Aviation Safety World, August 2006
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AviationSafety WORLD SPINNING DANGER OVERRUN Advancing prop/rotor safety RETHINKING PROTECTION STRATEGIES INSIGHT Hypoxia training C-FOQA ADVANCES Report from CASS LEADERS LOG Bisignani ION T OUNDA F Y T SAFE T LIGH F THE JOURNAL OF AUGUST 2006 What can you do to improve aviation safety? Join Flight Safety Foundation. Your organization on the FSF membership list and Internet site presents your commitment to safety to the world. • Receive Aviation Safety World, a new magazine developed from decades of award-winning publications. • Receive discounts to attend well-established safety seminars for airline and corporate aviation managers. • Receive member-only mailings of special reports on important safety issues such as controlled flight into terrain (CFIT), approach-and-landing accidents, human factors, and fatigue countermeasures. • Receive discounts on Safety Services including operational safety audits. An independent, industry-supported, nonprofit organization for the exchange of safety information for more than 50 years Wright Flyer photo/source: U.S. National Aeronautics and Space Administration If your organization is interested in joining Flight Safety Foundation, we will be pleased to send you a free membership kit. Send your request to: Flight Safety Foundation 601 Madison Street, Suite 300, Alexandria, VA 22314 USA Telephone: +1 703.739.6700; Fax: +1 703.739.6708 E-mail: [email protected] Visit our Internet site at www.flightsafety.org PRESIDENT’sMEssaGE CHANGES AT THE Speed of Flight ou are reading the second issue of Aviation flight instructor and ground instructor. Safety World. I sincerely hope that you like Importantly, by virtue of his position with what you see, for I am very proud of the ICAO, he is also well known in interna- new format of Flight Safety Foundation’s tional circles, where he has established Ypublication and of our staff who have done so an excellent reputation for his aviation much to make this change, the first in some 18 safety work. years. When we launched the inaugural issue From this, you will see that Bill is extremely of Aviation Safety World at a reception held in well qualified to move into the captain’s seat at the Washington last month, it was very well received, beginning of October. I will work with him to effect and I have been getting nothing but rave reviews a smooth transition. Further, I expect to continue since. to be involved with Flight Safety Foundation and At the Washington reception, we announced its activities for some time to come. More details other big news. After a career of more than 53 will be announced in due course. Meanwhile, I years in aviation, the past 12 of which have been know that you will join me in welcoming Bill and at the helm of Flight Safety Foundation, it was wishing him well in his new assignment. announced that I will retire from my position as So you can see that there are big changes going president and CEO later this year. on at Flight Safety Foundation, a unique organiza- Named as my successor was William (Bill) tion. For nearly 60 years, it has been in the fore- R. Voss, a 30-year professional in aviation. Bill front of promoting aviation safety improvements in 2004 left his management position at the U.S. and, over the years, has been credited with numer- Federal Aviation Administration (FAA) to serve ous safety initiatives, many of which are now taken with the International Civil Aviation Organization for granted. Today, its position is firmly established (ICAO) in Montreal where, for the past two and a and it is on a sound financial footing. half years, he has been director of the Air Naviga- All of us at the Foundation now look forward tion Bureau. Prior to joining ICAO, Bill gained to beginning a new chapter that will start us on considerable experience serving for 23 years in a the way to even greater heights, further improv- variety of senior positions with FAA. Forty-nine ing aviation safety and benefiting all who fly. years of age, he holds a masters degree in public administration and a bachelor of science degree in aviation maintenance management. In addition, he holds certificates as an air- frame and powerplant mechanic, airline trans- Stuart Matthews port pilot (single- and multi-engine) and FAA President and CEO control tower operator. He is also a qualified Flight Safety Foundation WWW.FLIGHTSAFETY.ORG | AVIATIONSAFETYWORLD | AUGUST 2006 | AviationSafetyWORLD contentsAugust2006 Vol 1 Issue 2 features 13 CoverStory | Rethinking Overrun Protection 20 InSight | Hypoxia Training Risks 13 22 AuditReview | European Ramp Checks 25 ThreatAnalysis | Misidentified Fix 20 28 GroundSafety | Walking Into Trouble 35 CausalFactors | Missed Cues 41 CabinSafety | Managing the Escape 44 FlightOps | CFIT Checklist Goes Digital 45 SeminarsCASS | C-FOQA Advances 22 departments 1 President’sMessage | Changes at the Speed of Flight 5 EditorialPage | Not Good Enough 6 AirMail | Letters From Our Readers | FLIGHT SAFETY FOUNDATION | AVIATIONSAFETYWORLD | AUGUST 2006 41 contents 28 35 AviationSafetyWORLD Stuart Matthews, 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 11 LeadersLog | Giovanni Bisignani Mark Lacagnina, senior editor [email protected], ext. 114 47 FoundationFocus | Members by Region Wayne Rosenkrans, senior editor [email protected], ext. 115 51 DataLink | 2005 Commercial Jet Hull Losses, Fatalities Linda Werfelman, senior editor [email protected], ext. 122 Rick Darby, associate editor 54 InfoScan | Hazard Alert! Lunch Ahead [email protected], ext. 113 Karen K. Ehrlich, web and print 58 OnRecord | Recent Accidents and Incidents 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 About the Cover Southwest Airlines accident at Editorial Advisory Board Midway International Airport. © Copyright 2005 Allan Goldstein, David North, EAB chairman Aerial Images Photography consultant J.A. Donoghue, EAB executive secretary We Encourage Reprints (For permissions, go to <www.flightsafety.org/asw_home.html>) Flight Safety Foundation Share Your Knowledge Mike Ambrose, director general If you have an article proposal, manuscript or technical paper that you believe would make a useful contribution to the ongoing dialogue about aviation safety, we will be European Regions Airline Association glad to consider it. Send it to Director of Publications J.A. Donoghue, 601 Madison St., Suite 300, Alexandria, VA 22314-1756 USA or <[email protected]>. Barry Eccleston, president and CEO The publications staff reserves the right to edit all submissions for publication. Copyright must be transferred to the Foundation for a contribution to be published, and Airbus North America payment is made to the author upon publication. Subscriptions: Subscribe to Aviation Safety World and become an individual member of Flight Safety Foundation. One year subscription for 12 issues Don Phillips, transportation reporter includes postage and handling — US$350. Special Introductory Rate — $280. Single issues are available for $30 for members, $45 for nonmembers. International Herald Tribune For more information, please contact the membership department, Flight Safety Foundation, 601 Madison Street, Suite 300, Alexandria, VA 22314-1756 USA, +1 703.739.6700 or <[email protected]>. Russell B. Rayman, M.D., executive director Aerospace Medical Association Aviation Safety World © Copyright 2006 by Flight Safety Foundation Inc. All rights reserved. ISSN 1931-6135 Suggestions and opinions expressed in Aviation Safety World are not necessarily endorsed by Flight Safety Foundation. Capt. Robert Sumwalt, US Airways (retired) Nothing in these pages is intended to supersede operators’ or manufacturers’ policies, practices or requirements, or to supersede government regulations. manager of aviation, SCANA Corp. WWW.FLIGHTSAFETY.ORG | AVIATIONSAFETYWORLD | AUGUST 2006 | Serving Aviation Safety Interests for More Than 50 Years OFFICers AND StaFF light Safety Foundation is an international membership organization dedicated to Chairman, Board of Governors Amb. Edward W. the continuous improvement of aviation safety. Nonprofit and independent, the Stimpson Foundation was launched officially in 1947 in response to the aviation industry’s need President and CEO Stuart Matthews F 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. recommend practical solutions to them. Since its beginning, the Foundation has acted in Treasurer David J. Barger the public interest to produce positive influence on aviation safety. Today, the Foundation ADMINIstratIVE provides leadership to more than 900 member organizations in 142 countries. Manager, Support Services Linda Crowley Horger FINANCIal MemberGuide Chief Financial Officer Penny Young Flight Safety Foundation 601 Madison Street, Suite 300, Alexandria, VA, 22314-1756 USA Staff Accountant Maya Barbee tel: +1 703.739.6700 fax: +1 703.739.6708 www.flightsafety.org MembersHIP Director, Membership and Development