AeroSafety WORLD MAKING THE CALL Doctor-pilot relations SIX-G ARRIVAL Copilot trainee error DIVE-AND-DRIVE Arguing the merits
AIR TOURING SAFETY ISSUES LINGER
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f the entire aviation industry should collaborate on one thing, it is safety. IAt a time of constrained resources, increased regulation and unprecedented scrutiny, the Flight Safety Foundation continues to be the leading advocate for safety and prevention of accidents, thereby saving lives. Show your commitment to the aviation community’s core value — a strong, e ective global safety culture. Join the Flight Safety Foundation.
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NEXT Move hen the position of president and groups representing governments, airlines and CEO of Flight Safety Foundation safety, we will come up with a practical solution. became available, it was immediately FSF recently published the Duty/Rest Guide- appealing to me. I recently had re- lines for Business Aviation, which updates the tiredW from International Aero Engines and was landmark “Principles and Guidelines For Duty debating my next move. I’ve spent my entire and Rest Scheduling in Corporate and Business career in aviation, in roles that focused on safety Aviation,” published by the FSF Fatigue Coun- and quality as well as positions in marketing and termeasures Task Force in 1997. The Duty/Rest sales. The opportunity to work at the Foundation update is the culmination of a joint effort by FSF and lead this team was irresistible. and the National Business Aviation Association As anyone who has spent time in aviation Safety Committee’s Fatigue Task Force, led by knows, Flight Safety Foundation is the voice of Leigh White. This is available on our website at safety. It is the conscience of the industry. While
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JUNE 2014 | 1 AeroSafetyWORLD
contents June 2014 Vol 9 Issue 5 features
8 InSight | Continuous Descent Approaches
16 CoverStory | Air Tours Assessment
20 SummitsBASS | Airman Medical Certificates
26 MaintenanceMatters | Fatigue-Conscious Behavior
16 29 FlightTraining | Refining MPL Programs 20 35 CausalFactors | Ground Idle on Final 39 StrategicIssues | Weather Research Paths
departments
1 President’sMessage | Next Move
5 EditorialPage | Child Restraint Devices
7 SafetyCalendar | Industry Events
2 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JUNE 2014 26 29 35
12 InBrief | Safety News
44 DataLink | Newly Harmonized Data
47 InfoScan | Data Review
51 OnRecord | Engine Fire on Night Takeoff 39 AeroSafetyWORLD telephone: +1 703.739.6700
Frank Jackman, editor-in-chief, FSF director of publications [email protected], ext. 116 About the Cover Report says U.S. air tour industry must address problem areas. Wayne Rosenkrans, senior editor [email protected], ext. 115 © Nelson Santiago | Depositphotos Linda Werfelman, senior editor [email protected], ext. 122
We Encourage Reprints (For permissions, go to
| | FLIGHTSAFETY.ORG AEROSAFETYWORLD JUNE 2014 | 3
EDITORIALPAGE
CHILD RESTRAINT Devices
s parents, we’d all like to think that there is recommended restraints for lap-held children, nowhere safer for our children than in our “and we have been recommending it ever since,” arms, particularly when our kids are very Hersman said. young. And from a nurturing or develop- During the question-and-answer session Ament standpoint, this is probably true. But is it following her speech, she said, “I couldn’t have true during a high-speed rejected takeoff, clear air imagined in 2004 [when she joined the NTSB] turbulence or a runway excursion when accelera- that we’d still be talking about this issue in 2014.” tion g-forces come into play? She described it as one of the “great disappoint- When traveling by air, parents generally are ments” of her tenure on the board. allowed to hold the smallest children, those under As soon as we wrap up this issue of AeroSafety the age of 2 years, on their laps, obviating the need World, I will be headed to Madrid to attend the to buy an additional seat. However, in the United International Air Transport Association’s (IATA’s) States there are no restraining devices for lap-held Cabin Operations Safety Conference. Among the children that are approved for use during takeoff conference activities are two workshops — half and landing, so parents are expected to secure a day each — on child restraint devices. In its these children using only their arms. conference materials, IATA said it is seeking an In a speech April 21 at the National Press Club “internationally recognized solution on accepted in Washington, Deborah Hersman, then the outgo- child restraint devices with a solution that is prac- ing chairman of the U.S. National Transportation tical, affordable, operationally realistic, feasible Safety Board (NTSB), made the issue of lap-held and harmonized globally.” children one of the focal points of what were es- I’m looking forward to the discussion, and I sentially her farewell remarks. “Some people say the hope that a solution to the issue is on the horizon. risk is small,” Hersman said. “I tell them, ‘No, a baby is small.’ We secure laptops and coffeepots, yet we do not secure our most precious cargo, our children.” In the late 1970s, NTSB recommended that the Federal Aviation Administration research and initiate a rulemaking on the restraint of Frank Jackman small children. After the crash of United Airlines Editor-in-Chief Flight 232 at Sioux City, Iowa, 25 years ago, NTSB AeroSafety World
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JUNE 2014 | 5 Serving Aviation Safety Interests for More Than 65 Years
OFFICERS AND STAFF ince 1947, Flight Safety Foundation has helped save lives around the world. The Chairman Foundation is an international non-profit organization whose sole purpose is to Board of Governors David McMillan provide impartial, independent, expert safety guidance and resources for the President and CEO Jon L. Beatty S aviation and aerospace industry. The Foundation is in a unique position to identify General Counsel and Secretary Kenneth P. Quinn, Esq. global safety issues, set priorities and serve as a catalyst to address the issues through data collection and information sharing, education, advocacy and communications. The Treasurer David J. Barger Foundation’s effectiveness in bridging cultural and political differences in the common cause of safety has earned worldwide respect. Today, membership includes more than FINANCIAL 1,000 organizations and individuals in 150 countries. Financial Operations Manager Jaime Northington
MEMBERSHIP AND BUSINESS DEVELOPMENT MemberGuide Flight Safety Foundation Senior Director of 801 N. Fairfax St., Suite 400, Alexandria VA 22314-1774 USA Membership and Business Development Susan M. Lausch tel +1 703.739.6700 fax +1 703.739.6708 flightsafety.org Member enrollment ext. 102 Director of Events Ahlam Wahdan, membership services coordinator [email protected] and Seminars Kelcey Mitchell Seminar registration ext. 101 Manager, Conferences Namratha Apparao, manager, conferences and exhibits [email protected] and Exhibits Namratha Apparao Seminar sponsorships/Exhibitor opportunities ext. 105 Membership Kelcey Mitchell, director of events and seminars [email protected] Services Coordinator Ahlam Wahdan Donations/Endowments ext. 112 Consultant, Student Susan M. Lausch, senior director of membership and development [email protected] Chapters and Projects Caren Waddell FSF awards programs ext. 105 Kelcey Mitchell, director of events and seminars [email protected] COMMUNICATIONS Technical product orders ext. 101 Director of Namratha Apparao, manager, conferences and exhibits [email protected] Communications Emily McGee Seminar proceedings ext. 101 Namratha Apparao, manager, conferences and exhibits [email protected] Website ext. 126 GLOBAL PROGRAMS Emily McGee, director of communications [email protected] Director of Basic Aviation Risk Standard Global Programs Rudy Quevedo Greg Marshall, BARS managing director [email protected] BARS Program Office: Level 6, 278 Collins Street, Melbourne, Victoria 3000 Australia BASIC AVIATION RISK STANDARD tel +61 1300.557.162 fax +61 1300.557.182 [email protected] BARS Managing Director Greg Marshall
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n an article comparing constant- angle, nonprecision, straight-in instrument approach procedures (IAPs) with “dive-and-drive” I(stepdown) IAP designs (“Continu- ous Descent,” ASW, 7/13, p. 38), the article’s source makes a case against airline flight crews’ continued use of dive-and-drive IAPs. In dive-and-drive, the pilot flying passes the depicted final approach fix (FAF) — or, if not depicted, the point where the aircraft is estab- lished inbound on the final approach course — at a specified altitude. He or she then typically descends, possi- BY ALAN GUREVICH bly with one or more stepdown fixes, to arrive at the minimum descent altitude (MDA) prior to reaching the missed approach point (MAP). On many IAPs today, a vertical descent point (VDP) provides a defined point on the final approach course from which a “normal” (usually 3.0-degree glidepath) descent from the MDA to the runway touchdown point may be commenced, pro- vided the pilot has established visual reference. But, as importantly, the VDP is almost universally considered now to The ASW article’s source first the descent, you may also have to be the last point from which it is ac- argued that dive-and-drive IAPs reconfigure the airplane. In his words, ceptable to be in your descent from the inherently are prone to becoming “You’re configuring the airplane late, MDA to the runway. Beyond the VDP, unstabilized because of the fairly steep quite often reading checklists right you’ll be too close and, hence, too steep. rate of descent — usually between down to the last moment.” Aside from Aviation regulations generally specify 1,000 and 1,500 fpm (the “dive”), which all other considerations, this was that the pilot cannot descend below operational experience and research deemed contrary to today’s stabilized- the MDA unless in a normal position consider unacceptable below 1,000 ft approach safety philosophy. I agree to continue the approach to landing. above ground level — required to level it would be contrary to stabilized- This is not a trivial point, as a pilot very off at the MDA sufficiently prior to the approach philosophy, but I don’t agree likely would run into trouble with a VDP. Second, even if prior to reaching that it is usually, or even commonly, pilot examiner during a practical test if the VDP, the pilot has sufficient visual called for. he flew past the VDP, and then decided reference to continue the approach, he A better method, according to to descend for landing. Either he would must fly level until reaching the VDP the article, is the constant-descent be steeper on approach than is deemed (the “drive”), and then re-establish a approach (CDA). Here the pilot flying safe, or he would touch down beyond descent. The source then said that an conducts an IAP designed or adapted the touchdown zone. added problem is that once you re-start for a continuous rate of descent from
8 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JUNE 2014 INSIGHT
distance vs. altitude numbers, having to constantly refer to it by looking down at the approach plate for the number, then to the flight instruments to see if “you’re there,” and also looking out the windscreen, is not easy or, perhaps, safe. Humans are not great multitask- ers, and flying an approach in bad weather already involves lots of tasks, without adding math — and math that must be accurate. Second, as mentioned, I disagree with the article’s quote about level of risk while changing configuration and doing checklists after passing the FAF. There may be some airlines that specify this, but I rather doubt it is anywhere near common. I can’t provide substanti- ation, but I know from the three or four operators with which I am familiar, that their standard operating procedures specify that the airplane be configured in the landing configuration by the FAF, with all checklists complete. This is required specifically so that the pilots do not have to concentrate on anything other than safely flying the last phase of the approach, and fully supports the stabilized-approach safety concept. This would apply in both CDA and dive- the FAF/FAF altitude to arrive at the altitudes which, if followed, approximate and-drive cases. MDA and VDP at the same time. The the proper descent rate. For IAPs that Third, the MDA of a nonprecision pilot then just continues the descent, do not, the pilot would have to calculate IAP is the lowest altitude to which a assuming sufficient visual reference these numbers as the airplane descends pilot can fly prior to having the run- has been established, to landing. or refer to another tool if available. way in sight, as opposed to reaching Visual reference is a complex concept Yet doing this mental calculation the decision height (DH)/decision beyond the scope of this article, so I’ll accurately, which is critical this close to altitude (DA) on a precision IAP. The just say “runway in sight” for simplic- the ground, is not assured, as pointed DH/DA allows continuing the descent ity from now on. out in the article itself. The pilot must for the brief period while the pilot I disagree with the CDA-only phi- accurately calculate while flying the decides whether there is sufficient losophy as presented for a few reasons. airplane, looking for the runway and visual reference to continue to land, First, as pointed out in the article, maintaining situational awareness. or executes a missed approach. Not so not all airplanes have the capability to Although letting an autopilot do the with the MDA. generate the guidance that many airlines flying can help, if you get behind — or, When you fly a CDA, the goal is to require for a CDA. The source noted worse, err in your calculations — you reach the MDA at the VDP. If you don’t that some nonprecision, straight-in IAPs can put yourself in a bad situation. Even have the runway in sight at that time, provide a table showing distances vs. when provided with a table giving you you must go around. But the problem is
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JUNE 2014 | 9 10 | No and yes. drive IAP solve any of problems? these at wrong the descent rate. using aCDA may you set up to off start descent is what we get paid to do, but I understand that judging final the landing, you may end up short or long. continue same the rate of descent to MDA-VDP, runway, the see and then out windscreen the as you approach the to touchdown. gradient than you want from VDP the VDP orthe asteeper via shallower path during CDA the get you will to 3-degree descent the glidepath, then or lower than that provided by a dictates that FAF the altitude higher be perhaps other altitude restrictions) point. But ifanything (obstacles or 3.0-degree glidepath to touchdown the of FAF the is to locate it on anominal establishing location the and altitude has achoice in.Iassume in goal the degrees; is this not something pilot the VDP at same the moment not 3 will be FAF altitude to arrive at MDA the and descent angle required from FAF/ the and-drive with. to begin same position as ifyou’d done adive- if you runway, the see you’ll inthe be or leveling off at minimums where, runway the see above 150ft minimums, are limiting yourself to having to either prior150 ft to reaching MDA. the You MDA, you then must to start level off from your descent to level at flight the for example, it to 150ft transition takes tions, and you may unsafe. be also If, are below MDA inviolation of regula- that you must miss approach, the you runway,the no problem; ifyou decide make go-around the decision. If you see inadescentstill as you reach MDA and that with aCDA, by definition, you’re INSIGHT Will latest the versions of dive-and- of idea ifthe aCDASo is to look There’s chance the also that the the samethe search for reference, visual autopilot the then allow you will to do iswhich arequirement at some airlines, reaching VDP. the is marginal, runway the to see before pilot with achance, weather the when only afew seconds, it provides the reaching VDP. the Even saves ifthis ity to looking for runway the prior to devotingwhile more crosscheck capac- can letit level off and at fly MDA the for navigation,used vertical pilot the required tasks. vs. distance other performing all while approach plate, checking altitude to go to domath or continuously refer to the reason. to approach end inamissed for that near MDA, the aCDA then is likely runway. the see If ceiling the is very approaching MDA, the where he might ing up or last the of 150ft so altitude pending on airplane design. and down vision to some extent, de- likelywill pilot’s restrict the forward it reached VDP the inadescent. This level at amore nose-up attitude than if by VDP. the and able be then to descent the start MDA, you may runway the see earlier runway;ifyouthe level earlier at the as likely reason the to be you can’t see scent point. But as ceiling the is just priornm (0.4km) to acharted de- allowed adescent to up begin to 0.2 at leastUnited inthe States, pilots are degrees. Amitigating factor is that, slightly than steeper nominal the 3 stable descent. make you This will from level at flight VDP the to a you have infact, will, to transition If an autopilot aCDA, to fly is used Yes, ifan because autopilot can be Yes, pilot the because not does have Yes, pilot the because is not giv- No, airplane the be because will No, inadive-and-drive because FLIGHT FOUNDATION SAFETY That’s entire the point of CDA. the criteria my company (rightly) requires: MDAthe inadescent, are which the pointthe where Ican cross VDP the at approach, as airplane the is already past no choice but to commence amissed at MDA. the Once that Ihave begins, autopilot to start level aircraft the will runway the next inthe visually 40ft, MDA, Iknow that ifIdon’t have the proaching minimums“ above 200ft the pilot the when monitoring ”ap calls - that automation the must CDAs), fly CDAsthe (actually, Ifly is our policy mentioned: dilemma the Oneachof math or table required. ment landing system glideslope. No display much very this, like an- instru constantthe descent angle required and CDA IAPs, but can calculate also they airplanethe either via dive-and-drive or that are capable fully of not only flying management/autoflightflight systems a large commercial transport has jet, seats at my airline. My airplane, new article,this Ihad fortune the to change looking outside.be tance table, there is not much to time mathdo the or check altitude/dis the - mentioned above. And ifyou have to beforemode you reach VDP, the as but it’s going to transition to level-off And I’ve still, exactly experienced While considering aresponse to |
WORLD AEROSAFETY | JUNE 2014 JUNE
© potowiz | FreeDigitalPhotos INSIGHT
another approach? What if that’s the DAs. That will likely mean the DH/DA only IAP available? If I assume, because will have to be somewhat higher than I just managed to see the runway as the old MDA for the same approach, to I passed the VDP after the autopilot allow for the transition from a descent leveled me off on the last approach, to a climb in the event of a missed that I’ll see the runway next time, do I approach. But at least then the pilot disconnect the automation on the next could reach DH/DA at the VDP and try and hand fly the descent the last 150 decide what to do. If there’s no runway, ft to the MDA, so the airplane doesn’t miss the approach knowing that the again start to level off? What if the airplane will (legally) descend (safely) weather has changed and I don’t see the below the DH/DA while transitioning runway this next time? Then I bust the to the missed approach climb or, if the MDA. Is this so unsafe as to be a real runway is in sight, then the descent While I’ve always looked with issue? I can’t answer that. path can be continued. Of course, this suspicion on the concept of a pilot- But I know that I could do that doesn’t address my concern about derived CDA, it was mainly because of nasty old dive-and-drive IAP on my today’s airline pilots calculating their the added mental workload needed to second approach, make sure I get to own CDA flight paths. That is their constantly monitor the “distance to go the MDA soon enough to ascertain I individual decision. vs. altitude” progress, and also because can still see the runway at minimums, In the past few months, I’ve of how often I’ve made errors doing this and then start the descent just prior learned that this appears to be exactly calculation in line operations. I’ve often to, or upon, reaching the VDP. Yes, what another airplane model in my gotten behind, or paid too much atten- it might take a higher rate of descent company’s fleet does. Some of the tion to the math, and lost situational from the FAF to get to the MDA early IAPs have been modified to take into awareness in one way or another. enough, but I don’t feel it would be account the amount of altitude used But by practicing CDAs in training such a high rate as to be a greater in leveling off during the CDA. An with an airplane that does all the cal- threat than not seeing the runway and altitude that is not an MDA is used as culating and flying for me, I’ve become having to again miss the approach. the missed approach decision point, more concerned about the other issue: And if I had done the dive-and-drive prior to the autoflight system begin- If I’d been able to descend to the MDA the first time around, I might already ning the level-off. I look forward to the even a few seconds prior to the VDP, be on the ground, with more fuel. day when all nonprecision IAPs make assuming the ceiling was right at mini- Perhaps, while planning for the ap- use of this new idea, with an aircraft- mums, I could’ve gained sufficient visual proach, if I know it’s going to take an generated CDA. reference to descend below the MDA. unacceptably high rate of descent to Alan Gurevich is a captain for an airline operat- True, I’d have had to start down very reach the MDA prior to the VDP, then ing wide-body aircraft in both U.S. domestic slightly before reaching the VDP to get it’s time to acknowledge that that ap- and international operations. His background on a 3-degree descent angle, or accept proach, and today’s weather, just aren’t includes flying military fighters and transports, a slightly steeper descent by leaving the a safe combination. and engineering work in both the aerospace and systems safety fields. MDA at the VDP. I feel those are accept- All of this is not to say that I don’t able choices, and certainly no worse than like the CDA concept. I just don’t like the possibility of not seeing the runway CDAs when the ceiling is close to the InSight is a forum for expressing personal opinions until the airplane is already leveling off, MDA. And how can I be sure of where about issues of importance to aviation safety and then having to miss the approach. I’ll break out in changing, or marginal, and for stimulating constructive discussion, pro Even if I have the runway in sight as conditions? and con, about the expressed opinions. Send your comments to Frank Jackman, director of the autopilot levels the airplane at the There is one other possibility: Have publications, Flight Safety Foundation, 801 N. VDP, I’m not supposed to disconnect the regulatory authorities recognize the Fairfax St., Suite 400, Alexandria VA 22314-1774 the autopilot and dive back onto the problem of flying approaches to MDAs. USA or [email protected]. glide path. So what do I do? Set up for Instead, convert all MDAs to DHs or
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JUNE 2014 | 11 INBRIEF Safety News Underwater Search
ransmission time should be extended from 30 days to 90 days for the underwater locating devices (ULD) installed in large Tcommercial airplanes to help searchers find flight recorders in the event of a crash into a large body of water, the European Avia- tion Safety Agency (EASA) says. In proposals released in early May, EASA also said that large airplanes that fly over oceans should be equipped with a new type of ULD with a longer locating range than the ULDs now in use. As an alternative, EASA said that these airplanes could be equipped with “a means to determine the location of an accident within 6 nm [11 km] accuracy.” Another proposal said that the recording capacity of cockpit
voice recorders should be increased to 20 hours, up from the cur- Bidgee/WikiMedia Commons rent requirement of two hours. EASA Executive Director Patrick Ky said that the propos- Air Ambulance Rules als, coming as the search for the missing Malaysia Airlines Flight MH370 was about to enter its second month, were intended to edical transfer flights in Australia would be enhance safety “by facilitating the recovery of information by safety reclassified as air transport category opera- investigation authorities.” Mtions under a proposal from the Civil Aviation The proposals must be adopted by the European Commission Safety Authority (CASA). before they take effect; if adopted, they would apply to aircraft The flights currently are regulated as aerial work, registered in EASA member states. and CASA says that Australia is the only nation using that designation. “This classification subjects Australia’s medical transfer operations to a different standard of regula- tion than the International Civil Aviation Organiza- tion standards and those of most other nations,” CASA said. CASA’s proposal calls for medical transfer flights to be subject not only to air transport regulations but also to “specific air ambulance operational require- ments … to provide the flexibility needed for medical flights,” the agency said.
Btfielder/WikiMedia Commons
Information Sharing
he European Aviation Safety Agency (EASA) and the International Air Transport Association (IATA) have agreed on a plan for sharing safety information and jointly analyzing safety trends. T The two organizations said that their analyses would be based primarily on information derived from EASA’s Safety Assess- ment of Foreign Aircraft program — which conducts about 11,000 ramp inspections on randomly selected aircraft and their crews, focusing on flight preparation and aircraft technical condition — and the IATA Operational Safety Audit (IOSA), which evaluates airline operational safety management. “Safety is aviation’s highest priority, and IOSA is the global benchmark for airline operational safety management,’ said IATA Director General and CEO Tony Tyler. “Working together through this information and trend-sharing partnership will contribute to making aviation even safer, while offering the potential to optimize the audit processes.” EASA Executive Director Patrick Ky added that the partnership with IATA will “facilitate the demonstration of compliance to the new rules affecting non-European Union airlines.” Both organizations said that the information-sharing program will help identify safety issues and lay the groundwork for improvements in the safety auditing process, including the European Union’s third-country operator assessments and authorization requirements.
12 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JUNE 2014 INBRIEF
Common Airspace Ice-Detection Study Sought
he European Commission (EC) ivil aviation authorities should ex- has made a formal request to five amine the possibility of installing Tcountries to “make a decisive Cinfrared cameras or other sensors move” to improve their functional to detect the presence of ice or frost airspace block (FAB) — a regional air on aircraft wings, the French Bureau traffic control unit designed as a central d’Enquêtes et d’Analyses (BEA) says. part of the Single European Sky. The BEA included the recommen- Belgium, France, Germany, Luxem- dation in its final report on the March bourg, the Netherlands and Switzerland 4, 2013, crash of a Beechcraft Premier are the first European member states to 1A shortly after takeoff from an airport receive letters of formal notice from the in Cranves-Sales that killed the general EC. Their FAB was formally established aviation pilot and one passenger, seri- in June 2013, six months later than re- ously injured the other passenger and quired by regulations, and subsequent destroyed the airplane. Accident investi- progress in reorganizing airspace has gators determined that the airplane had been slow, the EC said. stalled on takeoff and that its “observed ©Sheilades/istockphoto.com Several other FABs also are not behaviour … was consistent with a stall yet compliant with regulations, the due to contamination of the wings with frost or ice,” the report said. EC said, adding that they may receive The report said that the pilot’s “insufficient appreciation of the risks associated similar letters of formal notice in the with ground-ice led him to take off with contamination of the critical airframe future. surfaces” — and added that the same lack of understanding may have contributed “We have to finally overcome to 32 other accidents since 1989. In those accidents, the aircraft were not deiced national borders in the European before takeoff. airspace,” said Siim Kallas, EC vice “The investigation … showed that an onboard device for the detection of ice president responsible for transport. on the ground could have prevented the [2013] accident,” the report said. “FABs are a necessary, vital component As a result of its investigation, the BEA issued three safety recommenda- of the Single European Sky. Right now, tions, including its call for the European Aviation Safety Agency (EASA), the U.S. these common airspaces exist only on Federal Aviation Administration and other non-European civil aviation authori- paper; they are formally established ties to “study the technical and regulatory means to put in place … systems for the but not yet functional. I urge member detection of frozen contaminants on the critical surfaces of aircraft.” states to step up their ambitions and Another recommendation called for EASA and national civil aviation authori- push forward the implementation of ties to change pilot training requirements to include “periodic reminders on the the Single Sky.” effects of contaminants such as ice on stall and loss of control on takeoff.” The EC considers its system of The final recommendation said that the French Direction Générale de FABs “a cornerstone towards a single l’Aviation Civile should “define criteria to make it mandatory for aerodrome op- airspace that reduced the fragmenta- erators to have deicing/anti-icing facilities at aerodromes.” tion along national borders in air traffic management.” Benefits of the system include Rating Improvement higher safety standards, the EC said, adding, “By enabling airplanes to fly afety standards in the Philippines have improved and the country now merits without dealing with border crossings, a Category 1 rating from the U.S. Federal Aviation Administration (FAA) — FABs will remove the risk of border Sthe rating that signifies compliance with safety oversight standards established interference and national inconsisten- by the International Civil Aviation Organization (ICAO). cies in safety procedures.” The Philippines had held a Category 2 rating — signifying that a country lacks Other benefits include reductions laws or regulations to oversee air carriers in accordance with minimum interna- in fuel usage, costs, travel delays, noise tional standards — since January 2008, when it was downgraded as a result of an and emissions, the EC said. earlier FAA review. Member states have two months The FAA conducts the reviews under its International Aviation Safety Assess- from the receipt of a letter of formal ment program, which is intended to determine whether civil aviation authorities notice to respond. meet ICAO standards.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JUNE 2014 | 13 INBRIEF
Making a List
he European Commission’s 23rd update of its list of airlines banned from operating in the European Union (EU) has ©North Dakota Department of Commerce Treturned flying privileges to all airlines from Swaziland and to others from the Philippines and Kazakhstan. UAS Sites Operating The updated list prohibits operations in the EU for 294 airlines from 20 countries, plus two individual airlines. Ten additional air- wo of the six U.S. test sites selected for un- lines may operate under specific restrictions. manned aircraft systems (UAS) research have Swaziland is the second country to be removed from the list Tbegun operating, one in North Dakota and the because of aviation safety improvements; Mauritania, removed from other in Alaska, the U.S. Federal Aviation Adminis- the list in 2012, was the first. tration (FAA) says. The North Dakota site, under the jurisdiction of the state Department of Commerce, was the first to Crash Site Designated as Landmark receive a certificate of waiver or authorization (COA) from the FAA for flights using a Draganflyer X4-ES he area where wreckage fell after a 1956 midair collision 21,000 small UAS at a site in Carrington. The flights were ft over Grand Canyon National Park, Arizona, U.S., has been scheduled to begin in early May. Tdesignated as a national historic landmark. A primary goal of the Department of Commerce The collision, on June 30th of that year, of a Trans World Airlines is to use UAS in “precision agriculture,” including Super Constellation L-1049 and a United Airlines DC-7 killed all checking soil quality and crop status, the FAA says. 128 people in the two airplanes and is seen as the impetus for a new The second COA was issued to the University of emphasis on aviation safety and the modernization of airways across Alaska Fairbanks, authorizing the use of an Aeryon the United States. Scout small UAS for wild animal surveys at a test The Civil Aeronautics Board — a predecessor of the National range in Fairbanks. Flights began in early May and Transportation Safety Board — found the probable cause of the crash were intended to demonstrate how a UAS can locate, was each pilot’s failure to see the other’s airplane. identify and count caribou, bears and other large The National Park Service said that the hundreds of pieces of animals. aircraft wreckage in the remote section of the Grand Canyon, along with “evidence of Both sites also will collect safety-related opera- Chloe93/WikiMedia Commons tional data needed for the integration of UAS into the land disturbance” National Airspace System, the FAA said, adding that associated with the information “will help the FAA analyze current the crash, convey processes for establishing small UAS airworthiness “a sense of the and system maturity.” accident’s improb- The FAA said that the Alaska flights also “will ability due to the evaluate procedures for coordination with air traf- area’s uncongest- fic controllers, as well as the type and frequency of ed airspace [and] operational data provided to them.” the challenges In North Dakota, operators will collect mainte- associated with nance data “to support a prototype database for UAS recovering ac- maintenance and repair,” the FAA said. cident victims.”
In Other News …
The U.S. Federal Aviation Administration (FAA) has proposed a $547,500 civil penalty against Hawaiian Airlines for allegedly operating a Boeing 767-300 between July 2004 and July 2012 even though it was out of compliance with regulations that required inspections of some thrust reverser components. The FAA said that the airline had requested a conference to discuss the matter. … The European Commission has approved a plan to allow airlines outside the European Union (EU) to obtain a single safety authorization to operate within the entire EU.
Compiled and edited by Linda Werfelman.
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Date: 05/09/14 Client: Teledyne Controls Job #: 1154 File Name: 1154-Teledyne-WGL-AdR8 Page 1 of 1 Account Director: Editor: Designer: dr Revised By: Production: dr Color: 4C/Process Trim: 8.5"× 11" Bleed: 8.75"× 11.25" Safety:8.25"× 10.75" Fold: none Publication(s): AeroSafetyWorld Run Date(s): June Special Instructions: Approved By: COVERSTORY
Despite safety progress, the U.S. air tour industry must resolve duty time, flight surveillance and maintenance issues, a report says.
BY LINDA WERFELMAN
16 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JUNE 2014 © PauuletHohn/iStockPhoto tions, FAA the said. inresponseoped to NTSB safety recommenda- locations.” Many of changes the were devel- weather, at night and landing when at remote “enhanced procedures for in challenging flying helicopter operators would subject to be ter air tour operators and other commercial dates over next the few years, said helicop- nounced at inFebruary to effect take varying ably number high of helicopter accidents.” to helpneeded reduce current the “unaccept- lenges, and that safety new improvements are changing weather conditions and other chal - ment —often flights must cope with rapidly and law enforce services emergency medical - operators —like operators the of helicopter released inJanuary. The list noted that air tour list of transportation safety improvements, copter operations” on its 2014“Most Wanted” with “theto deal unique characteristics of heli- earlier year. this The NTSB included need the ministration (FAA) addressed similar concerns (NTSB)Board and Federal the Aviation Ad- Policy. Johns Hopkins Center for Injury Research and said report the by Sarah-Blythe Ballard of the Part 135commuter and on-demand operators, more stringent safety requirements applied to of withoutkm) base their subject being to the conduct commercial air tours within 25mi (40 tion Regulations (FARs) Part 91operators to eliminate allowing U.S. arule Federal Avia- quality assurance programs and to need the insufficient implementation of maintenance and duty hour limitations for air tour pilots, programs, of for evidence aneed flight stricter erators’ lack of adequate surveillance flight T report on air tour safety concerns. but some problems persist, according to anew for rest the of nation’s the aviation industry, FLIGHTSAFETY.ORG The FAA, inapackage changes of rules an- The U.S. National Transportation Safety Lingering problems include some op- cent well above 10-year period averages issues that pushed accident rates inare- regulators have addressed many of the he U.S. air tour community and federal |
WORLD AEROSAFETY | JUNE 2014 JUNE 1
with an average of 3.5fatalities each. 2010, including 30fatal crashes (20percent) es of U.S. air tour aircraft from 2000through and NTSB, the found that there were 152crash- on anbased examination of data from FAA the Ballard’s earlier study of air tour accidents, StudyEarlier of 100,000 hours 5.1 per flown. rate of turbine-powered all civilian helicopters offshore sites drilling reported anational crash of personnelferrying and supplies heavy-load to extremelythe hazardous activity of overwater investigation by NTSB the in2009.…Likewise, yearsthe 1992and 2001prompted aspecial rate of 100,000hours 3.5per between flown crashhelicopter services emergency medical in Hawaii, with afew exceptions. “Similarly, the operating forspecial rules air tours conducted ring to 1995document the that prescribed Regulation [SFAR] 71,” report the said, refer implementation of Federal Special Aviation alarming thatwas so it prompted emergency the tour crash rate hours of 100,000flight 3.4per report said. hazard” categories of commercial aviation, the elevatedthe rates recorded past inthe in“high hours for Part 91air tour accidents is similar to hours).”flight that of Part all 135operators 100,000 (1.3per hours)100,000 flight and more than two times that10 times of large commuter airlines (0.2per cident rate for air tour all aircraft is “more than 135 air tour operators. operators is 50percent Part more than [that of] said, “the crash rate among Part 91air tour Aviation,of Space, and Environmental Medicine. report, new the published February issue inthe hours) conducted inthose under Part 135,said under Part 91and alower rate 100,000 (2.3per hours)flight inair tour operations conducted hours,flight with rate ahigher 100,000 (3.5per during 100,000 was 2.7per industry that period “Prior to Hawaiian 1994,the helicopter air The rate of 3.5accidents 100,000flight per In addition, report the noted that ac- the “Within air the tour industry,” report the The average accident rate U.S. inthe air tour COVERSTORY 2 - |
17 COVERSTORY
“Exposing air tour patrons and pi- lots to the elevated crash rates normally associated with ‘high hazard’ flight during recreational and occupational activities that occur in visual meteoro- logical conditions is unacceptable, and stakeholders in the air tour industry should continue to work together to reduce this unnecessary risk.”
Industry Response Government and industry have re- sponded in recent years to many of the air tour community’s safety concerns. For example, in 1998, the FAA issued the final accident report said.3 The the proposed ADS-B [automatic FARs Part 136, Commercial Air Tours report cited a series of maintenance dependent surveillance–broadcast] and National Parks Air Tour Manage- errors and identified as contributing system implementation, Hawaiian ment, which deals specifically with air factors the mechanic’s and the quality air tour operators remain opposed to tour operations, with a separate section control inspector’s fatigue. the system, asserting that the system for flights conducted over the Grand Maintenance issues also were would introduce more FAA interfer- Canyon and other national parks. cited in four of the five nonfatal (also ence with operations,” the report said. In 1996, helicopter air tour op- noninjury) air tour accidents that oc- “They have also cited supplemental erators formed the Tour Operators curred from 2011 through April 2014; concerns about the cost of the com- Program of Safety (TOPS), which has in the fifth accident, which resulted in ponents, added weight to the aircraft dealt with a number of safety issues three injuries, the NTSB cited the pilot’s and not enough space in the aircraft including several maintenance-related failure to ensure that the helicopter had for modification.” safety issues. Some of these items sufficient fuel for the flight. Despite their reservations, however, have been the subject of NTSB safety Both fatal crashes, as well as three of some operators have taken steps needed recommendations. Ballard’s new report the nonfatal crashes, involved helicopters. for early implementation of ADS-B avi- cited a TOPS estimate that its members onics to enable their flight surveillance, account for 85 percent of air tour flight Safety Initiatives the report added. hours in a typical year, adding that their Ballard’s new study points to NTSB The industry also has been general- safety record — in comparison to that safety recommendations, increased ly receptive to the Part 136 requirement of all air tour operators — is “consider- oversight by the FAA and the air tour calling for the addition of personal ably improved.” industry’s 20 years of heavy involve- flotation equipment and aircraft float ment in the safety process and in rule- systems to their aircraft — a provision After the Study making efforts with helping to improve that the report describes as the most An ASW search of NTSB accident data the accident record. costly element of the regulation, the showed that, in the years following the Nevertheless, the report said several report said. study of the 2000–2010 period, seven air safety issues still require attention from Another regulatory requirement — tour accidents have been recorded, in- the air tour industry and the regulator. originally an SFAR 71 directive (and cluding two fatal accidents that killed five Real-time flight following, also now Appendix A to Part 136, “Special people each (see “Fatal Crashes,” p. 19). called flight surveillance, remains Operating Rules for Air Tour Operators The NTSB had not, at press time, deter- a problem because, “despite the in the State of Hawaii”) that Hawaiian mined the probable cause of one of the enhanced capabilities of weather air tour flights must remain at or above fatal accidents, but the other fatal crash detection, communication and 1,500 ft above ground level (AGL) — was traced to inadequate maintenance, tour-route tracking associated with has drawn criticism from operators that
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say the limit “inadvertently degrades “It is not clear whether the de- pilot fatigue and noting that the FAA safe maneuverability in an operating creased crash rate is due to the 1,500- has not acted on the NTSB’s recom- environment characterized by unstable ft AGL minimum requirement,” the mendations calling for more stringent meteorological conditions,” the report report added. “It is plausible that the in- duty time limitations for air tour said. creased incidence of VFR-IMC crashes pilots. The impact of the 1,500-ft re- could be related to helicopter flying Part 135 pilots are subject to limita- quirement should be the subject of at higher altitudes, where exposure to tions on flight time and requirements additional investigation, the report cloud cover is likely.” for adequate rest, but those provisions said, citing data that showed that, after The report added that TOPS has do not apply to their Part 91 counter- implementation of the requirement, consistently addressed the maintenance parts, the report said. the accident rate decreased from 3.4 issues that have been the focus of many “Commercial air tour pilots are per 100,000 flight hours to 1.8 per NTSB recommendations involving the exposed to multiple takeoffs, landings 100,000 flight hours. However, the de- air tour industry, including the expan- and maneuvers, resulting in a more crease was accompanied by an increase sion of safety audits to include a review demanding workload throughout the in crashes involving visual flight rules of TOPS members’ maintenance quality day relative to long-haul pilots,” the (VFR) flights into instrument meteo- assurance programs. document said, citing multiple studies rological conditions (IMC). The num- that have identified pilot fatigue as a ber of associated fatalities was similar, Unaddressed Issues primary safety hazard, especially for before and after the rules change, the Other issues have not been adequately those who conduct a number of short report said. addressed, the report said, singling out flights throughout their workdays. “Further, most U.S. commercial Fatal Crashes air tours are carried out by single pilots, so there are no opportunities to share the workload or take in-flight .S. National Transportation Safety Board (NTSB) accident data show two fa- rests, as there are for pilots who are tal crashes involving air tour aircraft during the period from 2011 through part of multi-pilot crews. … Given Uearly May 2014. Each accident involved a helicopter, and each killed the the known risks of fatigue and the pilot and four passengers. high crash rate of Part 91 air tour The fatal crashes occurred one month apart late in 2011. The NTSB has not released its final report on the first of the two crashes, operators, addressing human fatigue which occurred Nov. 10, when a Blue Hawaiian Helicopters Eurocopter in this population through flight time EC130-B4 struck a mountain near Pukoo on the Hawaiian island of Molokai. limitations could be beneficial.” In a preliminary report, the NTSB said that a company flight plan had been filed for the flight, which began at Kahului Airport on the island of Maui, and Notes that visual meteorological conditions (VMC) prevailed, although witnesses reported rain in the area at the time of the accident.1 1. Ballard, Sarah-Blythe. “The U.S. Com- Witnesses also said that “their attention was drawn to the helicopter when mercial Air Tour Industry: A Review they heard some form of ‘woop wooping’ sound” as the helicopter descended of Aviation Safety Concerns.” Aviation, toward the ground. Space, and Environmental Medicine Vol- The other crash involved a Sundance Helicopters Eurocopter AS350-B2 that ume 85 (February 2014): 160–166. crashed in VMC in the mountains east of Las Vegas at dusk on Dec. 7 (ASW, 4/13, 2. Ballard, S.B.; Beaty, L.P.; Baker, S.P. p. 20). In its final report on the accident, the NTSB cited a series of maintenance “Commercial Air Tour Crashes, errors as the probable causes of the crash.2 2000–2011: Burden, Risk Factors, and — LW FIA Score Validation.” Accident Analysis Notes and Prevention Volume 57 (2013): 49–54.
1. NTSB. Preliminary accident report no. WPR12MA034. Nov. 10, 2011.. 3. NTSB. Accident Report AAR-13/01, Loss of Control; Sundance Helicopters Inc.; 2. NTSB. Accident Report AAR-13/01, Loss of Control; Sundance Helicopters Inc.; Eurocopter AS350-B2, N37SH; Near Las Eurocopter AS350-B2, N37SH; Near Las Vegas, Nevada; December 7, 2011. Jan. 29, 2013 Vegas, Nevada; December 7, 2011. Jan. 29, 2013.
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JUNE 2014 | 19 SUMMITSBASS BY WAYNE ROSENKRANS BY WAYNE
isconceptions among professional told the Business Aviation Safety Summit (BASS pilots about their prospects of con- 2014) in San Diego, a conference hosted by tinued qualification for an airman Flight Safety Foundation and the National Busi- medical certificate can prove costly ness Aviation Association (NBAA). Min safety, health and financial terms, says Quay The FAA’s authority to issue waivers to pilots Snyder, a physician1 and president and CEO on some certificate requirements stems from of Aviation Medicine Advisory Service and its agency policy governing the work of aviation parent company, Virtual Flight Surgeons. In medical examiners (AMEs), and this policy es- the United States, inaccurate information has a sentially expects AMEs to help pilots identify, to tendency to seep into some pilots’ understand- the extent possible, any medical conditions that ing at different stages of the dynamic process of might prevent them from flying safely, Snyder revising Federal Aviation Administration (FAA) said. However, pilots should realize that the FAA medical certification standards, he said. is being tasked to do more with less while con- Looking back at 12 months of changes, stantly being asked “Is that safe?” with respect to through first quarter 2014, shows a mostly changes of medical certification standards and
Full Disclosure positive impact on this pilot community, Snyder special issuances under them, he said.
20 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JUNE 2014 SUMMITSBASS
“You’ll be safe if you stay healthy,” Snyder can’t act as a pilot-in-command — nor can you said. “Don’t avoid seeking any medical evalu- act as a required crewmember — if you have any ations. Get what you need because, generally, medical condition or are taking any medication the FAA will waive you. … The sense I hope I’m that may … make you [unsafe]. And you have to conveying is that the FAA has flexibility despite do this before every flight. It’s a self-certification not publishing the policies they’re using — flex- process separate from the medical certificate ibility to liberalize the standards.” that you hold.” Fred Tilton, a physician and former U.S. Although, as noted, the FAA does not Air Force F-15 pilot who retired from the FAA publish its aviation medical policy, the agency post of federal air surgeon in January, published periodically updates and posts its free Guide for policy-directive language to AMEs through the Aviation Medical Examiners3 — available online quarterly Federal Air Surgeon’s Medical Bulletin in the searchable Adobe Acrobat PDF format. that can be summarized as “issue a certificate The Guide discloses, for example, the long-re- whenever possible,” Snyder said. “He did not quested “do not issue, do not fly” list of medica- want to see them deferred. [Tilton would tell tions (Table 2, p. 23). The idea of publishing that AMEs,] ‘If you’re looking at a deferral, call the list had been controversial for years. “The most regional flight surgeon or call the Aeromed- important thing is ‘What’s the underlying condi- ical Certification Division in Oklahoma City tion you’re taking the medicine for?’” Snyder to see if you can get permission to issue that told BASS attendees. “You could be taking an certificate.’” allowed medicine for a disallowed condition — James Fraser, a former U.S. Navy physician or something that wouldn’t be safe.” appointed in March as federal air surgeon, has continued the deferral-averse stance, Snyder Fitness for Duty noted. Fraser has invited experts’ consensus Deficits in pilot cognition related to aging and about the latest scientific evidence for the impairments associated with medications or remaining prohibitions against AMEs issuing other known factors recently have become a an airman medical certificate. The physicians focus area for the NBAA Safety Committee often use an unofficial term — conditions AMEs and the FAA General Aviation Joint Steering can issue (CACI) — for the physical and mental Group, BASS presenters said. Snyder’s firm, conditions that previously required FAA-level for example, has been assessing flight opera- approval for special issuance of a medical cer- tions personnel during the past four years Thorough U.S. tificate (Table 1, p. 22). Those had resulted in for a major company that provides fractional aviation medical pilots not being able to fly after visiting an AME aircraft services. examiners for a medical certificate, having it deferred and “We have [the company’s] data on between waiting maybe three or four months to get the 30 and 40 people right now,” he said. “What was ultimately save time, certificate, Snyder said. initially surprising is we find a lot of different money and airman conditions‚ physical and mental — all [items on 2 medical certificates Personal Responsibility the FAA’s] IM SAFE checklist — but also many Compliance with FAA requirements, one tenet nuances.” Sleep apnea (ASW, 2/14, p. 34) and of pilots. of aviator professionalism, is the foundation depression (ASW, 5/12, p. 29) were the most of the national airman medical certification common conditions noted among these pilots, system. “The one regulation that we, as pilots, and others were of a psychologic, neurologic or have to look at every time we fly — [Fed- drug-induced nature. eral Aviation Regulations (FARs)] Part 61.53, Difficulties in safely performing flight duties, [“Prohibition on operations during medical sometimes manifested by such conditions, had deficiency”] — is not a medical regulation [but] been observed by coworkers in some cases. “The a certification regulation,” Snyder said. “You interesting part is that these are people who no
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JUNE 2014 | 21 SUMMITSBASS
one will fly with, have violated FARS, maintain a strong relationship with because you could be [in] a situation can’t pass training events [and] can no what he called a “good” AME, one where you have a disqualifying condi- longer requalify on recurrent training who is not only qualified as a physi- tion that’s never been looked at — and on their aircraft,” Snyder said. “In about cian, educated in the applicable FARs that’s an AME who’s not willing to 70 percent of [such] people, [AMEs] and closely monitoring pilots’ health make a phone call if something [e.g., an identify a treatable condition. [They] changes, but also motivated, willing and undesired test result] comes in,” he said. do cognitive testing before and after, ready anytime to communicate with the “If you don’t have an AME who — if and we see that treating the medical or FAA on the pilot’s behalf. “That’s the there’s a question — is willing to call psychologic condition returns [pilots] person to go to,” he said. “A good AME the FAA, you need to find a new AME to a healthy cognitive and psychologic is worth his or her weight in gold.” because that person who won’t call will state so they are qualified to fly, and the In his experience, however, some cost you a lot of money in sick leave, FAA routinely certifies them.” pilots claim it’s a great idea to search for downtime, wasted effort and extra tests. an AME who has a reputation for sign- If you don’t have a good AME who will Backlog Empowers AMEs ing medical certificates after a cursory pick up the phone, get rid of that AME.” One of every pilot’s health-related medical assessment or even without an During the past 12 months, this objectives should be to develop and examination. “That really is not good advice has increased in relevance. The FAA’s process of reviewing cases of U.S. pilots with prob- Evolving U.S. Airman Medical Certificate Standards for Health Conditions lematic medical conditions, Health Condition/Issue Change in Policy/Standard Effect on Pilots making decisions and issuing LASIK/PRK eye surgery Return to duty requires no appeal to If normal outcome — 20/20 distant vision — the waivers slowed significantly FAA or grounding period. treating physician’s clearance and documentation are sufficient for AME issuance. because of a temporary gov- Cataract eye surgery After correction of a single-vision If normal outcome, the treating physician’s ernment services interrup- cataract with one intraocular lens, clearance and documentation are sufficient for return to flying duties is simple and AME issuance. Treatment of any multifocal cataract tion. By April 2014, however, quick, but an adjustment period requires a three-month wait — or six months for a the average duration of this is required for more complex functionally monovision pilot — before resuming cataracts. flight duties. process dropped from several Hypertension No longer requires authorization for AMEs typically can issue a certificate based on months to 46 working days, special issuance certificate or waiver, pilot-presented documentation of diagnosis and or stress test or laboratory reports. successful treatment. Snyder said. Electrocardiogram Specific, formerly disqualifying results The AME can issue for 10 result variants that have “The good part is that will now be accepted as normal. been reclassified as “normal.” Abnormal results, [the FAA] pushed all the including erroneous results, require less costly follow-up evaluation. [backlogged] work out to the
Prediabetes AMEs can issue certificates without Pilots using a prediabetes medication other than AMEs,” he said. “The AMEs the special issuance procedure. insulin typically receive first-class and second-class certificates after a 60-day trial, but combining some are given more authority — allowed medications can be disqualifying. more autonomy — and are Heart surgery Pilots return to flight duty more Reapplying for a certificate is now allowed three encouraged to call the FAA quickly after some procedures. months after an angioplasty with stent or a valve repair. Bypass or valve-replacement procedures still to … reduce the paper flow require a six-month grounding period. Only one that’s coming in, the ‘band- initial radionucleide stress test is now required for subsequent issuance. width’ [workload] taken up in Pacemaker-battery Pilots return to flight duty more AMEs can issue the certificate when the surgical all the waivers going back and replacement quickly. wound has healed rather than requiring a two- month wait. forth. … If the AME is will- ing to make a phone call to AME = aviation medical examiner; BASS = Business Aviation Safety Summit; FAA = U.S. Federal Aviation Administration; LASIK = laser-assisted in situ keratomileusis; PRK = photorefractive keratectomy the FAA, you can speed that Note: A presentation to BASS 2014 in April drew attention to highlights of recent FAA policies and standards process up.” governing the issuance of airman medical certificates to pilots who have these conditions/issues. They are among changes that pilots can study in the April 2014 edition of the agency’s Guide for Aviation Medical Examiners. Disqualifying Diagnoses Source: Quay Snyder, M.D. FARs Part 67, Medical Table 1 Standards and Certification
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— technically the FAA’s only medical Evolving U.S. Airman Medical Certificate Standards for Medications regulation — lists only 15 diagnoses that disqualify an applicant for an air- Medication/Concern Change in Policy/Standard Effect on Pilots man medical certificate; that list can be Anti-depressants The period for AME observation FAA in 2010 grounded airline pilots a point of confusion, Snyder noted. The of a pilot being treated for major during their first 12 months of a depression (and other specified treatment limited to one dose of small number appears here because this conditions) with the approved SSRIs one medication, followed by 3 to 6 regulation also states that the federal Celexa, Lexapro, Prozac or Zoloft months of further evaluation before recently has been reduced. issuance, and then an annual cognitive air surgeon — “based on the case his- assessment costing up to $4,000. The tory and appropriate, qualified medical treatment evaluation is now six months, judgment relating to the condition in- and a 1-hour, computer-based, aviation- specific cognitive test costing about volved”— has the authority to identify $300 has been accepted by FAA and any condition, medication or treatment simplifies airman medical certificate issuance. that would make the person unable to “Do not fly” dosing intervals For specified medications on this list, One example was that a listed OTC safely perform the duties or exercise pilots must wait five dosing intervals antihistamine taken every 8 hours now the privileges of the airman medical before resuming flight duties. requires a 40-hour wait. certificate applied for or held. Chantix (smoking cessation) This medication was added to the AMEs cannot issue an airman medical FAA “do not issue” list because of certificate to pilots using this product. The Guide to Aviation Medical new labeling warning users of the Examiners, 336 pages long in 2014, possibility of depression or seizures. contains more than 300 disqualifying Malaria prophylaxis Mefloquine has been disallowed by Prescription anti-malarial medications diagnoses that for many years were FAA, and pilots should verify that only including Malarone usually are allowable medications are prescribed. suitable for airline pilots and strongly difficult for non-AMEs to discover. recommended during travel to some “There’s a downside in that [FAA medi- places. cal policy] is a mystery to everyone, Scheduled medicines All of these — some abused, for For example, Robitussin DM has such (including OTC) example, because of semi-synthetic restrictions, and if taken by a pilot, but the upside is that, as technology opioid properties — are disallowed requires a 60-hour grounding. improves [and] medicine improves, for airline pilots by the FAA “do not fly” list. they can adopt changes without going Nonsedating antihistamines Only 2 products — Allegra and Some commercial products advertised through a rulemaking process,” Snyder Claritin — are approved by FAA. as nonsedating nevertheless are on the said. FAA’s “do not fly” list.
In practice, if the airman brings Valium (various drugs of Valium is prescribed routinely before For example, a single 5-mg dose of the appropriate documentation (see abuse) surgical or dental procedures. Valium grounds the pilot for 24 hours; a 10-mg dose requires a 48-hour “Certificate-Keeping Tactics,” p. 24) grounding; and more than one dose, a to the office visit, the AME now can 21-day grounding. perform the examination and complete Erectile-dysfunction All of these are on the FAA “do not fly” One adverse effect is interference with a standardized worksheet for special medications list, requiring a wait before flight duty blue-yellow color vision, required to (e.g., 6 hours after taking Viagra or 36 correctly interpret the multifunction issuances. Assuming all requirements hours after taking Levitra or Cialis). display of the aircraft. are fulfilled, “the airman walks out with Prescription sleep Among those newly allowed by For example, Sonata, with its 6-hour a medical certificate — bypassing the medicines FAA are Ambien, Ambien CR, Edluar, waiting period before flight, may process that used to take two or three Intermezzo, Restoril, Rozerem and be recommended by a physician for Sonata, but pilots must follow quickly obtaining sleep while Ambien months,” Snyder said. the respective “do not fly” dosing may be recommended for sleeping A group of advocates for further intervals. longer during a 36-hour layover. updates, including Snyder, recently was BASS = Business Aviation Safety Summit; FAA = U.S. Federal Aviation Administration; OTC = over-the- counter (nonprescription); SSRI = selective serotonin reuptake inhibitor informed that the FAA has adopted Note: A presentation to BASS 2014 in April drew attention to highlights of recent FAA policies and 14 of the 18 most recently proposed standards governing the issuance of airman medical certificates to pilots who use these medications. changes, expanding “protocols for They are among changes that pilots can study in the April 2014 edition of the agency’s Guide for Aviation Medical Examiners.. conditions that we think should be Source: Quay Snyder, M.D. well within the authority of an AME to issue,” he said. “Some of the ones we Table 2
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weren’t successful in getting approved imme- prohibits driving a motor vehicle under the diately — but I think will — are in the cancer influence of alcohol (or other intoxicating sub- category, particularly lymphoma and leukemia.” stances or medications), potentially irreversible consequences to an aviation career can result. Intoxicated Driving Driving under the influence (DUI) and driving If a professional pilot in the United States is while intoxicated (DWI) are two common terms charged by police with violating a state law that for this offense. “The FAA doesn’t look kindly upon drink- ing,” Snyder told BASS attendees, referring to Certificate-Keeping Tactics such arrests, convictions and administrative ac- tions. If an applicant ever has registered a blood part from strategically selecting an aviation medical examiner alcohol level greater than 0.1499 in the context (AME) and building a long-term relationship, airline pilots can of an alcohol-related driving incident — in Aavoid or overcome problems in the issuance of a U.S. airman other words, 0.15 or higher — the AME cannot medical certificate by applying simple tactics to the office visits, ac- issue a medical certificate, he said. Likewise, cording to Quay Snyder, a physician and president and CEO of Aviation if the applicant refused to provide a breath- Medicine Advisory Service and its parent company, Virtual Flight alcohol sample to a law enforcement officer, Surgeons. His recommended tactics include: the AME cannot issue a medical certificate. In • Schedule the office visit early in the month of certificate expira- tion. That way, if Federal Aviation Administration (FAA) require- practical terms, the pilot is likely to lose flying ments impose a two-week wait before issuance, you still can fly privileges for three to six months while dealing on the current certificate. with the paperwork required before the FAA • Prescreen your medical status and history, and be ready to talk about rules on whether to restore the airman medical treatments received or available, and medications being taken. certificate. • Don’t show up sick on the day of the examination. The AME will The AME also must defer certification, for not be able to issue the certificate in that circumstance. From example, if any alcohol-related or drug-related the AME’s perspective, rescheduling the appointment does not driving incident occurred within the preced- result in a penalty and has no detrimental effect on obtaining a new certificate — even if the postponement causes the current ing two years and there has been another arrest, certificate to lapse. conviction and/or administrative action at any • Be ready for the physical examination by bringing all relevant other time. “[If] you had a minor-in-possession medical records, corrective lenses and hearing aids. If you charge 30 years before [the latest incident,] that already have an FAA letter of authorization for special issuance, is disqualifying; the AME cannot issue,” Snyder present the letter so the AME knows what documents must said. He cited that scenario because it was an be checked. There are more “conditions AMEs can issue” than actual case involving a pilot who was arrested ever — i.e., AMEs often have authority to immediately make decisions about issuance — but only if the pilot can present all for DUI while driving away from celebrating a required documents. daughter’s wedding to assist someone involved in • Don’t unwittingly induce strange electrocardiogram (ECG), a car accident. The arrested pilot had to provide heart rate or blood pressure measurements, which will prevent the AME a record from the 30-year-old incident. the immediate issuance of the certificate. Prior to an office visit Moreover, the AME cannot issue if the applicant involving these tests, minimize consumption of caffeine, a factor has had a total of two arrests, convictions or ad- that can induce unusual heart rhythms. Anything causing signifi- ministrative actions within the preceding 10 years, cantly high blood pressure during the visit can be a problem. By or has had a total of three arrests, convictions or the same token, a resting heart rate of 50 beats per minute or less — while normal among fairly well conditioned athletes — administrative actions within a lifetime, Snyder said. will be problematic for the AME, so performing an activity such Generally, the AME does not take further as jogging in place before the ECG is advisable so that the rate action until the pilot provides all police reports, exceeds this low end of the normal range of typical patients. driving records from all states that ever issued —WR the pilot a driver’s license, arrest records, court records and military records. This process also
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includes a requirement that the pilot to do that, although some [cases] can be apnea,’ you give that to the AME — write and sign two personal statements, extended.” Sponsors of the pilots dictate that’s the end of the evaluation. No one explaining the circumstances that how much random drug and alcohol more questions. … If you come in and caused a law enforcement officer to testing, generally off-duty testing, that [tell the AME, furnishing documents stop the pilot and investigate, and the each participant must undergo. and compliance data,] ‘I have sleep other describing the pilot’s entire drink- apnea and I’m on a CPAP [a continu- ing history from taking the first drink Sleep Apnea Update ous positive airway pressure machine] until the present time — including how Tilton, the former federal air surgeon, and I’m using my CPAP, the AME is much alcohol is consumed, what types generated controversy within the directed to clear you right then. Or of alcohol are consumed and in what professional pilot community by pro- you can continue to fly while you’re situations the pilot drinks alcohol. posing a new requirement that AMEs going through the evaluation as long “Then you have to get a substance- proactively screen all airline pilots for you’re making progress toward getting abuse evaluation [compliant with obstructive sleep apnea (OSA) based on the treatment initiated.” detailed] FAA standards,” Snyder said. factors such as body mass index (BMI). The only thing required for cer- “You may as well pay for [this] evalu- The proposal was withdrawn but led tificate renewal is delivering current ation up front with the person who’s to high awareness of this condition compliance data to the AME, such as qualified to do it. … So my bottom line and the serious risks to commercial validating the pilot’s correct use of the is ‘You can’t afford a DUI — not in this aviation. “OSA has been a disqualifying CPAP. The recent ASW article offers career.’” Some BASS attendees indicated condition since 1996 with the FAA,” details of three other OSA-treatment that they already were familiar with Snyder said. “People have been getting options allowed by the FAA. the national Human Intervention and waivers for it. In the past, there was no Motivation Study–based abstinence effort to screen for OSA.” Notes program, which began in the early In December 2013, 15 advocates 1. Snyder holds doctor of medicine and 1970s and essentially allows U.S. airline for pilot medical interests — including master of public health degrees. pilots who have a diagnosis of sub- Snyder — met with FAA officials and 2. He said that the FAA Aeronautical stance abuse to continue flying if they worked out an agreement on how to Information Manual [AIM], Section are identified to the FAA and if they address the issue of OSA in pilot ranks. 8-1-1, “Medical Facts for Pilots” — are participating successfully in the “[FAA] will screen based on BMI,” he which recommends use of the IM SAFE program (ASW, 9/06, p. 32). said, summarizing the status of new personal checklist — constitutes the only “It’s a wonderful, collegial program agreements as of mid-April. “If you guidance on physical/mental fitness for [among] the airline management, the have a BMI of 40 or greater … that’s duty published widely for all U.S. pilots. In the AIM edition last updated Aug. unions and physicians, both FAA and what’s considered morbidly obese, and 22, 2013, the checklist says every pilot commercial,” he said. “We’ve returned 98 percent of people who have a BMI should be able to say before flight, “I’m 4,800 airline pilots with drug and alco- like that will meet medical criteria for physically and mentally safe to fly; not hol dependence to flying. … They have sleep apnea.” being impaired by: illness, medication, to attend a 12-step [treatment] program. In practice, the pilots newly identi- stress, alcohol, fatigue [or] emotion.” They have to do weekly after-care, fied by these criteria now get 90 days to This AIM section elaborates on the scope of issues within each listed item, a group meeting with a professional see a primary care physician for assess- as well as broader aviation medical facts [substance-abuse counselor present]. ment of possible OSA, and several types to consider. Snyder said that a future They have to get annual psychiatric as- of physician-prescribed home studies edition will combine the “emotions” sessments. … The minimum period of are allowed. “The screening is different item content under the “stress” item and time for alcohol [abuse] is three years in [now, no longer requiring evaluation introduce “eating and hydration” as the that monitoring program, after which only by a sleep medicine specialist], last checklist item. they have to maintain abstinence for the and … unless you have [OSA] that’s not 3. FAA. Guide for Aviation Medical duration they hold the medical cer- treated, it’s not grounding,” Snyder said. Examiners. April 22, 2014.
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classroom course in fatigue coun- good sleep routine habits and avoid- risk management system (FRMS) and termeasures gave a short-lived ance of the majority of sleep routine and subsequently made available online at boost to aviation maintenance health and fitness bad habits, but there
Study finds need for frequent
© OSTILL | iStockphoto reinforcement of the principles of fatigue countermeasures. Fatigue
FIGHTBY LINDA WERFELMAN
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“Such policies are counter to per- sonal, organizational and public safety Do This, Not That and foster a culture where it is acceptable (and expected) to work when fatigued.” esearch into fatigue countermeasures has yielded many recommenda- The report cited previous studies tions for improving the quality of sleep and taking other action to limit that concluded that aviation mainte- Rfatigue.1 nance technicians slept an average of Recommended good habits include: five hours a night, and that people who • Using a pre-sleep routine at a consistent bedtime, sleeping only in the bed- routinely sleep less than seven hours room and modifying the sleep environment (by blocking out noise, keep- a night may experience “significant ing the room cool, silencing the telephone and asking not to be disturbed); daytime cognitive dysfunction that • Drinking plenty of water, eating nutritious meals that are not too large, accumulated to levels comparable to taking vitamins, exercising regularly (walking, stretching, strength train- ing and using cardio exercises) but not within the three hours before that found after severe acute total sleep bedtime; and, deprivation.” • Wearing sunglasses while going home from work in the morning, increas- Over the past two decades, some ing exposure to bright light, using relaxation techniques, socializing with industries that operate around the clock others and making family and friends aware of the work schedule. — including railroading, trucking and Bad habits to be avoided include: water transport — have adopted train- • Exercising right before going to bed, although exercise earlier in the day ing in fatigue countermeasures to help is beneficial; mitigate fatigue risks. • Eating unhealthy food; “The training can be beneficial to • Using caffeine or other stimulants, although caffeine consumed at strate- both the individual and the organiza- gic times during a work shift can boost alertness; tion,” the report said. “Individuals who • Using tobacco; replace bad sleep and health habits • Using alcohol to relax before bedtime; and, with good ones benefit from improved • Watching television in bed, watching the clock in bed and sleeping less sleep quality and quantity, while the than usual on days off. organization benefits from improve- — LW ments in performance and fewer Note safety-reducing turnovers, absentee- 1. Banks, Joy O.; Wenzel, Brenda M.; Avers, Katrina E.; Hauck, E.L. An Evaluation of ism and morale issues.” Aviation Maintenance Fatigue Countermeasures Training, DOT/FAA/AM-13/9. A report prepared by the U.S. Federal Aviation Administration (FAA) Civil Aerospace Medical A training program was developed Institute and Kenexa Inc. for the FAA Office of Aerospace Medicine. May 2013. that covered three areas — sleep ba- sics, including the sleep process, circa- dian rhythm, sleep disorders and sleep Measures that determined whether classroom training session and in fol- debt; fatigue basics, including fatigue- the program met its objectives included low-up activities. Thirty-three workers related hazards, causes and symptoms “gains in knowledge, increased aware- volunteered to attend the three-hour and how to assess fatigue; and fatigue ness of fatigue risk and the importance class, led by a CAMI researcher with countermeasures, including work of managing fatigue, and an increase in considerable classroom-instruction breaks, napping, sleep routine and the self-report of fatigue-relative positive experience. After each of three sec- sleeping environment. behaviors and reduction of negative tions of the class, the instructor led a The program’s objectives were to behaviors at home and work,” the docu- group discussion, reviewed the section’s “remember symptoms of fatigue and ment added. content and conducted a check on the fatigue countermeasures, recognize the participants’ understanding of what importance of managing fatigue risk and Airline Participation they had just been taught. incorporate practical recommendations A major airline — not identified in The evaluation focused on four for fatigue prevention and management the report — agreed to have its main- areas: “learning (positive change in into one’s daily routine,” the report said. tenance personnel participate in the knowledge of and attitude toward
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countering fatigue), behavior modifica- number of score changes in this area awareness of FRMS strategies as well tion (change in fatigue management were characterized as not statistically as the “consequences of fatigue, which behaviors at home and work), transfer significant, even though they were influenced some to change their daily (application of what was taught at home higher after training than they had activities in an effort to manage fa- and work) and reaction to the training been before.) tigue,” the report said. experience,” the report said. When the questionnaires about The document characterized the Of the 33 workers attending the fatigue knowledge were repeated workers’ response to the class as en- class, 24 participated in both of the first six weeks after the class for 14 par- couraging, especially in light of earlier two data-collection sessions, conducted ticipants, the average score was 68.9 studies that found resistance to the one week before the classroom session percent, down from the “after” ques- concept of fatigue management. and immediately afterward; only 14 tionnaires but still 40 percent higher “Modifying and sustaining new were available six weeks later to com- than the average had been before behaviors and attitudes toward fatigue plete a final, follow-up questionnaire, training, the report said. At the same can be challenging, since lifestyle the report said. time, the questionnaires measured a changes are required,” the report said. The 24 classroom participants had downward trend in awareness, self- “When resistance exists, a positive an average age of 50.4 years and had efficacy and intention toward fatigue approach would be to treat it as valu- spent an average of 29 years on the job. management, although, again, many able feedback. For instance, during They worked an average of 43 hours a of the differences were not considered class, some attendees voiced resistance week with an average of 2.8 hours of statistically significant. For example, to changing their sleep habits. The overtime. More than 90 percent worked when asked how motivated they were interaction provided the instructor a day or extended day shift, and 25 per- to avoid feeling fatigued, the aver- an opportunity to generate a bet- cent said they had received prior fatigue age score was 4.0 in the immediate ter understanding of how and why awareness training. post-training questionnaire and 3.4 six they needed to modify their sleep weeks later. Asked to what extent they environments.” ‘Immediate Impact’ thought they could successfully man- The document noted that duty The report said that evaluation results age fatigue, the post-training score was hour limitations and other rest of the impact of classroom training 3.7, compared with 3.2 six weeks later. requirements do not exist for main- showed an “immediate impact of train- When answers to the six-week tenance personnel, who therefore are ing on attendee fatigue-related knowl- follow-up questionnaire were compared “susceptible to high levels of physical edge.” Average scores on questionnaires with the pre-training responses, the and cognitive fatigue. Implementing designed to assess the 24 participants’ results were statistically insignificant. an effective fatigue countermeasures knowledge of fatigue increased from 50 The average scores were slightly lower training program is just one step that percent correct before the class to 75.2 when the respondents were asked how aviation maintenance organizations percent correct afterward. committed they were to managing should take in reducing fatigue risk to Before-and-after questionnaires fatigue and how motivated they were improve public safety.” — with identical questions — also to avoid feeling fatigued and slightly measured increases in participant higher when they were asked how often Notes awareness of the importance of not they thought about ways of managing 1. Banks, Joy O.; Wenzel, Brenda M.; Avers, being fatigued while at work, as well fatigue and how often they changed Katrina E.; Hauck, E.L. An Evaluation as their commitment to manage their their behavior or schedule to avoid feel- of Aviation Maintenance Fatigue fatigue, the report said. For example, ing fatigued. Countermeasures Training, DOT/FAA/ AM-13/9. A report prepared by CAMI when asked to rank, on a scale of 1 and Kenexa Inc. for the FAA Office of 2 Course Evaluation to 5, how important they thought it Aerospace Medicine. May 2013. was to not be fatigued while on duty, Although the course content was still 2. On the 5-point scale, 1 represented respondents scored an average of 4.2 being developed when the mainte- “never,” 2 represented “rarely,” 3 repre- in the pre-training questionnaire and nance personnel took the class, the sented “sometimes,” 4 represented “often,” 4.5 post-training, the report said. (A material generally increased their and 5 represented “always.”
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Airlines take a fresh look at all first officer training through the lens of their performance-based MPL programs. Timely Refinements BY WAYNE ROSENKRANS
few of the world’s airlines al- a proof-of-concept data analysis (ASW, MPL deficiencies and impediments ready are taking steps to refine 5/14, p. 38) for the International Civil encountered during implementation traditional ab initio pilot train- Aviation Organization (ICAO). (Table 1, p. 30) influenced an informal ing programs after comparing Airline case studies, other regulator working list of improvement priorities Athe performance of these cadets to that analysis, perspectives of approved train- — some tied to industry safety objec- of counterparts qualifying as first offi- ing organizations (ATOs) and positions tives, such as upset prevention and cers through multi-crew pilot licensing taken by the International Federation of recovery training — that could acceler- (MPL) programs. Airline representa- Air Line Pilots’ Associations (IFALPA) ate launches of new MPL programs. tives described these steps as seizing comprised much of the December A number of presenters and at- opportunities to provide the best as- agenda of the ICAO Multi-Crew Pilot tendees stressed that any performance pects of both program types in light of License Symposium. The accounts of level by MPL cadets and graduates that
the high MPL success rate reported by airlines’ experiences in overcoming merely matches that of traditionally © Monika Wisniewska|Dreamstime
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Case Studies of Challenges Facing Airline MPL Programs
Partnership/Start/Scale Problems/Adjustments Solutions/Recommendations Lufthansa Flight Training (Germany MPL was implemented in parallel with an advanced IFR skills improved quickly after replacing a turboprop Switzerland, United States and Japan); ab initio and integrated ATPL program already using aircraft procedures training platform with the Cessna February 2008; more than 800 cadets complex high-performance aircraft, MCC, CRM and Citation CJ1 FSTD and aircraft with a custom third- completed at least the basic phase, with airline jet FSTDs for first officers. Key issues were pilot radio console. UPRT was enhanced by the use of 400 graduates now flying as first officers the recruitment of sufficient instructor pilots for the the Grob Aircraft G120A aerobatic trainer. One future for Lufthansa, Germanwings and Luf- basic phase to prevent waiting periods, and airline enhancement will be targeted theoretical instruction thansa Cityline volatility causing reduced pilot demand coupled and scenario-based exams replacing multiple-choice with a European restriction on MPL holders’ ability to exams, partly to boost relevance for recognition of obtain employment with a different operator. threats, errors and undesired aircraft states. Air China Southwest, China Eastern Students with no prior flight training had difficulty The CJ1 is used in a manner similar to the Airlines, Civil Aviation Flight University of assimilating 900 hours of theoretical training at Lufthansa Flight Training MPL program. Airbus China, Civil Aviation University of China, one time, so this was divided into two parts. The A320 or Boeing 737 FSTDs are used for the type and China Academy of Civil Aviation Civil Aviation Administration of China has set 20 rating in the final advanced phase of the pro- Science and Technology (China, July takeoffs and landings in the type-rating aircraft as gram. Computer-based training and learning- 2008, 35 cadets in first three courses and the minimum. As in other states, instructor pilot management systems have accelerated English 80 more now enrolled; two of six early qualifications currently specify ratings and flight proficiency. Aptitude testing of candidates based MPL graduates have upgraded from first hours rather than competence-based selection cri- on latest international standards, new competency officer to captain at China Airlines and teria, but China Eastern is an exception by applying standards for instructors and uniform training for Xiamen Airlines) Airbus competency criteria. examiners and inspectors became critical priorities. Dragonair/Cathay Pacific Group, Hong Hong Kong Civil Aviation Department required Dragonair compares performance of its first gradu- Kong Civil Aviation Department and CAE safety management systems for airlines imple- ates of MPL and of 150 datasets of pilots in parallel (China, 2013, 76 cadets) menting MPL to help assure adequate consider- past/present CPL-IR programs. Competency-based ation of risk, including MPL laws. Adverse wind/ training of cadets on both tracks begins at the base weather, heavy traffic, aircraft scheduling and training stage. CPL-IR cadets typically perform 20 inefficient ATC at a Chinese airport used for base takeoffs and landings to achieve three-in-a-row training increase typical experience all cadets need rated satisfactory. MPL cadets averaged 22 to to master takeoffs and landings. Visual flying, raw attain proficiency. Results from data collected led data flying and manual flying elements in the in- to enhancement of descent-profile management, termediate phase have increased, along with extra terminal-area situational awareness, runway-exit pre-base practice in higher-fidelity FSTDs. finesse and ATC communication. Ethiopian Airlines, FlightPath Interna- Increased demand for pilots and a base-training Significant challenges have been ATC communica- tional and Ethiopian Aviation Academy airport with significant congestion have proved tion proficiency “gaps” and adapting to cultural/ (Ethiopia, October 2011, first 26 cadets to be special challenges. Chronic shortages and behavioral norms of power distance, particularly graduated in May 2013; 95 more cadets in high prices of avgas also have affected cadets’ cadets performing duties differently in the presence courses as of symposium) schedules, leading to use of the Diamond Aircraft vs. absence of people in authority. Modifying the DA42-VI, which uses Jet A. cadet-selection process was cited as a mitigation. Swiss Airlines and Swiss Federal Office of Unsatisfactory performance in MPL first officer Partners are pursuing new tools for ATC simulation Civil Aviation — comprising MPL Quality communication with ATC was noted. In 2010, a to reflect real-world voice communications that Board — and FlightSafety International completely modified MPL course added MPL topics often vary from official ICAO English phraseol- (Switzerland and United States, 2006, 133 to the continuing ATPL program for 140 students, ogy. MPL program cadets showed slightly more MPL students) including TEM and progress tests in every train- problems relative to their ATPL counterparts in ing phase. MPL students typically needed more approach phase monitoring, taking expected practice in a Diamond DA42 (34 vs. 25 landings) action at pilot-monitoring intervention thresholds, for mastery of takeoffs and landings before Airbus flight path awareness, navigation, automation A320 type-rating training. An electronic qualifica- management and mode awareness/selection. In tion system tracks cadet performance and helps to several cases, the MPL student “showed excellent calibrate instructor ratings of cadet competency. planning ability at the end of the base training but For example, data showed those in the ATPL struggled then with changing conditions on the program at a “slight disadvantage in the area of lis- line.” Providing additional simulator practice was tening watch and clearly weaker results in standard one response for both programs. phraseology, in ATC-related [communication] and in [speech] structure articulation” while the MPL group showed difficulties in standard phraseology of procedures more than in clarity of expression. ATC = air traffic control; ATPL = airline transport pilot license; CPL-IR = commercial pilot license-instrument rating; CRM = crew resource management; Date = implementation of first course(s); FSTD = flight simulation training device; ICAO = International Civil Aviation Organization; IFR = instrument flight rules; MCC = multi-crew cockpit; MPL = multi-crew pilot license program; Scale = cadets and graduates, as shown, as of December 2013; TEM = threat and error man- agement; UPRT = upset prevention and recovery training
Source: Presentations by airline partnerships at the ICAO Multi-Crew Pilot License Symposium Table 1
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trained first officers eventually will be deemed that we might be out there to get rid of solo insufficient, despite ICAO’s good-news proof- time; that was never included in the MPL provi- of-concept. This redoubles the need for careful sions,” he said. “There is no intent to eliminate selection of additional performance metrics, the solo time, not from an international per- they said. spective. The other point that was raised was the use of aerobatic airplanes for the purpose of Competency Confusion upset prevention and recovery training. … The Dieter Harms, a captain who consults as a senior provisions do not dissuade the states and the adviser to the International Air Transport As- ATOs from using aerobatic airplanes, but do not sociation (IATA) Training and Qualification establish it as a requirement.” Scarce availability Initiative and the Civil Aviation Administration of aerobatic aircraft in some states and regions of China on MPL implementation, said that his was cited, as was the possibility of negative improvement priorities merely reflect a growing transfer of training on recovery techniques consensus. He also is member of the European from inappropriate instruction in small, utility- Aviation Safety Agency’s MPL Advisory Board, category airplanes to large transport category and he chaired IATA’s MPL Implementation airplanes, he said. Working Group, A number of MPL-implementation lessons “First, solve the ‘competency confusion’ provided by the first 30 airlines now can be ap- … when people speak about [ICAO’s similar- plied globally. “I think that we all agree that this sounding Procedures for Air Navigation Ser- proof-of-concept has been completed … that vices–Training (PANS-TRG)] competencies and the MPL at this particular juncture has met the pilot core competencies,” he said. “We have expectations of the global community,” Fox said. to improve course-approval guidance [on the Leading explanations for MPL successes, as process by which state authorities approve an cited in the case studies, are: stringent cadet- MPL course]. There is also a lot of confusion selection process; competency-based training; ‘The MPL needs to be [about this] around the world. We have to link competent instructors; integrated threat and er- EBT [evidence-based training] and the MPL. … ror management; learning-management systems sustainable, it needs We have to follow what we call the ‘total systems and record keeping; continual feedback about to be repeatable, and approach.’ We have to adjust theoretical training programs from cadet pilot performance data, ca- to the competency principle. We have to adjust dets and sponsoring airlines; and robust global it needs continuous the base training to competency-based prin- MPL data sharing and analysis. “The MPL needs ciples. We have to remove the ‘European license to be sustainable, it needs to be repeatable, and improvement.’ restriction’ [for MPL holders]. We have to clarify it needs continuous improvement,” Fox said. and finalize the [solution to] uncertainty about As in the evolution of other performance- where and when we need motion [simulators based training in aviation — MPL presumes far during MPL Phase 3]. We have to clarify the air more from regulators than checking airlines’ traffic control [ATC] simulation. … [We have compliance with regulations — government over- to] improve the qualification requirements for sight can be a serious challenge for some states. MPL instructors, especially for Phase 2. Last, “The MPL is a very good example of the perfor- not least, [we have to] improve and continue the mance-based requirement,” Fox said. “[Oversight data collection and analysis process.” is] going to require some additional skills, and Symposium sessions generated examples I think we need to promote the skills for the of misunderstandings that actually should be regulators. … [There is] need for better inspector fairly simple for ICAO to clarify, said Mitchell and examiner qualifications, for sure, and that Fox, chief, Flight Operations Section, ICAO Air might be [in] improved guidance material” such Navigation Bureau. “There was a lot of concern as amendments that increase the overall level of expressed on the part of several of the speakers detail on this subject in PANS-TRG.
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actual flight time (including solo time) and sim- Typical Analysis: MPL Advanced Phase (IOE) Data ulator training also need further study. A similar at Dragonair, 2013 variation arises when balancing time spent on 80 220 instrument flying using raw data against time 76 74 70 185 spent on instrument flying with automation. Another area where variations among MPL 60 150 programs stood out was the number of full-stop 50 120 takeoffs and landings that different national Hours 40 85 regulators require MPL cadets to perform in the Sectors/landings 30 55 actual aircraft in which they will be type-rated. ICAO provisions call for a minimum of 12, a 20 20 Sectors to Sectors to Hand- own MPL ight number that the regulator can reduce but that in IOE MPL IOE CPL-IR landings training MPL many cases has been increased significantly. Fox said this is another program aspect that needs CPL-IR = commercial pilot license-instrument rating; FSTD = flight simulation training device; IOE = initial operating experience; MPL = multi-crew pilot license closer harmonization to be predictable from one Note: In parallel programs to train first officers, Dragonair MPL and CPL-IR cadets are scheduled state to another state, and to support eventual to perform 30 basic IOE sectors, then an FSTD continuation session, then 36 advanced-phase sectors leading to a full-sector, final line check of their qualification for release to line flying. recognition of MPLs among states. These data for the sectors actually flown show similarity between a relatively large dataset of av- IFALPA takes the position that MPL-specific erage sectors for CPL-IR cadets and the average sectors for the small, first class of MPL graduates. data collection and analysis should be expanded Source: Dragonair greatly and be uniform for comparisons over time, Figure 1 said Tanja Harter, an Airbus A320 captain and presenter representing the federation. “We need to Ironically, several presenters said, the qualifi- collect data from after the license [issuance] and cations for instructors under the MPL provisions not stop at the license [issuance but rather include] are prescriptive — i.e., requiring hours of experi- data beyond — up to captaincy — and maybe even ence in specific areas rather than evidence of the beyond that, including feedback not only through specific competencies — so they clash with the [line-]check data but also from the day-to-day ops basic idea of performance-based training. [i.e., routine flight data monitoring of operations to A number of presenters and attendees shared look for root causes],” Harter said. “Where did the the opinion that MPL programs would be en- strengths come from, and what’s causing the weak- hanced simply by tighter integration of knowl- nesses? And, if possible, correct those.” edge, practice and testing. An example would be interspersing activities focused on theoretical A Vulnerable Flower training with activities that require almost im- Many other data-collection possibilities were mediate practice in practical scenarios. Another advanced. “The ATPL [airline transport pilot is conducting mastery tests along the way that license] in the current training system has led to progressively measure each cadet’s progress fairly good safety data, so already we know that’s rather than conducting an all-encompassing test a good starting point,” added Stéphane Clément at the end of a training course. of CAE. “It would be good if we eventually could Another enhancement yet to be considered compare the MPL graduates to today’s reality.” — especially in Europe, where an MPL holder Clément added that some recognized only can fly for his or her sponsor airline — is a deficiencies, along with the complexity of MPL defined, internationally agreed path to employ- implementation, are “right now a barrier to ment for MPL graduates who do not obtain a adoption of MPL worldwide, and the more first officer position from that operator. clarity and the more simplicity … the smoother Differences in how airlines and ATOs at- the adoption will be and the faster the benefits tempt to provide MPL cadets a balanced ratio of will come.”
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Doug Farrow of the U.S. Federal are not wasting time and money for ATPL students a different way by Aviation Administration said that one the students or for us. So that is the looking at competencies, giving them a of the most sensitive performance difference. better chance to develop their compe- metrics is line operational evaluations “At some other point, there is a tencies, making them better pilots. … in actual line conditions. ICAO’s Fox possibility to transfer the idea of MPL This is, in my opinion, one major and noted that to his knowledge, airlines competency training to the CPL-IR very important side effect from MPL.” with MPL programs have yet to use [commercial pilot license–instrument Several speakers described some that tool to track MPL cadet/graduate rating] conventional training. That MPL cadets’ relative difficulty attain- performance. should be the next step.” ing the required level of proficiency in “We need better data, so we have to Nick Taylor of Transport Canada pilot–air traffic control communica- reengineer the questionnaires, and we Civil Aviation said that although some tion. ICAO’s Fox said there is reason have to include the [MPL first officer] airlines have had comparable outcomes to believe the issue is broader than upgrade issue because I think, in the from the MPL and the traditional ab MPL programs and does not necessar- next years, we will see more and more initio training of first officers, this is ily imply a problem communicating MPL graduates upgrading to captains,” the exception rather than the rule at a in English. “We tend to focus in on a Harms said. “This thing [MPL] is still global level. “My … very small observa- very rote practice of phraseology, but a little vulnerable flower; it is not yet tion of MPL [indicates] that it is fun- when [MPL cadets] get out into the real a robust system. If we take care of it, damentally better than the traditional world, it doesn’t always work that way, and if we do not allow misuse, then I route that we normally see,” he said. and some of the graduates are hav- predict that in a five-year period, MPL Bai Hongqiu, a captain and deputy ing problems in adapting to that,” he [will become] the leading system for director of flight training, Standards said, acknowledging a need for more our future airline pilot training.” Department of the Civil Aviation Flight guidance material on solutions, such as Dirk Kröger, a captain and vice University of China, said that after com- jump seat observations of line opera- president, Pilot Schools Division, paring the traditional, pre-airline train- tions, as some attendees suggested. Lufthansa Flight Training, cautioned ing backgrounds of first officers in states Another tool requested by IFALPA attendees that in cases where an airline and regions such as the United States, is official guidance on the expected role already has inserted competency-based Canada and Europe, officials came to the of MPL programs in the development training into a traditional ab initio pro- conclusion that “The world is different. of future commanders/captains. gram, the apparent similarity of MPL … Chinese airlines are very welcoming IFALPA’s Harter also indirectly pilot performance can be misleading to the MPL training. … In China, the touched on this last aspect of balanc- regarding true MPL benefits. [MPL] results are good; they’re excellent ing the time that MPL cadets spend “[For all] students who finally … totally different for students gradu- in flying airplanes, particularly solo pass the line training — [at] airlines ated from the CPL [course] compared to flights, which has not been captured in in which this is hopefully already the MPL students.” the data showing the success of MPL competency-based — we have the A representative from an Austrian programs. “We know there’s discussion same result,” Kröger said. “[Lufthansa, ATO cited an operator that considers about ‘fear factor,’ but I think that still, however,] heard a lot about high drop- MPL a “brilliant” solution based on real-flight training is required for actual out rates happening with the students results for cadets in four courses. The risk exposure,” she said. “Why? Because coming from different programs. … operator has been pressing for regula- there is some emotion involved when I saw a 0.5-percent failure rate in the tor approval to reduce the minimum you fly alone, and know you’re respon- IOE [initial operating experience], 12 landings in ICAO MPL provisions sible for your own [life]. And I think and that is our goal, and no failures in because that number has proven to be that makes the difference. Learning the intermediate or advanced phase a “waste of resources.” “This is reason through emotions can be very power- [of MPL]. We have selection [of only no. 1 for why to have MPL. … [MPL] ful, and sometimes we need it. [There’s] about 9 percent of total applicants up] makes us a different ATO now, giving no need to … to adjust the simulator front, and then a low dropout rate in us the opportunity to [also] train our to include the fear factor, that’s not the the beginning of the training, so we unscreened, regular, self-sponsored idea. The emotion is the thing.”
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CAUSALFACTORS
he drag created by the nil or negative the power levers, which contribute to propeller thrust produced by propellers set in the control, from being moved into beta/ground beta/ground idle range is very useful idle mode at the wrong time, such as on short in controlling taxi speed on the ground final approach. Twithout wearing out the wheel brakes, but it Like other aircraft manufacturers, Xian went can transform an aircraft’s aerodynamic ef- one step further in its MA60 twin-turboprop ficiency to that of a grand piano when selected transport by incorporating an electromechani- in flight. cal lock as a backup to the mechanical stops that Thus, a variety of mechanical latches, locks, help prevent the power levers from being moved levers and detents have been devised to prevent aft of flight idle in the air.
A copilot trainee inadvertently selected ground idle thrust on final approach. Six-G
BY MARK LACAGNINA
© Frikkie Bekker | AirTeamImages Arrival
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The electromechanical lock is designed Believing that the problem would persist as to release automatically when the weight-on- more of the aircraft were acquired, the airline wheels system is triggered on touchdown, solved the problem expediently by revising the allowing the pilot flying to subsequently release “Approach” checklist to require pilots to disable the mechanical stops and move the power levers the electromechanical lock before landing. from flight idle into ground idle and then into (The lock can be disengaged manually by pull- reverse (Figure 1, p. 38). ing up a knob located at the top of the central However, when Indonesia’s Merpati Nusan- quadrant and between the power levers. The tara Airlines added MA60s to its fleet, it found mechanical stops then can be disengaged by that some pilots were having difficulty moving pulling up tabs located in slots just below the the power levers from flight idle to ground idle power lever handles.) — delaying the selection of reverse thrust — on The checklist revision requiring the electro- landing because the electromechanical lock mechanical locks to be disengaged manually on tended to balk in release. approach was effected without the approval of civil aviation authorities and set the stage for a Xian MA60 costly mistake, according to Indonesia’s National Transportation Safety Committee (NTSC). The mistake occurred the morning of June 10, 2013, when a first officer-in-training disabled the electromechanical lock per the checklist but then inadvertently released the me- chanical stops and moved the power levers into ground idle while the aircraft was still hundreds of feet above the ground on approach to El Tari Airport in Kupang, Indonesia. The MA60 entered a rapid descent and struck the runway with a vertical velocity of 5.99 g (i.e., 5.99 times standard gravitational acceleration). The force of the impact was enough to crush the landing gear and cause the
Joshua Lim | Wikimedia Joshua Lim | aft wing attachments to fail. Five people aboard the aircraft were seriously injured; the other 45 he MA60 is a 60-seat twin-turboprop transport introduced by Xian occupants sustained minor or no injuries, said Aircraft Industry Co. of China in 2000. It is a stretched version of the NTSC’s final report on the accident. Tthe Y7-200, a short-takeoff-and-landing aircraft manufactured by Xian primarily for the Chinese air force. The design of the Y7, and con- sequently the MA60, was based on the Antonov 24, which Xian began Training Deficiency to build under license to Antonov in 1977. The MA60 was inbound to Kupang, in the The MA60 is powered by Pratt & Whitney PW127J engines rated at Timor area of Indonesia, on a scheduled flight 2,052 kW (2,750 shp) each. Maximum weights are 21,800 kg (48,060 lb) with 46 passengers and four crewmembers from for takeoff and 21,600 kg (47,620 lb) for landing. Cruise speed is 430 Bajawa, on Flores Island. The aircraft, PK-MZO, kph (232 kt), maximum range is 1,600 km (864 nm) and service ceiling is 25,000 ft. was manufactured in 2007 and had accumulated As of April 2014, 53 MA60s were in service in 23 countries. In 2011, 4,486 flight hours and 4,133 cycles. Xian introduced the MA600, which has upgraded avionics equipment, The pilot-in-command (PIC), 42, had 12,530 cabin improvements and more powerful engines. A 70-seat version, flight hours, including 2,050 hours in type. He the MA700, was in development. was employed by Merpati Nusantara Airlines Sources: Aviation International News and Wikipedia in 1994 and earned an airline transport pilot certificate and a type rating in the MA60 in
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The controller advised the pilots that Runway 07 was in use and that the weather conditions at the air- port included surface winds from 110 de- grees at 11 kt, 10 km (6 mi) visibility and a few clouds at 2,000 ft. Surface temperature was 30 degrees C (86 degrees F). At 0938, the PIC told the controller that the aircraft was The MA60 was 2004. He later qualified as a route instructor for descending through 10,500 ft in visual meteo- descending at the airline and had logged 218 flight hours in rological conditions. About 10 minutes later, he 1,280 fpm when it that capacity. reported that the aircraft was on left base for a touched down on the The second-in-command (SIC), 25, joined visual approach to Runway 07. The controller runway. The landing the airline in 2012. He had 311 flight hours, said that he had the aircraft in sight, cleared the gear was crushed, including 117 hours in type. He held a commer- crew to land and advised that the surface winds and the fuselage cial pilot certificate with an instrument rating were from 120 degrees at 14 kt. was torn on impact. and an MA60 type rating. The SIC had accumu- Flight data recorded on final approach showed lated 142 flight hours, including 24 hours as an that the left power lever was moved into ground observer, in a line training program leading to idle when the aircraft was about 112 ft above the qualification as a first officer. ground, followed by the right power lever at 90 ft. The airline had planned to have the PIC con- Airspeed was 113 kt — about 11 kt above duct the SIC’s first officer check ride during the the target speed — and the MA60 was descend- flight from Bajawa to Kupang, but the SIC had ing at 1,280 fpm when it touched down about requested a delay “to be more confident prior to 58 m (190 ft) from the approach threshold of the the flight check,” the report said. 2,500-m (8,203-ft) runway. Of special note is that the SIC had displayed “The vertical deceleration recorded on the a tendency to delay moving the power levers flight data recorder (FDR) was 5.99 g and fol- to ground idle and reverse after touchdown, lowed by –2.78 g,” the report said. “The longitu- even after the electromechanical lock had been dinal deceleration after impact was calculated as disengaged on approach. The report said that approximately 0.7 g.” this deficiency likely played an influential role in The aircraft came to a stop on the runway the accident. after sliding for 261 m (856 ft). The flight at- tendants conducted an evacuation through the Visual Approach main entrance door at the rear of the aircraft. The aircraft departed from Bajawa at 0902 local Two passengers and the PIC sustained back in- time with the SIC as the pilot flying. Twenty juries, one passenger suffered a neck injury, and minutes into the flight, the PIC told the El Tari another passenger suffered a broken wrist. Airport traffic controller that the aircraft was at The report classified the damage to the air- 11,500 ft and 110 nm (204 km) northwest of the craft as “substantial.” Photographs of the wreck- Kupang VOR (VHF omnidirectional radio). age show that the main landing gear and the © Stringer . | Reuters
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nose landing gear had collapsed on im- a gradual reduction of power beginning airworthiness regulations and that any pact, the fuselage had buckled and torn at 1,500 ft on approach and selection of change in procedure related to the de- near the forward section of the cabin, ground idle at about 200 ft. The result vice would require specific approval by and the entire wing had tilted leading- in each case was a rapid descent from Indonesia’s Directorate General of Civil edge-down, causing both propellers to which recovery was not possible, the Aviation (DGAC). separate when the forward sections of report said. Moreover, the report said that the power plants struck the runway. At the time of the accident, the the airline’s board of instructors had state-owned airline operated a diverse not explored factors that might have Unrecoverable Descent fleet that comprised Boeing 737s, contributed to the operational prob- Examination of the accident aircraft CASA 212s and de Havilland Twin Ot- lem experienced in the first MA60s revealed that the electromechanical ters, as well as 14 MA60s. Management introduced to the fleet. “The problem lock was in the open position, indicat- personnel told investigators that after might exist due to aircraft system ing that the crew had disengaged the the first two MA60s entered the fleet, problem, runway condition or pi- lock on approach as prescribed by the the airline encountered several prob- lot operation error,” the report said. checklist revision. lems with the power lever lock system, “The investigation could not find any Post-accident interviews with the “whereas the automatic power lever evidence of safety assessment, risk pilots indicated that the SIC had been lock system sometimes failed to open analysis and approval related to the focused on proving that he deserved after landing,” the report said. checklist revision.” to be designated as a qualified first officer during the flight to Kupang and No Risk Analysis Checklist Re-Revised likely had been overly conscious of his Based on recommendations by its Among the actions taken by Merpati “repeated error [of] delay on moving board of instructors, the airline revised Nusantara Airlines after the accident the power levers to ground idle during its MA60 “Approach” checklist in April was the removal from the “Approach” landing,” the report said, noting that 2012 to include the item “PL LOCK checklist of the item requiring disen- these factors likely contributed to his … OPEN.” The checklist specified that gagement of the electromechanical inadvertent selection of ground idle the power lever lock must be opened power lever lock. thrust during the approach. (disengaged) on approach by the pilot The airline also revised its training After the accident, the NTSC super- monitoring. procedures to caution pilots against vised tests conducted in an MA60 flight Although Xian had revised the touching, in flight, the tabs beneath the simulator flown by instructor pilots for master minimum equipment list in power lever handles that disengage the Merpati Nusantara. The tests simulated 2008 to include provisions for oper- mechanical ground idle stops. ating the MA60 with the Based on the findings of the ac- Positions of Engine Power Lever electromechanical lock cident investigation, NTSC recom- inoperative, the flight crew mended that the DGAC review its Takeo Flight idle operating manual did not oversight of changes made by opera- Max takeo Ground idle include any procedure for tors to safety-related procedures and Max reverse disengaging a function- to specifically review the MA60 master feather ing lock on approach. The minimum equipment list to ensure report noted that manual that it complies with airworthiness disengagement of the elec- requirements. tromechanical lock does not cause a caution light This article is based on NTSC Aircraft Accident Investigation Report KNKT.13.06.19.04, to illuminate or an aural “Merpati Nusantara Airlines, Xi’An Aircraft NTSC = Indonesian National Transportation Safety Committee warning to sound. Industry MA60, PK-MZO; El Tari Airport,
Source: NTSC Aircraft Accident Investigation Report KNKT.13.06.19.04 The NTSC concluded Kupang, Republic of Indonesia, 10 June 2013.” that the lock is a “safety The report is available at
38 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JUNE 2014
7 FLIGHTSAFETY.ORG © Lorenzo Rossi|Dreamstime accurate andmore accessible. |
WORLD AEROSAFETY Specialized aviationweather information forpilotsmore services aimtomake | JUNE 2014 JUNE SEARCHING FOR SEARCHING Administration (FAA). Aviation Weather Research Program (AWRP) of Federal the Aviation governmentfederal turned to amore effort, establishing specialized the requirementsparticular for aviation weather United in the States, the and forecasting new techniques have helped, certainly but to the meet W ciency. improvements General innumerical forecast models efit aviation the industry’s level of safety and operational- effi improves of weather accuracy the forecasts greatly will - ben risk factoreather acritical for is still aviation. Anything that
BY EDBROTAK STRATEGICISSUES |
39 40 © Cãtãlin Fãtu|Wikimedia CC-BY-SA 3.0 | done in-house at FAA Headquarters in research basic the and development is risk of incidents/accidents. Some of tion community can to the use lessen of developing products that avia the - aviationspecific hazard, with goal the search groups. group Each with a deals System Implementation Plan. Next Generation Air Transportation AWRP is an also integral of part the of dedicated studies.” scientific solvedbe or mitigated by results the management,and traffic may which or National Airspace System capacity it relates to problems inaviation safety research into aviation meteorology as and more accessible. AWRP funds and forecasts that are more accurate ing weather observations, warnings research“The is aimed toward produc impacts aviation,” agency said. the dangerous weather, inturn, which, of atmospheric conditions that cause increase understanding scientific the Weather Research Branch. AWRP under direction the of FAA’s the continued. This program the became systems, but research the was aspect was phased out, replaced to be by other operational component of AWPG later such as turbulence, icing, etc. The standardthe aviation weather hazards applied research of AWPG emphasized data to aviation the community. The currentspecific and short-term forecast ofgoal was which to provide aviation- Generator (AWPG) Program, the duced Aviation the Weather Products STRATEGICISSUES The AWRP is broken down into re- “The goal of goal AWRP the “The is to In early the FAA 1990s,the intro- 1 The The - heights, etc. was The to trick relate nity such needed, as visibility, ceiling forecast elements aviation the commu- often models didnot these directly computers improved over time, but The numerical models and host their weather products was challenging. butries rather to augment them. (AIRMETs) and other weather- adviso airmen’s meteorological information meteorological advisories (SIGMETs), areanal forecasts (TAFs), significant was not to replace standard the termi- duced and updated quickly. The goal generated results that pro could be - human input, and to provide computer- weather products, rely which heavily on to go beyond standard the aviation rologists, atime-consuming practice. werestill done mainly by hand by meteo- with aviation weather forecasts. These vention. However, was this not case the from acomputer with little human inter weather forecasts come almost directly cast automated. became Many of today’s years, much of standard the public fore- forecasting techniques improved over the aviation weather research. of universities are also involved in tion Systems Development. Anumber through its Center for Advanced Avia- poration works closely with FAA the plications program. The MITRECor Boulder, Colorado, has an aviation ap- for Atmospheric Research (NCAR) in contracted out. The National Center Research Team. projects Other are Washington by Aviation the Weather Producing aviation new these One of goals of the AWRP the was As numerical weather models and - - FLIGHT FOUNDATION SAFETY superior inforecasting aviation hazards one-hour update rate, was model this of (8-mi)resolutiongrid 13-km and a and came online in2012.With afine Weather Forecast Model was developed levels. For example, Rapid the Refresh to forecast elements at various flight merous layers vertical that used could be hours. featured models also These nu- faster schedule, not typical sixor the 12 areassmaller and produce forecasts on a powered, models that cover small-scale Aviation meteorologists turned to high- do not forecast rapid changes inthem. elementsnot these detect and certainly nonaviation weather forecasting may computer inday-to-day, models used of time.in ashort The standard period insizeandsmall can change quickly hazards on ameteorological are scale and “fuzzy logic” were implemented. native techniques involving statistics ments that are to pilots. crucial Imagi- what models the did ical. ADDSical. is hosted by National the data, including text, digital, and graph- utilizes anumber of formats to display operational in1996.This web portal (ADDS) was developed and became to general the public. in disseminating weather information ganization already experienced highly tion’s National Weather an or Service, andOceanic Atmospheric Administra- community was given to National the readilyucts available to aviation the and low ceilings and visibility. such as icing, turbulence, convection Another problem was that aviation The Aviation Data Digital Service The jobof prod new making these - |
WORLD AEROSAFETY forecast to ele - | JUNE 2014 JUNE - STRATEGICISSUES
Weather Service at its National Centers before a flight. It should be noted in the future. The forecasts are gener- for Environmental Prediction’s Avia- that the AWRP also has helped in the ated automatically using input from tion Weather Center (AWC) site in development of new and more user- a high-resolution numerical model Kansas City, Missouri. ADDS products friendly methods of displaying these augmented with the latest data from are available for operational use either products. In terms of new products, pilot-generated and automated PIREPs, under the individual forecast element the AWC also displays supplementary and lightning data. It is meant to aug- website links (convection, turbulence, ADDS weather products for enhanced ment PIREPs and SIGMETs. Future icing, etc.) or from the ADDS website situational awareness. These should improvements will include increasing homepage
The Aviation Digital Data Service website homepages for the Aviation Weather Center and the National Center for Atmospheric Research.
U.S. National Oceanic and Atmospheric Administration and Administration and Atmospheric Oceanic National U.S. Research Atmospheric for Corporation © University
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JUNE 2014 | 41 42
| Images: © University Corporation for Atmospheric Research STRATEGICISSUES Research Program. Aviation Weather products from the ceiling andvisibility Icing, turbulence,and is by determined WSR-88D (Doppler weather with current begins NCAR, convection. This sponsored by AWRP the and developed by Convective Weather Forecast (NCWF), of ADDS convective products. The National for aircraft There inflight. are variety awide three-hour increments. current analysis and gives 12-hour forecasts in indicated by various colors. It with starts the level height is shown increments in2,000-ft level as displayed inmap form. The freezing layer. Another product is lowest the freezing is includedity expected for entire the vertical probability of icing. Maximum icing sever (from noscale icing to severe icing) and the forvided eachlevel: icing inafive-step severity increments.2,000-ft Two forecasts are pro- for levels flight from MSL 1,000ft to FL300,in forecast for current the out time to 12hours of continental the United States with an icing cast Icing Product displays an interactive map of previous observations. The CVAcurring. provides also 24hours’ worth instrument meteorological conditions are- oc information indetermining where is useful Convection is, of course, amajor concern For icing, Current the Icing Product/Fore- - in the forecastin the are projected cloud-top heights, two-hour increments to eight hours. Included Product at starts hour four and out goes in convective SIGMETs. that NCWF the should to not replace used be forecast. Products contain also reminder the shorter-lived individual storms are not also well initiation, growth or decay of such systems, and lines. Itas squall cannot accurately forecast the long-lived convective mesoscale systems such minutes. The NCWF works with existing best automatically generated and five updated every The convective-hazard and field forecasts are direction of movement for individual storms. one-hour forecast for location, and speed 6 indicating asevere hazard. six-level, color-coded with Level is used scale tornadoes and/or low-level wind shear. A lence, severe icing, hail, frequent lightning, information may field show severe turbu- hazard detection field tion forecast for convection what the is called providesNCWF also aone-hour extrapola- cloud-to-groundtected lightning The strikes. radar,surveillance 1988),echo tops and de- The Collaborative Convective Forecast Basically, NCWF the gives an accurate FLIGHT FOUNDATION SAFETY for eachstorm. This |
WORLD AEROSAFETY | JUNE 2014 JUNE STRATEGICISSUES
expected changes in growth, area cover- age of convection, the direction and speed of movement of the convection, and the confidence level of the forecast (high or low). The Extended Convective Forecast Product (ECFP) goes well beyond the six- or eight-hour forecast period of the NCWF, all the way out to 72 hours. Again, utilizing an interactive map of the continental United States, the ECFP gives a proba- bilistic forecast of
thunderstorm activ- Research Atmospheric for Corporation © University ity. The ECFP is also just a planning tool designed for dispatchers and runs as a desktop/laptop computer appli- Example of the and others who are involved with the develop- cation. All data are in 3D (three dimensional) Aviation Digital ment of flight plans, typically not the pilots. graphics and are accessible for various flight Data Service Flight This product is available continuously and is levels or vertically at points along flight paths. Path Tool available updated every six hours. Current and forecast surface weather condi- at the Aviation One new product being developed and tions for various terminals can be displayed as Weather Center. tested is the Consolidated Storm Prediction meteorograms, graphical displays of the time for Aviation (CoSPA), which is an advanced variations of several weather elements at a spe- mathematical technique for making accurate cific location. The data can be animated, and thunderstorm forecasts well beyond the stan- route information can be stored and recalled dard time range. Typically, convective storms are to get quick updates in the future. Basically, a forecast out to two hours based on extrapolation user can enter a flight path and get all perti- of current motion. CoSPA starts with this and nent weather information and warnings on adds high-resolution model data to produce one display. a convective forecast out to eight hours. The Edward Brotak, Ph.D., retired in 2007 after 25 years goal — minimizing flight delays due to thunder- as a professor and program director in the Department storms — could produce millions of dollars in of Atmospheric Sciences at the University of North savings to aircraft operators. Carolina, Asheville. A product that combines much of the available current and forecast data in a highly Note usable format is the Flight Path Tool. This is an 1. AWC. “Experimental Product Description interactive map display that features all of the Document.”
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JUNE 2014 | 43 DATALINK
BY FRANK JACKMAN Analysis of Newly Harmonized Data Confirms Global Priorities
pproximately 61 percent of all commercial aviation accidents in 2013 occurred during the approach and landing phases of flight, according to an analysis of harmonized International Civil Aviation Organization Accidents by Phase of Flight, 2013 (ICAO) and International Air Transport Association (IATA) safety data. AThe analysis was included in the recently released ICAO Safety Report 2014 En route 10% Edition. Forty-three percent of 103 accidents considered using the harmonized accident criteria occurred during the landing phase, followed by 18 percent Approach during approach and 12 percent during takeoff (Figure 1). The other 27 per- 18% Landing 43% 1 cent occurred during the en route, standing and taxi phases. Taxi In September 2010, IATA, ICAO, the U.S. Department of Transportation 8% Takeo and the European Commission signed a memorandum of understanding 12% on a global safety information exchange (GSIE), the objective of which is to identify information that can be exchanged between the parties to enhance Standing 9% risk reduction activities in aviation safety, according to the ICAO Safety Report. The GSIE developed a harmonized accident rate beginning in 2011 Note: Using harmonized data. through cooperation between ICAO and IATA to align accident definitions, Source: International Civil Aviation Organization Safety Report 2014 Edition criteria and analysis methods used to calculate the harmonized rate. The Figure 1 analysis includes accidents meeting the ICAO Annex 13, Incident Reporting, Data Systems and Information Exchange, criteria for all typical commercial Accidents by Category, 2013 airline operations for scheduled and nonscheduled flights. For 2013, ICAO and IATA further harmonized the accident analysis process and developed a Controlled ight into terrain common list of flight phases and accident categories to facilitate the sharing and integration of safety data between the two organizations, ICAO said. Loss of control–in ight
The 103 accidents in 2013 considered using the harmonized criteria Runway safety were scheduled and nonscheduled commercial operations, including ferry Ground safety flights, for aircraft with a maximum certificated takeoff weight of more than 5,700 kg (12,566 lb). Operational damage Of the 103 accidents, 36 fell into the “runway safety” category, which Injuries to and/or incapacitation of persons includes excursions and incursions, overshoot/undershoot, tail strike Other and hard landing events (Figure 2). Twenty accidents were categorized as “operational damage,” described as damage sustained by the aircraft while Unknown
operating under its own power. This includes in-flight damage, foreign 0 10 20 30 40 object debris and all system or component failures including gear-up land- Number of accidents ings and gear collapses. Note: Using harmonized data. The next most common category was “ground safety,” with 15 acci- Source: International Civil Aviation Organization Safety Report 2014 Edition dents. Ground safety includes ramp safety, ground collisions, all ground servicing, pre-flight, engine start/departure and arrival events, taxi and Figure 2
44 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JUNE 2014 DATALINK
towing events. Con- Accidents by ICAO RASG Region, 2013 Accident Rate by ICAO RASG Region, 2013 trolled flight into ter- rain (CFIT) and loss 50 15 of control–in flight 40 12 (LOC-I) accounted 30 9 for seven and six ac- 20 6 cidents, respectively. 10 per Accidents 3
The ICAO Safety million departures Number of accidents 0 0 Report also included a AFI APAC EUR MID PA AFI APAC EUR MID PA harmonized regional Region Region analysis using the AFI = Africa; APAC = Asia Pacific; EUR = Europe; ICAO = AFI = Africa; APAC = Asia Pacific; EUR = Europe; ICAO = organization’s regional International Civil Aviation Organization; MID = Middle East; International Civil Aviation Organization; MID = Middle East; PA = Pan America; RASG = regional aviation safety group PA = Pan America; RASG = regional aviation safety group aviation safety group Note: Using harmonized data. Note: Using harmonized data. (RASG) regions: Pan Source: International Civil Aviation Organization Safety Report 2014 Edition Source: International Civil Aviation Organization Safety Report 2014 Edition America (PA), Af- rica (excluding North Figure 3 Figure 4 Africa; AFI), Middle East (MID), Europe ICAO Global Accident Rate, 2009–2013 Scheduled Commercial Flight Accidents and Fatalities, 2009–2013 (EUR) and Asia Pacific (APAC). Ac- 4.1 4.2 4.2 670 Accidents 3.2 626 cording to the analysis, 2.8 Fatalities RASG-PA had the 372 388 most accidents, fol- Accidents per Accidents Number 173 million departures lowed at a distance 102 104 118 99 90 by RASG-EUR and 2009 2010 2011 2012 2013 Year 2009 2010 2011 2012 2013 RASG-APAC (Figure Year 3). RASG-AFI, how- ICAO = International Civil Aviation Organization ever, had by the far the Source: International Civil Aviation Organization Safety Report 2014 Edition Source: International Civil Aviation Organization Safety Report 2014 Edition highest accident rate at Figure 5 Figure 6 more than 14 acci- dents per million departures (Figure 4), followed analysis: APAC and North America, Central by RASG-MID, with fewer than four accidents America and Caribbean (NACC), ICAO said. per million departures. Exposure data for small aircraft operations are The vast majority (79 percent) of the 103 difficult to obtain, but the number of accidents accidents analyzed involved passenger flights. is well-documented, ICAO said. There were a Approximately 16 percent involved cargo flights total of 12 accidents involving fixed wing air- and 5 percent involved ferry flights. Most of the craft with a maximum takeoff weight (MTOW) accidents occurred to jet aircraft (54 percent), of less than 5,700 kg conducting scheduled com- but ICAO pointed out that turboprop aircraft, mercial operations. Of these, eight occurred in which suffered 46 percent of the accidents, rep- the NACC region and four in the APAC region. resent a much smaller percentage of the global Six of the accidents were fatal accidents, and 22 commercial fleet than do jet aircraft. people were killed as a result. The 2014 Safety Report was the first to The Safety Report also included the more include a section dedicated to aircraft below traditional ICAO accident statistics for sched- the traditional 5,700 kg mass limit, albeit on uled commercial operations involving aircraft a limited basis. Because of data acquisition is- with an MTOW greater than 5,700 kg, using sues, only two regions were considered in the the accident definition and categorizations
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JUNE 2014 | 45 DATALINK
contained in Annex 13. On that basis, the global accident rate last year was High-Risk Accidents as 2.8 accidents per million departures, which ICAO said is the lowest since a Percentage of All Accidents, 2013 the ICAO Accident/Incident Reporting database began tracking the global accident rate with 2005 occurrence data (Figure 5, p. 45). 32% 22% 20% Both the number of accidents (90) and the number of fatalities were 78% 80% down in 2013 (Figure 6, p. 45). For the third straight year, the number of 68% accidents declined. The 173 fatalities in 2013 represent a decline of 53 per- cent from 2012; the fatalities are 65 percent less than the average number for the previous five-year period and the fewest number of fatalities suf-
Percentage of accidents Percentage fered in commercial scheduled air transport since 2000, ICAO said. Accidents Fatal accidents Fatalities When looked at by RASG region, as noted, PA had the most accidents Other High-risk occurrences (39, or 43 percent of the total) in the context of significantly more depar-
Source: International Civil Aviation Organization Safety Report 2014 Edition tures (13.8 million, or 43 percent) than any other region in 2013 (Table 1). RASG-MID had the lowest accident rate per million departures at 1.8, Figure 7 followed by RASG-APAC at 2.2. RASG-AFI’s accident rate was 12.9 per million departures, which is lower than its accident rate in the harmonized High-Risk Category statistics analysis. Based on its analysis of historic accident data, ICAO has Accident Distribution, 2013 identified three high-risk accident occurrence categories: runway safety- related events, LOC-I and CFIT. These categories together represented 68 62% 60% Accidents percent of all accidents in 2013, comprising 78 percent of fatal accidents Fatal accidents Fatalities and 80 percent of all fatalities (Figure 7). Runway safety–related accidents accounted for 62 percent of all the 33% accidents within these high-risk categories, but only 22 percent of all fatal 22% 22%
Percentage accidents and only 6 percent of all fatalities (Figure 8). Conversely, LOC-I 13% accounted for 3 percent of the high-risk category accidents, but 33 percent 6% 3% 2% of all fatal accidents and 60 percent of all fatalities. CFIT accounted for 2 Runway LOC-I CFIT percent of the high-risk category occurrences, but 22 percent of all fatal safety-related accidents and 13 percent of all fatalities. CFIT = controlled flight into terrain; LOC-I = loss of control–in flight Note Source: International Civil Aviation Organization Safety Report 2014 Edition 1. The Common Taxonomy Team, formed by ICAO and the U.S. Commercial Aviation Safety Team, defines standing as the period “prior to pushback or taxi, or Figure 8 after arrival, at the gate, ramp or parking area, while the aircraft is stationary.”
Analysis of ICAO Accident Data by RASG Region, 2013
Estimated Percent Departures Accident Fatal Share of of Fatal Percent of Share of RASG (in millions) Accidents Rate* Accidents Fatalities Accidents Accidents Fatalities Traffic AFI 0.7 9 12.9 1 33 10% 11% 19% 2% APAC 8.6 19 2.2 1 49 21% 11% 28% 27% EUR 7.9 21 2.7 2 71 23% 22% 41% 25% MID 1.1 2 1.8 0 0 3% 0% 0% 3% PA 13.8 39 2.8 5 20 43% 56% 12% 43% World 32.1 90 2.8 9 173
ICAO = International Civil Aviation Organization; RASG = regional aviation safety group *per million departures Source: International Civil Aviation Organization Safety Report 2014 Edition
Table 1
46 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JUNE 2014 INFOSCAN Annual Safety Report 2013 Annual Safety Report 2013
AAAir Accidents InvestigationIB Branch Annual Safety Report 2013 Data Review BY LINDA WERFELMAN
REPORTS
Annual Safety Report 2013 The report’s data show a total of 744 aviation U.K. Air Accidents Investigation Branch (AAIB). 77 pp. Figures, accidents and serious incidents in 2012, includ- indexes, tables. October 2013. Available from the AAIB at
FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JUNE 2014 | 47 INFOSCAN
followed by the U.S. Federal Aviation Administra- Human factors requirements for using flight tion, the recipient of 19 recommendations; and deck displays and controls are discussed in a the U.K. Civil Aviation Authority, which received number of regulatory and guidance documents, 11, the report said. (A number of recommenda- the report said, and in many cases, generic hu- tions were made to more than one addressee.) man factors material is scattered throughout a In an introductory section of the report, document that is several hundred pages long. AAIB Chief Inspector Keith Conradi wrote Therefore, this report was designed to that, because of the recent introduction of the consolidate human factors material that applies European Union (EU) Safety Recommendation to “all types of flight deck displays and controls Information System, which provides a central used for all types of aircraft,” the report said. repository for recommendations from all EU “The guidance addresses the human factors/ member states, the AAIB will review the format pilot interface aspects of the display system of its annual safety report before publication of hardware, software (e.g., the depiction and the 2014 document. organization of information display elements and features), and the design of control devices. Human Factors Considerations in the Design and Human Factors Considerations in A discussion of the importance of establishing a the Design and Evaluation of Flight Evaluation of Flight Deck Displays and Controls Deck Displays and Controls design philosophy and considerations for assess- Version 1.0
DOT/FAA/TC-13/44. Yeh, Michelle; Jo, Young Jin; Donovan, Colleen; Michelle Yeh1, Young Jin Jo2, Colleen Donovan1, and Scott Gabree2 ing workload, managing errors, implementing 1 Federal Aviation Administration 800 Independence Avenue, SW Gabree, Scott. U.S. Department of Transportation John A. Volpe Washington, DC 20591
2 John A. Volpe National Transportation Systems Center automation, and protecting against and manag- Cambridge, MA 02142 National Transportation Systems Center. 361 pp. Appendixes, figures,
Final Report – November 2013 DOT/FAA/TC-13/44 DOT-VNTSC-FAA-13-09 index, tables. Available from the Volpe Center at Prepared for: Federal Aviation Administration Human Factors Division dot.gov/our-work/safety-management-and-human-factors/ 800 Independence Avenue, SW Washington, DC 20591 In its introduction, the report said that it human-factors-publications-and-papers>. should not replace the FAA’s aircraft-specific his report, designed as a “single-source regulatory and guidance information but instead reference document for human factors help “raise the level of awareness regarding Tregulatory and guidance material for flight human factors to facilitate the identification deck displays and controls,” is intended to help and resolution of human factors issues as well in the early identification of a number of human as to support consistency and compatibility in factors issues on the flight deck. designs within and across flight decks.” “The flight deck is an information-intensive The report’s 10 chapters discuss issues environment,” the report said. “The number of including display hardware and how hardware flight deck displays and controls has prolifer- resolution, size and other characteristics affect ated as new technology offers new capabilities the readability of cockpit displays; the design, and formats for presenting information and new layout and operation of controls and related methods for control and interaction. Under- usability issues; flight deck design philosophy; standing how a display system or control will be error management and mitigation, as well as the used by pilots and flight crews and how it will potential for human error; workload and work- interact with other flight deck displays and con- load evaluation techniques; and automation. trols is essential. Consideration of human fac- A series of appendixes provide additional in- tors issues early on and throughout the design formation on the best use of the report; a list of process will help to ensure that the displays and related research reports and other helpful docu- controls will support all flight crew functions, ments; sample checklists, evaluation procedures tasks and decisions.” and “scenarios for identifying human factors 48 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JUNE 2014 INFOSCAN considerations as part of flight deck display and Aviation Regulations Part 121, as well as the control evaluations”; and a list of regulations FAA offices responsible for oversight of the related to human factors. air carriers’ VDRPs. The review found that instances of noncompliance reported through Further Actions Are Needed to Improve VDRP usually are identified “through the air FAA’s Oversight of the Voluntary Disclosure Office of Inspector General carrier’s internal quality control processes, Audit Report Reporting Program analysis of safety data and employee reporting AV-2014-036. U.S. Department of Transportation Office of Inspector FURTHER ACTIONS ARE NEEDED TO IMPROVE through the aviation safety action program FAA’S OVERSIGHT OF THE VOLUNTARY DISCLOSURE REPORTING PROGRAM General (OIG). April 10, 2014. 20 pp. Exhibits, figures. Available from Federal Aviation Administration Report Number: AV-2014-036 OIG at the U.S. Federal Aviation Administration’s specified employee groups to disclose possible T(FAA’s) handling of its voluntary safety re- safety violations without fear of penalty],” the porting programs describes the programs as cru- report said. cial in improving air carrier safety and suggests The review found that the FAA has made that the FAA ensure that it takes advantage of all progress since the 2008 incident in “ensuring opportunities to use the associated safety data. that air carrier disclosure reports meet VDRP The report focused on the FAA Voluntary requirements.” Disclosure Reporting Program (VDRP), which Nevertheless, the report detailed several allows air carriers to voluntarily report areas of persistent problems, including an insufficient noncompliance with FAA regulations and to make emphasis on underlying causes of VDRP- corrections without being subject to civil penalties. covered violations and the ineffective collection The voluntary reporting process also provides the and analysis of VDRP data to “identify trends FAA with valuable safety oversight information. and target safety risks.” “While VDRP provides an important oppor- To address those concerns, the report rec- tunity to identify and mitigate safety issues, it ommended that the FAA “add dedicated data requires close monitoring by FAA to ensure the fields in the VDRP electronic system for air program is not misused,” the report said. “For carriers to describe the root cause(s) associated example, in 2008, we reported a serious abuse with the noncompliance and identify whether of the program in which FAA allowed a major the violation occurred due to the actions of an airline to repeatedly self-disclose violations of individual or a systemic problem” and “require mandatory safety directives without ensuring inspectors to evaluate the root cause(s) determi- the carrier had developed and implemented nation to ensure repeat self-disclosures do not solutions to prevent recurrence of the problems.” go undetected and potential systemic issues are A 2012 law required an OIG review of the identified.” FAA’s oversight of VDRP, and this report de- Other recommendations included calls to scribes the findings of that review, which found “ensure that inspectors’ ability to obtain safety that the FAA has strengthened controls designed data is not further restricted through efforts to to prevent misuse of the program and has im- streamline voluntary safety programs” and to proved its analysis of safety data. “analyze VDRP data from a national perspective The report said that OIG auditors visited to aid in the identification of system-wide trends 10 air carriers operating under U.S. Federal and patterns that represent risks.” FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JUNE 2014 | 49 ONRECORD Engine Fire on Night Takeoff Fuel leak resulted from partial separation of a fuel flow transmitter. BY MARK LACAGNINA The following information provides an awareness of problems that might be avoided in the future. The in- formation is based on final reports by official investigative authorities on aircraft accidents and incidents. JETS Single-Engine Landing Damage was limited to the left engine and Boeing 757-200. Substantial damage. Three minor injuries. its mounting pylon and cowlings. “Examination he captain told investigators that she ob- of the engine found extensive fire damage and served a slight yaw as the landing gear thermal distress in the fan and core compart- Twas being retracted during departure in ments, with the vast majority of the thermal dis- visual meteorological conditions (VMC) from tress and the most extensive fire damage located Hartsfield–Jackson Atlanta (Georgia, U.S.) Inter- in the fan compartment between and including national Airport shortly after midnight on June the intermediate case and the turbine exhaust 21, 2011. The 757 was climbing through 3,000 ft case,” the report said. a few seconds later when the flight crew received Further examination of the Pratt & Whitney indications of a fire in the no. 1 (left) engine. PW2037 turbofan engine revealed that the fire The crew shut down the left engine, declared had started when the fuel flow transmitter’s an emergency and turned back to the airport. end housing partially separated from the main They subsequently conducted an uneventful, but housing, creating a 0.3-in (0.8-cm) gap, through overweight, single-engine landing on Runway which fuel under high pressure escaped from 26L, said the report by the U.S. National Trans- the housing and ignited on contact with the hot portation Safety Board (NTSB). engine cases. After the 757 was stopped on the runway, The end housing on the fuel flow transmit- aircraft rescue and firefighting personnel extin- ter (FFT) is attached to the main housing with guished the engine fire. The captain ordered an four through-bolts. The bolts engage threaded emergency evacuation through the exits on the inserts in the main housing, which has tapped right side of the airplane. Three passengers sus- threads that accommodate the inserts. Investiga- tained minor injuries while exiting the airplane tors found that three of the threaded inserts had on slides. The other 169 passengers and the six been partially pulled out of the main housing, crewmembers were not hurt. and one had sheared. FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JUNE 2014 | 51 ONRECORD “All of the inserts and the bolts the U.K. Air Accidents Investigation who had logged 1,500 of his 10,800 were in good condition,” the report Branch (AAIB). flight hours in type. said. “However, the main housing Videos showed that the right engine VMC with light winds prevailed at tapped threads that accommodate the had emitted a flash of flame and a large Dekalb Peachtree, and the flight crew was inserts exhibited sheared and flattened cloud of smoke. “This was accompa- cleared for a visual approach to Runway threads at each of the four locations,” nied by a bang, followed by significant 20L, which was 5,001 ft (1,524 m) long. the report said. shuddering of the engine pylon and The Beechjet was on a right base leg Investigators found several incon- nacelle,” the report said. when the pilot took control from the co- sistencies in the FFT component main- Examination of the Rolls-Royce pilot and began a turn to final approach. tenance manual, including specification Trent 772B-60 engine, which had “During the approach, the en- of two different torque values for the undergone 5,200 cycles since its last hanced ground-proximity warning end housing bolts and inadequate in- overhaul, revealed that a blade on the system (EGPWS) sounded the aural structions for the application of graph- high-pressure turbine had fractured caution ‘sink rate, sink rate’ and also the ite lubricant to the bolts. Tests showed just above its root. The blade was aural warning ‘pull up, pull up’ sev- that the amount of lubricant applied, as carried downstream, causing further re- eral times,” the report said. “The CVR well as whether lubricant is intentional- lease of debris that caused the interme- [cockpit voice recorder] did not record ly or inadvertently applied to the wash- diate- and low-pressure spools to seize. comments from either flight crew- ers, are significant factors in proper “The blade failure was caused by member about the cautions or warn- installation of the bolts. Moreover, the high-cycle fatigue crack propagation ings. They performed no maneuvers in manual did not specifically state that with crack initiation resulting from response to the cautions or warnings used washers must not be used during ‘Type 2 sulphidation’ corrosion,” the and elected to continue the approach reassembly of the component. report said, explaining that this type of to the runway rather than perform a The report said that, based on the corrosion occurs when a metal compo- go-around, which is what they should findings of the accident investigation, nent comes in contact at high tem- have done.” changes to the FFT maintenance man- perature with sulfur from fuel or from The CVR captured a comment, “way ual were proposed to “ensure a more airborne contaminants, which causes too fast,” by the pilot during final ap- consistent FFT assembly practice.” decay of the protective oxide layer and proach. Witnesses told investigators that weakening of the component. the Beechjet’s flaps did not appear to be Power Loss Prompts RTO extended. The airplane was 0.5 nm (0.9 Airbus A330-243. Substantial damage. No injuries. Unstable and Unprofessional km) from the runway and 153 ft above he A330 was departing from Man- Beech 400A. Substantial damage. Two serious injuries, runway threshold elevation when a two minor injuries. chester (England) Airport with 328 groundspeed of 194 kt and a descent rate Tpassengers and 11 crewmembers efore taking off from Gadsden, greater than 2,150 fpm were recorded. for a scheduled flight to the Dominican Alabama, U.S., for a business flight The Beechjet touched down with Republic the morning of June 24, 2013. Bto Atlanta, Georgia, the morning about 2,970 ft (905 m) of runway re- The aircraft was accelerating through of June 18, 2012, the pilot calculated a maining. The pilots deployed the thrust 105 kt on Runway 23R when it abruptly reference landing speed of 120 kt and reversers and speed brakes, and applied yawed right. The captain called out a landing distance of 3,440 ft (1,049 maximum wheel braking, but the air- “stop” and took control from the copilot. m) at Dekalb Peachtree Airport. The plane overran the runway, traveled down The pilots completed the rejected pilots did not review these calcula- an embankment and across a service takeoff (RTO), bringing the aircraft to a tions after departure, according to the road, and came to a stop about 800 ft stop on the runway. NTSB report. (244 m) from the departure threshold. “Initially, it was unclear what had The copilot, who had 3,500 flight The landing gear separated, and the taken place, but an ECAM [electronic hours, including 150 hours in type, fuselage partially fractured in two plac- centralized aircraft monitor] warning flew most of the flight from the left es. Both pilots were seriously injured, confirmed that a right engine fail- seat while receiving almost continuous and their two passengers sustained ure had occurred,” said the report by instruction and coaching by the pilot, minor injuries. 52 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JUNE 2014 ONRECORD NTSB said that the probable cause of the ac- factors were “the failure of either pilot to call for a cident was the “flight crew’s failure to obtain the go-around and the flight crew’s poor crew resource proper airspeed for landing” and that contributing management and lack of professionalism.” TURBOPROPS In-Flight Break-Up The wreckage of the King Air later was found Beech King Air E90. Destroyed. One fatality. in Karnack, Texas. “A review of the radar data, company in DeKalb, Illinois, U.S., had available weather information and airplane wreck- hired the pilot to transport aircraft parts age indicated that the airplane flew through a A to Mexico and then deliver the King Air to heavy to extreme weather radar echo containing a another operator. The flight to Mexico, planned thunderstorm and subsequently broke up in flight.” for July 6, 2012, was delayed for inspection of NTSB concluded that the probable cause of a recent propeller installation and a return of the accident was “the pilot’s inadvertent flight the airplane to service by the company’s chief into thunderstorm activity” but said that a mechanic. However, shortly after midnight, the contributing factor was “the failure of [ATC] chief mechanic told the pilot that he was too personnel to use available radar information tired to perform the inspection and would com- to provide the pilot with a timely warning that plete the work the next morning. he was about to encounter extreme precipita- Nevertheless, the pilot departed without au- tion and weather along his route of flight or to thorization from DeKalb at 0230 to position the provide alternative routing to the pilot.” airplane to Brownsville, Texas, the NTSB report said. It was his first flight in the airplane. The Weakened Gear Collapses pilot had not obtained a preflight weather brief- ATR 42-320. Substantial damage. Four minor injuries. ing or filed a flight plan, but he did request and MC with winds from 210 degrees at 16 receive flight-following service from air traffic kt prevailed at Jersey Airport in Britain’s control (ATC). VChannel Islands the morning of June 16, The King Air was in cruise flight at 14,500 ft 2012, and the flight crew conducted a visual at about 0400 when a Dallas–Fort Worth Center approach to Runway 27. “The commander controller told the pilot, “I’m showing some reported that both the approach and touchdown moderate, heavy and extreme precipitation seemed normal, with the crosswind from the now [at] 12 o’clock and about two miles. It just left resulting in the left main gear touching first,” popped up.” the AAIB report said. “Yeah, I’m seeing some weather, sir,” the Both pilots heard a noise that they thought pilot said. “Do you have a recommendation [for] was from a tire bursting, and the aircraft rolled deviation left or right?” left until the wing tip and propeller struck the “No, I really don’t,” the controller replied. “It runway. The aircraft quickly came to a stop looks like you are heading right for it. It looks to the left of the runway centerline. The com- like the heavier stuff, most of it, is to your left, to mander shut down the engines, and the flight the east, so maybe going west would be better.” attendant assisted the passengers in evacuating Accordingly, the pilot advised that he was the aircraft. Four of the 40 passengers sustained changing course 25 degrees to the right. “That’s minor injuries during the evacuation. fine,” the controller said. “Whichever way you Examination of the left main landing gear need to go is fine.” A few minutes later, the con- revealed that the upper arm on the left side troller inquired about the pilot’s ride conditions, brace had fractured. “Evidence provided by the but there was no response. Radar contact was flight data recorders indicates that the land- lost shortly thereafter. ing was not extraordinary and that it was not FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JUNE 2014 | 53 ONRECORD considered to have been a contributing fac- The pilot later told investigators that they tor in the collapse of the landing gear leg,” the could not return to Townsville because the air- report said. Investigators found signs that the craft exceeded its maximum landing weight. “He side brace had been cracked when subjected to also considered changing the transponder to the overload during a previous flight. radio failure code of 7600, however elected to continue with the code previously assigned as Radio Contact Lost the aircraft had already been identified on radar Mitsubishi MU-2B. No damage. No injuries. by Townsville ATC,” the report said. he flight crew was ferrying the MU-2 from the The aircraft remained in ATC radar contact Solomon Islands to Melbourne, Victoria, Aus- throughout most of the flight but was not in Ttralia, with an intermediate stop at Townsville, radio contact for 3 hours and 35 minutes. The Queensland, on April 5, 2013. Shortly after depart- aircraft was about 230 nm (426 km) north of ing from Townsville at 1354 local time, the pilots Melbourne and at 21,000 ft when the crew was heard static in their headsets and found that they able to establish normal radio communications were able to hear radio transmissions from ATC with ATC on a frequency relayed by the crew of but that their VHF (very high frequency) radios another aircraft. The MU-2 subsequently was were transmitting only carrier wave (no voice). landed without further incident. The pilots tried unsuccessfully to resolve Investigators found that the radio malfunc- the problem by turning the two VHF radios tion resulted from water that had leaked onto, on and off, changing frequencies, recycling the and caused corrosion of, two main radio isolator circuit breakers, changing headsets and using breakers. “The aircraft had been left outside for the handheld microphone, said the report by some time and subjected to tropical storms,” the the Australian Transport Safety Bureau (ATSB). report noted. PISTON AIRPLANES Prop Feathering Delayed time between overhauls of the Lycoming TIGO- Piper P-Navajo. Substantial damage. One fatality. 541 engine is 1,200 hours or 12 years. he pilot took off from Dalton, Georgia, U.S., NTSB said that a contributing factor in the the afternoon of June 30, 2012, to have an accident was the absence of guidance in the Tannual inspection performed in Doug- pilot’s operating handbook that the propeller las, Georgia. The NTSB report noted that the should be feathered before rpm decreases below inspection was 12 days overdue. 1,000 rpm after a power loss. Witnesses about 2 mi (3 km) from the departure runway saw the Pressurized Navajo Sick Pilot Loses Control flying low and descending. One witness said that Beech B95 Travel Air. Substantial damage. Four fatalities. the left engine appeared to be at full power, and he pilot landed the Travel Air in Holbrook, the right engine and propeller were not operat- Arizona, U.S., for fuel during a flight from ing. The airplane pitched up above a power line, TCalifornia to Texas on June 24, 2009. Wit- rolled right and descended into wooded terrain. nesses said that the pilot appeared to be ill and Examination of the wreckage revealed that that he rested on a sofa while his passengers the propeller had not been feathered promptly had lunch. after the right engine failed for reasons that Shortly after takeoff from Holbrook, the could not be determined because of impact airplane made a 45-degree right turn at about 300 and fire damage. The report said that the right ft and then entered a left turn. The roll steepened engine had accumulated 1,435 hours since it was past the vertical, and the airplane descended to overhauled 24 years earlier; the recommended the ground, killing the four occupants. 54 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JUNE 2014 ONRECORD “It was very likely that the acute gastrointes- The flight crew was unable to extend the tinal distress the pilot was suffering at the time main landing gear on approach to Grand impaired his ability to successfully fly the airplane,” Turk. They conducted a go-around and tried the NTSB report said. “Due to his condition, the without success to extend the main gear. “The pilot likely decided to return to the departure air- pilot declared an emergency and committed port but failed to maintain control of the airplane.” himself to a wheels-up landing,” the report said. “He raised the nose landing gear and Leak Causes Gear to Jam feathered both engines on final approach, Piper Chieftain. Substantial damage. No injuries. closing the firewall fuel valves and selecting fter landing at Providenciales, Turks and fuel off. The landing was successful, and there Caicos Islands, the evening of June 28, was no fire.” A2013, the pilot noticed that the left main Examination of the left main gear revealed landing gear oleo strut was leaking oil. “After that the leak originated from a twisted and consultation with his employer, it was decided broken O-ring seal. The leak prevented the oleo to ferry the aircraft back to its base [on Grand strut from extending fully and caused the torque Turk] for rectification,” said the AAIB report. link to foul inside the wheel well. HELICOPTERS Fuel Unporting Causes Flameout Tail Rotor Driveshaft Disconnects Bell 206-L3. Substantial damage. No injuries. Bell 206L-4. Substantial damage. No injuries. efore departing on a chartered survey he helicopter departed from Abbeville, flight of the Buccaneer Archipelago in Louisiana, U.S., the morning of June 6, 2013, BWestern Australia the morning of June 8, Tfor an apparent fire-fighting mission. It was 2013, the pilot determined from gauge indica- the LongRanger’s first flight following extensive tions that the LongRanger had sufficient fuel maintenance that had included removal and for the flight. installation of the tail rotor gearbox. “The operator’s fuel management system After about 40 minutes of flight, the helicop- was almost totally reliant on the fuel quan- ter was approaching a canal at 20 ft to pick up an tity indicating system and, as a consequence, external load of water when the pilot heard a loud lacked a high level of assurance,” the ATSB pop. The helicopter began to spin, and the pilot report said. was unable to recover. He reduced power, and the The helicopter was at 1,000 ft and head- helicopter descended into the canal and settled in ing to Cone Bay for refueling when the engine about 3 ft (1 m) of water. Damage was substantial, flamed out. The pilot deployed the floats, but but the pilot and his passenger were not hurt. the LongRanger rolled inverted shortly after Examination of the helicopter revealed that touching down on the water. The pilot and his the tail rotor driveshaft had become partially four passengers were rescued by a boat crew. disconnected. “Of the driveshaft’s two bolts, one “The ATSB found that, without the pilot remained with its associated nut,” the NTSB realising, the fuel on board was probably suffi- report said. “However, the other bolt had backed ciently low to allow momentary unporting of the out of the driveshaft but remained in the cou- fuel boost pumps, which interrupted the flow of pling; its corresponding nut was missing.” fuel to the engine,” the report said. “Contribut- The safety board concluded that the probable ing to the pilot’s lack of awareness of the fuel cause of the accident was the “failure of mainte- state was a likely malfunction of the helicopter’s nance personnel to ensure adequate torque of a fuel quantity indicating system and a faulty low tail rotor driveshaft coupling bolt, which resulted fuel caution system.” in the partial disconnection of the driveshaft.” FLIGHTSAFETY.ORG | AEROSAFETYWORLD | JUNE 2014 | 55 ONRECORD Preliminary Reports, March 2014 Date Location Aircraft Type Aircraft Damage Injuries March 2 Hadhramaut, Yemen Antonov 26 substantial 6 NA The flight crew conducted a gear-up emergency landing in the desert after encountering technical problems during a cargo flight from Sana’a to an oil field in Masila. The occupants of the aircraft reportedly were kidnapped by anti-government tribesmen. March 3 Kish Island, Iran Dassault Falcon 20E destroyed 4 fatal The Falcon was being operated by the Iranian Civil Aviation Organization to calibrate navigation equipment at the island airport when it struck the Persian Gulf about 4 km (2 nm) offshore. March 3 Guasdualito, Venezuela Beech King Air 90 destroyed 2 NA The King Air reportedly had narcotics aboard when it entered Venezuelan airspace illegally and was forced by armed forces to land in an open field. The aircraft subsequently was destroyed by fire. March 8 Indian Ocean Boeing 777-200 NA 239 NA Search efforts were continuing at press time for the 777, which was believed to have diverted from course during a scheduled flight from Kuala Lumpur, Malaysia, to Beijing, China, and descended into the Indian Ocean about 2,600 km (1,404 nm) west of Perth, Australia. March 9 Tenerife, Spain McDonnell Douglas MD-11F substantial 3 none The flight crew returned to the airport after an uncontained failure of the no. 2 engine occurred during initial climb on a cargo flight. March 12 Villavicencio, Colombia Beech King Air C90 destroyed 5 fatal The King Air was on a medevac flight from Bogotá to Araracuara when the flight crew diverted to Villavicencio due to technical problems. The aircraft subsequently stalled and crashed on approach. March 13 Gillingham Hall, Norfolk, England Agusta Westland AW139 destroyed 4 fatal Night instrument meteorological conditions prevailed when the helicopter struck terrain shortly after takeoff. March 13 Philadelphia, Pennsylvania, U.S. Airbus A320-214 substantial 154 none The nose landing gear collapsed after the flight crew rejected a takeoff from Runway 27L at Philadelphia International Airport. March 14 Stuart, Florida, U.S. Cessna 402 destroyed 1 minor The 402 crashed in a garden on final approach. March 18 Seattle, Washington, U.S. Eurocopter AS350-B2 destroyed 2 fatal, 1 serious Witnesses said that the helicopter began to rotate after lifting off from a rooftop helipad and then descended onto a city intersection, striking a vehicle and seriously injuring the occupant. The pilot and passenger were killed. March 19 Gisborne, New Zealand MD Helicopters 500N substantial 1 fatal, 1 serious The helicopter was engaged in a night firefighting mission when it crashed in Hawkes Bay. March 19 Aurora, Colorado, U.S. Piper 601P Aerostar destroyed 1 fatal The pilot was performing low-level aerobatics over a residential area when the Aerostar struck trees and crashed in a field. March 20 Charleston, South Carolina, U.S. Cessna 421B substantial 3 none The 421 veered off the runway and struck two runway lights after the right main landing gear collapsed on landing. March 22 Ridgway, Colorado, U.S. Socata TBM-700 substantial 5 fatal The pilot was conducting an area navigation approach to Montrose Airport in day VMC when he told an air traffic controller that the airplane was in a spin and that he was trying to recover. The TBM then descended into a reservoir. March 26 Traverse City, Michigan, U.S. Cessna Citation 560XL none 4 none The flight crew landed the Citation without further incident after the rudder jammed on approach. March 27 Chandigarh, India Beech King Air B200 substantial 9 minor The King Air was taking off for a flight to Delhi when it stalled on initial climb and crashed on the runway. March 28 Karauli, India Lockheed C-130J destroyed 5 fatal The aircraft, operated by the Indian air force, was on a training mission when it struck terrain. NA = not available This information, gathered from various government and media sources, is subject to change as the investigations of the accidents and incidents are completed. 56 | FLIGHT SAFETY FOUNDATION | AEROSAFETYWORLD | JUNE 2014 e Foundation would like to give special recognition to our BARS Benefactors, Benefactor and Patron members. We value your membership and your high levels of commitment to the world of safety. Without your support, the Foundation’s mission of the continuous improvement of global aviation safety would not be possible. bars benefactors benefactors patrons 59th annual Business Aviation Safety Summit 67th annual International Air Safety Summit November 11–13, 2014 Jumeirah at Etihad Towers Abu Dhabi, United Arab Emirates Hosted by: Flight Safety Foundation Benefi2nd tannual Dinner Wednesday, November 12 Jumeirah at Etihad Towers, Abu Dhabi, United Arab Emirates The 67th annual International Air Safety Summit (IASS) will be held November 11–13, 2014 at the Jumeirah at Etihad Towers, Abu Dhabi, United Arab Emirates. In conjunction with 2nd annual Foundation Benefi t Dinner — Wednesday, November 12. Details coming soon! Please visit the website below for hotel information and further details about the event as they become available. fl ightsafety.org/IASS2014 @Flightsafety #IASS2014