat of criminal sanctions; industry face abundant incentives establishing either civil or criminal Being mindful that a predominant for the safe operation of flight. The liability. In addition, use of rela- risk of criminalization of aviation acci- aviation industry every day puts its tively untrained and inexperienced dents is the refusal of witnesses to coop- safety reputation and human lives technical “experts” by prosecutorial erate with investigations, as individuals on the line, and has a remarkable or judicial authorities, as compared invoke rights to protect themselves safety record which is due in large to official accident investigating au- from criminal prosecution, and choose measure to the current willingness thorities, can result in flawed tech- not to freely admit mistakes in the spirit of operators and manufacturers to nical analyses and a miscarriage of of ICAO Annex 13 for the purpose of cooperate fully and frankly with the justice, while interfering with the preventing recurrence; investigating authorities. The ben- official accident investigation. Considering that the vast majority of efit of gaining accurate information 5. Urge national aviation and acci- aviation accidents result from inadver- to increase safety standards and dent investigating authorities to: (i) tent, and often multiple, human errors; reduce recurring accidents greatly assert strong control over accident Being convinced that criminal inves- outweighs the retributive satisfac- investigations, free from undue tigations and prosecutions in the wake tion of a criminal prosecution, con- interference from law enforcement of aviation accidents can interfere with viction and punishment. Increasing authorities; (ii) invite interna- the efficient and effective investigation safety in the aviation industry is tional cooperation in the accident of accidents and prevent the timely and a greater benefit to society than investigation under Annex 13; (iii) accurate determination of probable seeking criminal punishment for conduct professional investigations cause and issuance of recommendations those “guilty” of human error or to identify probable cause and to prevent recurrence; tragic mistakes. contributing factors and develop BE IT THEREFORE RESOLVED, that the 3. Urge states to exercise far greater recommendations in a delibera- below organizations: restraint and adopt stricter guide- tive manner, avoiding any “rush to 1. Declare that the paramount lines before officials initiate criminal judgment;” (iv) ensure the free and consideration in an aviation ac- investigations or bring criminal voluntary flow of essential safety cident investigation should be to prosecutions in the wake of aviation information; (v) provide victims’ determine the probable cause of disasters. Without any indicia of loved ones and their families with and contributing factors in the proper justification for a criminal in- full, accurate and precise informa- accident, not to punish criminally vestigation or charges, the aviation tion at the earliest possible time; flight crews, maintenance em- system and air disaster victims and and (vi) address swiftly any acts or ployees, airline or manufacturer their loved ones are better served omissions in violation of aviation management executives, regula- by resort to strong regulatory over- standards. tory officials, or air traffic control- sight and rigorous enforcement by lers. By identifying the “what” and national and international aviation DATED: October 17, 2006 the “why” of an accident, aviation authorities, and by pursuit of claims William R. Voss, President and CEO safety professionals will be better through civil justice systems to Flight Safety Foundation obtain compensation. equipped to address accident Keith Mans, Chief Executive prevention for the future. Criminal 4. Urge states to safeguard the safety Royal Aeronautical Society investigations can and do hinder investigation report and probable Jean-Claude Bück, President the critical information-gathering cause/contributing factor conclu- Académie Nationale de l’Air et de portions of an accident investiga- sions from premature disclosure, l’Espace tion, and subsequently interfere and use directly in civil or criminal Alexander ter Kuile, Secretary General with successful prevention of proceedings. Although use of Civil Air Navigation Services future aviation industry accidents. official accident reports may save Organisation
14 | flight safety foundation | AeroSafetyWorld | January 2007 | 14 auditreview A he September 2006 Aviation Safety World Pilot training records are necessary to vali-
article in this series described the FSF Au- date the training provided for pilots. Following for uditing dit Team’s most frequent findings related an accident or significant incident, the investi- to flight monitoring, training and person- gating agency, such as the U.S. National Trans- Tnel. Let’s look at the team’s recommendations for portation Safety Board (NTSB), will request best practices in these areas. copies of the training records for the crewmem- Flight crew altitude awareness callouts were bers involved. inconsistent in six of 20 audits (30 percent) The ready availability of complete and ac- conducted in 2004. The FSF Audit Team recom- curate records is paramount to ensure that the mends that operators develop a flight crew alti- company, as well as the individual crewmember, tude awareness program based on the December receives proper credit for training during the 1995 Flight Safety Digest article, “Altitude Aware- investigation. ness Programs Can Reduce Altitude Deviations.” Detailed training records can be augmented Flight departments should stress pilot read- by a computer-based tracking/recording system back/hearback procedures when air traffic control- to monitor the required training. This system lers assign altitude changes. Flight crew recording can document a list of the pilot record contents of the altitude assignment is a best practice. and provide next-due information. The NTSB
Departments should establish an altitude and U.S. Federal Aviation Administration (FAA) assignment procedure that requires the pilot now accept copies of computer-based tracking/ Practices Best monitoring (PM) to select a new altitude in the recording documents. altitude alerter and challenge the pilot flying In reviewing many different operators’ train- (PF) with the new altitude while pointing at the ing records, the FSF Audit Team has examined alerter setting. The PF should repeat the new many methods of compiling and arranging such altitude while pointing at the alerter to confirm files. In the team’s opinion, the most effective that the correct altitude has been set. training record files consist of a five-part folder, The FSF Audit Team recommends a policy with categories of training and personal data that requires the PF to make the altitude callouts. separated as follows: This pilot is actually controlling the aircraft, so it is critical that he or she is keenly aware of the al- Licenses (Photocopies) titude. The role of the PM is to back up and chal- • Airline Transport Pilot (ATP) rating, with lenge the PF if the callout is not made. Altitude second page showing aircraft type ratings, callouts should be made prior to the sounding of which is mandatory; the altitude alerter’s “1,000 ft to level-off” tone. • Flight instructor, if applicable; An effective altitude awareness program should discourage crewmembers from doing • Advanced ground instructor, if applicable; nonessential tasks (such as paperwork, eating or and, searching for the next destination approach chart) • Airframe and powerplant (A&P), if at times when altitude callouts must be made. applicable. Another way that operators can foster im- provement in this area is to conduct standard- Certificates (Photocopies) ization or route checks at least annually, in the • First- or second-class medical certificate; simulator or with a third pilot in the aircraft, to ensure the altitude awareness standard operating • Random drug-testing document — verifi- procedures (SOPs) are being followed. cation, not the results; and, Improperly organized and inconsistent pilot • Radiotelephone operator’s permit, an training records were found in six of 20 audits International Civil Aviation Organization by the FSF Audit Team. requirement. By Darol Holsman www.flightsafety.org | AeroSafetyWorld | January 2007 | 15 auditreview
Qualification Documentation (Originals or Photocopies) • Flight crew company qualification autho- rization letter; and, • Flight time records.
Supplemental Documents (Photocopies) • Passport — first two pages; and, • Driver’s license — current.
Flight Training Verification Documents (Originals) Simulator Training Documents • Primary and secondary aircraft initial training documents with instructor com- ments; and, • Primary and secondary aircraft recurrent training — most current attendance with the listing of the areas covered.
Pilot supplemental training issues were a finding in another six of 20 audits by the FSF Audit Team. Pilot supplemental training is not mandated in any specific regulatory document for U.S. Federal Aviation Regulations (FARs) Part 91 operators. Part 135, 121, 125 and 129 operators have a clearly defined training regimen that is spelled out in the regulations. The team has established the following guidelines for Part 91 operators and noted the authority for the train- ing requirements, if applicable.
Professional Supplemental Training (Originals or Photocopies on File) • Instrument landing system (ILS)/precision runway monitor (PRM); • International procedures; • Reduced vertical separation minimum (RVSM)/required navigation performance (RNP)-10/RNP-5/minimum navigation performance specifications (MNPS); • Crew resource management (CRM) — ini- tial and then recurrent every 36 months; • Cardiopulmonary resuscitation (CPR)/au- tomated external defibrillator (AED) and first aid — initial and then recurrent every 24 months; © Chris Sorensen Photography
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• Minimum equipment list (MEL) use and Current copies of the prospective employee’s application — annual review; FAA license and medical and flight-hour • High altitude training/oxygen physiology records should be on file and verified before — every three to five years; indoctrination and aircraft type training. Prospective employees should be advised that Fire training should • Hazardous materials familiarization — ev- any falsification of a pilot record is cause for im- ery 24 months; mediate termination. include actually • Winter operations — aircraft surface Medical certification was the subject of extinguishing a fire contamination training, with an annual findings in six audits. In those audits, ATP rated review because of frequent changes; pilots maintained only an annual second-class with an aircraft-type • Mountain operations — every 24 months; medical certificate. When exercising the privileges of an ATP fire extinguisher • Aircraft upset/advanced maneuvering rating, a pilot must hold an FAA first-class — every three to five years; every 24 months. medical certificate in accordance with Part 61.23 • Aircraft emergency evacuation — every 24 (a)(1). months or change of aircraft type; If an operator has an established policy • Ditching — every 36 months; that a captain/pilot-in-command must be ATP • Survival — every 36 months; and, rated to operate a company aircraft, a first- class medical certificate should be an ongoing • Fire — every 24 months. requirement. Fire training should include actually extinguish- The practice of maintaining a second-class ing a fire with an aircraft-type fire extinguisher medical certificate or annually completing every 24 months, as recommended for flight a first-class medical review and then letting crewmembers by the National Fire Protection it lapse to a second-class medical certificate Association. during the second six-month period should be NTSB has recommended to FAA that all discontinued. Maintaining a first-class medi- pilots be required to have annual weather cal certificate as an ATP is an industry best refresher training. FAA has not adopted this practice. recommendation as of November 2006. Alternatively, an operator establishing Personnel factors were cited in the findings a requirement for a first-class medical cer- of six of 20 audits. tificate annually and having its personnel also Although employee background checks have complete a more extensive company manage- become routine since the Sept. 11, 2001, terror- ment–level medical review is also an industry ist attacks, the FSF Audit Team still finds some best practice. ● operators whose human resources or personnel departments have not established this require- This article extends the discussion of the aviation depart- ment or conduct inadequate checks. ment problems most frequently found by the FSF Audit Team, based on the final reports submitted to clients that Operators should verify that the corporate contracted for operational safety audits during 2004, human resources or personnel department has detailing the observations, findings and recommenda- established an employee background check pro- tions identified during the review (Aviation Safety World, cedure and ensure that an FAA license verifica- September 2006, page 46). Observations are documented tion and an accident/incident record review is policies, procedures and practices that exceed the industry completed. best practices; findings identify areas in which the team advises the client to adopt better policies, procedures or The key members of the flight operation practices to parallel industry best practices; and recom- leadership team, such as the director/manager mendations describe actions that could be taken by the cli- and chief pilot, should be fully aware of the con- ent to meet industry best practices. The recommendations tents of the employee background check. cited in this story are the opinions of the FSF Audit Team. www.flightsafety.org | AeroSafetyWorld | January 2007 | 17 coverstory
By Mark Lacagnina missed opportunities
The pilots did not notice a misset pressurization mode selector and misidentified a warning about cabin altitude. After hypoxia struck, autoflight systems kept the 737 flying until the fuel ran out.
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By Mark Lacagnina missed opportunities he Helios Airways Boeing 737- flight management computer and A green “ALTN” light indicates that 300 was climbing through 16,000 the autopilot, depletion of the the system is in the alternate mode. A ft after departing from Larnaca, fuel and engine flameout, and the green “MANUAL” light indicates that Cyprus, on Aug. 14, 2005, when impact of the aircraft with the the system is in the manual mode. Tthe captain reported a takeoff configu- ground.” ration warning to operations person- The 737-300 pressurization system was Unscheduled Leak Check nel. The warning horn that the captain designed to maintain a cabin altitude The mode selector had been set to heard was actually for a problem with of 8,000 ft at the aircraft’s maximum manual for a pressurization-system the cabin-pressurization system, ac- certified ceiling, 37,000 ft. The mode check the morning before the accident. cording to the Hellenic Air Accident selector, which is in an overhead The unscheduled maintenance was per- Investigation and Aviation Safety Board panel above the first officer’s seat, has formed in response to a technical log in Greece. Unaware of the problem, the three positions: “AUTO” (automatic), entry by the flight crew that had landed pilots were incapacitated by hypoxia, “ALTN” (alternate) and “MAN” (photo, the aircraft in Larnaca at 0425 after a and the aircraft, on automatic control, page 21). With the system in automatic flight from London. The technical log continued toward Athens, entered a mode, which normally is selected for entry stated that an inspection of the holding pattern and plunged to the flight, the crew selects the planned aft galley service door was required ground after the engines flamed out. cruise altitude and destination altitude because the door seal “freezes, and hard None of the 121 occupants survived. in the appropriate windows on the bangs are heard during flight.” In its final report, the board said that mode selector, and a cabin pressure After conducting a visual inspec- the direct causes of the accident were: controller positions the outflow valve tion of the door and the pressurization to maintain a programmed cabin- check, a ground engineer (maintenance • “Nonrecognition that the cabin pressure schedule. The alternate mode technician) wrote in the technical log pressurization mode selector was is selected to change from one cabin that no defects were found and that no in the ‘MAN’ (manual) position pressure controller to the other. With leaks or abnormal noises occurred. The during the performance of the the system in manual mode, the flight report said that although the airplane ‘Preflight’ [checklist] procedure, crew has “direct” control of pressuriza- maintenance manual included no spe- the ‘Before Start’ checklist and the tion, using a toggle switch to position cific requirement to return the mode ‘After Takeoff’ checklist; the outflow valve. “Manual control is selector to “AUTO” after the check, primarily used as a backup to automatic it would have been prudent for the • “Nonidentification of the warn- control,” the report said. ground engineer to have done so. ings and the reasons for the There are four annunciator lights The report also noted that a activation of the warnings (cabin above the pressurization control panel. rapid decompression of the accident altitude warning horn, passenger An amber “AUTO FAIL” light indicates aircraft’s cabin had occurred during a oxygen masks deployment indica- a failure of the automatic mode. An flight from Warsaw, Poland, to Larnaca tion, master caution); [and,] amber “OFF SCHED DESCENT” light on Dec. 16, 2004. The decompres- • “Incapacitation of the flight crew illuminates if the aircraft descends sion occurred when the aircraft was at due to hypoxia, resulting in the before reaching the planned cruise Flight Level (FL) 350 (approximately
© Kostas Iatrou/aviation-images.com continuation of the flight via the altitude set in the “FLT ALT” window. 35,000 ft) and near the point at which
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the flight crew had planned to begin descent. found during a cabin pressure leak check and The crew conducted an emergency descent outflow valve test. and landed the aircraft at the destination. The Cyprus Air Accident and Incident Investigation A Mode Overlooked Board, which investigated the incident, con- The accident occurred during a scheduled flight cluded that the decompression likely occurred to Prague, Czech Republic, with an en route either because the outflow valve opened due stop in Athens. The captain, 59, was a native of to an electrical malfunction or the aft galley Germany. He had 16,900 flight hours, including service door opened due to an improperly po- 5,500 flight hours as a 737 captain. He had been sitioned handle. Maintenance actions included employed by Helios Airways from May 2004 adjustment and rigging of the door and re- to October 2004 and had flown for two other placement of the no. 2 cabin pressure controller aircraft operators before returning to Helios and the chemical oxygen-generator cylinders Airways in May 2005. “According to interviews in the passenger service units. Technical log of his peers at [Helios Airways], during the first entries indicated that no abnormalities were period [of employment], he presented a typical ‘command’ attitude, and his orders to the first officers were in command tone,” the report said. Boeing 737-300 “During the second period, his attitude had im- proved as far as his communication skills were concerned.” The first officer, 51, was a native of Cyprus. He had 7,549 flight hours, including 3,991 flight hours in type. “He had expressed his views several times [to family, colleagues and friends] about the captain’s attitude,” the report said. “He had also complained about the organizational structure of the operator [and its] flight sched- uling, and he was seeking another job.” The report said that a review of his training records “disclosed numerous remarks and recommenda- tions made by training and check pilots refer- ring to checklist discipline and procedural (SOP
© Alan Lebeda/aviation-images.com [standard operating procedure]) difficulties.” The flight crew did not reset the pressuriza- he Boeing 737 was designed to use many components and as‑ tion mode selector to automatic before departure. semblies from the 727. Deliveries of the first production model, “The fact that the mode selector position was Tthe 737‑200, which has Pratt & Whitney JT8D engines, began in not rectified by the flight crew during the aircraft 1967. The larger 737‑300 was introduced in 1984 with quieter and preflight preparations was crucial in the sequence more fuel-efficient CFM International CFM56 engines, rated at 20,000 of events that led to the accident,” the report said. lb (9,072 kg) thrust. The 737-300 can accommodate 128 to 149 passengers and 1,068 The challenge for the pertinent item on cubic ft (30 cubic m) of cargo. Maximum standard takeoff weight is the “Preflight” checklist refers to both the air- 124,500 lb (56,473 kg). Maximum landing weight is 114,000 lb (51,710 conditioning and pressurization systems. The kg). Maximum operating speed is Mach 0.82. Cruising speed is Mach response is: “Pack(s), bleeds on, set.” The report 0.75. said that the pressurization mode selector rarely Production ceased in 2000 after 1,113 737-300s were built. is positioned to a setting other than automatic, Source: Jane’s All the World’s Aircraft and many pilots interviewed during the inves- tigation said that they typically respond “set”
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after checking only that the cruise altitude and The pressurization landing altitude are set correctly. system mode selector The aircraft departed from Larnaca at 0907. was in the manual, The first item on the “After Takeoff” checklist “MAN,” position is to check the pressurization system. “This was during the accident the second missed opportunity to note and cor- flight and was moved rect an earlier error,” the report said. beyond that position About 0910, the flight crew was cleared to by impact forces. climb to FL 340 and to fly directly to the Rhodos (Rhodes) VOR (VHF omnidirectional radio). The captain’s acknowledgement of the clearance was the last recorded communication between Hellenic Air Accident Investigation and Aviation Safety Board the flight crew and air traffic control (ATC). made in the two months preceding the acci- Warning Horn dent. “The crew became preoccupied with the The aircraft was climbing through 12,040 ft, and equipment-cooling-system situation and did cabin altitude was slightly below 10,000 ft, at not detect the problem with the pressurization 0912, when the warning horn sounded. Activa- system,” the report said. tion of the warning horn in flight indicates a The equipment-cooling system includes fans problem with cabin pressurization, the report and ducts that direct cool air to and warm air said. On the ground, the warning horn sounds away from electronic equipment on the flight when the throttles are advanced and the aircraft deck and in the electrical and electronic bay. is not in the correct takeoff configuration “Loss of airflow (mass flow) due to failure of — that is, with trim, flaps and/or speed brakes an equipment cooling fan or low air density set incorrectly. associated with excessive cabin altitude results According to the quick reference handbook, in illumination of the related equipment cooling among the actions that the flight crew should ‘OFF’ light,” the report said. take in response to a cabin altitude warning or rapid depressurization are to don their oxygen Communication Difficulties masks and stop the climb. That neither action The captain told the dispatcher about the was taken is one indication that the crew re- equipment-cooling problem, but the dispatcher acted to the warning horn as if it were a takeoff did not understand what he was saying and sug- configuration warning. The report noted that the gested that he talk with the on-duty ground en- crew did not silence the horn, and the loud noise gineer — the same person who had conducted that it produced likely increased their stress. the unscheduled maintenance before departure. The captain established radio communica- The dispatcher did not tell the ground engineer tion with a dispatcher in Helios Airways’ Opera- what the captain had reported before handing tions Center about 0914 and reported a “takeoff him the microphone. configuration warning.” About one minute later, The ground engineer told investigators that the “MASTER CAUTION” and “OVERHEAD” the captain asked for the location of the cooling lights illuminated on the flight deck annunciator fan circuit breakers and that he replied that the panel. On the overhead panel, the “PASS OXY circuit breakers were behind the captain’s seat. ON” light, indicating that the passenger oxygen The ground engineer also told investigators masks had deployed, and the equipment-cooling that he did not understand the nature of the system “OFF” lights also had illuminated. The problem that the captain was experiencing. The report noted that nine technical log entries report said that the communication difficulties about the equipment-cooling system had been likely arose because “the captain spoke with a www.flightsafety.org | AeroSafetyWorld | January 2007 | 21 coverstory
German accent and could not be understood by at [1132] that the captain’s seat was vacant [and] the British engineer. … Moreover, the com- the first officer’s seat was occupied by someone munication difficulties could also have been who was slumped over the controls,” the report compounded by the onset of the initial effects of said. The captain likely had vacated his seat to hypoxia.” check the cooling fan circuit breakers. The F-16 pilot also saw oxygen masks dangling from pas- Off the Air senger service units and three passengers sitting Helios Airways’ training program did not motionless, wearing oxygen masks. specifically require that flight crewmembers and The investigation did not determine what cabin crewmembers be trained to recognize the actions the cabin crew took or whether they symptoms of hypoxia. The report said that the attempted to communicate with the flight crew lack of this training is “a common situation in after the passenger oxygen masks deployed. the airline industry.” The cockpit voice recorder (CVR) provided The aircraft was climbing through 28,900 data only for the last 30 minutes of the three- ft about 0920, when the flight data recorder re- hour flight. The report said that the F-16 pilot’s corded the keying of the no. 2 VHF radio, which observations indicated that few passengers had was tuned to an ATC frequency. “This marked donned their masks. the last known attempt of radio communication The passenger-oxygen system was designed by the flight crew,” the report said. Attempts to supply oxygen for 12 minutes. “In order to The F-16 pilot saw by the airline’s Operations Center and ATC to retain consciousness after the depletion of the re-establish radio communication with the flight oxygen from the passenger oxygen system, a per- a man who was not crew were unsuccessful. son on board would have had to make use of one The aircraft continued to climb at an average of the [four] portable oxygen bottles,” the report wearing an oxygen rate of 3,030 fpm. The pressurization outflow said. The valves in three of the bottles were found mask enter the valve remained about 12 percent open during open. The report said that at least one of the the flight, and the average cabin altitude rate of bottles likely had been used by a cabin attendant. flight deck, sit in the climb was 2,300 fpm. Cabin altitude reached a The aircraft was on its tenth circuit of the maximum of about 24,000 ft. holding pattern about 1149, when the F-16 pilot captain’s seat and “The aircraft leveled off at FL 340 [about saw a man who was not wearing an oxygen don headphones. 0923] and continued on its programmed route,” mask enter the flight deck, sit in the captain’s the report said. The aircraft crossed the Kéa seat and don headphones. From the F-16 pilot’s VOR about 1021 and “began what appeared to description of the man’s clothing, investigators be a standard instrument approach procedure concluded that the person likely was the cabin for landing at Athens International Airport, attendant who had used one of the portable oxy- Runway 03L, but remained at FL 340,” the report gen bottles. “The F-16 pilot may not have been said. The aircraft flew over the airport about able to observe an oxygen mask on the person’s 1029 and turned right, toward the Kéa VOR, in face because the portable oxygen bottle mask accordance with the missed approach procedure was clear in color,” the report said. (Figure 1). The aircraft crossed the VOR about The CVR recorded sounds of an oxygen 1037 and entered the published holding pattern. mask being removed from its stowage box and oxygen flowing through the mask. The F-16 F-16 Intercept pilot tried to attract the cabin attendant’s atten- Two Greek air force F-16s intercepted the aircraft tion, but he did not respond. during its sixth circuit of the holding pattern. The F-16 pilots observed no external structural Attendant Attempts Control damage, smoke or fire. “One of the F-16 pilots About 1150, the left engine flamed out due to observed the aircraft at close range and reported fuel starvation. The aircraft turned steeply left
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Flight Path of Helios Airways Boeing 737, Aug. 14, 2005
1203 Airplane strikes terrain 1159/7,084 ft Right engine Turkey ames out
1123/FL 340 1029/FL 340 Intercept Airplane over ies by F-16s Athens 1150/FL 340 International Left engine Airport ames out 0907 Airplane departs Greece from Larnaca, Cyprus 0914/15,955 ft Communication on company radio 1037/FL 340 frequency begins Airplane 0920/28,900 ft enters Communication on holding company radio pattern frequency ends Cyprus 1021/FL 340 Airplane crosses Kéa VOR 1012/FL 340 0937/FL 340 First of 20 unanswered calls Airplane crosses 0923 0912/12,040 ft by Athinai Area Control Center Rhodes VOR Airplane levels o Cabin altitude at FL 340 warning horn sounds 0930/FL 340 0915/17,012 ft First of seven Master caution unanswered calls by light illuminates Nicosia Area Control Center
FL = Flight level VOR = VHF omnidirectional radio Times are local.
Source: Hellenic Air Accident Investigation and Aviation Safety Board
Figure 1 to a northerly heading and began to descend. and the heading changed from northerly to The report said that recorded fluctuations in southwesterly. About this time, the cabin atten- airspeed and altitude indicated that the cabin dant appeared to acknowledge the presence of attendant, who held a commercial pilot license the F-16. “He made a hand motion,” the report issued by the United Kingdom, was making an said. “The F-16 pilot responded with a hand effort to control the aircraft. signal for the person to follow him on down CVR data indicated that he attempted to towards the airport. The [cabin attendant] only transmit two radio messages about 1154. The pointed downwards but did not follow the F-16.” first was: “Mayday, mayday, mayday. Helios Although the cabin attendant was a licensed Airways Flight 522 Athens” followed by an un- pilot, investigators concluded that anyone with intelligible word. The second message, spoken similar flight experience likely would not have a few seconds later in what was described by been able to control the 737 with both engines the report as a very weak voice, was: “Mayday, inoperative and in the existing conditions of mayday.” Neither message was transmitted, hypoxia and extreme stress. The report said, however, because the microphone key had not however, that the cabin attendant apparently at- been depressed. tempted to level the aircraft before it struck hilly The 737 was descending through 7,084 ft terrain near Grammatiko, about 33 km (18 nm) about 1159, when the right engine flamed out northwest of the airport, about 1203. www.flightsafety.org | AeroSafetyWorld | January 2007 | 23 coverstory
The remains of 118 occupants were the country. CAA audits of Helios these concerned Boeing 737 aircraft, recovered and examined by a forensic Airways had found several deficien- while the other two events concerned pathologist; the bodies of the other three cies. “Management pilots appeared McDonnell Douglas aircraft. These occupants are believed to have been con- to be insufficiently involved in their nine reports all referred to aircraft that sumed by the post-accident fire. “Accord- managerial duties,” the report said. took off with the pressurization selector ing to the pathologist’s report, the cause “Training and duty records were found inadvertently set to ‘MAN.’” of death for all on board was determined to be incomplete. Manuals were found The report said that Boeing had to be multiple injuries due to impact, in to be [partially] deficient; they did not taken or was in the process of taking addition to the extensive burns for 62 of always adhere to regulations, and on several actions before the accident them,” the report said. The pathologist’s some issues they were out of date. In to reduce the likelihood of 737 pres- report also said that the occupants likely the two months before the initiation surization incidents. Among actions were “in deep, nonreversible coma due to of the first flight operations with the underway was a revision of the B737 their prolonged exposure (over 2.5 hours) [accident aircraft], the airline appeared Flight Crew Training Manual to include to the high hypoxic environment” when to be effectively scrambling to piece information on distinguishing between the impact occurred. together manuals and paperwork. This a cabin altitude warning and a takeoff suggested that an underlying pressure configuration warning. “A number of Latent Causes was prevalent to proceed with little remedial actions had been taken by The report said that the following were regard for the required formalities.” the manufacturer since 2000, but the latent causes of the accident: Moreover, flight crew training records measures taken had been inadequate indicated that no follow-up action and ineffective in preventing further • “Operator’s deficiencies in the or- had been taken in response to the first similar incidents and accidents,” the ganization, quality management officer’s record of insufficient checklist report said. and safety culture; discipline and ineffective performance Among actions taken in response • “Regulatory authority’s … in- in abnormal situations. to the findings of the accident inves- adequate execution of its safety The report said that the Cyprus De- tigation was Airworthiness Directive oversight responsibilities; partment of Civil Aviation (DCA) ap- (AD) 2006-13-13, issued in June 2006 peared to be completely dependent on by the U.S. Federal Aviation Admin- • “Inadequate application of crew the U.K. CAA for safety oversight and istration. The AD required revision of resource management principles; that the DCA’s Safety Regulation Unit the 737 airplane flight manual (AFM) [and,] was understaffed and lacked leadership “to advise the flight crew of improved and oversight. There was no record that procedures for preflight setup of the • “Ineffectiveness of measures taken the DCA took action to ensure that cabin pressurization system, as well as by the manufacturer in response to airlines responded to deficiencies and improved procedures for interpreting previous pressurization incidents issues considered by CAA auditors to and responding to the cabin altitude/ in the particular type of aircraft.” require urgent attention. configuration warning horn,” the report Helios Airways was established in 1999 said. The AD also required that the and had begun operating the accident Previous Problems following message be inserted in the aircraft in May 2004. At the time of the Investigators reviewed several previ- AFM: “For normal operations, the pres- accident, the airline also was operating ous occurrences worldwide involving surization mode selector should be in two 737-800s and an Airbus A319 from aircraft pressurization problems. “Of ‘AUTO’ prior to takeoff.” ● Cyprus to 28 destinations in 11 coun- interest and relevance to the [Helios tries. The airline had 228 employees, Airways accident were] nine reports This article is based on Hellenic Air Accident about one-third of whom were part- of pressurization problems directly Investigation and Aviation Safety Board Aircraft Accident Report 11/2006, “Helios time, seasonal employees. attributed to the crews’ failure to set Airways Flight HCY522, Boeing 737-31S, at Cyprus contracted with the U.K. and verify the proper position of Grammatiko, Hellas, on 14 August 2005.” The Civil Aviation Authority (CAA) to the pressurization mode selector to 198-page report contains illustrations and assist in overseeing three airlines in ‘AUTO,’” the report said. “Seven of appendixes.
24 | flight safety foundation | AeroSafetyWorld | January 2007 seminarsIASS Committing to automation Technologies influence hand-flying skills, ATC safety nets, airport moving maps and runway-debris detection.
By Wayne Rosenkrans | From Paris
Alan Bond
omplications often emerge when presence of debris that could cause use of automation during normal commercial air transport adopts foreign object damage (FOD). operations can result in degradation of new automated systems, several the ability to precisely maneuver the presenters said at Flight Safety Automation Exceptions aircraft without automation,” Landry CFoundation’s International Air Safety Flight crews accustomed to “glass” said in a proposal to the industry. Ini- Seminar (IASS) Oct. 23–26 in Paris. flight decks can counteract subtle tial practice six times a month, then 15 Among examples cited were difficulties degradation of their basic instrument to 30 minutes once or twice per month for airline pilots compelled to hand-fly flying skills by periodic hand-flying should be sufficient, he said. transport jets in response to “automa- practice during line operations under Although flying without the auto- tion exceptions,” air traffic control approved conditions, said Capt. Den- pilot, autothrottles and flight director (ATC) systems that generate unwar- nis Landry of the Air Safety Commit- — for example, during climb from ranted/nuisance short-term conflict tee and Northwest Airlines Master 10,000 ft until entry into reduced alerts (STCAs) and runway surface Executive Council of Air Line Pilots vertical separation minimum airspace radar that occasionally misreports the Association, International. “Exclusive in visual meteorological conditions www.flightsafety.org | AeroSafetyWorld | January 2007 | 25 seminarsIASS
Speakers from left, Landry, Bourdais and Patterson
Photos: Wayne Rosenkrans
— sharpens skills and “control feel” for Landry said that the airline industry and processes and lack of purpose regard- takeoff and landing, the primary objec- regulators would have to conduct formal ing safety nets among ATC safety tive is to establish a practice regime of research and development, and create managers. “Safety nets come in almost rule-based behaviors that helps pilots policies and guidance to establish the ‘automatically’ when ATC systems are effectively allocate attention to flight- proposed practice regime. renewed or upgraded,” Griffin said. path issues. Landry defines automa- Some survey respondents suggested tion exceptions as events that may Ground-Based Safety Nets downlinking resolution advisories compel pilots to revert to operating the Nuisance STCAs have inhibited efforts by (RAs) from airborne collision avoid- airplane either without automation or 60 European air traffic service provid- ance systems (ACAS) to ATC facilities; contrary to automation-directed flight ers to employ four ground-based “safety Eurocontrol so far has verified the paths. These situations include “flight nets” — that is, system safety defenses technical feasibility of doing this via management and guidance computer based on automation — to reduce the risk data link but with an eight-second systems or flight management systems of midair collisions, said Martin Griffin, delay. Related studies were pending that are not operationally stable or ATC domain manager for Eurocontrol. at the end of 2006. “While STCA and require pilots to create workarounds for In addition to STCA, the most mature ACAS are typically expected to be system deficiencies [such as faulty soft- safety net, others are the minimum safe complementary, dependent on conflict ware modifications]; go-arounds that altitude warning (MSAW), approach path geometry, they sometimes necessarily are not flown as programmed; partial monitor and airspace penetration warn- operate in the same [five-second] time or full pitot-static system failures; traf- ing systems. STCA has been mandated, frame, which can be dangerous,” Griffin fic alert and collision avoidance system and standardized implementation has said. “Controllers often are oblivious resolution advisories; precision radar been expedited as a pan-European safety that an RA has been given to the pilot.” monitor instrument approach system objective for 2007–2011. Eurocontrol’s Safety Nets Planning breakout maneuvers; [terrain awareness “The main challenge is to find the Implementation and Enhancements and warning system] escape maneu- optimum balance for a particular local Task Force, which conducted an inter- vers; ‘slam dunk’ [visual] approaches; situation between minimizing the num- national workshop in October 2006, abbreviated instrument approaches ber of nuisance alerts and maximizing believes that safety net improvements initiated from altitudes considerably the warning time when tuning the dif- can be achieved primarily through above the normal descent profile; ferent STCA parameters,” Griffin said. standardization by the end of 2008. rapid-decompression descents; and “There is also a dire lack of training ATC instructions requiring divergence for controllers on STCA. This occurs Airport Moving Maps from planned or assigned flight paths.” because we have no standard for STCA Automation that displays guidance to Correct action is essential if the flight or safety nets in Europe. Sometimes airline flight crews for precise all- crew confronts an automation exception, controllers didn’t even realize that they weather taxiing was introduced in 2003 he said. Without awareness and practice, had STCA functionality [or they] had by a few airlines to help reduce runway “blind over-reliance” on automation can it turned off.” Other air traffic control- incursions. This airport moving map generate subconscious complacency, lers have reset STCA parameters so that technology will be standard on all- reluctance or unwillingness to override this radar software functions only as an new airliners such as the Airbus A380 guidance displayed by the flight direc- ATC decision-support tool for routine and Boeing 787, and will be avail- tor. “Disregarding or eliminating the operations. Particularly troubling from able for retrofitting other types, said automation … often presents the best, if a 2004 survey of air traffic service André Bourdais, an Airbus navigation not the only, option available,” he said. providers were vague decision-making engineer. Airport data for about 300 air
26 | flight safety foundation | AeroSafetyWorld | January 2007 seminarsIASS Alan Bond
carrier airports already are available. As available, upgraded airport moving maps conditions of all-weather operations in with selection of appropriate automa- probably also will enable flight crews to Vancouver. “[A] relatively small area tion modes/functions for flight-path observe real-time movement of sur- of focus, coupled with the fact that the control, however, airport moving maps rounding aircraft and vehicles, perform individual performing the runway check require correct mode selections. After a evasive maneuvers and receive ground- is in a moving vehicle, makes a compre- mode has been selected, a range can be conflict resolution advisories. ATC clear- hensive scan very difficult,” Patterson selected for a strategic or detailed view ances involving the airport surface also said. Even adhering to the international of the airplane’s surroundings. could be data-linked to the display. recommendation to inspect each runway “Installations are either done as an every six hours, Vancouver’s runways are additional mode on the [forward-facing] Fine-Tuned Debris Alarm “known to be clear for only 0.5 percent of navigation display (ND) or as a function In 2001, Vancouver (British Columbia, any 24-hour period.” on the [side-facing] electronic flight bag Canada) International Airport Authority In 2006, each of two parallel (EFB),” Bourdais said. Airport moving and radar specialists at QinetiQ decided runways received two radar sensors maps are being designed as the “corner- to adapt millimetric wave radar and positioned approximately one-third stone” of coming software enhancements automation to remotely detect debris as of the total runway length from each for display of taxi routing, collision avoid- small as the cap of a ballpoint pen on threshold. Called QinetiQ Tarsier, the ance and weather overlays, he added. paved surfaces. But the potential for false system was in initial operating capabil- “[Improved situation awareness] alarms — defined as “any time a FOD ity mode at the end of the year. Each is achieved by an adapted depiction retrieval person responded to reported sensor has power output equivalent to of a digital airport map [an assembly [debris] coordinates and found no de- a mobile phone and has no effect on of several geometrical figures (points, bris” — was an early concern, said Brett other airport systems. Employees in lines or polygons)] merged with aircraft Patterson, the airport’s director of opera- the airport operations center advise current position and heading,” he said. tions safety planning. False alarms have ATC and request runway closure only Any airport database compliant with been caused by things such as hangar if a visual/audible alarm occurs. After recently adopted standards can generate doors opening and helicopter rotor- debris removal, radar confirms that the accurate displays at any desired size or blade scintillation. Two incidents involv- runway is clear before reopening. resolution, with intelligent decluttering ing debris on runways in 2000 — one “FOD radar has consistently identi- that helps the flight crew view and in- involving large pieces of an Airbus A330 fied [runway debris] before pilots or terpret only the graphical objects, labels engine cowling and the other a large airport personnel, even during daylight, and symbols relevant to the immediate aluminum tube from a de Havilland and it provides responding personnel task. “Runway labels are made to always Dash 8 — had convinced the authority with the latitude and longitude coordi- be visible on the map to promote to pursue a technologically advanced nates of the [debris] to within 3.0 m [9.8 maximum awareness so that pilots can runway debris-detection method. ft],” Patterson said. Short-term plans call anticipate arrival at intersections and Investigators found that human fac- for software versions that distinguish know they are close to a runway,” Bour- tors reduce the effectiveness of conven- large versus small FOD-radar targets, dais said. “Smooth transitions [between tional surface-inspection methods. These improve record keeping and control different modes and ranges] ensure that include individual attentiveness, varia- the lens of a video camera at each radar pilots never lose visual contact during tions in basic visual acuity, non-uniform sensor antenna tower — based solely on all taxiing phases.” visual sampling, inadequate sensitivity radar-generated position coordinates When automatic dependent sur- to visual contrasts and poor visibility — to transmit sharp magnified video veillance-broadcast (ADS-B) becomes of debris during nighttime and adverse images for risk assessment. ● www.flightsafety.org | AeroSafetyWorld | January 2007 | 27 incidents; and ineffective incident and accident investiga- tion. Regions need to improve Common coordination of regional programs, the Roadmap said. The focus areas for industry are: impediments to reporting Route and analyzing errors and inci- dents; inconsistent use of safety management systems (SMSs); inconsistent compliance with Ahead regulatory requirements; in- Global Aviation Safety Roadmap consistent adoption of industry demands sharper safety focus best practices; nonalignment by states, regions and industry. of industry safety strategies; insufficient number of qualified rans By Wayne Rosenk personnel; and gaps in use of safety-enhancing technology.
Roadmap Origins The ISSG was formed after the ICAO Air Navigation Commission (ANC) invited
© iStockphoto International industry representatives to a May 2005 meeting to discuss methods of integrating dis- strategic action plan detailing past October at the International Air parate efforts, ensuring consistency preferred practices for states Safety Seminar in Paris, Graeber said and reducing duplication. The ISSG and industry to address high- on behalf of the ISSG, “Future industry prepared and received the ANC’s ap- priority safety deficiencies has support in global and regional safety proval of Global Aviation Safety Road- Abeen delivered to the International Civil initiatives will be tied to the Roadmap map, Part 1, seven months later, and Aviation Organization (ICAO) by the — if you want some help, show us how the Roadmap was endorsed by the Industry Safety Strategy Group (ISSG).1 [your request] is tied to the Roadmap Directors General of Civil Aviation Titled Implementing the Global Aviation and we’ll have the discussion. If it’s Conference on a Global Strategy for Safety Roadmap, the plan distills the something that’s really different, it goes Aviation Safety in March 2006. The ISSG’s consensus on 2006–2014 priori- to the back of the line. Organizations Council of ICAO in June 2006 asked ties into one document and represents were pulled in different directions with- the ISSG for the Roadmap implemen- an industry commitment to tightly out the Roadmap. Regions can use the tation plan to help update its Strategic coordinate future safety initiatives [Roadmap] objectives and best practic- Objective on Safety. through one process.2 es to engage international stakeholders Coming in time to be considered Published in December 2006, the [and] to develop a regional safety plan.” during the early 2007 revision of ICAO’s plan provides a common framework The Roadmap identified areas Global Aviation Safety Program (GASP), to match limited resources to almost where national governments need the plan also has been advanced as “the unlimited needs, according to R. Curtis improvement: inconsistent imple- primary guide to how states and indus- Graeber, Ph.D., senior technical fellow, mentation of international standards; try work together,” Graeber said. The aviation safety, for Boeing Commercial inconsistent regulatory oversight; ISSG will coordinate any further activity Airplanes. Presenting the plan this impediments to reporting errors and with the ANC GASP Ad Hoc Working
28 | flight safety foundation | AeroSafetyWorld | January 2007 strategicissues
Group; ICAO Technical Cooperation • Guidance on acceptable metrics A closely related objective is Bureau; Cooperative Development of for evaluating the effectiveness of designed to help states, regions and in- Operational Safety and Continuing Air- corrective actions; and, dustry apply risk-assessment principles. worthiness Programs (COSCAPs); and It says, “The intention of [programs ICAO regional offices. • A “best practice maturity model” that collect and analyze data] is to both In 2007, the ISSG’s outreach will that enables classification of a derive appropriate metrics/measures include industry segments not explicitly state, region or company over- for identifying the precursors to safety part of the current ISSG or ICAO ac- all or with respect to any focus incidents so that they can be managed tivities, such as cargo, on-demand and area. The model provides criteria in day-to-day operations [and] identify corporate operators. “While regional for assigning one of four matu- and reinforce those behaviors that have differences will dictate different imple- rity levels from “developing” to a positive effect on safety performance.” mentations of best practices at different “highly evolved” as a method of To develop a regional action plan, levels of maturity, there is much benefit comparing relative performance the recommended steps are: select the that can be gained by sharing what over time. region for analysis, working from the works — and what doesn’t — in various ISSG’s categorization of countries or regions that share common challenges,” Basis for Safety Initiatives subsets if possible; include and en- the plan says. In the Roadmap, the ISSG Although inherently reactive, planning gage all affected stakeholders; outline considers best practices to be collective based on accident data still provides existing strengths and enablers, i.e., lessons learned by the commercial avia- an acceptable basis for mapping safety local factors that support the safety of tion community. initiatives. “It is absolutely essential that aviation; identify current and future The plan provides the following the lessons learned from … accidents risks/factors in the operating environ- detailed elements to regions, states and remain at the forefront of safety- ment; conduct a gap analysis for the industry: enhancement activities,” the plan says. majority of the organizations, establish- “Analysis of recent accidents in regions ing their current maturity levels relative • Twelve defined Roadmap focus with poorer safety records shows that to their counterparts and to Roadmap areas; nearly all were caused by previously best practices; develop prioritized • Acceptable objectives for regional well-understood factors with equally recommended actions; and assign this safety teams that choose to work well-understood mitigating actions.” action plan to industry organizations on any Roadmap focus area; Beyond reactive methods, how- or government entities responsible for ever, the plan urges consideration of correcting safety deficiencies. • Best practices for identifying and prognostic/predictive approaches to analyzing gaps between the current risk assessment such as flight data Straight Talk safety status and the targeted status; monitoring and periodic auditing The plan is unequivocal about the • Technical knowledge, meth- of civil aviation authorities, airlines, role of the global commercial avia- ods and information sources airports, air navigation service provid- tion community as a potent force for to correct safety deficiencies, ers (ANSPs), maintenance organiza- change wherever standards have not including processes for develop- tions and training organizations. Best been implemented, and a catalyst ing regional action plans. In one practices for these methods include for universal adoption of best prac- of the appendixes to the Road- using metrics from standards of the tices. This translates into several best map strategic action plan, the USOAP and the IATA Operational practices, including one that says, ISSG demonstrates a completed Safety Audit (IOSA), ICAO annexes “States apply coordinated initiatives to regional assessment template for and safety oversight/management ensure that noncompliant states do not Sub-Saharan Africa with entries manuals, and products developed by engage in activity which could be seen based on sources such as the the international consensus of special- as unacceptably increasing the risk of ICAO Universal Safety Oversight ists, such as the Flight Safety Founda- operation.” Audit Program (USOAP) results tion Approach-and-Landing Accident Also among the plan’s recurrent
for states; Reduction (ALAR) Tool Kit. themes are adoption of “just culture” © i S tockphoto International www.flightsafety.org | AeroSafetyWorld | January 2007 | 29 strategicissues
principles including “open reporting” of disciplines of the aviation industry,” the would address some of these accident incidents by all aviation professionals, plan says. “ICAO [SMS requirements types. sharing and analysis of data at regional do] not yet extend to all … [suppliers To reduce the risk of approach-and- and worldwide levels and free exchange of goods and services such as] aircraft landing accidents, aircraft operators of lessons learned from operations. The maintenance, aeronautical information should consider how to facilitate stabi- plan says, “[Just culture is] defined as services and meteorology.” Audit pro- lized approaches by providing “aircraft an atmosphere of trust in which people cesses of industry organizations should capability to fly constant-angle/con- are encouraged and even rewarded include SMSs. “To be truly effective, stant-slope final approaches [including] for providing essential safety-related the interface with other SMSs must also flight path target or flight path direc- information, even if self-incriminat- be recognized and managed,” the plan tor, other vertical flight management ing, [so that hazards and risks may be says. system (FMS)/autopilot/flight director more clearly understood] but in which Leaders of states, regions and modes [or] both; aircraft capability to all parties clearly understand which industry must have “both detailed fly area navigation (RNAV) and re- types of behaviors are acceptable or knowledge of current best practices and quired navigation performance (RNP) unacceptable … and persons reporting an organizational commitment to adopt RNAV approaches; head-up displays need not fear reprisal.” Open reporting them in a timely manner,” the plan says. (HUD) for enhanced situational aware- “encourages reporting … beyond that Designated individuals should take ness during visual approaches at night which is mandated [and is] also confi- responsibility for researching, updat- or in marginal daytime visual meteo- dential in that the reporter’s identity is ing and disseminating best practices, rological conditions; [and] auto-land protected,” the plan says. recommending which to adopt and capability.” following up on line managers who Operators also should facilitate SMSs Everywhere ideally will have been empowered to “optimum use of braking devices Although the value of an SMS in risk ensure implementation of safety-criti- such as anti-skid systems … auto- reduction cannot be overestimated, cal items. Quantitative and qualitative brake system; [and] thrust reversers.” the ISSG says that this potential has assessments of threats and technology ANSPs should consider methods of not been realized yet. “To maintain the by regional specialists — with early in- “preventing unstabilized approaches safety of the whole aviation system, it volvement of regulators — also are ap- by gaining an enhanced understand- is important to ensure consistency in propriate to avoid “piecemeal solutions ing of modern aircraft performance the use of SMS across all sectors and that do not recognize system issues.” characteristics, e.g., deceleration Graeber characteristics; [FMS] reprogram- Considerable Technology ming requirements [for flight crews The plan highlights current technologies responding to ATC instructions]; designed to enable aircraft operators, and SOPs.” They also should consider ANSPs, airports and others to address implementing the minimum safe approach-and-landing accidents, loss altitude warning (MSAW) capability of control, controlled flight into terrain of terminal/approach radars. (CFIT), rejected-takeoff accidents, fuel- Airports should consider imple- related forced landings, midair collisions, mentation of “visual approach slope ground accidents, in-flight fires, severe indicator/precision approach path weather, turbulence encounters, wind indicator at each runway end … ; the shear avoidance, and aircraft mainte- installation of a visual glide slope nance risks. Appendixes recommend indicator at each runway end … ; sources of ICAO standards and recom- runway-remaining markings/runway- mended practices, industry best practices, edge lighting; [and an] EMAS (en- standard operating procedures (SOPs) gineered material arresting system)
Wayne Rosenkrans Wayne and education/training. A few examples … bed at each runway end where the show how Roadmap recommendations terrain configuration does not allow
30 | flight safety foundation | AeroSafetyWorld | January 2007 strategicissues
for the provision of a runway [end] Work Force Realities and qualifications issued by other safety area.” The FSF ALAR Tool Kit The plan projects a 15-year passen- regulatory authorities/civil aviation is among the plan’s recommended ger-traffic growth of 4.1 percent an- authorities; [and] providing incentives resources. nually — a demand for air transport to attract potential candidates into the To reduce the risk of CFIT, op- by as many as 7 billion passengers by industry.” erators should consider “horizontal 2020 — requiring all industry sectors Small, deliberate steps are the most situation display/navigation displays to take action without delay. “Even likely path to success under these (NDs); terrain awareness and warn- today, some sectors in some regions Roadmap concepts, according to the ing systems [TAWS], in association are experiencing significant short- ISSG. “Otherwise, an attempt [at] the with GPS [global positioning sys- ages of suitable technical staff,” the immediate implementation of all best tem] navigation; radio altimeter or plan said. “As a result, the industry practices may detract from the basic TAWS automatic altitude callouts, is witnessing significant migration obligations of states and industry orga- with standardization across the fleet of professional staff from one region nizations to correct those infrastructure to maximize effectiveness; primary to another to meet this need. This and other deficiencies that are already flight displays (PFDs) with verti- relocation is to the [safety] detriment identified,” the plan says. “No region cal situation displays for enhanced of certain regions. of the world has attained the highest terrain awareness and enhanced level of focus area maturity by all of awareness of applicable minimum their states, airlines/operators and other safe altitude; aircraft capability and constituents.” ● operating policy for the conduct of constant angle/[constant] slope final Notes approaches for all types of approach- 1. The Industry Safety Strategy Group es; aircraft capability and operating (ISSG) comprises Airbus, Airports policy for the conduct of RNP RNAV Council International, Boeing approaches; [and] aircraft capability Commercial Airplanes, Civil Air for the conduct of approaches with Navigation Services Organisation, FMS-based or GPS-based vertical Flight Safety Foundation, International guidance (e.g., FMS landing system Air Transport Association (IATA), and International Federation of Air Line and global navigation satellite system © iStockphoto International Pilots’ Associations. landing system approaches).” To reduce the risk of loss of con- “A major challenge faced by all sec- 2. ISSG. Implementing the Global Aviation trol, operators of aircraft without full tors of the aviation industry concerns Safety Roadmap. Dec. 4, 2006. The flight envelope protection3 should the recruitment, training and retention complete document is available at
espite political pressure to • FAA-approved initial or transi‑ conduct the landings required ground the Mitsubishi MU‑2B tion training for pilots who have to meet recent flight experience in the United States, the Federal not flown an MU‑2B in two years; standards; Aviation Administration (FAA) • Approved requalification train‑ • Manipulation of controls only Dhas found, again, that the airplane is ing for pilots who have flown an by pilots who meet the SFAR not inherently unsafe but that special MU‑2B in the previous two years requirements; experience, training and operating but have not received the ap‑ requirements are needed for pilots, • A minimum of 2,000 hours as proved training; instructors and examiners.1 PIC, including at least 800 hours On Sept. 28, 2006, the FAA pub‑ • Approved differences training for as PIC of multiengine airplanes lished a notice of proposed rule making pilots who operate more than one and 300 hours as PIC of MU‑2Bs (NPRM) for a special federal aviation model; to provide flight instruction in regulation (SFAR) that would impose the airplane. At least 50 of the 300 • Approved recurrent training the following key requirements: hours of required PIC time would every 12 months; have to be logged in the previous 12 months; • A minimum of 100 hours of expe‑ • Mandatory use of MU‑2Bs by rience as pilot-in-command (PIC) pilots, designated pilot examin‑ • At least 100 hours as PIC of of multiengine airplanes to act as ers and check airmen to accom‑ MU‑2Bs for designated pilot PIC of an MU‑2B; plish biennial flight reviews and examiners and check airmen; and,
© Chris de Stefani, airphototicino/Airliners.net dangerous? New questions about the safety of the MU-2B have been answered with proposed special requirements for those who fly the complex, speedy twin-turboprop.
BY MARK LACAGNINA
32 | flight safety foundation | AeroSafetyWorld | January 2007 FLIGHTtraining
• A “functioning” autopilot aboard the of data, including those shown in Table 1 (page airplane for flight under instrument flight 34), indicated that the frequency of fatal MU‑2B rules or in instrument meteorological con‑ accidents involving loss of control is 3.5 times ditions or nighttime visual meteorological greater than airplanes in the comparison group. conditions. “The most frequent and fatal type of ac‑ cident … involves uncontrolled descent from Accident Spikes altitude during and after flight in reported or As with special certification reviews (SCRs) of suspected icing conditions,” the FAA said. the MU‑2B conducted by the FAA in 1983–1984 and 1996–1997, an increase in accidents was Under the Microscope cited as the reason for the recent “safety evalua‑ The safety evaluation was launched in July tion” (Figure 1). 2005 and focused on certification, mainte‑ Lacking activity, or flight hour, estimates, nance, operations and training. The evaluation the FAA compiled accident rates based on the concluded that the airplane meets its certifica‑ number of airplanes on the U.S. registry. The tion requirements and that current maintenance agency found that the MU‑2B’s accident rate requirements are sufficient. However, a flight from 1966 through September 2005 is twice standards information bulletin for airworthiness as high as similar twin-turboprop airplanes was issued in November 2005, directing FAA — Beech 90 and 100 series King Airs, Cessna aviation safety inspectors to ensure that proper 425 and 441 Conquests, Commander 680s and procedures and equipment are used by main‑ 690s, and Piper PA-31T Cheyennes. Analyses tenance technicians during critical procedures, or just different?
Mitsubishi MU-2B Accidents in the United States, 1983–2005
10 25 Total Accidents 9 Fatal Accidents
8 Fatalities 20
7 Number of Fatalities
6 15
5
4 10
Number of Accidents 3
2 5
1
0 0 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Source: U.S. Federal Aviation Administration
Figure 1 www.flightsafety.org | AeroSafetyWorld | January 2007 | 33 FLIGHTtraining
Comparative U.S. Fatal Accident Data, 1966–September 2005
Contemporary Twin-Turboprop Airplanes MU-2B Commander Beech Cessna Piper Accident Type Short Body Long Body Total 680 690 90 100 425/441 PA-31T Total Loss of control 27 26 53 10 33 54 12 20 24 153 CFIT 1 10 11 3 1 7 1 3 4 19 Emergency maneuver 4 4 8 1 0 2 0 0 3 6 Ramp 1 3 4 0 0 2 1 0 0 3 Midair collision 1 1 2 0 3 1 0 1 2 7 Ground collision 0 0 0 0 0 1 1 1 0 3 Missing/unknown 0 2 2 0 0 0 0 0 0 0 Other 0 1 1 0 2 0 0 0 1 3 Total 34 47 81 14 39 67 15 25 34 194
CFIT = Controlled flight into terrain
Source: U.S. Federal Aviation Administration
Table 1
including the adjustment and rigging to reduce pilot workload. The FAA and with revisions and a standardized cockpit of fuel controls, propeller blade angles MHIA both recommend that the auto‑ checklist developed by MHIA. and flaps. pilot not be used in icing conditions be‑ A flight standardization board cause it could mask detrimental effects Political Pressure (FSB) was convened to study train‑ of icing on the airplane’s performance Two fatal accidents in 2004 — on May ing requirements. The board reviewed and handling characteristics. 14 and Dec. 10 (see appendix, page 20 existing training programs and The FAA also considered requiring 36) — prompted numerous congres‑ found little standardization. “Only a a type rating, which long has been rec‑ sional inquiries about the safety of the few emphasized the different handling ommended by MHIA, but concluded MU‑2B. The FAA’s Web site includes characteristics of the MU‑2B or special‑ that the requirement would not ensure 13 letters from members of the U.S. ized operational techniques,” the FAA that pilots receive recurrent training Congress, most of whom forwarded said. A standardized training program in the MU‑2B. During the evaluation, correspondence from constituents — developed by Mitsubishi Heavy Indus‑ the FAA surveyed and held meetings relatives of pilots killed in the accidents tries America (MHIA) was adopted with MU‑2B pilots, operators, training — and requested information about the after being revised by the FAA to meet providers and special-interest groups. airplane.2 At least six letters said that the proposed SFAR requirements. “All participants agreed that something the airplane should be grounded until FSB flight test data analyzed by needed to be done to improve the its safety record is thoroughly analyzed. human factors personnel at the Civil safety record of the MU‑2B,” the FAA In the NPRM, the FAA said that it Aerospace Medical Institute showed said. “Everyone supported mandatory found no justification to ground the that use of an autopilot significantly type-specific, recurrent, standardized airplane. “The airplane meets its origi‑ reduces workload and stress, and im‑ training for pilots.” nal type certification basis as found in proves pilot performance. The resulting Many participants said that the three type certification analyses,” the proposed requirement for a functioning airplane flight manuals (AFMs) need to agency said. autopilot during specific operations was be reviewed and revised, and that a stan‑ After the NPRM was published, adopted in lieu of proposing a require‑ dardized cockpit checklist be developed Tom Tancredo, a representative from ment for a second flight crewmember. for the airplane. The FAA agreed, and the Colorado, called on President George The SFAR does not require that the au‑ proposed SFAR includes requirements to Bush to replace the FAA administrator topilot be used, just that it be available have and use an AFM that is up-to-date and the chairman of the U.S. National
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Transportation Safety Board because in the United States today are being proposed compliance time — 180 days they “consistently failed to take appro‑ operated for personal use under Federal after publication of the SFAR — should priate action on this issue.” Tancredo Aviation Regulations (FARs) Part 91. The be extended to at least one year. MHIA, also introduced legislation that would FAA estimates that 64 MU‑2Bs are being which provides spare parts and technical force the FAA to ground the airplane flown by 18 Part 135 operators, primarily services, administers service centers and until it “certifies that the aircraft is safe for on-demand cargo service. conducts free Pilot’s Review of Profi‑ and a law is enacted approving the cer‑ “This shift to air-taxi and personal- ciency seminars, said that an extension tification.” However, proposed legisla‑ flight operations increased the expo‑ is necessary to train more instructors. tion such as this rarely becomes law. sure of the MU‑2B to certain known The proposed requirement that only hazards: more frequent night flights; a SFAR-qualified pilots manipulate the Bird of a Different Feather significantly higher number of hours controls was roundly criticized. Many The MU‑2B was certified in the United flown than in previous operations; an comments said that a multiengine- and States under Civil Aviation Regulations increase in single-pilot operations; and instrument-rated pilot should be al‑ (CAR) 10, which included CAR 3 stan‑ operation by pilots who may not be get‑ lowed to manipulate the controls under dards for normal category airplanes and ting the level and frequency of training the supervision of a qualified PIC. special conditions applicable to turboprop that corporate pilots typically receive,” Several commenters, including two airplanes. Mitsubishi Heavy Industries the FAA said. of the largest fleet operators — Ameri‑ produced 764 MU‑2Bs between 1965 and The 2005–2006 safety evalua‑ can Check Transport and Bankair, cited 1986. The most significant model change tion concluded that the MU‑2B is “a the difficulty of maintaining the origi‑ came in 1970, with the introduction of complex airplane requiring operational nal autopilots and called for retention the “long-body” MU‑2B.3 techniques not typically used in other of the current master minimum equip‑ The FAA estimates that there are light turboprop airplanes but more ment list provisions for operating the 397 of the airplanes — 194 short-body similar to those of turbojet aircraft that airplane with an inoperative autopilot. models and 203 long-body models require a type rating.” The potential economic impact was — and about 600 MU‑2B pilots in the Double-slotted Fowler flaps along criticized by several commenters who United States. There once were 675 the full span of the trailing edge of the called for less burdensome requirements, MU‑2Bs on the U.S. registry; the FAA wing provide short-field takeoff and such as training to proficiency instead of said that 213 have been “withdrawn landing capability. Spoilers provide a set number of hours. Epps Air Service, from use or written off” and 65 have roll control, and the outboard flap which operates 10 MU‑2Bs, said that been registered in other countries. section on each wing incorporates a the market value of the airplanes has Initially popular among corporate/ trim aileron. Wing loading is relatively dropped substantially since publication business aircraft operators, most MU‑2Bs high — 59 lb/sq ft (288 kg/sq m) for of the NPRM and that because of the the short-body models and 65 lb/sq high turnover in the employment of Part Tancredo ft (317 kg/sq m) for the long-body 135 pilots, training costs will be higher models — compared with about 39 than estimated by the FAA. lb/sq ft (191 kg/sq m) for the F90 King Many commenters applauded the Air, Conquest II, Commander 690 and FAA for resisting the political pressure Cheyenne II. Several pilots who partici‑ to ground the airplane. According to pated in the safety evaluation said that U.S. legal requirements, the agency has because of the high wing loading and until April 2008 to publish a final rule other design characteristics, the air‑ or withdraw the proposed SFAR. ● plane must be “flown by the numbers” — that is, according to the AFM. Notes
Feedback 1. The recent safety evaluation of the MU‑2B by the U.S. Federal Aviation Administration The FAA received about 70 public com‑ (FAA) followed special certification reviews ments on the NPRM. Most said that the (SCRs) conducted in 1983–1984 and www.flightsafety.org | AeroSafetyWorld | January 2007 | 35 FLIGHTtraining
1996–1997. The first SCR focused on the for “MU‑2.” The safety evaluation docket Although “MU‑2B” is the generic name airplane’s engines, fuel system, autopilot, can be accessed by conducting a keyword for the production airplanes, subsequent flight control system and handling char‑ search for “MU‑2” on the U.S. Department models have series identifications as well as acteristics during approaches in instru‑ of Transportation’s docket management marketing designations: for example, the ment meteorological conditions and with system site,
Appendix Mitsubishi MU-2B Fatal Accidents, United States, 2004–2005
Date Location Aircraft Model Aircraft Damage Fatalities March 11, 2004 Napa, California MU-2B-40 destroyed 2 The aircraft crashed during an approach in visual meteorological conditions (VMC) to Napa County Airport at 2030 local time. The preliminary report by the U.S. National Transportation Safety Board (NTSB) said that the wreckage was found in a river 3 mi (5 km) south of the airport seven days after the accident. March 25, 2004 Pittsfield, Massachusetts MU-2B-36 destroyed 1 The aircraft was on a cargo flight in VMC when it descended rapidly from 17,000 ft. Several witnesses said that the aircraft was in a flat spin with the engines operating when it struck terrain at 0533. The pilot had about 6,500 flight hours, including more than 2,000 flight hours in type. NTSB said that the probable cause of the accident was “the pilot’s loss of aircraft control for undetermined reasons.” May 14, 2004 Ferndale, Maryland MU-2B-60 destroyed 1 The pilot, who had more than 6,800 flight hours, was conducting a nighttime cargo flight to Baltimore–Washington International Airport and was cleared to land on Runway 33R. The report said that the pilot attempted to reverse course after entering a “modified downwind” for Runway 15L. Witnesses saw the aircraft enter a steep left bank at about 700 ft and descend to the ground. NTSB said that the probable cause of the accident was “the pilot’s failure to maintain airspeed during a sharp turn, which resulted in an inadvertent stall.” Dec. 10, 2004 Englewood, Colorado MU-2B-60 destroyed 2 Soon after departing from Runway 35R at Centennial Airport for a nighttime cargo flight, the pilot told the tower controller that he needed to return to the airport. The aircraft was on downwind for Runway 35R when the pilot reported that he had shut down one engine. The aircraft overshot the turn to final, entered a steep left bank and descended to the ground. NTSB said that the probable cause of the accident was “the pilot’s failure to maintain minimum controllable airspeed [VMC].” The pilot had 2,496 flight hours, including 364 flight hours in type. The report said that a pilot-rated passenger was aboard to receive aircraft-familiarization training. May 24, 2005 Hillsboro, Oregon MU-2B-25 destroyed 4
After takeoff, the pilot was conducting a steep climb at an airspeed below mcV when a partial power loss occurred in the left engine. The aircraft rolled into a steep left bank, pitched nose-down and spun to the ground. NTSB said that “the pilot’s failure to obtain minimum controllable airspeed” was the probable cause of the accident and that “the pilot’s lack of recent experience and recurrent training in type” was a factor. Aug. 4, 2005 Parker, Colorado MU-2B-60 destroyed 1 The preliminary report said that the aircraft struck terrain after descending below the glideslope during an instrument landing system (ILS) approach to Centennial Airport. The accident occurred at 0206 in instrument meteorological conditions. The pilot had more than 4,800 flight hours, including 1,200 flight hours in type. Sept. 22, 2005 West Memphis, Arkansas MU-2B-36 destroyed 1 About 20 minutes after departing from West Memphis for a positioning flight in nighttime VMC, the pilot told air traffic control that he needed to return to the airport “to have something checked out,” the preliminary report said. A witness, a professional pilot, saw the aircraft flying “way too low” and “excessively slow” before it struck a large earthmoving vehicle and terrain near the airport. The pilot had 12,600 flight hours, including 1,900 flight hours in type.
Source: U.S. National Transportation Safety Board
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© iStockphoto © Karl Jacobson/Jetphotos.net Risks As air traffic and wildlife populations increase,on Feathered collisions between aircraft and wildlife — especially birds — are increasingly likely.
BY LINDA WERFELMAN ildlife strikes at airports around that bird strikes damage engines more the world destroyed moreWings than 163 often than any other aircraft component. aircraft and killed more than 194 people from 1988 through 2005, and As an example of the extent of the change, Wthe threat to human health and safety is increas- in 1969, 75 percent of the 2,100 passenger ing, a 2006 report by the U.S. Federal Aviation aircraft in the United States had three or Administration (FAA) says.1 four engines; by 2008, only about 10 percent The report warned of an increase in the of the 7,000 passenger aircraft in the United “risk, frequency and potential severity of States will have three or four engines. wildlife-aircraft collisions” during the next de- cade, primarily as a result of three factors: • The populations of many species most com- monly involved in strikes — and many bird • The replacement of older aircraft with species with the largest body weights — have three or four engines with quieter, two- increased dramatically in recent years. For engine aircraft “increases the probability of example, the Canada goose population in life-threatening situations resulting from Canada and the United States increased aircraft collisions with wildlife, especially about 7.9 percent a year from 1980 through with flocks of birds,” because of the reduc- 2005, and the population of white-tailed tion in engine redundancy. In addition, deer — estimated at 350,000 in 1900 — in- research indicates that birds “are less able creased to at least 17 million in 1997. to detect and avoid modern jet aircraft with quieter engines than older aircraft • As wildlife populations have increased, with noisier engines” — one of the reasons so has air traffic — 29.9 million aircraft
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Wildlife Strikes Involving U.S. Civil Aircraft, 1990–2005 the problem increased, leading to an increase in reporting of the events. 8,000 Nevertheless, the report estimated 7,000 that less than 20 percent of wildlife 6,000 strikes for the 16-year period were re- ported to FAA; in addition, information 5,000 about the extent of damage and cost 4,000 estimates often was incomplete. 3,000 Of the wildlife strikes reported 2,000 during the 16-year period, 144 involved
Number of Reported Strikes reports of injury or death to humans — 1,000 nine deaths and 172 injuries. Waterfowl 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 and birds of prey were most frequently identified as the types of birds involved, Source: U.S. Federal Aviation Administration and deer were the most frequently Figure 1 identified terrestrial mammals (land- based mammals, excluding bats). movements in the United States Airport in Texas and Kennedy Inter- alone in 2005, compared with national Airport in New York. This Engines Incur Most Damage 17.8 million in 1980, the report system detects birds but does not scare The report said that commercial air- said. Growth is expected to them away and often is paired with craft were involved in 84 percent of the continue to increase by at least 2 other bird-scaring technologies.3,4 reported wildlife strikes in the 1990– percent each year through the end 2005 analysis. Reports were received of the decade. Millions in Damages from throughout the United States, in- The FAA report included an estimate cluding some from U.S. territories, and New Technologies that aircraft strikes of birds and other from other countries if U.S.-registered As wildlife strikes increase, airport wildlife cost the U.S. civil aviation aircraft were involved. authorities are turning to a variety of industry US$557 million a year, plus Of the bird strikes, 51 percent oc- programs to remove birds and other 580,029 hours of aircraft down time. curred between July and October, and wildlife from the paths of aircraft. The data showed a dramatic in- 63 percent occurred during daytime. Among the new technologies is crease in reported wildlife strikes in the About 59 percent of bird strikes oc- a laser bird repellent, the TOM500, United States in recent years — a trend curred during the landing phase of developed by Lord Ingénierie for the that is likely to continue, the report flight, and 38 percent occurred during French Direction Générale de l’Aviation said. From 1990 through 2005, authori- takeoff and climb; 60 percent occurred Civile and being tested at Montpellier ties received reports of 66,392 wildlife 100 ft above ground level or lower. Airport in France. strikes involving civil aircraft in the Of the terrestrial mammal strikes, The device uses a green laser beam United States (Figure 1). Of these, 97.5 58 percent occurred between July and — safe for the human eye — to scan percent involved birds. In the final year November — 33 percent of deer strikes runways and frighten away birds. of the period, 7,136 wildlife strikes were occurred in October and November. Several months after installation of the reported — more than quadruple the Sixty-three percent occurred during TOM500 at Montpellier Airport, birds 1,744 strikes reported in 1990. nighttime, 55 percent during the landing no longer appeared in the runway area; The report said that the increase roll and 34 percent during the takeoff no bird strikes have occurred at the probably was a result of several develop- roll; 8 percent occurred when the air- airport with the device in operation.2 ments: Aircraft operations and wildlife craft was in the air — for example, when Another new system is DeTect’s populations both increased, leading an aircraft’s landing gear struck a deer. Merlin radar system, being tested to an increase in the actual number Aircraft engines were the components at Dallas/Fort Worth International of wildlife strikes, and awareness of most often damaged by bird strikes,
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accounting for 32 percent of all damaged For example, the cost of repairs was to the airport. Wetlands, dredge spoil components, the report said. Of the 8,750 estimated at $9.5 million for an Airbus containment areas, waste-disposal reported bird strikes involving aircraft A310 that had multiple bird strikes to an facilities and wildlife refuges can attract engines, more than 400 involved more engine during an attempted takeoff from hazardous wildlife. Such land uses are than one engine: 421 events involved Subic Bay, Philippines, on June 24, 2005 often incompatible with aviation safety strikes to two engines, 10 involved strikes (see appendix, page 40). The engine and and should either be prohibited near to three engines, and five involved strikes cowling were replaced, and the airplane airports or designed and operated in a to four engines. Of the engines that were was out of service for four days. The manner that minimizes the attraction struck, 3,011 were damaged: 2,822 events birds were identified as Philippine ducks. of hazardous wildlife.” involved damage to one engine, 93 in- Repairs cost about $1.5 million The report also urged more compre- volved damaged to two engines, and one after a Dec. 30, 2005, strike in which hensive reporting of wildlife strikes to en- involved damage to three engines. a vulture crashed through the wind- able analysts to more precisely determine Of the reported terrestrial mam- shield of a Bell 206 near Washington, the extent of related safety issues and the mal strikes, the components most often Louisiana, U.S., injuring the pilot, who economic costs of the problem. ● reported as damaged were the landing experienced difficulty with his vision as Notes gear, propeller and wing/rotor. he conducted a precautionary landing 1. Cleary, Edward C.; Dolbeer, Richard A.; Of the 64,734 bird strike reports, because the bird’s blood was in his eyes. Wright, Sandra E. Wildlife Strikes to Civil 53,309 discussed the extent of damage The report said that, to fight the Aircraft in the United States, 1990–2005. to the aircraft. Less than 1 percent of problem of wildlife strikes, airport Federal Aviation Administration (FAA) the aircraft were destroyed, 4 percent authorities first must assess wildlife National Wildlife Strike Database, Serial incurred substantial damage, 8 percent hazards on their airports and then “take Report No. 12. Washington, D.C. June 2006. incurred minor damage, and 85 percent appropriate actions, under the guidance 2. Lord Ingénierie. Bird Strike: Laser Bird were not damaged. of professional biologists trained in Repellent TOM500.
Appendix Selected U.S. Wildlife Strikes, 2005
Date Location Aircraft Type Phase of Flight Components Damaged Jan. 7 Bowerman, Washington Raytheon Hawker 1000 climb no. 1, 2 engines During climb, the pilot pulled the airplane’s nose up to avoid birds, possibly dunlins, but they were ingested into both engine cores. A post-landing inspection found that the landing gear also was covered with small birds. The area is a wildlife refuge, but no specific warning had been issued. Jan. 12 Tokyo Boeing 747 takeoff engine, wing During takeoff, the crew saw two birds on the runway centerline and other large birds under the airplane’s nose and to the left, and then heard a loud bang. The airplane yawed left. An inspection showed that two fan blades had broken through the cowling, and others had been damaged. A bird ingested into the engine was identified as a hooded crow. Feb. 18 Oakland, California McDonnell Douglas MD-10 climb engine During climb, a bird of an unidentified species was ingested into the no. 2 engine. An inspection showed that two blades had separated from the inlet fan and one blade had cut through the acoustic panel. Feb. 20 Miami Cessna Citation Ultra climb none The airplane struck a turkey vulture during climb. The crew believed that the impact was not hard and saw no indications of major damage. After landing, a hole with a 1.0-ft (0.3-m) diameter was found in the airplane’s tail. Feb. 27 Orlando, Florida Boeing 737-300 takeoff engine A gull struck an engine during takeoff. The strike had no apparent effect on engine operation, but a post-landing inspection found that several fan blades were dented. March 4 San Jose, California Boeing 757-200 climb engine As the crew rotated the airplane for takeoff, a flock of gulls and small birds landed on the runway. At least one bird was ingested into the left engine. The crew returned to the airport and taxied to the gate. An inspection found that several fan blades were bent. March 30 Miami Swearingen SA 227 landing roll propeller, fuselage During landing, a white-tailed deer — the last deer in a group of eight — was struck by a propeller blade, which separated and punctured the fuselage. April 1 Oakland, California Boeing 757-200 climb engine During climb, a common loon was ingested into an engine. The crew declared an emergency and landed at a nearby airport. An inspection found that fan blades and the nose cowling had been damaged. April 9 Chicago Boeing 737-300 climb radome, horizontal stabilizer, engine During climb, the airplane struck several birds of an unknown species, and one bird was ingested into the no. 2 engine. April 17 Brentford, South Dakota Bell 407 en route windshield As the helicopter was being flown to the site of a vehicular accident, three blue-winged teal ducks struck the windshield, which shattered. Blood from the ducks temporarily blinded the pilot, who was directed by his crew to a safe landing site. April 20 between Denver and San Francisco Boeing 777 en route engine A bird strike involving an unknown species occurred while the airplane was en route. A post-flight inspection found blade damage. April 24 New York City Boeing 747 takeoff engine As the airplane was rotated for takeoff, it struck several gulls. The no. 2 engine was shut down because of vibration, and the crew dumped 18,700 lb (8,482 kg) of fuel before landing. Several fan blades were damaged. May 9 Brownwood, Texas Rockwell NA265 takeoff engine The captain rejected the takeoff after hearing a loud bang and losing directional control of the airplane. Bird residue from an unknown species was found in the left engine. May 31 Kauai, Hawaii Boeing 757 takeoff engine During takeoff, the pilots saw a barn owl on the right side of the airplane and felt vibration in the right engine. They conducted a precautionary landing at a nearby airport. An inspection found damage to the engine. June 10 Kansas City, Missouri McDonnell Douglas DC-9 climb engine During the takeoff roll, the first officer saw a small bird, later identified as an American kestrel, fly in front of the airplane and disappear to the left. As the airplane was rotated, it vibrated and rolled left, and loud banging noises were heard. The crew conducted an emergency landing. An inspection found damage to several fan blades and the fan case. June 24 Subic Bay, Philippines Airbus A310 takeoff engine, cowling, wing A loud bang was heard during the takeoff roll, followed by vibration and a “pull” to the right. An inspection found damage to fan blades, the nose cowling and a fan cowling. The bird was identified as a Philippine duck.
Continued on next page
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Appendix Selected U.S. Wildlife Strikes, 2005
Date Location Aircraft Type Phase of Flight Components Damaged Aug. 4 Refugio, Texas Cessna 421 landing nose landing gear, propellers The airplane struck a deer while landing. Aug. 17 Merritt Island, Florida Cessna 421 descent wing, tip tank, electronics During descent, a collision with a black vulture “ripped the wing,” tore a hole in a fuel tank and damaged an annunciator light that would have confirmed whether the landing gear had been extended. The pilot conducted an emergency landing. Aug. 23 Phoenix MD Helicopters MD 520 en route windscreen, rotor blades During cruise at 400 ft above ground level, a bird — an American coot — hit the windscreen, shattering the left side. In addition, the rotor blades were scratched. Sept. 1 Lorain County, Ohio Falcon 20 climb engines, tail, wings, fuselage, landing gear After rotation, the airplane hit a flock of birds, later identified as mourning doves, and the no. 1 engine flamed out. After the crew retracted the landing gear, the airplane struck another flock, and no. 2 engine speed decreased. The crew could not maintain airspeed or altitude, and the airplane crashed into a ditch and an airport perimeter fence. Sept. 3 Cleveland Boeing 757 climb engines Just after rotation, the crew saw a large flock of European starlings and tried to avoid hitting the birds. They heard several birds strike the airplane. Engine instrument indications were normal, and the flight was continued to its destination. An inspection found damage to both engines. Sept. 13 Fort Worth, Texas McDonnell Douglas DC-10 landing engine During landing, between 15 and 20 rock pigeons were ingested into the no. 3 engine. Sept. 30 unknown McDonnell Douglas DC-10 unknown engine During maintenance, technicians found indications that a wood duck had struck the no. 1 engine. Oct. 16 Ogdensburg, New York Raytheon Beech 1900 takeoff engines, propellers, landing gear, nose, fuselage During the takeoff run, the airplane struck a coyote, causing the nose landing gear to collapse and propeller blades to cut through the airplane’s skin. Oct. 17 Vacaville, California Raytheon Beech 400 landing engine, landing gear, fuselage, pitot tube During the landing rollout, the airplane struck about 20 wild turkeys, including one that was ingested into an engine. Nov. 1 Sioux Falls, South Dakota Airbus A300 climb engine While the airplane was climbing through 6,000 ft, a large bird, later identified as a mallard, struck the no. 2 engine. The crew felt engine vibrations and heard related noise. They returned to the departure airport, where an inspection found damage to several fan blades and other parts of the engine. Nov. 30 Denver Boeing 747 approach engines, wing During approach, Canada geese struck the no. 1 and no. 2 engines. The engines appeared to continue to function normally, although a subsequent inspection found core ingestion and damage to fan blades in both engines. Holes were found in both flaps, with “a leg with webbed foot” protruding from one hole. Dec. 13 Harrisburg, Pennsylvania Embraer 145 approach engine During approach, the crew saw “a streak” outside the left window and felt a jolt. They detected an odor, turned off the air-conditioning pack and reduced power to idle. When they tried to increase power, violent compressor stalls occurred. Investigators said the airplane struck a Canada goose. Dec. 28 Chicago Boeing 737-300 climb engine During climb, a large bird — later identified as a snowy owl — was ingested into the no. 2 engine, and the crew performed a precautionary landing. An inspection found that the engine was destroyed. Dec. 28 Sacramento, California Boeing 737-500 climb engine The crew saw a large white bird of an undetermined species fly by the left side of the airplane and heard a loud pop before the engine began vibrating. The crew returned to the airport for a precautionary landing. All fan blades were replaced. Dec. 30 Washington, Louisiana Bell 206 en route destroyed During cruise at 50 ft above ground level, a large vulture crashed through the windscreen, and the pilot was temporarily unable to see because of wind and the bird’s blood in his eyes. The pilot tried to land in a bean field, but the left skid hit the ground and the helicopter tipped onto its side.
Source: Cleary, Edward C.; Dolbeer, Richard A.; Wright, Sandra E. Wildlife Strikes to Civil Aircraft in the United States, 1990–2005. Federal Aviation Administration National Wildlife Strike Database, Serial Report No. 12. Washington, D.C. June 2006.
www.flightsafety.org | AeroSafetyWorld | January 2007 | 41 threatanalysis Conclusions from the analyses of six approach and landing incidents that might have resulted in controlled flight into terrain but for timely warnings by TAWS.
BY DAN GURNEY
last line of Learning DefenseFrom Experience
ost flight crews on most warnings and prompt, correct action including: false visual cues during days manage the threats and by the flight crew serve as the last line a “black hole approach”; instru- avoid error-prone behav- of defense against controlled flight ment approach charts that lack ior that can occur in flight into terrain.1 altitude/range tables, are clut- operations,M as presented in this series tered and difficult to decipher, of “TAWS saves” analyses. However, in Threats or depict ambiguous procedures; some situations, threats and opportu- The threats that were identified in the nonprecision approach proce- nities for error can overcome human incident analyses can be placed in two dures; and approach procedures defenses, and a technological solution groups: incorporating distance measuring is required. If the threats involve ter- • Threats arising from pre- equipment (DME) offset from rain or obstacles, then terrain aware- existing conditions that can be the runway threshold or primary ness and warning system (TAWS) encountered in most operations, navaid.2
42 | flight safety foundation | AeroSafetyWorld | January 2007 threatanalysis © iStockphoto International • Situational threats arising from particular operating procedures (SOPs); and failing to flight conditions and situations, including: understand a procedure or to have a shared nighttime and/or instrument meteorologi- mental model of the procedure. These are cal conditions; a late change of plan; and errors that originate in the cognitive process failure to react, or react correctly, to alerts — that is, what we think about, how and on and warnings. what we focus our attention, and why we believe that something is important. In isolation, these threats may pose no undue risk; but when they combine, the risk of cata- • Selection of a wrong course of action, strophic error increases significantly. an error that often involved simple slips, All the pre-existing conditions can be identi- mistakes or memory lapses. Typically the fied by management audit and crew vigilance. result of inadequate training or poor dis- The risk-assessment process should identify cipline, this type of error originates from conditions that might act as risk multipli- weaknesses in cognitive control — that is, 3 ers. For example, runways that are prone to the way we control our thinking through black hole conditions should be considered as self-discipline, double-checking, manag- significant risks at night. Similarly, nonprecision ing time, avoiding preconceptions and not approaches and instrument approach proce- rushing to conclusions.
Photo: BAE Systems dures depicted on cluttered or ambiguous charts should be considered as particularly All the errors could have been — and should high risks. have been — detected before the TAWS warn- Whenever threat conditions ings occurred through self-monitoring and are identified, they should be cross-crew monitoring not only the aircraft’s reported and either elimi- flight path but also individual and crew behav- nated, mitigated or avoided. ior. Such monitoring requires application of Flight crews must recognize crew resource management (CRM) skills involv- situational threats. This ing communication for developing a shared requires focused attention, mental model and cross-checking facts and instrument-scan patterns common understandings. that help maintain good An error is a source for learning and an Learning flight path awareness and opportunity to gain experience. When errors From Experience sound decision making to are detected in normal operations, they should avoid or mitigate the risks be reported so that the circumstances can be presented by the threats. identified and assessed, and safety actions taken Defense if warranted. Confidential reporting systems Errors increasingly are being used to bring errors This altimeter was in The errors identified in the incident analyses to light. However, crews also should openly a BAe 146 that struck appear to have originated from circumstantial debrief errors to identify the contributors and a mountain 120 ft conditions or from unidentified or mismanaged the mechanisms of detection and recovery. The below the summit on threats, with the following results: crew should pay attention to the good points as approach to Melilla, well as the not-so-good, what was interesting Spanish Morocco, on • Inadequate situational awareness when the and previously not known, and why. Sept. 25, 1998. The flight crew believed that they understood Moreover, it is essential for each pilot to flight crew did not the situation but did not. This led to errors conduct a self-debriefing to clarify his or her respond immediately that included: succumbing to visual illusions understanding of any error, the situational to a GPWS warning, or misidentifying visual cues; misinterpret- threats under the circumstances and/or the and all 38 people ing procedures depicted by instrument beliefs and behavior that may have led to the aboard were killed. approach charts or incorporated in standard error.
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Threat and Error Management relative to the runway in terms of alti- surprise the pilots and enable them to Monitoring is an essential element tude, distance and time. hone their pull-up reaction. During the in threat and error management. Yet, Humans tend to build internal debriefing, the crew might argue that the in each of the incidents, monitoring models, or patterns, of the way things warning was out of context, they “knew failed for one reason or another. In should be, both in the sense of an where they were” and there was no real some incidents, the crews either lacked “ideal” current situation and for future terrain threat. The counter argument is information, such as altitude/range events. Crews need to guard against that this is precisely the mindset that the tables, or failed to use information that short-term tactical thinking in which incident crews might have had. They like- was available, such as electronic flight response to what is expected often ly were convinced that they knew where information system (EFIS) maps. The dominates the sound assessment and they were and that the TAWS warning solution to these problems requires judgment of strategic thought. Pilots was wrong, not them. Fortunately, except organizational action to provide vital must control their thinking, consider for hesitation by one crew, the incident information and procedures, and per- early what a situation could become, crews reacted correctly, pulled up and sonal commitment to use them. consider options and alternatives, and, avoided impending collisions with terrain The monitoring process must be if in doubt, ask questions. or obstructions. accurately defined in SOPs, trained and The most important element in Training must overcome the doubt- practiced to enable skillful application. decision making is the objective. When ing mindset and the compulsion to un- To be effective, monitoring must be the objective is a safe landing on the derstand the situation before responding truly independent; there is little value runway, the situation-assessment to a TAWS warning. A pull-up must be in both pilots using the same source process must include attention to the conducted without hesitation. as a cross-check. Independent cross- location of the runway and a continual Moreover, the use of conditional checking also is important for flight updating of the shared mental model phrases in TAWS procedures should path control; there is no point in the pi- of the aircraft’s position relative to the be avoided. There is no need for the lot monitoring calling out altitudes and runway. Crews should use all their “if visual” and “if certain of position” ranges for the pilot flying to follow dur- tools: display the runway position on phrasing that often was included in ing the approach if the pilot monitoring the EFIS; pay attention to vertical dis- previous ground-proximity warning has misidentified the information or plays; and select the terrain map for all system (GPWS) procedures to prevent the information is incorrect. approaches, as well as for departures. reaction to inappropriate warnings. “Monitoring independence” starts TAWS is significantly more reliable with the approach briefing. Each Taking Action than GPWS and is not prone to gener- pilot should monitor the briefing by A TAWS warning can create surprise ating inappropriate warnings (Figure cross-checking the details on his chart and stress due to the unexpected 1). When a TAWS warning is gener- and ensuring that he understands the nature of the event. Generally, pilots ated, there is no time for thinking plan for the approach. An approach experience the need to understand the and assessment; the crew must react briefing is a “flight plan for the mind” situation before taking action and, thus, immediately. After climbing to the and provides a master pattern for begin a new assessment process. This minimum safe altitude, the crew must subsequent comparisons. The crew delays action. Stress also increases dif- determine the reason for the warning must have a common understanding, ficulties in perceiving information and before descending again. Remember a shared mental model that is correct thinking, which also delays action. that most TAWS warnings are the for the situation. Most pilots think in A TAWS warning requires immedi- result of human error. pictures but communicate with words; ate action without thought, an automatic both processes can be taught and behavior. To gain this skill, crews need Building Defenses improved. to practice their pull-up technique in re- All six incidents involved aircraft with sponse to a TAWS warning in surprising, modern technology, “glass” flight Situational Awareness stressful training situations. For example, decks and equipment that should have In each incident, the flight crew lost simulator instructors can place a “glass enhanced situational awareness. Yet, all awareness of the aircraft’s position mountain” in the aircraft’s flight path to the incidents involved close encounters
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with terrain or obstacles. The aviation Frequency of Inappropriate TAWS Warnings industry was “lucky” that accidents were avoided and a good safety record 3.10 was maintained — but just how lucky? In the majority of the incidents, the flight crews apparently were unaware of the aircraft’s position relative to the runway, either in space or time, or both. In two incidents, the aircraft were at very low altitudes, with crews preparing 1.17 to land, yet were still 1.5 nm (2.8 km) from the runways. The single incident Legs per 1,000 Flight Inappropriate Warnings Warnings Inappropriate 0.69 in which an obstacle warning was generated involved the only aircraft in 0.03 the operator’s fleet that had the TAWS obstacle mode activated. 1996 1998 2000 2003 Year Luck in these incidents could be defined as having defenses that just TAWS = Terrain awareness and warning system matched the hazard or risk. However, in Source: Dan Gurney, from Honeywell an industry that seeks defense in depth Figure 1 and considering that all of the incidents involved the last defense — the crew [This series, which ran inAviation Safety to describe ground-proximity warning pulling up following a TAWS warning World from July through December 2006, system (GPWS) equipment that provides —“luck” is unacceptable. We cannot is adapted from the author’s presentation, predictive terrain-hazard warnings; “Celebrating TAWS Saves, But Lessons Still to enhanced GPWS (EGPWS) and ground col- expect that the last line of defense will Be Learned,” at the 2006 European Aviation lision avoidance system (GCAS) are other always hold; in one incident, the crew Safety Seminar, the 2006 Corporate Aviation terms used to describe TAWS equipment. failed to react immediately and cor- Safety Seminar and the 2006 International Air 2. A black hole approach typically occurs rectly to a warning. Safety Seminar. Don Bateman, Yasua Ishihara during a visual approach conducted on a In-depth defenses should be based and the Honeywell EGPWS safety team moonless or overcast night, over water or contributed to the research and preparation of on active threat and error manage- over dark, featureless terrain where the the paper.] ment at all managerial and operational only visual stimuli are lights on and/or levels. This requires constant vigilance Dan Gurney served in the British Royal Air Force near the airport. The absence of visual to identify threats and errors, risk as- as a fighter pilot, instructor and experimental test references in the pilot’s near vision affects pilot. He is a co-author of several research papers sessment and timely decisions to select depth perception and causes the illusion on all-weather landings. Gurney joined BAE that the airport is closer than it actually corrective courses of action. These pro- Systems in 1980 and was involved in the develop- is and, thus, that the aircraft is too high. cesses depend on thinking skills, which ment and production of the HS125 and BAe 146, The pilot may respond to this illusion by are the foundations of airmanship, lead- and was the project test pilot for the Avro RJ. In conducting an approach below the correct ership and professional management. 1998, he was appointed head of flight safety for flight path — that is, a low approach. In As of Nov. 1, 2006, more than BAE Systems. Gurney is a member of the FSF the extreme, a black hole approach can re- CFIT/ALAR Action Group, the FSF European 35,000 aircraft had been fitted with sult in ground contact short of the runway. Advisory Committee and the FSF steering team 3. A checklist designed for assessing such TAWS. Aircraft equipped with the developing the “Operators Guide to Human risks, the Approach-and-landing Risk system had flown 300 million flight Factors in Aviation.” sectors without a controlled-flight-into- Awareness Tool, is part of the FSF Approach- and-landing Accident Reduction (ALAR) terrain accident. This is a major success Notes Tool Kit. Information about this and for the industry, and every effort must 1. Terrain awareness and warning sys- other resources for preventing ALAR and be made to continue and protect this tem (TAWS) is the term used by the controlled flight into terrain is available at achievement. ● International Civil Aviation Organization
How Airbus hen 873 people jumped out of an emptied a Airbus A380-800 onto slides in 78 seconds last March, two pursers and packed A380 12 16 flight attendants helped validate seconds faster Wthe airplane’s new evacuation technology, pro- than necessary. cedures and training. Although this full-scale emergency evacuation demonstration in Ham- By Wayne burg, Germany, was certified within days by the Rosenkrans European Aviation Safety Agency (EASA) and the U.S. Federal Aviation Administration (FAA), cabin safety researchers likely will spend years analyzing the data. At Flight Safety Foundation’s International Air Safety Seminar (IASS) in Paris in October 2006, an Airbus official added details of how a Lufthansa cabin crew guided about 11 passen- gers per second off the airplane, which has 16 doors, through the eight doors on the right side. Francis Guimera, A380 program safety director, said, “Without a doubt, cabin crew are the most important element in case of an emergency [or] an evacuation demonstration. … Never before have so many people been safely evacuated
from an aircraft. Because of the double-deck Airbus configuration, a single-shot [demonstration] attendants. Another demonstration would be — both decks at the same time — was requested required to raise that seating number. by EASA and FAA to identify any possible slide The demonstration’s purpose was to deter- interference.” mine if this airplane type can be evacuated in a The A380-800 — which received joint timely manner, that is, within 90 seconds, as re- EASA/FAA type certification on Dec. 12, quired by Part 25.803 and Appendix J to Part 25 2006 — is an all-new four-engine jet transport of the EASA Joint Aviation Requirements and airplane that typically is expected to have 555 the U.S. Federal Aviation Regulations (FARs). passenger seats in three classes with two aisles The demonstration also is intended to confirm per deck, but can be configured to carry more the adequacy of emergency procedures and the than 800 passengers in high-density seating. A effectiveness of crew training. passenger seating configuration of 110 seats is Engineering innovation was critical for allowed by EASA/FAA regulations for each pair evacuation to be feasible. “For an aircraft of such of Type A exits.1 The A380 is equipped only size, you find it necessary first to imagine the with Type A exit doors, with the eight pairs appropriate evacuation means,” Guimera said. designated forward to aft on the main deck as Overall, the evacuation system comprises eight M1, M2, M3 (overwing), M4 and M5, and on door-mounted slides and two fuselage-mounted the upper deck as U1, U2 and U3. This airplane overwing slides for the main deck, and six fuse- ver in a Flash’ ver preferably will be evacuated as two separate lage-mounted slides for the upper deck. Beside cabins, and forward and aft staircases will offer each door is a door-and-slide indication panel a potential secondary escape route. The demon- that helps any crewmember to correctly handle O stration established a maximum passenger-seat- the powered-door operation and to confirm ‘ ing capacity of 853 with the minimum 18 flight that slides are fully inflated. Briefing cards and Airbus
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After the demonstration, hangar lighting reveals evacuation system equipment — including predeployed upper deck slides — that had been visually concealed beforehand from volunteer passengers and crewmembers.
placards inform passengers how to operate the system. Because the upper deck door sills are 7.87 m (25.80 ft) above the ground, the correspond- ing slide/ramps provide integral blinder walls and a curved ramp to mitigate passenger fear of heights. Each of these slides is 14.7 m (48.25 ft) long. They are designed so that the maximum velocity of a person arriving at the ground is no faster than that for a person descending from a current single-deck aircraft. Manufacturer Goodrich’s Tribrid gas- generator module — along with new slide fabrics, adhesion methods and light-emitting diode (LED) exterior lighting — exemplify the new technology developed for the system. A reservoir within the module for each slide contains carbon dioxide in liquid form as a coolant, and a gaseous mixture of carbon dioxide and nitrogen. “The [electrically fired squib and solid] propellant provide the energy to expand the primary gases that transform the liquid coolant into a mixed gas discharged into [slides],” Guimera said. www.flightsafety.org | AeroSafetyWorld | January 2007 | 47 CABINSAFETY
Another evacuation innovation is no occupants are still remaining in was all over in a flash. All we had to do the “intelligent” slide for each M1 door, the aircraft.’ In stair management, we was dictate the pace for them to jump.” i.e., a ramp extension operated auto- were very interested to see if there was Airbus photos of before-and-after matically by aircraft-attitude sensors. any possibility of migration between demonstration activities do not show This means that if an A380 is sitting on the upper deck and the main deck. We the low level of illumination that evacu- the ground in a tail-low attitude with succeeded [during the demonstration] ees actually experienced. At the evacu- the main gear extended — causing the … there was no movement of people ation signal, normal cabin lighting door sill to exceed the normal 5.1 m between the upper deck and the main changed to floor-proximity emergency (16.7 ft) height — an electrically actu- deck.” escape path lighting and outside illumi- ated cutter releases an additional length In Hamburg on the morning of the nated slides — yellow LEDs integrated of ramp that will rest on the ground. demonstration — Sunday, March 26 into railings — outlined the escape In preparation for the demonstra- — 18 cabin crewmembers from the 42 route. Forty infrared-sensitive video tion, a pool of 42 Lufthansa cabin crew- on standby were called to the Airbus cameras were used, and two videos members trained in Toulouse, France, hangar. They received a briefing about were shown and discussed at the IASS. completing a three-day subset of the the on-site safety plan, in which 80 slide Table 1 shows that the upper deck full A380-800 cabin crew curriculum. assistants would handle all evacuees as was evacuated in the same amount of They also spent a half-day visiting the they reached the ground. Otherwise, time as the main deck. The rate at every demonstration aircraft. “We addressed this briefing was highly restricted in its door — ranging from about 1.3 to 1.8 only topics that were relevant,” Guimera content per EASA/FAA regulations. Af- evacuees per second — exceeded the said. “[We told them,] ‘Make yourself terward, recalling his experience with theoretical average rate of 1.2 evacuees heard, help those in the vicinity of the the volunteer passengers, Lufthansa per second per door required to evacu- [assigned cabin] area and verify that flight attendant Stefan Kaiser said, “It ate the occupants within 90 seconds.
Airbus A380-800 Emergency Evacuation Demonstration1
Time Rate Door First Last Elapsed (Evacuees Evacuation Begins to Evacuee Evacuee From Start per Passenger Crew Total Door Designation Start Time2 Open3 on Slide on Ground (Seconds) Second) Evacuees Evacuees4 Evacuees Five Main Deck Doors Used – Right Side M1 16:27:37 16:27:42 16:27:50 16:28:49 72 1.5 105 3 108 M2 16:27:37 16:27:42 16:27:50 16:28:48 71 1.4 98 3 101 M3 (overwing) 16:27:37 16:27:41 16:27:48 16:28:55 78 1.4 106 3 109 M4 16:27:37 16:27:42 16:27:49 16:28:54 77 1.8 137 2 139 M5 16:27:37 16:27:42 16:27:50 16:28:52 75 1.3 92 2 94 Main deck subtotal 538 13 551 Three Upper Deck Doors Used – Right Side U1 16:27:37 16:27:43 16:27:49 16:28:51 74 1.4 101 1 102 U2 16:27:37 16:27:43 16:27:47 16:28:52 75 1.3 94 4 98 U3 16:27:37 16:27:43 16:27:49 16:28:55 78 1.6 120 2 122 Upper deck subtotal 315 7 322 Total 853 20 873
Notes 1. These unofficial data are based on two exterior infrared video recordings presented by Airbus at Flight Safety Foundation’s International Air Safety Seminar in Paris in October 2006. Accuracy is subject to screen resolution of the videos, a limited view of the M3 overwing slide and other factors. 2. These are local times in Hamburg, Germany, on March 26, 2006. Sudden darkness in the cabin, except for emergency lighting, signaled the evacuation start time. 3. Each time represents the first visible motion of the door on the videos. Only a very low level of exterior illumination was allowed during the demonstration. 4. Crewmembers comprised two pursers, 16 flight attendants and two pilots. They were unaware of which doors to use until the evacuation signal.
Source: Flight Safety Foundation
Table 1
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The fastest time, at the M2 door, ap- have been a concern. One of FAA’s satisfactory slide operation at minus peared to be about seven seconds better most cited figures is that 269 (4.6 per- 55 degrees C (minus 67 degrees F). than slowest time at the M3 overwing cent) of 5,797 evacuees were injured “This new requirement is setting a and U3 doors. in 19 demonstrations conducted from new standard,” Guimera said. “[A380 Evacuees at the upper deck doors 1972 to 1991 — a rate that FAA called certification] was also the first time appeared to show no hesitation. On the “unacceptable” in 2004 while advocat- that the authorities were not satisfied main deck, however, one passenger at ing safer alternatives. Thirty-three to demonstrate the slide/raft capability M5 stepped through this door toward passengers and no crewmembers were only by a simple analysis.” So Airbus the slide, grabbed the right door frame, injured during the A380 demonstra- conducted full-scale tests in the Pacific turned back and climbed toward the tion; Airbus categorized the injuries as Ocean in which one A380 slide/raft door before turning again and jumping minor and cited one fractured femur, was inflated and boarded adjacent to a onto the slide. For about four seconds, friction abrasions, sprained knees and floating platform, then detached into other evacuees jumped around this pas- bruises. open water for a sea trial. senger without delay. In addition to standard EASA and A380 evacuation tests continued Guimera noted that one video FAA certification requirements, the after the March 26 demonstration. shows a crewmember at the U1 door agencies created various special condi- Three days later, for example, Airbus taking about 10 seconds to jump after tions for “novel or unusual design fea- conducted a full-scale migration test. the last person from his area had tures,” a standard term in certification “We installed 150 passengers on the jumped. “An interesting thing to see is regulations. Special conditions relevant main deck forward part and 70 on the delay because [this flight] attendant to evacuation addressed the A380’s the upper deck,” Guimera said. “We was checking that all of his area was full double-deck passenger cabins and opened only … the forward left door free of passengers,” Guimera said. very large seating capacity; forward [on the main deck] … to evaluate the Crowding on the M3 overwing slide and aft staircases connecting the main crowding of people coming from the for about 17 seconds caused its inflated and upper decks; method of outside upper deck to the main deck. Finally, barrier to fold down and outward so viewing from closed doors; slide/rafts we succeeded in evacuating 220 people that about a half dozen passengers ap- for all upper deck doors for ditching; within two minutes … with no [ad- peared to lose their balance and/or fall performance of escape systems installed verse] interaction.” onto the slide before they descended. in nonpressurized compartments after Guimera also addressed questions “It was a concern, so we had to rein- cold soak from a long flight and with about computer simulation of evacu- force the barrier on the M3 overwing 25-kt wind from the critical angle; the ations. “Unfortunately, evacuees may slide,” Guimera said. unique slide-inflation subsystem; and create bottlenecks and confusion at the Videos shot inside the cabin show escape and/or removal of crewmembers top of slides,” he said. “[Software does pursers and flight attendants shouting from crew rest compartments. not yet] simulate such anticipation [or commands and assertively directing The demonstration was one of how] migration between decks is to be the evacuees to the best alternate exit many forms of extensive evacuation- avoided by appropriate gestures and whenever crowding slowed the flow at related testing. Goodrich alone correctly positioning [cabin] crew dur- the exit the crewmember was moni- expected to conduct up to 2,500 tests ing the preflight briefing. We cannot toring, he added. Guimera cited a few of the A380 evacuation system, as one support the idea to have a demonstra- examples of how Airbus interpreted example. “This also was the first time tion done only by simulation — the real the videos, measuring a “normal rate” that the authorities have requested that test is certainly more revealing.” ● of 1.85 evacuees per second. “We have the manufacturer simultaneously inflate five [aft] slides so it was more crowded,” all the slides on one aircraft [using only Note he said. “[For the M4 door,] we have an battery power],” Guimera said, refer- 1. A Type A exit is a floor-level exit with a excellent report — 137 passengers were ring to a test completed successfully in rectangular opening of not less than 106.7 evacuated within 75 seconds.” June 2006. cm (42 in) wide by 182.9 cm (72 in) high Injuries during evacuation demon- Another special condition noted with corner radii no greater than one-sixth strations for airplane certification long by Guimera was FAA’s requirement for of the width of the exit. www.flightsafety.org | AeroSafetyWorld | January 2007 | 49 DataLink
Swiss Watch Accidents and incidents involving large Swiss-registered aircraft increased in 2005, but there were no fatalities for the fourth year in a row.
BY RICK DARBY
or the fourth consecutive year, large among the lowest in the 1996–2005 period, and Swiss-registered aircraft — with maxi- the average of 2.68 from 1999 through 2005 has mum takeoff weights greater than 5,700 exceeded the average of 0.98 for 1996 through kg/12,500 lb — were involved in no 1998. Ffatal accidents in 2005, the Swiss Aircraft The number of accidents and serious inci- Accident Investigation Bureau said.1 The rate dents involving Swiss-registered airplanes in the of accidents and serious incidents2 in the medium category of 2,250 kg–5,700 kg (4,960 category increased compared with 2004, and lb–12,500 lb) increased from two in 2004 to was the third highest in the 1996–2005 period three in 2005 (Table 2). The number of helicop- (Table 1). ter accidents and serious incidents in 2005, four, The accident and serious incident rate for was half that of 2004. 2005 was 2.90 per 100 aircraft, compared with Among accidents and serious incidents 1.61 for 2004 and an average of 2.09 for the involving all types of Swiss-registered aircraft previous nine years.3 The spike in fatality rates — airplanes, helicopters, gliders, balloons in 1998 is attributable to the accident involving and airships — airplanes in the large category Swissair Flight 111 on Sept. 2, 1998, near Peggy’s nearly doubled their proportion, from 13 per- Cove, Nova Scotia, Canada. That event killed cent in 2004 to 24 percent in 2005. Airplanes all 229 occupants after a fire began above the in the medium category represented 6 percent McDonnell Douglas MD-11’s cockpit ceiling of the total in 2004 and 10 percent in 2005. and spread rapidly, resulting in loss of control Helicopters, involved in 25 percent of the total while the flight crewmembers were attempting number of accidents and serious incidents in an emergency landing. 2004, were involved in 14 percent of 2005’s Nevertheless, as Table 1 shows, the overall total. rate of accidents and serious incidents in the The distribution of accidents and serious year of the Swissair Flight 111 accident was incidents by flight phase is shown in Table 3
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Rate Up in 2005 Accidents, Serious Incidents, Fatalities and Rates, Swiss-Registered Aircraft,* 1996–2005
Accidents and Accidents and Serious Incidents Year Registered Aircraft Serious Incidents per 100 Aircraft Fatalities 1996 232 2 0.86 0 1997 229 2 0.87 0 1998 246 3 1.22 229** 1999 256 7 2.73 0 2000 285 7 2.46 31 2001 306 11 3.59 26 2002 304 6 1.97 0 2003 257 9 3.50 0 2004 248 4 1.61 0 2005 241 7 2.90 0
* Aircraft with maximum takeoff weight greater than 5,700 kg/12,500 lb ** Fatalities in 1998 resulted from the accident involving Swissair Flight 111.
Source: Swiss Aircraft Accident Investigation Bureau/Flight Safety Foundation
Table 1
Helicopter Accidents and Serious Incidents Down 50 Percent Accidents and Serious Incidents Involving Swiss-Registered Aircraft in Switzerland and Abroad, and Non-Swiss-Registered Aircraft in Switzerland, 2004–2005
Accidents and Accidents and Serious Incidents Accidents and Serious Incidents Serious Incidents Involving Involving Swiss-Registered Aircraft Involving Swiss-Registered Aircraft Non-Swiss-Registered Aircraft In Switzerland Abroad In Switzerland Total Persons Injured Total Persons Injured Total Persons Injured 2005 2004 2005 2004 2005 2004 2005 2004 2005 2004 2005 2004 Airplanes with MTOW 2,250 kg (4,960 lb)–5,700 kg/12,500 lb 2 0 1 0 1 2 0 1 0 0 0 0 Airplanes with MTOW > 5,700 kg/12,500 lb 3 1 0 0 4 3 0 0 0 1 0 0 Helicopters 4 8 2 5 0 0 0 0 0 0 0 0 Total 9 9 3 5 5 5 0 1 0 1 0 0
MTOW = Maximum takeoff weight
Source: Swiss Aircraft Accident Investigation Bureau
Table 2
(page 52). For airplanes in the large and middle The report indicated the numbers of air- categories, those during landing increased in prox incidents4 investigated by the bureau an- 2005 from the previous year, but for helicopters nually between 1998 and 2005 (Figure 1, page they decreased. In four of five phases, from 52). The nine airprox incidents for 2005 were “starting and climb” through “landing,” helicop- the lowest number since the two in 1998, a 36 ters had fewer accidents and serious incidents in percent reduction from the 14 in 2004 and a 53 2005 than in 2004. percent reduction from the 19 in 2003.
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Fewer Helicopter Accidents, Incidents in Most Flight Phases Flight Phase, Accidents and Serious Incidents Involving Swiss-Registered Aircraft in Switzerland and Abroad, and Non-Swiss- Registered Aircraft in Switzerland, 2004–2005
Ground and Rolling, Descent and Hovering Flight Starting and Climb Cruise Approach Landing 2005 2004 2005 2004 2005 2004 2005 2004 2005 2004 Airplanes with MTOW 2,250 kg (4,960 lb)–5,700 kg/12,500 lb 0 0 0 1 0 0 0 0 3 1 Airplanes with MTOW > 5,700 kg/12,500 lb 2 1 2 1 1 2 1 1 1 0 Helicopters 1 0 1 2 1 2 1 3 0 1 Total 3 1 3 4 2 4 2 4 4 2
MTOW = Maximum takeoff weight
Source: Swiss Aircraft Accident Investigation Bureau
Table 3
Notes Airprox Incidents Down 1. Swiss Aircraft Accident Investigation Bureau. Investigated Airprox Incidents, Switzerland, 1998–2005 Statistics Concerning Accidents and Serious Incidents 22 Involving Swiss-Registered Aircraft in Switzerland and Abroad and Foreign-Registered Aircraft in 19 Switzerland. Available via the Internet at
2. A serious incident is defined as an “occurrence 14 13 13 associated with the operation of an aircraft under circumstances which nearly led to an accident.” 10 9 3. The numbers of accidents and serious incidents, and of registered aircraft, were published in the re- port. Flight Safety Foundation calculated the rates. The accident investigation bureau stopped publish- 2 ing flight hours after 1999; therefore, the only rates that could be derived for the whole period were the Number of Investigated Airprox Incidents ratios of accidents and serious incidents to regis- 1998 1999 2000 2001 2002 2003 2004 2005 tered aircraft. Year 4. An airprox incident is defined as “a situation in Airprox incident is defined as “a situation in which, in the opinion of a pilot or of the air traffic which, in the opinion of a pilot or of the air traffic control personnel, the distance between aircraft moving under their own power as well as their relative positions are such that the safety of the aircraft involved could be endangered control personnel, the distance between aircraft in flight or on the ground in the aircraft-moving area.” moving under their own power as well as their rela-
Source: Swiss Aircraft Accident Investigation Bureau tive positions are such that the safety of the aircraft involved could be endangered in flight or on the Figure 1 ground in the aircraft-moving area.”
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Pilot Project A sociological study of airline pilots finds that most report satisfaction in their jobs, but some are alienated from management and have safety-related concerns.
BOOKS flight and to seek clarification from the captain if, on the basis of a piece of information known A Sociology of Commercial Flight Crew only to themselves, they believe a decision to be Bennett, Simon A. Aldershot, England, and Burlington, Vermont, U.S.: ill-advised.” Ashgate, 2006. 224 pp. Tables, appendixes, bibliography, index. Pilots’ responses to the questionnaire and his study looks at airline pilots from an in interviews yielded primary data, mostly angle that Bennett says has been more or verbatim comments. Concerns included how Tless bypassed previously — how pilots are interaction with management at their airlines affected by the social environment they inhabit. potentially affects safety, although it cannot be A pilot, Bennett says, is “a social actor. That determined from the sample group how repre- is, someone with a history; a work life; a home sentative such concerns are among airline pilots. life; a social life; someone caught up in numer- One pilot said that commercial pressures ous social and economic networks.” Six in-depth created a “hidden culture of short cuts.” The interviews and questionnaire responses were pilot said, “Turnaround [between-flight] issues designed to give a coherent picture of pilots’ revolve around safety and blame. Nobody minds interactions with their profession. working fast to get the job done, but there can One reason for the study, the author says, is be perceived pressure to take short cuts. It is as that “the success of commercial aviation is due much about perceived pressure [as] of actual … to the imagination, ambition and dedication pressure. The airline will be very sure to leave of its employees. In my opinion, commercial a good audit trail of its procedures to show on aviation’s future prosperity depends in large paper that everything is being done correctly, part on developing more subtle understandings but it is not the projected culture that counts, of those who work in the industry. Only if the it is the hidden culture, the whispers between industry understands its key resource can it be pilots, discussions over coffee, chats during nurtured and used to best effect.” turnarounds.” The social setting in which pilots work Another pilot said, “We need more respect also has safety implications. “The introduction from the management group, nonpartisan of crew resource management … has served safety departments, and rules and regulations to flatten (but not eliminate) the flight deck’s that do not contain the words ‘where possible’; authority gradient,” Bennett says. “To improve ‘may’; [and] ‘taking into account all the fac- safety margins, much of the imperiousness of tors.’” Another cited “commercial pressure; a the rank of captain has been engineered away. management attitude that finance is everything; First officers (and flight attendants) are encour- performance-related pay awards when a human aged to contribute to the management of the resources desk jockey tells me how I am flying www.flightsafety.org | AEROSafetyWorld | January 2007 | 53 InfoScan
my airplane, and consequently what my pay strongly contrasts with what is typical today — a raise will be.” paradigm of tabulating error as if it were a thing, Nevertheless, to judge from the verbatim followed by interventions to reduce this count. quotes, most pilots still enjoy, and some even get A resilient organization treats safety as a core a thrill, from what they do. “Sense of achieve- value, not a commodity that can be counted. … ment,” “financial security” and “camaraderie” Rather than view past success as a reason to ramp are frequently reported phrases. One said, “As a down investments, such organizations continue pilot, you feel part of the plane. There’s nothing to invest in anticipating the changing potential to beat climbing up through the cloud first thing for failure because they appreciate that their in the morning on a gray day with dawn break- knowledge of the gaps is imperfect and that their ing and seeing all those wonderful colors. I love environment constantly changes.” what I do, and even if I won the lottery tomor- Resilience engineering begins, they say, with row, I’d go on flying.” a focus on methods and tools:
Resilience Engineering: Concepts and Precepts • To analyze, measure and monitor the re- Hollnagel, Erik; Woods, David; Leveson, Nancy (editors). Aldershot, silience of organizations in their operating England, and Burlington, Vermont, U.S.: Ashgate, 2006. 409 pp. environment; Tables, figures, bibliography, index, appendix. • To improve an organization’s resilience he concept of resilience in systems design vis-à-vis the environment; and has received considerable attention in recent Tyears (Aviation Safety World, December • To model and predict the short- and 2006, page 54). Resilience is among the latest long-term effects of change and line generation of risk management principles that management decisions on resilience and, go beyond reactivity. The trouble with a reactive therefore, on risk. method — looking at past accidents to find ways to keep the same sort of accident from happen- REPORTS ing again — is that it is ill suited to today’s un- Fire Safety of Advanced Composites for Aircraft derstanding of accident causation as the result Mouritz, A.P. Australian Transport Safety Bureau (ATSB). B2004/0046. of a complex interaction of human, mechanical April 2006. 36 pp. Figures, tables, references. Available via the Internet and institutional factors, rather than single- at
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average heat-release rates, total heat release, “In this report, we described the benefits of flame-spread rate, smoke and combustion gases. color use in ATC displays,” the researcher says. Tables present the composite materials, ranked “We also derived a rationale for how to achieve from best to worst in fire safety terms. Currently these benefits based on accumulated vision and used composites and others that may be used in cognitive research. We also identified several future designs are included. drawbacks of color use in ATC displays and pre- Glass-reinforced phenolic composites are sented the potential consequences of inappro- the most common of those used in cabins, and priate use of colors in the domain of perceptual the database shows their excellent fire reaction and cognitive information processing.” performance. Carbon-reinforced epoxy com- An example of misjudged color design, the posites, those with the most frequent structural report says, is using the same color for different applications, have poor fire resistance, according purposes, or in contradiction to a convention that to the data. controllers have assimilated through experience. “For example, red is usually the top choice Color and Visual Factors in ATC Displays to convey warning and alert messages,” the Xing, Jing. U.S. Federal Aviation Administration (FAA) Office of report says. “Controllers would naturally infer Aerospace Medicine. DOT/FAA/AM-06/15. Final report. June 2006. 22 pp. Figure, tables, references, appendixes. Available via the that a red code conveys urgent information, Internet at
investigators and analysts, and that “distribution includes basic operational information and is provided at no charge to persons actively em- best practices for approaching an aircraft and ployed in the fields of aviation accident investi- using doors and seat belts. Other modules are gation, analysis or litigation.” mission-specific. “Going Bush” describes safety require- Flight Safety Information (FSINFO), ments for transporting hunters. “The
Information Journal * Australian Transport Safety Bureau and reports. P.O. Box 967, Civic Square A bonus to receiv- ACT 2608 ing the electronic Australia newsletter is its Web Internet:
about an aviation event in Singapore may con- *** Civil Aviation Authority of New Zealand tain a link to a local source, such as The Straits Peter Singleton, editor and webmaster Times newspaper, where additional informa- Aviation House tion is available. 10 Hutt Road Petone P.O. Box 31, 441 Lower Hutt AUDIO-VIDEO New Zealand E-mail: [email protected] Safety Around Helicopters Civil Aviation Authority of New Zealand (CAA) and Video New **** Video New Zealand Zealand. DVD. 70 minutes. June 2006. Available on loan from 42 Cypress Drive CAA*** or by purchase from Video New Zealand.**** Maungaraki, Lower Hutt 5010 New Zealand he video is divided into modules. The first, E-mail: [email protected] “Introduction,” is appropriate for everyone Twho operates in or around helicopters. It — Rick Darby and Patricia Setze
56 | flight safety foundation | AEROSafetyWorld | January 2007 OnRecord Crew Continues Takeoff After Engine Surges at V1 After shutting down the engine and dumping fuel, the Boeing 777 crew returned to the airport for a single-engine landing.
BY MARK LACAGNINA
The following information provides an aware- crew then returned to the airport and conducted ness of problems in the hope that they can be a single-engine landing. None of the 300 occu- avoided in the future. The information is based pants was injured. on final reports on aircraft accidents and inci- Investigators found debris on the runway dents by official investigative authorities. from a composite core panel that had broken and separated from the Rolls-Royce Trent 800 JETS engine when it began to surge. The report said that a detailed examination of the engine found Compressor Liners Found Eroded that erosion of the high-pressure compressor Boeing 777-300. Minor damage. No injuries. (HPC) casing liners had reduced compressor he aircraft was departing from Melbourne efficiency. Rolls-Royce told investigators that (Australia) Airport at 0104 local time Aug. proper clearance between the HPC casing and T25, 2004, when the left engine surged at rotor blades is critical for engine-airflow control V1, which informally is called takeoff decision at takeoff thrust settings. speed. The flight crew continued the takeoff and The engine’s total service time was 15,614 then shut down the engine because of repeated hours, during which it had undergone 4,527 surges, or compressor stalls. The Australian cycles. Twenty-one days before the incident, Transport Safety Bureau (ATSB) report said that a borescope examination of the engine was the cockpit voice recorder recorded a loud bang performed in response to an engine-condition-
0.8 seconds before the automatic V1 callout and monitoring alert about a change in turbine gas 57 more bangs before the engine was shut down temperature. Minor damage that was within 70 seconds later. acceptable limits was found on a few of the HPC “Due to forecast turbulence, the crew blades, and the engine was returned to service. maintained an altitude of approximately 3,000 “The borescope inspection only permitted lim- ft above ground level [AGL] to dump fuel and ited examination of the HPC casing liner mate- reduce the aircraft’s weight for landing,” the rial in the immediate vicinity of the borescope report said. “Air traffic services vectored the inspection port,” the report said. aircraft over Port Phillip Bay for the fuel dump, Eroded HPC casing liners were found in two which took approximately one hour.” The flight other Trent 800 engines, which subsequently www.flightsafety.org | AEROSafetyWorld | January 2007 | 57 OnRecord
were removed from service. Among actions About three minutes after the crew turned taken by Rolls-Royce after the incident was a the seatbelt sign back on, the airplane encoun- change in condition-monitoring procedures to tered moderate turbulence. Two passengers and include a detailed review of engine-parameter a flight attendant fell while attempting to return data if troubleshooting prompted by an alert to their seats. The two passengers received finds no explanation for the alert. minor injuries; the flight attendant suffered a fractured pelvis. The other 147 occupants were Birds Strangle a Falcon not injured. Dassault Falcon 20D. Substantial damage. One minor injury, one uninjured. Control Lost on Wet Runway he airplane was 15 ft above the runway Cessna CJ1. Substantial damage. Seven uninjured. during takeoff from Lorain County (Ohio, isual meteorological conditions (VMC) TU.S.) Regional Airport for an on-demand prevailed for the business flight to Mur- cargo flight at 1950 local time Sept. 1, 2005, Vfreesboro, Tennessee, U.S., on May 16, when flocks of birds rose from both sides of 2006, but a weather front was approaching the runway. Several birds were ingested by the the airport. The automatic terminal informa- engines, said the U.S. National Transportation tion service said that the winds were from 240 Safety Board (NTSB) report. The right engine degrees at 3 kt and the runway was wet. The surged and lost power. About 10 seconds later, approach controller cleared the pilot to conduct the copilot observed that the left-engine fan a visual approach to Runway 18.
speed, N1, was decreasing below 50 percent. The pilot said that as he landed the airplane The stall-warning horn sounded, and the on the first third of the 3,900-ft (1,190-m) run- pilot landed the airplane gear-up on the runway way, heavy rain began to fall and wind direction about 3,000 ft (915 m) beyond the point of rota- and velocity changed. The pilot lost directional tion. The airplane overran the 5,000-ft (1,525- control of the airplane after the tires began to m) runway, struck a fence, crossed a road and hydroplane at midfield. “The pilot stated that came to a stop in a cornfield. The pilot was not there was insufficient runway remaining for him injured; the copilot received minor injuries. to initiate a go-around,” the NTSB report said. “The airplane went off the runway sideways, Turbulence Closely Follows Seatbelt Sign collapsed the left main landing gear and came to Boeing 737-800. No damage. One serious injury, two minor injuries. a complete stop.” ight turbulence persisted during the climb after the airplane departed from Hamilton, No Training, No Protection LBermuda, on Oct. 22, 2005, for a flight to Douglas DC-9. Minor damage. One fatality. Boston. The flight crew decided to leave the assengers were being boarded at Norfolk, The stall-warning seatbelt sign illuminated. The turbulence sub- Virginia, U.S., on Sept. 12, 2003, when an sided when the airplane was about 230 nm (426 Pairline employee drove a tractor toward the horn sounded, and km) northwest of Hamilton at Flight Level 340 airplane in preparation to push it back from the (approximately 34,000 ft). gate. The NTSB report said that the employee the pilot landed the “However, more turbulence was forecast for had been assigned to baggage-room duties that
airplane gear-up on [an area] about 150 miles [278 km] ahead of the day and was not qualified or authorized to con- airplane,” the NTSB report said. “The captain duct push-back operations. She had not received the runway. announced to the passengers that the seatbelt training in push-back operations since 1992. sign would be turned off for 10 minutes to allow “Another airline employee on the ramp saw them an opportunity to move about the cabin the tug driver maneuver the tug toward the tow- but would be turned on again due to the upcom- bar connected to the airplane’s nosegear, heard ing turbulence.” a loud noise and saw the towbar buckle and ‘go
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into the air,’” the report said. “The tug struck the he was having control difficulties,” the ATSB radome of the airplane, and the airline employee report said. “The copilot assisted the [pilot] who was driving the tug was fatally injured after by applying back-pressure on the right control being trapped between the tug and the airplane.” column.” However, the pilots were not able to NTSB said that the absence of a protective maintain a climb. enclosure over the cab of the tug was a factor in The copilot observed that the elevator-trim the accident. indicator was in the full nose-down position. He attempted unsuccessfully to apply nose-up eleva- Clogged Fuel Vent Downs a Homebuilt tor trim. The pilot reduced power, and the nose- Velocity Jet 900. Destroyed. One minor injury. down pitch forces decreased but still required he pilot was conducting his first flight in the opposing control inputs by the pilots. “The pilots homebuilt airplane at Millbrook, New York, reported that the aircraft descended to about 150 TU.S., on May 24, 2006. The NTSB report ft AGL during the incident,” the report said. said that he had no prior experience and had The copilot declared an urgency condition, received no training in turbine airplanes. After pan-pan, and advised the airport tower controller liftoff, the airplane climbed above the traffic pat- of the problem and the crew’s intention to return tern altitude at a rate of 4,000 to 5,000 fpm and for a landing. He then released the control wheel accelerated above 200 kt on the downwind leg. and, “in desperation,” used both hands to apply The pilot reduced power to flight idle. He back-pressure to the pitch-trim wheel. “The co- told investigators that the airplane was low on pilot reported that after using ‘excessive force,’ the base leg, but the engine did not respond when trim wheel released from the nose-down position he advanced the throttle. “I got too slow, lost and was moved towards the neutral position,” the control and crashed 100 feet short of the run- report said. “The pilots regained control of the way,” he said. aircraft and landed shortly after.” An examination of the airplane found that Investigators found that when the elevator- the fuel tank vent was clogged with dirt and in- trim switch on the left control wheel was moved sect remains. NTSB said that the probable cause left to the “DOWN” position or moved right to of the accident was “the pilot/owner’s inad- the “UP” position and released, it did not return equate preflight [inspection of the airplane].” to the center, neutral, position. “With electrical power on, selection of ‘UP’ or ‘DOWN’ pro- TURBOPROPS duced a noise consistent with operation of the trim servo motor but did not result in move- Pitch Trim Runaway ment of the trim tab,” the report said. Debris, a Embraer EMB-110P2 Bandeirante. No damage. No injuries. “sticky substance” and corrosion were found in he company’s chief pilot was conducting a the trim-switch mechanism, and the trim servo private flight on Sept. 1, 2005, to re-establish motor clutch did not slip, or disengage, properly Trecent flight experience in the aircraft and at design torque limits because of inadequate to practice newly adopted flight crew proce- lubrication. dures. Two other company pilots were aboard: The pilots did not pull the electric trim one was serving as copilot/supervisory pilot; the system circuit breaker during the incident, as other was observing. called for by the emergency checklist. “Given On initial climb from Bankstown Airport in that the electric trim was probably driving when New South Wales, Australia, the aircraft pitched the crew were having control difficulties, pulling nose-down. The pilot used the manual pitch- the electric trim servo circuit breaker would trim system and the electric pitch-trim system have deactivated the electric trim servo motor but was unable to reduce the nose-down pitch and … allowed the pilots to regain manual trim forces. “The [pilot] indicated to the copilot that control,” the report said. www.flightsafety.org | AEROSafetyWorld | January 2007 | 59 OnRecord
Crew Uses Wrong Takeoff Speeds four hours of flying, the pilot was instructed Dornier 328-110. No damage. No injuries. by air traffic control (ATC) to enter a holding efore departing from Ronaldsway Airport on pattern at 11,000 ft — about 6,500 ft AGL. The the Isle of Man, U.K., on Nov. 28, 2005, the NTSB report said that the pilot had about 1,987 aircraft was treated with a heated mixture of flight hours and had logged nine hours of flight Similar to an B Type II+ deice/anti-ice fluid and water to remove time in actual IMC in the six months preceding an accumulation of frost. The flight crew selected the accident flight; however, he had not flown at accumulation of a V1/VR (takeoff decision speed/rotation speed) of night during that period. ice on the airframe, 109 kt based on the aircraft’s takeoff weight, 12,300 Soon after entering the holding pattern, the kg (27,117 lb). However, when the commander pilot was cleared to conduct an instrument land- thickened deice/ pulled the control column aft at that speed, the ing system (ILS) approach. Two minutes after aircraft did not rotate. The commander rejected he acknowledged the clearance, ATC lost radio anti-ice fluid the takeoff and stopped the aircraft on the runway. contact with the pilot. also degrades None of the 19 occupants was injured. Search efforts were terminated that night In its report, the U.K. Air Accidents Investi- because of the weather conditions and dark-
the aerodynamic gation Branch (AAIB) said that the V1/VR speed ness. The next morning, the wreckage of the selected by the crew was for normal conditions airplane was found about 2.8 nm (5.2 km) from performance of the and was incorrect for the situation. “Contamina- the airport. “The airplane impacted terrain in tion must have been present on the tail surfaces a vertical descent and flat attitude,” the report aircraft. because the aircraft would not rotate at the said. “Evidence of forward velocity and/or lead- ‘normal’ rotation speed for its configuration ing-edge deformation was not observed on the and load, but it was not possible to determine wings or fuselage. Mixed ice was noted along the whether the contaminant was ice or thickened leading edges of both wings.” [deice/anti-ice] fluid,” the report said. NTSB said that the probable cause of the
In addition to providing V1/VR speeds for accident was “the pilot’s failure to maintain normal takeoff conditions, the Dornier 328 airspeed during the approach, which resulted in
airplane flight manual (AFM) includes V1/VR an inadvertent stall.” speeds that are about 20 kt higher to provide an additional margin above stall speeds during take- GPU Strikes Rotating Propeller off in icing conditions and/or after the aircraft De Havilland Canada Dash 8. Substantial damage. No injuries. has been treated with thickened deice/anti-ice he aircraft was parked at a stand and was fluids such as Type II or Type IV fluids. The being prepared for departure from Aberdeen report noted that, similar to an accumulation of T(Scotland) Airport on Oct. 7, 2005. A ground ice on the airframe, thickened deice/anti-ice fluid power unit (GPU) was used to provide electri- also degrades the aerodynamic performance of cal power for starting the aircraft’s engines. Soon
the aircraft. The AFM specified a V1/VR speed after the GPU cables were disconnected from the of 128 kt for the incident conditions. The higher aircraft, the GPU began moving forward, toward speed increases accelerate/stop distance by 330 m the aircraft. Nobody was in the cab, and the GPU (1,083 ft) to 1,350 m (4,429 ft); the usable length struck the rotating propeller on the right engine of the runway was 1,613 m (5,292 ft). and came to rest against the fuselage. The flight crew shut down the engines, and all 54 occupants Icing Triggers Stall on Approach exited through the cabin door. Cessna 425 Conquest I. Destroyed. One fatality. All four blades on the propeller and the pro- ark nighttime instrument meteorological peller hub were damaged, and the fuselage was conditions (IMC) prevailed at the destina- dented. The aircraft operator determined that Dtion, Gallatin Field in Bozeman, Montana, the right engine required a complete overhaul. U.S., on Nov. 29, 2005. On arrival, after almost The GPU also was substantially damaged.
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An examination of the GPU found that, southerly heading. “The airplane continued to because of worn engine-governor components, fly south past the airport, entered a left turn and the engine idling speed was significantly higher turned back to the north,” the report said. The than normal and sufficient to override the park- airplane stalled and descended to the ground ing brake. The AAIB report concluded that the about 2.5 nm (4.6 km) north of the approach GPU’s “FORWARD-NEUTRAL-REVERSE” end of Runway 18. selector had been moved to the “FORWARD” NTSB said that the probable causes of the position, most likely because of “human inter- accident were “the pilot’s failure to preflight the vention.” However, the gate in the selector was airplane, the pilot’s improper in-flight decision found to be worn, and the report said that the not to land the airplane on the runway when he selector might have moved to the “FORWARD” had the opportunity and the inadvertent stall position when it was jolted as the GPU cab door when the pilot allowed the airspeed to get too was closed. low,” and that a contributing factor was “the lineman’s improper servicing of the airplane.” PISTON AIRPLANES ‘Unchecked Descent’ Below Minimums Missing Dipstick Causes Oil Loss Pilatus Britten-Norman Islander. Destroyed. Two fatalities. Piper Chieftain. Destroyed. Two fatalities. he pilot, who had been on leave and had not he passenger arrived at Ankeny (Iowa, U.S.) flown for 32 days, conducted a brief solo flight Regional Airport at 0900 local time Nov. 8, Tat the Glasgow, Scotland, airport to regain T2005, but because the charter flight had not currency on March 15, 2005. He then landed the been confirmed by the customer, the operator aircraft to board a paramedic for an air ambu- had not assigned a pilot to the flight. The flight lance flight to Campbeltown Airport in Argyll. scheduler called several company pilots before The pilot had been assigned the flight at finding one who could accept the assignment, the 2136 local time; he had been awake since 0645. NTSB report said. The pilot arrived about 1005. “The task was to collect a 10-year-old patient A witness said that the pilot spent about two min- who was suffering from suspected appendicitis utes in the office before he walked directly to the and fly him to Glasgow for hospital treatment,” airplane, boarded and started the engines. the AAIB report said. While servicing the airplane, a lineman The airplane departed from Glasgow at had placed the oil-quantity dipstick on the 2333. ATC services were not available at Camp- right wing while adding oil to the right engine beltown Airport. At 0008, the pilot established at 0930. He did not replace the dipstick in the radio communication with an airport flight in- oil-filler tube. The lineman also left the engine- formation service (AFIS) officer, who reported cowling dipstick-access door open. that visibility was 4,500 m (2.8 mi) in rain, “The pilot taxied the airplane forward about broken clouds were at 400 ft and 900 ft AGL, 5 ft [2 m] and abruptly stopped and shut down and surface winds were from 240 degrees at both engines,” the report said. The pilot exited 15 kt. The pilot said that he would conduct the airplane, closed the dipstick-access door, the VOR/DME (VHF omnidirectional radio/ reboarded the airplane, restarted the engines distance measuring equipment) approach to and resumed taxiing. About three minutes after Runway 11 and “hopefully break visual” for departing from Runway 18, the pilot told ATC a circling approach to Runway 25. Published that he needed to return to the airport due to an minimums for the straight-in approach are oil leak. He reported on the Unicom frequency 380 ft — 341 ft above runway elevation — and that he was shutting down the right engine. 1,300 m (0.8 mi). The report said that the airplane was at The report said that the aircraft’s descent rate 550 ft AGL when it overflew the airport on a was 1,050 fpm when it descended below 1,540 ft, www.flightsafety.org | AEROSafetyWorld | January 2007 | 61 OnRecord
the minimum altitude for the outbound segment engine. The pilot was conducting a left turn to of the procedure turn. ATC radar contact then avoid trees when the airplane struck a hill. The was lost. About 0018, the pilot reported that the pilot and passenger exited the airplane before it aircraft was inbound on the procedure turn, was consumed by fire. which is conducted over water northwest of the Investigators found pieces of paper lodged airport. The AFIS officer said that visibility had between the impeller and housing of the turbo- decreased to between 1,500 m and 2,500 m (0.9 charger, which had separated from the right en- mi to 1.6 mi) and asked the pilot to report when gine on impact. “An examination of the pieces of The pilot’s body was he had the airport in sight. The pilot did not ac- paper extracted from the turbocharger revealed knowledge the request or reply to further radio that they were from an air-filter instructional found about nine transmissions by the AFIS officer. “The aircraft sheet,” the report said. “It was also determined months after the was subsequently located on the seabed 7.7 nm that the replacement air filter had been installed [14.3 km] west-northwest of the airport,” the on the right engine approximately four months accident by the crew report said. The paramedic’s body was found in prior to the accident.” The airplane had been the wreckage. The pilot’s body was found about operated about 54 hours after the air filter was of a fishing vessel. nine months after the accident by the crew of a installed. fishing vessel. The report said that when the manufacturer AAIB said that the following were causal fac- packages new air filters, the instruction sheet is tors of the accident: folded and inserted inside the canister, and the canister is placed in a plastic bag. Maintenance • “The pilot allowed the aircraft to descend personnel failed to remove the instruction sheet below the minimum altitude for the aircraft’s from the canister when the air filter was in- position on the approach procedure, and this stalled in the accident airplane, the report said. descent probably continued unchecked until the aircraft flew into the sea; Beaver Stalls While Crossing Ridge De Havilland DHC-2. Destroyed. One fatality. • “A combination of fatigue, workload and lack of recent flying practice probably fter completing a flight in the float- contributed to the pilot’s reduced perfor- equipped aircraft to two wilderness camps, mance; [and,] Athe pilot was returning to the company’s base camp at Squaw Lake, Quebec, Canada, on • “The pilot may have been subject to an the afternoon of Sept. 1, 2005, when deteriorat- undetermined influence such as disorien- ing weather conditions forced him to conduct a tation, distraction or a subtle incapacita- precautionary landing on Elross Lake, which is tion which affected his ability to safely 15 nm (28 km) northwest of the base camp, said control the aircraft’s flight path.” the report by the Transportation Safety Board of Canada. Internal Debris Causes Engine Failure About 1630 local time, the pilot reported Cessna 320E. Destroyed. Two serious injuries. to a company dispatcher by VHF radio that he airplane was between 100 and 200 ft there “seemed to be a break in the weather” AGL during departure from Missoula, and that he intended to continue the flight to TMontana, U.S., for an aerial-mapping flight the base camp. Another company pilot told the on June 21, 2005, when the right engine lost accident pilot that the weather at Squaw Lake power. The NTSB report said that the airplane, was poor and that the flight should not be at- which was about 83 lb (38 kg) over maximum tempted. The report said that an airport near gross weight, descended into a gully when the the base camp was reporting 2 mi (3,200 m) engine failure occurred and climbed slowly after visibility, 600 ft vertical visibility and surface the pilot feathered the propeller and secured the winds at 18 kt.
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“Rescue efforts were initiated in the eve- and that the waves were going in the wrong ning when the aircraft did not arrive at the direction. The winch operator shouted, “We’re base camp,” the report said. The wreckage of moving backwards.” The report said that the he- the aircraft was found on a mountain ridge 4 licopter struck the water before the commander nm (7 km) from Elross Lake the next day. “The could react. Water rapidly filled the helicopter, severity and type of the damage, and the angle at but all five crewmembers exited before it sank. which the aircraft contacted the terrain indicate They later were rescued by the crew of a military the aircraft was in an aerodynamic stall at the helicopter. time of impact,” the report said. “In an attempt Investigators found that the pilots had not to cross the [ridge], the pilot perhaps lost visual used the radio altitude warning system, the reference to the ground and subsequently con- radar system or the global positioning system trol of the aircraft, and/or he encountered mod- during the approach. “The investigation has erate to severe turbulence and strong updrafts revealed that the pilots underestimated the dif- causing the aircraft to stall … at an altitude from ficulty of landing under the circumstances then which recovery was not possible.” prevailing and that the procedures and the tech- nical equipment available for them to be able to HELICOPTERS perform a safe landing were not employed,” the report said. Air Ambulance Strikes Sea During Approach Sikorsky S-76A. Extensive damage. No injuries. Spatial Disorientation Cited in Control Loss ighttime VMC prevailed for the air Robinson R44. Substantial damage. No injuries. ambulance flight on Sept. 18, 2004. The isibility was reduced by low fog and flat Nhelicopter, with five crewmembers aboard, light conditions during the charter flight departed from Gotland, Sweden, to pick up a Vfrom Iliamna, Alaska, U.S., to a remote patient with an acute heart condition on the site on March 12, 2006. About 10 nm (19 km) island of Häradsskär. from Iliamna, “the pilot was unable to discern “The weather was judged to be good, and the any topographic features on the snow-covered sortie was viewed by the crew as a routine mis- terrain, and he elected to make a precautionary sion,” said the report by the Swedish Accident landing to wait for better visibility,” the NTSB Investigation Board. As the helicopter neared report said. “After about 10 minutes, he decided the island, the crew observed lights in the win- to continue to his destination.” dows of the patient’s house. “Apart from this, the As the helicopter moved forward after take- only external reference point in the area was the off, the pilot’s vision again was affected by blow- light from the lighthouse,” the report said. “The ing snow and the flat light conditions. The pilot commander decided, after passing the island, to attempted to establish a stable hover. He told in- make a right turn and then approach it from the vestigators that he believed the aircraft was not north and into the wind.” moving when the right skid struck the ground. The commander told the other crewmembers The helicopter rolled right, and the main rotor that he would conduct a relatively steep approach. blades struck the ground. “As the main rotor “He felt that the initial glide towards the island blades struck the ground, the helicopter rolled was without problems even though he lacked vi- onto its right side,” the report said. The pilot and sual contact with the ground and the strong light passenger were not injured. from the lighthouse at times masked the weaker NTSB said that the probable causes of the light from the house windows,” the report said. accident were “the pilot’s continued flight into Soon after the copilot called out a radio alti- adverse weather conditions and his spatial dis- tude of 100 ft, the winch operator observed that orientation and loss of control during a subse- the helicopter was rapidly approaching the water quent landing attempt.” ● www.flightsafety.org | AEROSafetyWorld | January 2007 | 63 OnRecord
Preliminary Reports Date Location Aircraft Type Aircraft Damage Injuries Nov. 6, 2006 Piacenza, Italy Piper Cheyenne I destroyed 2 fatal Nighttime visual meteorological conditions (VMC) prevailed when the airplane crashed in a forest during a flight from Malta to Milan. Nov. 7, 2006 Corozol, Belize Cessna 207A NA 6 NA The airplane was on a 30-nm (56-km) flight to Corozol from Orange Walk when engine problems occurred. The pilot ditched the airplane 4 nm (7 km) from shore. The six occupants were rescued by the crew of a marine vessel. Nov. 8, 2006 Takhli Air Base, Thailand Learjet 35A destroyed 7 fatal The Thai air force airplane was 150 ft above ground level on takeoff when the captain reported an engine problem. The airplane stalled and struck an empty hangar during the emergency landing. Nov. 8, 2006 Alamogordo, New Mexico, U.S. Cessna 337C destroyed 1 fatal Daytime VMC prevailed when the airplane veered right off the runway on landing, crossed a taxiway and struck a hangar. Nov. 9, 2006 Walikale, Democratic Republic of Congo Let L-410UVP destroyed 1 fatal, 4 minor Engine problems occurred soon after the airplane took off from a road used periodically as a runway. The road had been reopened for traffic when the flight crew returned for an emergency landing. The airplane struck several vehicles, killing a passenger in one vehicle, before veering off the road, striking several houses and stopping in a field. Nov. 12, 2006 Rottnest Island, Australia Partenavia P.68B Victor destroyed 6 minor The airplane crashed on a salt lake bed soon after takeoff. Nov. 13, 2006 South Bend, Indiana, U.S. Cessna T303 Crusader destroyed 5 fatal The airplane climbed in instrument meteorological conditions to about 5,700 ft after takeoff, entered a spiraling left turn and struck a cornfield in an 80-degree nose-down attitude. Nov. 14, 2006 Big Bear Lake, California, U.S. Cessna 421B destroyed 3 fatal A witness saw dark smoke emerge from the left engine after the airplane lifted off. The airplane yawed left, and the landing gear remained extended. The airplane crashed on the shore of a lake about 7 nm (13 km) from the airport. Nov. 15, 2006 Progreso, Mexico CASA 212 Aviocar 400 substantial 7 none Both engines flamed out about five hours after the Mexican naval airplane departed from Cancún for a maritime patrol mission. The flight crew ditched the airplane 1.9 nm (3.5 km) offshore. All seven occupants escaped before the airplane sank. Nov. 17, 2006 Ocumare del Tuy, Venezuela Cessna 207 NA 3 fatal The pilot encountered engine problems soon after takeoff for a cargo flight. During an attempted landing on a city street, the airplane struck a telephone pole and a bus. The pilot and two occupants of the bus were killed. Nov. 17, 2006 Puncak Jaya, Indonesia De Havilland Canada DHC-6 destroyed 12 fatal The Twin Otter was on a charter flight from Mulia to Ilaga when it struck a mountain at 10,500 ft. Nov. 18, 2006 Leticia, Colombia Boeing 727-23F destroyed 5 fatal Nighttime VMC prevailed with patches of fog when the cargo airplane struck a 150-ft antenna about 2 nm (4 km) from the airport during a visual approach. The three flight crewmembers and two passengers were killed. Nov. 19, 2006 Kingstown, St. Vincent and the Grenadines Rockwell 500S NA 2 fatal Radio contact was lost soon after the pilot reported over Bequia Island and four minutes from landing in Kingstown. The next day, debris from the airplane was found on the ocean. Nov. 22, 2006 Cunday, Colombia Cessna 208 Caravan destroyed 3 fatal The Colombian air force airplane struck a mountain during an approach in low visibility to Tolemaida Air Force Base. Nov. 27, 2006 Tehran, Iran Antonov 74T-200 destroyed 36 fatal, 2 serious The Iranian air force airplane crashed on takeoff from Mehrabad Airport. Nov. 29, 2006 Mindelheim–Mattsies, Germany Grob G.180 Spn destroyed 1 fatal The test pilot was killed when the prototype business jet struck terrain during a demonstration flight. NA = not available This information was gathered from various government and media sources, and is subject to change as the official investigations of the accidents and incidents are completed.
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Flight Safety Foundation
19th annual European Aviation Safety Seminar EASS Staying Safe in Times of Change
March 12–14, 2007 Amsterdam, Netherlands
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]. 2006 Getty© Copyright Images Inc.