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Contents
The Official Publication of THE UNITED KINGDOM FLIGHT SAFETY COMMITTEE ISSN: 1355-1523 WINTER 2011
FOCUS is a quarterly subscription journal devoted Editorial 1 to the promotion of best practises in aviation safety. It includes articles, either original or reprinted from other sources, related to safety issues throughout all areas of air transport Chairman’s Column 2 operations. Besides providing information on safety related matters, FOCUS aims to promote debate and improve networking within the industry. It must be emphasised that is not intended FOCUS Cabin Crew Fire Training 3 as a substitute for regulatory information or company publications and procedures. by Nick Butcher
Editorial Office: The Graham Suite, Fairoaks Airport, Chobham, Woking, Surrey. GU24 8HU TCAS RAs - How to fly them and why it matters 6 Tel: 01276 855193 Fax: 01276 855195 by Alex Fisher e-mail: [email protected] Web Site: www.ukfsc.co.uk Office Hours: 0900 - 1630 Monday - Friday
Advertisement Sales Office: Sliding Away 9 UKFSC by David Thomas The Graham Suite, Fairoaks Airport, Chobham, Woking, Surrey GU24 8HU Tel: 01276 855193 Fax: 01276 855195 email: [email protected] Heavy Metal Front Man Ramps Up Industry Loading Awareness 11 Web Site: www.ukfsc.co.uk Office Hours: 0900 - 1630 Monday - Friday
Printed by: Preventing Landings without Clearance 13 Woking Print & Publicity Ltd The Print Works, St. Johns Lye, St. Johns, Woking, Surrey GU21 1RS Tel: 01483 884884 Fax: 01483 884880 A Dark and Stormy Night and 90 seconds to Disaster 15 e-mail: [email protected] Web: www.wokingprint.com
FOCUS is produced solely for the purpose of improving flight safety and, unless copyright is Runway Incursions 18 indicated, articles may be reproduced providing by Adrian Leonard that the source of material is acknowledged.
Opinions expressed by individual authors or in advertisements appearing in FOCUS are those of Better Safe than Sorry 21 the author or advertiser and do not necessarily reflect the views and endorsements of this journal, the editor or the UK Flight Safety Committee. Members List 24 While every effort is made to ensure the accuracy of the information contained herein, FOCUS accepts no responsibility for any errors or omissions in the information, or its consequences. Front Cover Picture: Bruce Dickinson: Captain with Astraeus, Iron Maiden Lead Singer and Presenter Specialist advice should always be sought in in “Safety in the Balance” DVD. See page 11. relation to any particular circumstances. Photographer John McMurtie / © Iron Maiden Holdings 2011
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EDITORIAL
UK Flight Safety Committee - 50 Years in Aviation Safety Reflections of a Past Chairman
by Rich Jones, Chief Executive UKFSC
n the Spring edition of FOCUS, the One sensitive situation is where the captain is But the Report on the AF447 accident has not Iopportunity was taken to remind our PNF, when the link between command and yet fully addressed two important issues, readership that 2011 is the 50th action is indirect and the monitoring role which relate in turn to pilot experience and anniversary year of the UK Flight Safety reversed. Accidents have revealed situations training: the extreme final position of the Committee. From our early beginnings where co-pilots have been over-deferential to horizontal stabiliser and the aerodynamic under the Department of Transport and captains – but also where captains have configuration which allowed the aircraft to Civil Aviation, we became an independent allowed co-pilots PF excessive latitude. I will enter a deep stall. Was it that the crew did not association of aviation safety professionals always treasure one anecdote from a friend, select Direct Law – to be able to use the trim in September 1961, with the specific aim of who became concerned at his co-pilot PF’s late wheels, and was it that the deep stall was not promoting flight safety across the dive at the threshold with idle thrust; he said ‘I recognised? I am not in the position to pursue commercial air transport sector. In have control’ – before he himself could no these questions, but what is the general response, we were delighted to receive the longer have been so confident at making a potential for mishap on aircraft with a following reflections from Harry Hopkins, smooth recovery. On clearing the runway the powerful stabiliser? who was Chairman of the Committee aggrieved co-pilot demanded ‘why did you do between 1982 and 1986. that captain’; my laconic friend was As ever, aviation safety is full of questions. economical in his reply: ‘because I wanted to I belatedly congratulate the UKFSC and its live!’ It is not a bad basic command philosophy. Chairman on its 50th anniversary. Over that The BA chief maintenance engineer once spoke time membership has steadily widened, so that up at a company safety meeting at which I was views on safety can be contributed over a present. The matter of hurt feelings and spectrum of professions within the industry sensitivities was being bandied about. He said, with some exasperation: ‘some of us AN APOLOGY AND A CLARIFICATION and from an ever wider range of geographical FOCUS EDITION NO 84 areas of operation. sometimes have to be nasty to some of us.’ Apology - Ryanair Might I now exploit the privilege of being a In the Chairman’s column in Focus of Autumn past Chairman by offering some personal 11 is titled ‘The Right Attitude’. Tony Wride The Editor wishes to apologise to Ryanair and its pilots comments. starts with comment on the fundamental for any distress or concern that may have been caused issues, which can never be re-emphasised through the views expressed by the authors in relation to the Ciampino incident in their article ‘Bird Strike I have often found myself returning to three enough, and then refers to the AF447accident to an Airbus A330. Mitigation – Beyond the Airport’, which was published in principles as lying at the root of aviation safety, FOCUS Magazine Issue 84. The Executive Board of the which I feel should form the groundwork of UK Flight Safety Committee acknowledges that any any safety philosophy, on which detailed My mind goes back to arguments which were comment on the actions of the crew involved prior to guidance and regulation can then be planted. I running through BALPA and IFALPA many the publication of the final accident investigation report believe that these basics can never change: decades back: ‘Why are airliner cockpits not was premature and recognises that certain phraseology provided with clear angle of attack in the article could be interpreted as implied criticism of information?’The question still largely remains, actions taken by the crew involved, which was not the Safety is the survival of error; design, intention of the Editor in publishing the article. construction and operation are all inescapable yet angle of attack sensors are widely fitted. sources of error. Clarification - The Increasing Risks and Dangers of Over nearly fifteen years, when I was Portable Electronic Devices on Commercial Aircraft Safety gives weight to the risk that an incident conducting air tests for Flight International, I could have been an accident, at another time very rarely found this information to be From my Editorial on lithium battery fires in portable or place. missing as a supplementary fit in the flight electronic devices, I am grateful to Captain John deck of a test aircraft. Of course certification Goodyer from Thomson Airways for pointing out that my comment that 'lithium and water do not mix well Safety depends on identifying and quitting a test pilots have to explore well beyond the normal flight envelope, but history shows that together' could be misleading. The CAA and FAA advice degrading situation at a prudently early stage. recommends the use of water extinguishers or, where line pilots not infrequently find themselves in In any field of human activity mistakes will be these are not available, copious amounts of water, after made, in spite of all attempts to avoid them; that situation too. the use of a Halon type extinguisher to put out a lithium the final line of flight safety defence must lie battery fire in the passenger cabin when airborne. with the operatives – aircrew, controllers and Awareness of attitude is not fully serviced by Although lithium metal from any split battery cells will others. Any dismissal of an incident as ‘no the primary flight instruments: do they display react with water to cause bright flashes and small explosions, it is essential that any remaining lithium actual risk’ may then lead to a failure to take to the necessary precision? For example, the width of the target on the PFD of the A330 is batteries are cooled down to prevent thermal runaway serious action and the very real prospect of a and further serious cell explosions and fire. similar situation occurring in the future, with about one degree, over a 2.5 degree scale, far graver consequences. The companion to which equates to a variation in vertical speed Rich Jones this is the finding of ‘an isolated incident’. of the order of 1,000ft/min in the cruise. (The Chief Executive and Editor Aren’t they all, the first time? Concorde ADI was graduated in single degrees UK Flight Safety Committee between 20 degrees nose-up and 10 degrees nose-down.)
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CHAIRMAN’S COLUMN
Mishaps and fuel for thought!
by Capt. Tony Wride, Monarch Airlines
ver 100 years ago the Wright likelihood and spend an inordinate amount of fuel. On the flip side we now have a breed of Obrothers took to the air for the first time and resources coming up with 'fuel saving' Captains who are actively time and so started the Aviation Industry. mitigations should the gear become stuck. 'shaving' the required figure back as much as It wasn't long before they had their first However, this is where a realistic view has to possible which means that they arrive at 'mishap' and learned some valuable be taken. How many other incidents, in destination on 'finals' with diversion fuel and lessons which they subsequently applied relation to the thousands of commercial not much more! What does this mean in to ensure a greater chance of success, and flights that happen every day, have occurred? terms of safety? Well my concern is that what survival! As time passed improvements in To my knowledge this B767 incident was the this 'shaving' is doing is giving the crew even aircraft design continued but 'mishaps' still first for a long time of an aircraft having to do more pressure to land off the approach occurred which invariably led to some a total 'wheels up' landing. regardless, or face an immediate diversion. As major lessons being learned.Those lessons the saying goes "There is no greater pressure have been applied in order to make more In this time of increased financial pressure, than a lack of fuel pressure!" So what happens improvements. Given that we have had and Safety Departments having limited to that crew when at just above 1000ft they over 100 years to learn the lessons from resources, the Safety Managers have to select the gear down and the extremely our predecessors 'mishaps' you would 'target' their activity to achieve as much as unlikely 'mishap' occurs? They have no spare think that as an industry we would have they can with the resources they have. But fuel, they have to declare an emergency, go learned everything by now and that let's consider this. If on landing, the B767 had around to have time to try the alternate 'mishaps' wouldn't happen anymore. landed hard, broken up and caught fire killing extension system but they are already eating a large number of the passengers, the lawyers into their diversion fuel. And what about the Unfortunately, as has been seen recently with would have been after the airline for huge other aircraft expecting no delay to their the B767 wheels up landing, despite all the amounts of compensation and one of the first arrival with more 'fuel shaving' captains who best efforts sometimes things just don't work things that would be asked is had a Risk will have no option but to divert immediately? and s**t happens! If we look back through Assessment been carried out! Therefore, can history at the number of 'wheels up' landings an airline afford not to do thorough Risk Let me make one thing clear. I'm not that have occurred, due to mechanical failure Assessments on just about every possible advocating everybody carrying lots of extra rather than hostile fire, we would see that 'mishap'? A difficult argument could ensue fuel, just applying some caution to the once aircraft began to be fitted with a but until the Airline Board realise just how practice of trying to cut back too much. We retractable undercarriage initially the numbers exposed the Company could be and resource all have a duty to be realistic with how much were high until the engineers learned to design the Safety Department appropriately they are fuel we carry if the industry is going to survive in backup systems, like gravity extension, so taking a Risk! and if I was to point a finger at anybody it that the likelihood of a 'wheels up' landing, would be those Captains that have always and therefore the risk, was reduced. If a Safety Whilst on the subject of Risk and the effect of taken the excessive amounts of extra on a Manager was doing a Risk Assessment on the the current financial situation on the industry, regular basis. They are the ones who have likelihood of one of the Company's aircraft I have watched how Airlines have taken some wasted the most and almost forced Airlines to ever having to do a wheels up landing he or quite drastic measures to reduce fuel costs. introduce strict fuel policies. Arguably fuel she would most likely have put it in the Very Just about every airline now has a fairly rigid saving is not just the remit of pilots. Have you Unlikely category therefore requiring no 'Fuel Policy', has changed SOPs to try and ever wondered as you look at the sky over action. Equally of they had looked at the likely minimise fuel burn including such things as Heathrow at several very large aircraft consequences of a 'wheels up' landing they having a lower Acceleration Altitude and a ‘holding’, how much fuel is being wasted? would most likely have said extensive aircraft reduction in the contingency from 5% to 3%. damage but no injuries. Aircraft now arrive at their destination with In other news, although not a 'mishap' it is a very little, in fact almost no, extra fuel should safety event! Our excellent Chief Executive, any 'mishaps' occur. I fully understand the Rich Jones, has decided to move on to greener rationale behind introducing a fuel policy, it pastures, if you can call the CAA that! Rich has could be argued that if the industry is going to been the driving force behind updating and survive then such measures are vital, but I do progressing the UKFSC and we all owe him a wonder if by doing this we are setting up a debt of gratitude. I would like to thank him on section of the 'James Reason Cheese' that will behalf of the membership for all his hard work be a factor in a future accident! and wish him all the best for the future.
Let me explain my rationale. It is well known that there are Captains who would always carry some extra fuel above what the Flight Having watched the video of the B767 Plan required, in fact some would take landing, and I have to say that the crew of unrealistic extra amounts given the prevailing that particular flight did an excellent job, conditions at the destination with an there might be a temptation to reassess the associated additional cost for carrying that
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Cabin Crew Fire Training
by N J Butcher
n November 2006, the Royal Case studies are a useful tool in the training of IAeronautical Society and the Guild of Air in-flight fires and should be incorporated into Pilots and Air Navigators published a paper cabin crew training whenever relevant. entitled: ‘Smoke, Fire and Fumes in Transport Aircraft – Past History, Current Note: The requirements of EU-OPS 1 will in Risk and Recommended Mitigations’ time be overtaken by the transition to EASA Part-OPS. However, the actual cabin crew fire The Royal Aeronautical Society is now training requirements in EASA Part-OPS are considering updating this paper to include a anticipated to be essentially the same. section regarding how the European DC-9 accident – Cincinnati June 1983 Requirements for cabin crew fire training The flight crew will have to make rapid should be achieved. Background assessments of the situation and a decision regarding diversion to the nearest suitable Many of the issues to be addressed in this In the Bradford City football stadium disaster aerodrome, or if flying over water, may as an second edition are equally applicable to flight in May 1985, a fire totally destroyed one large absolute last option, have to decide on crew fire training. The aim is to provide spectator area. The fire, although quite small ditching the aeroplane. guidance to operators, third party training to start with, spread rapidly along the length organisations and instructors, and to identify of the spectator stand. It took less than four According to the FAA, delaying the aeroplane’s advisory material. Recommendations made minutes for the entire stand to be engulfed in descent by only two minutes is likely to make by Aviation Authorities and other safety flames. There were 56 fatalities. The cause of the difference between a successful landing related organisations will also be included. the fire was probably a match or cigarette being dropped on debris that then ignited. and evacuation, and a complete loss of the aircraft and its occupants. The second edition of this paper will also identify the several initiatives conducting by Cabin crew must be able to deal with a Aviation Authorities and other aviation safety fire/smoke situation immediately and organisations. aggressively, and locate the source of the smoke and/or fire as quickly as possible. Cabin The European requirements (EU-OPS 1) are crew will need to initiate fire fighting action not very specific as to how compliance with immediately. Every second lost is likely to the requirements for fire training should be bring the situation nearer to disaster. achieved. Little additional information is issued by EASA in respect of cabin crew fire The flight crew will need to have accurate and training, although the UK CAA and the US Bradford City Stadium fire – May 1985 concise information from the cabin crew as FAA have both issued advisory material. If a fire on the ground with the potential for the situation develops, and cabin crew will need to be aware that the flight crew will at There are omissions in the requirements of several different means of escape can be so this time have a very high work-load. Cabin EU-EU-OPS 1 Subpart ‘O’. For example devastating and with so many fatalities, how crew should be trained to communicate the ‘hidden’ fires and restrictions on the use of effectively would an aircraft crew deal with a essential information to the flight crew circuit breakers are not specifically mentioned, serious in-flight fire? although these are both critical issues and regarding an in-flight fire, so that the flight need to be addressed in cabin crew training. An in-flight fire is one of the most significant and potentially catastrophic emergency crew can make objective decisions as to an emergency descent and/or diversion. This Cabin crew fire training is usually delivered in scenarios that the crew will face. Prompt should be reflected in both theoretical and full compliance with the requirements of EU- assessments and actions by flight crew and practical training and specific procedures OPS 1 Subpart ‘O’. However, it is possible that cabin crew will determine the outcome of the should be included in the operator’s CCOM. some operators and third party training emergency. Failure to act immediately to a organisations might be achieving less than is fire threat is likely to have fatal consequences. In recent years several initiatives have been required, possibly due to a lack of understanding undertaken by Aviation Authorities and other of how to implement the mandatory If a fire does occur in any area of the aircraft aviation safety organisations, and these requirements. accessible to the cabin crew during flight, the cabin crew will have to fight the fire whilst include: keeping the flight crew fully aware of what is happening.
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■ US National Transportation Safety Board removes the opportunity for crew to Review and Recommendations on In- experience the discharge of halon on a live fire. flight Fires (2002); The size of a fire to be extinguished in ■ US Federal Aviation Administration practical training and the level of difficulty in Advisory Circular 120-80 (2004); extinguishing the fire are critical to achieving requirements for crew proficiency. A fire that ■ UK Civil Aviation Authority Safety Plan of is easily extinguished is likely to lead to a 2006/2007; sense of false security and may not prepare ■ Royal Aeronautical Society and the Guild the crew member for dealing with an actual Practical fire training - 25 years ago of Air Pilots and Air Navigators Paper – in-flight fire event. Therefore, the size of the Smoke, Fire and Fumes in Transport fire should present the cabin crew with an The differing fire scenarios that cabin crew Aircraft (2006); actual challenge in terms of extinguishing the may encounter during flight is not always fire, and also that fire re-ignition should be adequately addressed in theoretical and ■ UK Civil Aviation Authority Cabin Crew addressed in practical training. practical fire training. One major concern is Fire Training Analysis (2009). the increase in the use of Passenger Electronic Additionally, the type of fire extinguisher used Devices (PED’s) which are mainly powered by The time available to successfully deal with an in training may not adequately replicate the lithium batteries. Dealing with a lithium in-flight fire is extremely limited – perhaps a type of fire extinguisher carried in the battery fire on board an aircraft presents fact that some cabin crew and flight crew are operators’ aeroplane. Also, the difficulty of several difficulties and it might be that cabin not fully aware of. This should be stressed initiation of discharge of the extinguishing crew will be unaware of how to deal with such during crew training and case study examples agent is very often not included in practical an in-flight fire event due to the lack of should be included to demonstrate the training, and in many cases is not achieved specific operational procedures and importance of the need for urgent action. by cabin crew as a demonstration of associated training. individual proficiency. In AC 120-08, the FAA identified that the time Many operators and training organisations for the situation to become non-survivable Some 25 years ago, during training, crew achieve the requirements for cabin crew fire was as little as seven minutes, and that only usually fought fires outside. These fires were fighting in separate training scenarios, with 33% of events with ‘hidden fires’ would reach usually quite large, and often visually cabin crew extinguishing a fire without the use an aerodrome before the fire became challenging, as well as being difficult to of PBE, and the use of PBE by cabin crew when uncontrollable. This issue is not addressed in extinguish with re-ignition being a major not extinguishing a fire. This appears to be any EU-OPS 1 requirement or in any EASA issue. However, it was decided that since such meeting the mandatory requirements with advisory material. fires were not realistic to a cabin fire situation little consideration as to the probability of a and the requirement was changed to crew serious in-flight smoke or fire event when both It is obvious that the speed and effectiveness fighting a fire representative of an interior fire extinguishers and PBE will need to be used of both flight crew and cabin crew actions are aircraft fire. This has resulted in cabin crew simultaneously, perhaps in conjunction with vital to a successful outcome of an in-flight now fighting fires of such a small size that the use of other equipment such as fire gloves. fire event, although the importance of this is extinguishing the fire provides little difficulty not always reflected in flight crew or cabin or challenge, and with no real degree of Logistically combining fire extinguisher crew training. proficiency being demonstrated. training with PBE training is certainly feasible
Training in the use of Protective Breathing Problems with achieving realistic fire Equipment (PBE) during practical training also training presents problems. The vast majority of cabin crew will never remove PBE from its container It is widely recognised that the provision or remove it from its sealed packaging, other of realistic cabin crew and flight crew fire than during an actual in-flight fire emergency. training presents many practical and Most cabin crew will never don PBE which has logistical difficulties. a neck seal that fully replicates a live unit and therefore difficulty in donning such The Montreal Protocol prohibits the discharge equipment is not effectively experienced. Combining practical fire extinguisher training with of halon during fire-fighting training and practical PBE training
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since some operators and training Items also to be addressed in the second ■ The US Federal Aviation Administration organisations do combine both elements of edition of this paper will include: Advisory Circular – Number 120-80 practical fire training. It would seem entirely logical for the mandatory requirements to ■ Effectiveness of cabin crew fire fighting ■ The UK Civil Aviation Authority – Safety reflect the likelihood of an in-flight fire event procedures Plan of 2006/2007 when different items of fire safety equipment will need to be used at the same time. ■ Hidden fires ■ The UK Civil Aviation Authority – Cabin Crew Fire Training Analysis Gas-powered fire training rigs are now quite ■ Electrical fires and lithium battery fires commonly used. Usually the actual fire is ■ Guidance on meeting the fire training controlled by the instructor. In the case of ■ Communication and coordination requirements of EU-OPS 1 Subpart ‘O’ some fire training rigs, it is the instructor who actually turns off the gas supply thereby ■ Instructors ■ Case studies of catastrophic in-flight fires extinguishing the fire, rather than the individual cabin crew member achieving this. ■ Third party training ■ Case studies of non-catastrophic in-flight Therefore the standards applied by the fires and smoke events instructor(s) must be consistent with the ■ ‘Combi’ Aircraft procedures and will need to be specifically ■ Additional reference material defined in the Operations Manual. An ■ The cabin crew training requirements of additional consideration is the acceptability EU-OPS 1 Subpart ‘O’ and legality of such a procedure whereby the cabin crew member has not actually ■ The US National Transportation Safety extinguished the fire as required by EU-OPS 1 Board Review and Recommendations Subpart ‘O’.
UK FLIGHT SAFETY COMMITTEE
APPLICATION FOR THE POST OF CHIEF EXECUTIVE
Applications are invited from experienced safety professionals for The successful applicant will also need to have: the immediate appointment to this post. The successful applicant ■ Strong people skills and confidence in speaking to large groups will have a substantial career in aviation safety. ■ A command of the English language The UK Flight Safety Committee is an independent not-for-profit ■ association of aviation safety professionals dedicated to the Sound writing skills with the ability to edit our FOCUS magazine improvement of flight safety in the commercial aviation sector. The ■ The ability to plan and manage meetings, events and seminars office is located at Fairoaks Airport near Woking in Surrey. ■ A working knowledge of IT The Committee promotes and facilitates safety information exchange among our 100 Members through regular meetings, a dedicated Interested parties are invited to e-mail their application together website, a quarterly magazine and a Flight Safety Officers with their Curriculum Vitae by 16 DECEMBER 2011 to: The Familiarisation Course. Chairman, UK Flight Safety Committee at [email protected] final selection interviews will be notified and held at Fairoaks Airport The successful applicant will be required to: in early January 2012. ■ Manage and motivate a small team and manage the annual budget ■ Demonstrate a broad knowledge of all aspects of aviation safety ■ Represent the UKFSC at aviation safety forums in the UK and worldwide
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TCAS RAs How to fly them and why it matters
by Alex Fisher, GAPAN
he last (at the time of writing) pilots who apply it the confidence to the single controller on duty noticed the TEurocontrol ACAS Bulletin reported manoeuvre the aircraft secure in the conflict late, issued a descent clearance to the that in a recent study, only 55% of TCAS knowledge that they won’t ever plaster the Tu 154 to FL350, and then returned to working RAs occurring in the TMA were correctly passengers on the ceiling. another arrival into Friedrichshafen.The descent flown, and the figure for en route was clearance coincided with the TCAS Climb RA to little better at 65%. This doesn’t sound What do these acceleration numbers actually the Tu 154, which was coordinated with a encouraging, but only 10 years ago, a mean in terms we can understand? First, a Descend RA to the B757. Unbelievably (but similar study showed that none of them little bit of arithmetic and school physics: sadly not by any means uniquely) the Russian were flown right (see fig 1 from the crew elected to follow the ATC clearance ■ 2002 ECASA study), so maybe the trend 1g = 32 ft/sec/sec…so. opposite to the RA. Both aircraft started to was encouraging. But maybe not, as the descend at roughly the same rate. The fact that ■ earlier study was looking at not only the 1/4g = 8ft/sec/sec = 480 ft/min/sec (i.e this was a coordinated RA is important; at the vertical speed achieved, but the time it for every second you maintain 1/4g, your time this meant that TCAS was inhibited from took to get there, I’m not sure the more vertical speed will increase by nearly 500 issuing a reversal, telling the 757 to climb (the recent study did. ft/min). latest change to TCAS, 7.1, corrects this ■ 1/3g = 10ft/sec/sec = 600ft/min/sec. wrinkle). All it could do was to tell the 757 to increase descent, which it did, but not soon ■ To achieve +/- 1500 ft/min takes 3.3 enough and the two aircraft collided at just seconds at normal rate. below FL 350, the Tu 154’s left wing hitting the 757’s fin (An Enhanced Advisory, Increase climb, ■ To achieve +/- 2500ft at enhanced rate was also given to the Tu 154, but they were takes 2 secs more. clearly not in listening mode).
■ To achieve a 3000 ft/min reversal at enhanced rate takes 5 secs. FDR data (extracts) of the B757-200 (last minute) Figure 1: Delay (s) vs.Vertical speed (fpm) The last three figures are the important results, they tell you how long you have to As you can see, an admittedly small sample of reach the advisory rate. A few of you may pilots fell into two groups, aggressive and slow, have seen and remember the advice given in straddling and missing what the TCAS JAA TGL11, or the CAP it replaced, which were designers were looking for in terms of just about the only public documents to response. mention reaction times. Both are no longer current. They gave a figure of 5 seconds for the time to achieve the vertical rate. This was TCAS assumes: a deliberate simplification as it was felt that a 5 second reaction time to an RA was ■ for a corrective advisory: overgenerous given that there was a warning – 5 seconds reaction time, followed by through the preceding TA, so we could – 1/4g acceleration to satisfy demand. ‘borrow’ a couple of seconds and assign them to the acceleration phase. As I hope will ■ For enhanced advisories become clear, precision isn’t important, a ball Referring to Fig 2, the 757 recorder data: (‘Increase…Or ‘…NOW’): park figure is. Just how important is shown by – 2 seconds reaction time a case study that must surely be familiar to – 1/3g acceleration. everyone by now. 1. TCAS Descend RA is received.
But does anyone know what ‘x’ g feels like and 2. After a 2 second pause a modest decrease how to achieve it? Probably not, not even the The Uberlingen Accident in g of about 0.15g is seen briefly. The test pilots, but there is a very simple way to average g decrement is less than 0.1g. achieve the right acceleration. Not only does At 2 am in clear night conditions, a Tu 154 and a B757 were converging at roughly right angles this ensure that TCAS is used to its full 3. An Increase Descent RA is received. potential, the right technique should give at FL360 in the Zurich FIR. Due to distraction,
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4. There is an odd wobble in the g trace but it 2. 0.25g acceleration to 1500 ft/min The answer is to think is clear than no sustained 0,33g is applied; followed by 0.33g acceleration to 2500 the results are:- ft/min after the enhanced RA (what TCAS TA = Traffic Advisory = Think Ahead = Think is expecting). Attitude 5. 1500 ft/min is achieved 14 seconds after the start of the RA, and 12 seconds after The results are not dramatic at first sight; the In other words, to react to any subsequent RA, the advisory is complied with. more aggressive response results in about 80ft think what attitude change will be more altitude change in the first stage, appropriate, and the time to do that thinking 6. The increased of 2500 ft/min rate is increasing to about 100ft after the ahead when the TA is announced. reached about 7 seconds later. strengthening of the RA. But just consider, TCAS is only ‘shooting’ for 400ft clearance, In cruise, the most an initial RA will demand is Clearly this reaction was a lot less than TCAS slow reaction wastes a quarter of it. And the a climb or descent of 1500ft/min; the attitude was expecting, and yet the Accident Tu154 only clipped the 757’s fin, the effect of change in degrees, ▲p, to achieve that is given Investigators despite correctly listing the TCAS that extra 100ft would have been no accident. by: ▲pº = 1000/TAS(kt) assumptions declared ‘the crew had reacted Of course extra clearance could have been correctly to the RA’. I beg to differ. This is not achieved if the 757 crew had the ability to You don’t need to be wizz calculator, if you meant as criticism of the 757 crew; they instantly work out what was happening and prefer, think of the following table: performed as fig 1 showed, pretty much like gone for an increased vertical rate at any time, many crews do, especially when asked to preferably early on, but this misses the point, To achieve 1500ft/ min change in V/S: accelerate down (doubtless partly through slow reactions risk miss distance. Period. Condition TAS kt ▲ pitchº concern about the safety of anyone not Cruise 500 2 strapped in ‘down the back’; in this case the But what if your aircraft doesn’t have such a Hold 230 4-5 flight was all cargo, but the co-pilot was not display but is equipped with a ‘TA/RAVSI’, or back in his seat at the start, so similar thoughts is a current Airbus without an EFIS Final 150 7 may have occurred to the handling pilot). presentation of required attitude to comply? A little more thought is needed. You could Use this as the target initial attitude change, Altitude Deviation and Acceleration simply try to ‘drive’ the VSI to the right value, and then adjust to get the vertical speed right. The sequence is shown in the next figures. but this isn’t ideal, there are lags even in an ‘instantaneous’ VSI, and in some aircraft the scale is less than ideal.
Proper Reaction to RAs
The preceding section has shown the time available to achieve the RA and the consequences of not doing it. But that still doesn’t tell us how to achieve those rates reliably and with confidence.
If you are flying an aircraft with an RA display such as the Boeing/Honeywell one shown in fig 4, nothing could be simpler.When the RA appears, start the indicated adjustment and count slowly Fig 3 up to 4 or 5; at the end of that time you should be looking at the picture on the right and you will have achieved around 0.25g in the process.
Does this matter? For an answer refer to fig 3. I have plotted altitude against time for two cases;
1. 0.1g acceleration to 1500 ft/min followed by 0.1g acceleration to 2500ft/min after the enhanced RA (approximates to the Fig 4 B757 reaction at Uberlingen).
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Conclusion
Proper reaction to an RA is important. Getting the right vertical speed in the right time gives TCAS the best chance of a successful resolution, while minimising the chance of disturbance in the cabin.
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Sliding Away
by David Thomas
still decelerating as it approached the end of the runway. The first officer indicated that the terrain looked more even to the left of the runway, and the captain responded by turning the nosewheel steering toward the left.
The first assumption one might make after reading this brief account is, considering that the crew touched down 357 m down the runway, the incident must have been the result of a mishandled approach and landing. Case closed or not?
The aircraft had been slightly above the glideslope below 250 ft, crossing the runway threshold 10 ft high and carrying an extra 5 kt for icing; the extra speed might not have been Despite wet snow on the runway, the A321 crew expected normal winter landing conditions. necessary. These deviations can be easily understood considering the short notice to n the evening of March 26, 2006, an F). Although the wind, from 030 degrees at 6 the crew about the change in runway Airbus A321 operated by My Travel kt, marginally favored the nonprecision O condition and the crew's mindset of medium Scandinavia was involved in a serious approach to Runway 36, the instrument braking action. In normal line operations on a landing incident at Sandefjord Airport Torp landing system approach to Runway 18 was dry runway, both the extra height and the in southern Norway.Although damage was in use. On descending through Flight Level extra speed would have been insignificant. minimal, the aircraft stopped about 65 100 (approximately 10,000 ft), an additional degrees off the runway heading with the 5 kt was added to the approach speed based The flight data recorder indicates that the nose-wheel against the concrete base of on a formula that took into account the icing autobrake was armed but may have been an antenna and the right main wheel conditions. disengaged accidentally. Aerodynamic braking approximately 2m (7 ft) from the end of and engine reverse produced a deceleration of the runway. As the aircraft descended, snow began to settle on the runway. Three minutes before landing, 0.16 g, increasing to 0.20 g when manual braking was applied at 110 kt. This crew’s experience illustrates the problem the air traffic control tower informed the crew of detecting and describing braking action on that the runway was contaminated with 8.0 In calculating landing performance using Airbus contaminated runways that has become the mm (0.3 in) of wet snow and the friction coefficients indicated medium braking. A tables, 8 mm of wet snow was considered subject of significant discussion. 1 glance at the actual landing distance (ALD) equivalent to /4 in of slush. Airbus takes into account contaminant drag and uses varying During the preflight preparation for the figures in the quick reference handbook effective Mu1 (friction) values that are midday departure from Tenerife, Canary indicated that the 72-tonne (158,733-lb) groundspeed-dependent for fluid contaminants. Islands, Spain, crew members had received a aircraft would require an ALD of 1,812 m It is, therefore, difficult to establish an equivalent company briefing pack containing a snow (5,945 ft), with maximum manual braking after average aircraft braking coefficient (ABC) value. notice to airmen (SNOWTAM) indicating that touchdown. The landing distance available the runway at Torp was wet with good braking (LDA) was 2,569 m (8,429 ft). In contrast, Boeing does not consider action, and a terminal area forecast calling for contaminant drag and uses an average snow with deteriorating visibility as the The aircraft touched down softly 357 m (groundspeed-independent) ABC value for afternoon progressed. (1,171 ft) beyond the touchdown point, and both the reversers and spoilers were promptly each contaminant. Just before descent, the automatic terminal deployed. The captain thought that the Below 110 kt, the ABC was approximately information service indicated that the runway autobrake had disarmed because of the lack 0.05; this reduced to 0.04 after the parking was dry with pod braking action and visibility of braking action. Eight seconds later, the first brake was set at 70 kt and the wheels locked. was 2.5 km (1.6 mi) in light snow. There was officer applied full manual braking and shortly If Airbus used the same methodology as broken cloud at 500 ft, the temperature was afterward, when they still were unable to feel Boeing, the crew would have been aware minus 2 degrees C (28 degrees F), and the any braking action, the captain took control before touchdown that 8 mm of wet snow dew point was minus 3 degrees C (27 degrees and applied the parking brake.The aircraft was
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corresponds to an average (groundspeed- fluid contaminant tolerances, this was not seen line with the committee's proposals. As an independent) ABC value of 0.05 - associated as a contributory factor. interim solution, Airbus has settled on a plan with poor braking action. Why did such a to factor its ALDs to calculate an operation recently completed runway friction test The unreliability of ground friction-measuring landing distance (OLD), which is designed to suggest the braking action was medium? devices is not the sole reason for the incorrect reflect the actual performance achieved by a braking action report. Other factors are the air line pilot. After landing on a snow-covered runway in temperature and dew point. The AIBN has Torp, Norway, the A321 stopped with its investigated 30 incidents and accidents that If the TALPA matrix had been available for use nosewheel against an antenna’s concrete base. occurred on contaminated runways over the on the evening of the Torp runway incident, last 10 years and has highlighted a number of the crew would have factored their 1,812 m coinciding factors. The most common - ALD to obtain an OLD of 2,563 m (8,409 ft) - evident in 21 of the 30 occurrences - was a 6 m (20 ft) less than the LDA. 9 difference of 3 degrees or less between the air temperature and the dew point. David Thomas is a captain with a major U.K. airline. The narrow temperature-dew point split indicates that the relative humidity of the air Notes mass will be at least 80 percent. Given these conditions, with an air temperature at or below 1 Airbus uses the term effective Mu, while other manufacturers, including Boeing, use ABC, referring to freezing, the air mass immediately above the the percentage of the airplane's weight on the wheels runway surface is close to, or at, saturation, (W-L), which is converted into an effective stopping causing freezing on contact with the runway force. For example, an airplane with a W-L of 100,000 lb 2 (45,360 kg) would create 20,000 lb (9,072 kg) of surface. This phenomenon was derived from stopping force for an ABC of 0.20. ABC depends on tire findings by the AIBN and is referred to as the 3- pressure, tire wear, aircraft speed, aircraft weight and Kelvin- Spread Rule. The AIBN has concluded anti-skid system efficiency.
that poor braking action often is associated 2 Water vapor can change to ice without becoming liquid. with moist low-level atmospheric conditions. This is likely if the air is saturated and is cooled below Although the rule is not an absolute, it is a good the freezing point. The process is known as sublimation.
indicator of hazardous conditions. It is likely 3 As it skidded off the runway, through an airport fence that at Torp, the lower layers of wet snow had and onto a road, the 737 struck two cars, killing one frozen to form ice on the runway. passenger. Another occupant of a vehicle received serious injuries, and three others received minor injuries. The airport's winter regulations in 2006 said Of 103 people in the airplane, 18 received minor injuries. that it was a priority to offer a runway free of Four years after the accident, have things The U.S. National Transportation Safety Board said the snow and ice and that when runway friction changed? probable cause of the accident was the flight crew's failure to promptly apply reverse thrust. The pilots were decreased below poor, the affected areas were distracted by the airplane autobrake system, which they to be dosed until satisfactory braking action As a result of a Dec. 8, 2005, runway excursion had not used before, the NTSB said. could be re-established. accident involving a Southwest Airlines 737- 700 at Chicago Midway International Airport Both Airbus and Boeing support the view that (ASW, 2/08, p. 28),3 the U.S. Federal Aviation friction readings from ground friction- Administration issued Safety Alert for measuring devices may not represent actual Operators 06012 and a related advisory ABC. In a number of countries, friction- circular. The agency also formed the Takeoff measuring devices can only be used on and Landing Performance Assessment (TALPA) compacted snow and ice or on a bare runway. Aviation Rule-Making Committee. Although The Accident Investigation Board Norway the committee's recommendations have not (AIBN) has highlighted the uncertainty of been adopted, a primary provision is the friction measurements from friction measuring runway safety matrix, designed to produce a devices. Their findings suggest tolerances on standardized reporting method, developed fluid contaminants of plus or minus 0.20; on from different types of surface condition dry contaminants, tolerances are plus or minus reports and aircraft data. 0.10. The friction-measuring device used at Torp was certified for use only in up to 3.0 mm Airbus released a letter in mid- 2010 advising (0.1 in) of wet snow. However, considering the operators to add safety margins to its ALDs, in
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Heavy Metal Front Man Ramps Up Industry Loading Awareness
by UKFSC Focus Magazine Article – Winter 2011
knowing that he was a keen enthusiast, I could The film is not intended to replace the need straeus Airlines Captain and legendary think of no-one better.” In addition to his line for formal training, rather to compliment it. AIron Maiden front man, Bruce flying, Bruce is also a qualified Crew Resource the general consensus of the GHOST team Dickinson, is the presenter of a brand new Management Instructor. was that whilst the majority of current flight safety production. Safety in the training does cover what to do and how to do Balance, which is available free of charge, is The team then secured the services of some it, the reason why is often missed. part of a joint initiative by the Civil Aviation enthusiastic film tutors and students from Authority (CAA) and the UK aviation Exeter College, who throughout 2010, shot For Jason, as an ex-Loadmaster, the industry to highlight the importance of safe scenes at a number of locations including importance of accurate aircraft loading was and accurate aircraft loading. London Heathrow, East Midlands and at brought home in no uncertain terms in the The DVD, which was released during the Oxford Aviation’s Crawley Simulator. Jason late 1990s, when he was involved with an summer of 2011, was commissioned by the said: “The footage jumps deliberately from accident that was the direct result of a gross Ground Handling Operations Safety Team various locations and aircraft as we wanted to loading error. Both the crew members on (GHOST), a CAA/ industry group committed involve as many airlines, ground handling board were killed in the accident. “Once you to develop strategies to mitigate the safety agents and airports as we could. So, viewers have experienced that kind of thing, you are risks from aircraft ground handling and shouldn’t get cynical when they see Bruce go left in no doubt that the worst case scenario ground support activities. The group is made up the stairs of an Airbus A340, through a can and does happen. Sometimes the up of representatives from UK airlines and Boeing 747, down the steps of a Boeing 757 challenge can be trying to make others airport operators. and into the cargo hold of an Airbus A321. It believe that the outcome can be more than a was meant to happen like that!” paperwork error. It is so important that Jason Sandever, the CAA’s Aircraft Loading everyone involved is aware of the potential Inspector, was the focal point of the project. “It consequences,” he said. was clear we needed to make something that was not only engaging but also related directly All who watch the film should indeed get an to the target audience. Having worked within overview of just why it is so important that the ramp environment, I knew we had to do aircraft are loaded according to a plan, both something a bit different.” When it came to for cargo, baggage and passengers. Any deciding who would be asked to present the changes to the load must be reported to the film, Bruce was the obvious choice.“Having seen appropriate person and all loads must be him in action in another aviation mini-series and restrained. Whilst new and existing ramp
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personnel are the obvious target audience for the film, it is hoped airlines and airports will screen it for other staff including, dispatch personnel; local and centralised load planners; airline and agent representatives; cargo warehouse employees; commercial departments; airline management; and of course flight deck and cabin crew.
Since the release of Safety in the Balance in involved are very aware that the DVD alone will is available on DVD, please contact mid June, there have been requests for copies not change an industry wide problem overnight [email protected] for details. of the DVD from various Training, Safety and - so will no doubt remain busy! Standards Departments around the globe. Photographer John McMurtrie / © Iron Maiden That’s in addition to the worldwide As well as the benefit the DVD will bring to Holdings 2011 distribution provided by UK based Airlines and those involved in the loading process, the Ground Handling Agents. Some of the more project also brought together many people interesting requests came from locations such from different organisations, in many cases as Hawaii, El Salvador, Greenland, Alberta and forging strong working relationships which Airbus Flight Operations. the CAA hope will help to improve safety standards in the future. Feedback received has shown that Bruce and the team have managed to successfully Safety in the Balance was only made possible complete a product that is not only educational with the assistance and continued support of but also enjoyable to watch. However, all the organisations and individuals involved. It
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Preventing Landings Without Clearance
■ great many reports to NASA's frequency, five made initial contact with the Forgetting to “Contact the Tower at the AAviation Safety Reporting System tower but did not receive landing clearance. Marker” identify pilots' failure to obtain clearances Nine of the 37 reporters stated they had prior to landing. How to prevent Landings never received a frequency change. Another pattern in the 37 reports was the without Clearance ? likelihood of pilots' forgetting to contact the This finding has important safety tower if they were told to do so in advance. This reporter's experience is typical: implications. If an aircraft is not on tower Nine reporters indicated they were told to frequency, the tower will not be able to "contact the tower at the marker", sometimes I was the pilot flying on an IFR approach into contact it directly should a go-around or as far as 20 miles out. Seven of these never MEM for runway 36R. My Captain was in other safety-related action be necessary. switched to tower frequency (in the other communication with Memphis approach two reports it was not stated whether a control. They told him to contact the tower at Also, pilots who land without changing to frequency change occurred). the outer marker. The weather was IMC and tower frequency, as instructed, could be in when we arrived at the marker, we were in the violation of a Federal Airworthiness The following example was typical: process of making final landing configuration of Requirement (FAR), which requires aircraft our aircraft.The Captain forgot to call the tower, operating into airports with an operating My First Officer and I were returning from and we landed the aircraft safely and without a control tower to establish two-way radio Harlingen, Texas to Austin, Texas on our tenth conflict with another aircraft, on runway 36R. communications with the control tower and final leg of the day. We logged eight hours (unless aircraft are not equipped for two-way that day of flight time in rough weather Fortunately, most incidents like the above do communications). (thunderstorms, turbulence, and occasional not result in traffic conflicts or other windshear).Austin approach control cleared us ■ hazardous consequences. However, their High Workload for the ILS 31L approach to Austin Mueller potential for a breach of safety is high. So Airport while we were approximately 10 miles that we could better assess the factors Twenty-one reporters implied that their outside the marker and instructed us to contact contributing to landing-without-clearance workload was high during approach. The tower at the OM...After landing and turning off events, we analyzed a small number (37) of reporters' sources of workload were varied - the runway, I noticed that we were still on ASRS reports and identified areas where some were in a training situation, and some approach control frequency and had forgotten safety improvements might be possible. were busy coping with weather conditions, as to contact tower at the marker. on this approach: ■ Confusion Over Phraseology During approach to CLE we were on vectors to intercept ILS 28 at 3000 feet, which we did. We Pilots' confusion over phraseology may be an began to encounter precipitation, freezing rain additional factor in their failure to contact the and snow. We were cleared for the approach tower. Some pilots may mistakenly believe and to contact tower at PARMA. As we that the instruction "contact the tower at the approached PARMA we were told to keep 170 marker" means they are supposed to change knots to PARMA. Our bug speed was 121 knots. frequency immediately, but not call the tower Approaching PARMA LOM we began to until they reach the marker. This experience light turbulence. Our airspeed misunderstanding may result in their leaving Contributing Factors dropped by 20 knots and gained 30 knots the approach frequency prematurely and maximum.The glide slope intercept moved very being unavailable for contact if the approach Procedural, workload, and memory factors fast to center of bull'seye with over 1000 fpm controller needs to issue other instructions. appeared to be the main contributors to the descent to stay on glide slope.There was also 20 group of ASRS landing-without-clearance degrees of crab and fluctuation to stay on The Airman's Information Manual explains the incidents. localizer. This was very distracting to us and to proper procedures for complying with other aircraft on approach. We placed a lot of frequency changes: ■ Pilot Not on Tower Frequency concentration on maneuvering the aircraft on the glide slope and localizer and failed to "When instructed by ATC to change Pilots landing without clearance were often change over to tower at the marker ... After we frequencies, select the new frequency as soon on a frequency other than the tower touched down we realized we did not switch to as possible unless instructed to make the frequency. tower frequency for landing clearance. change at a specific time, fix, or altitude.If you are instructed to make the frequency Of the 34 pilot reporters who mentioned the The large number of incidents citing workload change at a specific time, fix, or altitude, frequency they were using when they landed, factors suggests that when workload is high, monitor the frequency you are on until 25 said they were on approach frequency, pilots should exercise additional caution to reaching the specified time, fix, or altitude while only eight were on tower frequency. Of verify that landing clearance has been received. unless instructed otherwise by ATC". [ASRS the eight reporters who did change to tower emphasis in bold type.]
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represents the point at which they need the to the tower at the OM… Switching to the frequency change to occur. tower at the marker is so routine it never dawned on me that the First Officer might not have done it… In the future I will say "are we Techniques for Prevention cleared to land?" instead of merely saying "cleared to land?" Since the incident the Our analysis of ASRS incidents led us to the company has added a "cleared to land" check conclusion that the best safeguard against on the 1000 foot call out. landing without a clearance is to develop procedures to ensure that a frequency change ■ Change to Tower at a Fixed Point SOME ATC CONSIDERATIONS. One has taken place and landing clearance has suggestion for decreasing the number of been received. As these reports show, it is not Another way for pilots to stack the deck in landings without clearance came through advisable during a busy approach for pilots to their favor is to develop a habit of always loud and clear in the ASRS reports we rely on memory to determine whether they checking that they are on tower frequency at reviewed. Pilots suggested that controllers not have been cleared to land. a fixed point, such as at the outer marker or give the change to tower frequency until they when completing the landing checklist. A want it to occur. ■ Create a Visual Reminder - and Check It fixed altitude may also be the landing clearance reminder, as this reporter notes: "In These reports were typical: Some pilots have developed an effective future I will check at 1000 foot AGL that we technique of performing a positive action that are on tower frequency". If a pilot reaches this Landed on runway 26R in A TL without creates a visual reminder that is checked as pre-determined fixed point and has not yet clearance. Cleared visual 20 miles out told to part of their landing procedure. All three of been instructed to change to the tower contact tower at marker. It seems this is the these elements reduce the likelihood of frequency, a request to approach control to only phase of flight in which you are passed to landing without a clearance. For example, change frequency is recommended. another controller and told to contact them at some pilots leave one of the taxi lights off a different time... If approach control wants until landing clearance is received. They put Even pilots who routinely use this technique you to contact tower then it should be at the the light on when the clearance is received, can forget to change frequency if they allow time of transmission or the flight crew should giving them a visual reminder, the switch distraction or complacency to interfere. be told to switch by the approach controller position. They then visually check that the when it is required. light is on as part of the landing checklist. I always go to tower and call at the final approach fix, but was still doing checklists and In summary, I feel we were led into a trap by Another technique is to combine a visual then became too pre-occupied with the giving us an automatic change-over to tower at reminder with an audible confirmation of approach. I missed that part of my approach marker, which reduced approach controller's tower frequency. When the landing checklist habit pattern. workload, but also increases the pilots, calls for "cleared to land", the pilot-not-flying especially in those types of conditions [dark (PNF) visually checks the communications and stormy night]. radio to ensure that the correct tower Conclusion frequency has been set, then verbalizes, Approach controllers we talked to while "cleared to land [specific tower frequency]". There are no fool-proof techniques we know preparing this article told us they have several of to prevent landings without clearance. But reasons for giving the instruction to "contact In order for any reminder to work, that final fewer of these events are likely to occur if tower at the marker". One is to maintain an check has to be performed. Several reporters pilots adopt techniques that will help them optimal arrival traffic flow. If the change to learned this the hard way: remember during busy approaches to "tune tower occurs too early (prior to the marker or in" to the tower and verify that they have final approach fix), tower controllers may slow Since the incident I have adopted the technique received landing clearance. incoming traffic or issue other instructions of mentioning "cleared to land" on final gear that disrupt the approach facility's arrival and altitude call out. Reprinted with kind acknowledgement to spacing, especially in busy terminal areas. Smart Cockpit.com/Ludovic Andre I flew the ILS to 26L and all checklists were Also, if the approach controller delays issuing completed normally. At 500 feet I called "30 the frequency change to tower until an aircraft flaps, final setting (normal procedure), cleared actually reaches the marker, frequency to land?" The First Officer and Second Officer congestion may make it impossible to verified 30 degrees flaps and said nothing complete the change to tower in a timely way. more. I thought I had heard a clearance to land so did not question the First Officer again. I For many controllers, then, the phraseology landed… Approach control answered and we "contact tower at the marker" accurately realized that the First Officer had not switched
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A Dark and Stormy Night - and 90 Seconds to Disaster
by Macarthur Job
hortly after taking off at night in rain to the right, its heading increased in that he resumed his confused control manipulation, Sand thunderstorm conditions from direction, which happened to be the captain’s forcing the autopilot to switch to control wheel Douala, on the Cameroon coast in West initial intention. steering pitch mode. His inputs were mostly to Africa, a Boeing 737 entered an increasing, the right on both control wheel and rudder uncorrected bank. Responding erratically Although deviations in pitch and speed were pedals, further aggravating the situation, and when the bank angle warning sounded, the also increasing, the first officer made no he cried out in alarm, ‘We are crashing!’ This captain precipitated a spiral dive. Both monitoring calls, confining his efforts to was echoed by the first officer, the captain pilots were still wrestling the controls adjusting the heading selector knob to exacerbating the situation with a prolonged when the 737 plunged into a swamp and accompany the uncontrolled heading changes. input of right rudder. disintegrated, killing all 114 aboard. The captain, wanting his autopilot engaged, As the aircraft’s angle of bank passed 90 then called ‘OK, command.’ Although its degrees, it suddenly pitched down and The flight engagement was not confirmed by the first entered a spiral dive.The first officer called to (Reconstructed from flight data and cockpit officer, or by the flight mode annunciator, or the captain to level the wings to the right voice recordings) by the behaviour of the aircraft itself, he then, hastily correcting himself, insisted assumed it had engaged. It is possible that desperately, ‘Left, left, left, Captain! Operated by Kenya Airways, the Boeing 737- activation of the aircraft’s speed trim as the 800, registration 5Y-KYA, was making a airspeed increased, could have reinforced this At this point the flight data recorder showed scheduled flight from Abidjan on the Ivory impression. The Flight Data Recorder confliction in the controls, with the captain Coast to Nairobi, Kenya, on the night of 5 May indicated a slight control column pressure just applying right aileron and nose-up elevator, 2007, with a one hour en route stop at as the captain called ‘OK, command’, so it was while the first officer was correctly trying to Douala, Republic of Cameroon. The departure possible the selection was made, but that apply left aileron and nose-down elevator. from Douala was scheduled for midnight local pressure on the column interfered with the time, but because of heavy rain, was delayed. autopilot’s engagement. But the first officer’s belated attempts to Just before 0100 hours, the aircraft was recover the situation came much too late. cleared to taxi for Douala’s Runway 12. Its As the aircraft climbed through 2400ft at Spiralling down steeply, the Boeing plunged airways clearance, passed while taxiing, was 180kt, both pilots carried out the required violently into the mangrove swamp to direct to Nairobi at Flight Level 370. The first change in altimeter setting, still not noticing the south-east of Douala Airport, exploding officer was conducting communications with the deteriorating flight parameters. Yet these on impact. the tower, but when ready for take-off, the were plainly visible on their electronic captain intervened to request the tower’s attitude director indicators, from which they approval to maintain an initial heading were both reading the altimeter settings. Investigation slightly to the right of the runway heading because of rain and thunderstorms ahead. The captain still seemed unaware of the The site of the crash, a relatively short aircraft’s changing attitude but as the bank distance southeast of the end of Runway 12, Without waiting for the first officer to obtain angle passed 35 degrees he uttered an was located at 0730 next morning in an a clearance to do so, the captain began the expression of surprise just before the bank extensive low-lying mangrove swamp on the take-off with five degrees of flap set. The angle warning sounded. Grabbing the northern side of the Dibamba River, close to a undercarriage was retracted after lift-off, and controls, he mistakenly applied right aileron, wide inlet on the Gulf of Guinea. Because of with the aircraft showing a tendency to roll to further aggravating the bank. the inaccessible nature of the swamp, it the right, the captain maintained a wings proved extremely difficult for investigators to level attitude with left aileron. At 1000ft the The flight data recorder showed the examine the wreckage. captain called ‘Heading select’, and the first ‘Command A’ autopilot (i.e. the captain’s officer responded, ‘Select checked,’ indicating autopilot) was then selected, probably by the The aircraft had impacted at a descent angle the captain performed the selection himself. captain himself, engaging the control wheel of about 50 degrees while steeply banked to steering roll and level change modes. Over the the right, forming a crater five metres deep. Over the next 55 seconds, there was no next five seconds, the confused movements Trees were knocked down and mud flung in all control input at all.The crew’s attention could of the control wheel diminished and the bank directions for up to 30m. None of the pilots’ have been on the weather radar display angle stabilised at 50 degrees. remains could be identified, but 86 of the because of their proximity to thunderstorms, other victims were identified by DNA analysis but at this stage the autopilot was not But the captain was evidently not and another four by fingerprinting. engaged. With the aircraft still tending to roll comprehending the autopilot’s correction, for
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With the exception of the flight data and The Crew A proficiency check only three months before cockpit voice recorders, none of the the accident revealed deficiencies similar to recovered wreckage was subjected to detailed The captain, aged 52 years, had a total of those found in earlier checks. He nevertheless technical examination. 8682 hours flying experience, of which 3464 passed the check. The captain had undergone hours were command time, including 823 CRM training courses, but his proficiency The flight data recorder was found on the hours as a 737 captain. As well as Boeing checks repeatedly revealed he had difficulty in surface of the swamp with only slight external 800s, he was qualified to fly Boeing 737-300s crew coordination. damage, but with its underwater locator and 700s, and the Airbus A310-300. He was beacon units torn off. Finding the cockpit voice familiar with the air route, and properly rested The first officer, aged 23, had held a Kenyan recorder posed a more complex problem. beforehand. commercial pilot’s licence for 18 months and had a total of 830 hours flying experience, Pumps were used to drain the water-filled The captain flew as a first officer on B737- including 170 hours on type. Trained in South crater, and with the aid of an acoustic pinger 300s for two years before being assessed in Africa, where he obtained his commercial receiver flown from Boeing in the USA, the 2002 for command. The check pilot licence, he failed his initial instrument rating recorder’s motherboard, battery pack, considered the assessment unsatisfactory test, but was successful on his second underwater locator beacon, and finally because of poor knowledge of systems, attempt. The same thing occurred during his memory module were progressively found. including the autopilot, and insufficient radio telephony tests. No major difficulty was encountered in monitoring of the flight mode annunciator. reading out either of the recordings. Training reports mentioned difficulties in Assessments during his training as a 737 first adherence to procedures and cockpit officer in 2006 included requirements for scanning. His initial B737-300 command improvement in crew coordination. Progress The Airport check was inconclusive, calling for a second reports showed he was not monitoring and flight. He passed a final command check by a calling out deviations by the pilot flying; not Douala International Airport, elevation 10 different check pilot. monitoring the autopilot when engaged, and metres, lies just over two nautical miles ‘lagging behind the aircraft’. His situational south-east of the city. Its single Runway 12- After he received his initial B737 rating in awareness and radiotelephony procedures 30 is 2950m long and equipped with 1997, he demonstrated ‘recurring also needed to be improved and he needed to highintensity lighting, approach lighting, a shortcomings’ – deficiencies in crew resource be less tense in carrying out procedures. His VOR DME, and a Category 1 instrument management, knowledge of aircraft systems, overall performance during training and landing system. The airport also has an NDB. operating procedures, cockpit scanning, subsequent checks was nevertheless situational awareness, and decision making. considered satisfactory. He had logged 113 His performance was found to be hours on the Boeing 737-700 and 57 hours The Aircraft unsatisfactory during proficiency checks, and on the 737-800, and had flown into Douala he was required to undergo further training. twice before. The Boeing 737-800 was less than a year old, had flown only a little over 2000 hours, and During later recurrent training, an instructor was fully serviceable for the flight. Its weight at urged him to be more attentive to checklists Operational Procedures the time was 10,000kg less than the maximum and aircraft limitations, be systematic in permissible, and its centre of gravity was within responding to system failures, and more Before starting, the captain used a wrong the correct range. Its maintenance had been consistent in briefings and adherence to aircraft call sign. The aerodrome controller carried out in conformity with an approved standard operating procedures. A 2004 clarified the confusion after about 15 maintenance programme. training session resulted in recommendations minutes. Communications with ATC were that he take time to analyse system failures then conducted by the first officer up to the Some differences existed between the B737- and to discuss them with his first officer. point where he read back the airways 700 and B737-800 flight instrument displays. clearance and said he would call back for a Because company pilots were flying the 700 A 2005 line proficiency check cited take-off clearance. But just before takeoff the and 800 concurrently, the differences could deficiencies in the captain’s command ability captain intervened to request a modified possibly affect interpretation during an and teamwork and knowledge of aircraft airways clearance because of the instrument scan. The position of the autopilot systems. He also tended to be ‘overbearing’. A meteorological conditions ahead, and the command (CMD) indication in the 700 was 2006 line check found the captain’s aircraft took off without a clearance. also different from that in the 800. performance below standard, requiring a further line check.
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Weather conditions at the time of the take- No call-out was heard from the first officer captain’s skills were deemed to be acceptable, off were stormy, with numerous while variations were taking place in pitch and despite that fact that his examiners regularly thunderstorms, heavy rain showers, a low speed, with roll increasing beyond 25 reported his weaknesses. The Kenyan Civil ceiling, and little wind. The night was degrees. One single announcement by the Aviation Agency should have identified the completely dark, with no external visual first officer of the variations on the flight problem during its oversight inspections of the references available once the runway was left mode annunciator, airline, and should have acted on the behind. In the face of these disquieting recommendations of the airline’s examiners conditions, a special weather briefing was or of the excessively changing flight for appropriate action. required before take-off. parameters, would have alerted the captain to the deteriorating situation long before the The Boeing crew had received a bank angle warning sounded. Probably Comment meteorological forecast, but did not request ‘lagging behind the aircraft’, the first officer any verbal briefing. Preoccupied by the failed to discern that the uncontrolled flying This tragedy bears a marked similarity to the adverse conditions, they used the aircraft’s was the result of the captain’s confusion. Flash Airlines Boeing 737-300 accident that radar while on the apron and during taxiing to followed a night take-off from Egypt’s Sharm analyse the meteorological situation on their The captain’s reaction was another example el-Sheikh Airport on 3 January 2004, which departure route. of spatial disorientation, resulting from a long was reviewed in the March-April 2010 issue of slow turn on a dark night, with no exterior Flight Safety Australia. Once aligned on the runway, they again used visual reference, without monitoring the the radar, choosing a trajectory that would attitude indicator. The consequences of the It seems incredible that in both cases, the avoid the worst of the weather after disorientation were further aggravated by his experienced captains concerned did not becoming airborne. They were therefore failure to follow the recovery procedures know how to recover on instruments from aware of the meteorological situation, and prescribed by the company. The investigation unusual attitudes. Both accidents emphasise from available data it was obvious the recommended that all the company’s flight again the importance of maintaining basic weather had improved sufficiently for a safe crew should receive formalised training in manipulative flying skills, rather than relying departure that met company and airport upset recovery. entirely and blindly on today’s highly departure minimums. sophisticated aircraft automation systems for The captain had a strong character – consistently safe operations. The procedure for engaging the autopilot, set authoritative and domineering, which at times out in the company’s standard operating manifested itself as overconfidence and Reprinted with kind acknowledgement to procedures, was less precise than in the Boeing arrogance. In contrast, the first officer was Flight Safety Australia B737 manual. The procedure in use at time of reserved and not assertive. He seemed the accident recommended that the pilot flying intimidated by the meteorological situation do the engaging, with the other pilot confirming and his announcement to the cabin crew just the flight mode annunciator indication. When before take-off betrayed his anxiety about the the captain made the call ‘command’, the first weather. He also appeared subdued by the officer did not respond. He might not have strong personality of the captain. Although he heard the captain’s call, or heard the captain’s had undergone CRM training several months call but not crosschecked the flight mode before, he failed to monitor the obvious and annunciator, or seen no changes in the flight vital lapses in the handling of the aircraft during mode annunciator and not told the captain the accident flight, seemingly placing his entire because standard operating procedures did not confidence in the captain’s flying ability. make confirmation mandatory. In the light of the findings of the investigation, The variations in procedures from those the airline’s management should have taken recommended by Boeing, the lack of a measures to avoid pairing these pilots because required confirmatory announcement by the of the deficiencies found during their training, monitoring pilot, and the lack of standards and because of their psychological traits. The generally, confused the engaging of the company’s system for addressing the handling autopilot. The confusion was accentuated by of weak pilots appeared adequate, but its the response of the aircraft’s speed trim to application to the captain’s performance was deteriorating manual control. not sufficiently aggressive. As a result, the
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Runway Incursions
by Adrian Leonard, Senior First Officer - Virgin Atlantic Airways Boeing Fleet Safety Officer
he CAA has compiled a “Significant poor aircraft lighting and poorly educated access to airports, improved airport surface TSeven” list of risks to aviation, one of airport staff. When analysing the human markings and explicit ATC clearance for all which is runway incursions. factors involved in runway incursions, the runway crossings. The Royal Air Force has also most common cause is “pilot failed to follow set up a runway incursions steering group clearances”. The remaining factors apply to within their MAA. ICAO Definition: pilots, ATC and drivers and include failure to follow procedures, failure to follow The CAA has introduced the following ■ “Any occurrence at an aerodrome instructions/signals, lack of situational preventative measures: involving the incorrect presence of an awareness, lack of experience/familiarisation, aircraft, vehicle, or person on the poor/lack of ability/airmanship, poor/lack of ■ Identified an Action Plan to reduce CAT A protected area of a surface designated for pre-flight planning, poor R/T contact, and B incidents to zero and reduce C and the landing and take-off of aircraft”. erroneous expectation and a lack of D incidents significantly. management oversight. Runway incursions statistics are broken down ■ Promoting a greater understanding by into the following categories: industry of the risk associated with runway incursions. ■ CAT A – serious incident in which a collision was narrowly avoided ■ Local Runway Safety Teams (LRSTs). HIGH RISK ■ Providing a greater oversight of AAIB ■ CAT B – incident in which separation recommendations. decreases and there is a ■ Distributed coffee mug coasters to significant potential for publicise runway incursions. collision HIGH RISK ■ Ensuring runway/taxiway/holding position ■ CAT C – ample time to avoid a collision signage compliant with CAP 168. ■ CAT D – little or no risk of a collision In addition to the CAA, the National Transport ■ Ensuring runway safety is maintained (In the UK there were no CAT A or B incidents Safety Board (NTSB) has recognised the during “work in progress”. in 2009; however, there were two CAT B dangers of runway incursions and has put incidents in 2010 and one CAT B in Q1 2011. them on their “Most Wanted” list. Following a The likelihood of a runway incursion is further FAA Runway Safety “Call to Action” meeting, reduced by strict adherence to SOPs, One would expect runway incursions to occur serious runway incursions have reduced by maintaining aircraft to a high standard (eg. more frequently during periods of low visibility 50% (Year 2009 compared to 2008). This lighting), good command of the English eg. Tenerife 1977, Milan Linate 2001, but this reduction was achieved by introducing pilot language, accurate Notams and sterile cockpit is not the case. Main cause factors include: and controller education programmes to procedures. poor taxiway markings, complex R/T improve situational awareness, workshop procedures, language barriers, callsign forums, pamphlets, websites, controlled confusion, out-of-date/inaccurate Notams,
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On the subject of language, would you know There is also some useful information what to do if you were given the instruction, online eg. Newark (www.airportflightcrew “annuler le décollage”? This instruction was briefing.com/newark): given to an Air France aircraft at CDG airport during low visibility procedures as a BA aircraft was crossing the runway further upfield. The AF aircraft rejected the takeoff as instructed; however, the BA aircraft continued to cross the runway oblivious to what was happening. ATC speaking in a foreign language adversely affects the situational awareness of other crews; however, this practice continues eg. Cuba (Spanish), some Caribbean islands (French).
The following runway incursions preventative measures are available at LGW: Vehicles have transponders (SQUIDS) which means that they are easier to track during LVPs. In the Some Other Technologies: tower is a system called “RIMCAS” (Runway Incursion Monitoring and Collision Avoidance ■ Rumble Strips System). If two a/c are on the runway then there is an amber warning in ATC. If two a/c These were set up near runway entrances at are on the runway and accelerating towards Southampton but the trial was unsuccessful each other, then there is a red warning and because they were too rough for light aircraft audio alert. There is also an “Approach and were not felt by larger aircraft. Monitoring Aid” which gives an alert if an a/c ■ RIPCAS - Runway Incursion Prevention is aiming for the wrong runway or a taxiway. Collision Avoidance System If the a/c is “outside the funnel” within 4nm then it is issued a go around instruction. This system is used in Malpensa and involves flashing red lights to indicate that red stop An example of a recent runway incursion at In addition to the technologies present at bars have been crossed. LHR is as follows: Pilots were cleared to hold LGW, LHR has split ground frequencies to ■ FAROS – Final Approach Runway point N11 but proceeded to NB11. LVPs were reduce R/T congestion, Hotspots on Occupancy System in force at the time, meaning that the airfield AERAD/Jeppesen plates and “RUNWAY was safeguarded and aircraft were required to AHEAD” markings at some intersections/ On approach, if the PAPI lights flash then the hold at the CAT 2/3 holding point (in this case holding points. N11) before being cleared to enter the runway. runway is occupied. Hence, by exceeding this holding point it was a MAN ATC also has RIMCAS and at runway ■ OANS - Onboard Airport Navigation runway incursion rather than just exceeding intersections there are small grey boxes on System the cleared holding point/taxi clearance. either side of the taxiway with a laser beam This is on board the A380 aircraft and shows between. If the beam is crossed then ATC will the position to the pilots of the aircraft at the LHR has recently published “Hotspots”, one of get a tone. Recently a GPS trial that warns airport. Obviously very useful during LVPs. which is the holding points referred to in this drivers if they are entering the runway has incident. proved very successful.
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One particular technology which is being introduced an increasing number of airports in the USA is: Runway Status Lights (RWSLs) RED MEANS STOP!
This is a “Smart system” and uses surface radar data. It is fully automatic in that no inputs are required either from ATC or pilots. Lights on the runways and taxiways inform pilots and ground vehicle operators when a runway is unsafe to enter/cross or to begin take-off. airports. Automated warning systems There are also “Take off hold lights” enhance runway safety, but education and situational awareness are the keys to The following example details RWSLs at preventing incursions. Boston, Logan International.
Another technology which has been installed References: by some long haul carriers is the Honeywell system, “SmartRunway”. ICAO Manual on Prevention of Runway Incursions Doc 9870. European Action Plan Prevention of Runway Incursions (EAPPRI) Edition 2. SmartRunway is a “low cost” modification to EAPPRI Edition 2 Appendix D – Flight Crew Best Practices. the Enhanced Ground Proximity Warning VAA Ops Manual Gen Part A Chapter 14. Feedback from CAA System (EGPWS) and it provides situational Runway Incursion Steering Group Quarterly Meetings NTSB. awareness to pilots as an audio warning and www.honeywell.com/www.rwsl.net (for extra cost) a visual warning in the flight www.eurocontrol.int/runway-safety deck. Amongst other things, it can help prevent www.airportflightcrewbriefing.com/newark pilots taking off from taxiways, the wrong runway, without flaps or from too short a runway. It also complies with the NTSB using standard RTF, using a common language, recommendation following the attempted adopting a Sterile Flight Deck procedure, takeoff from the wrong runway of Comair effective LVPs, courses to educate personnel, Flight 5191 in Lexington, Kentucky in 2006. LRSTs, accurate Notams, stopbars and aircraft lighting. Pilots can familiarise themselves with NTSB recommendation AAR 07-045 “operators RWSLs by reading the relevant section in the install on their aircraft cockpit moving map Jeppesen booklets for LAX, and BOS, and look displays or an automatic system that alerts out for RWSLs being fitted in the coming years pilots when a takeoff is attempted on a taxiway to MCO, LAS, ORD, IAD, NEW and SFO (bear in or a runway other than the one intended”. mind that LAX and SFO are in the top ten list for runway incursions). In summary, aside from the multitude of technologies available, runway incursions can Lastly, runway safety is a shared responsibility be reduced by addressing callsign confusion, among pilots, controllers, vehicle drivers and
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Better Safe Than Sorry – Speak up if you see safety problem
by Staff writers
happened and had the opportunity to share their own views.
To the crew involved, this was a clear example of a professional, united team with excellent communication between all sections. There was an open, honest and professional approach by each person in their specific role and this naturally led to good teamwork.
As one flight attendant said: “We were happy about the decision of the flight crew to turn back and we tried to help those passengers who became grumpy to understand why. It’s better to be on the ground wishing to be in the air than the other way around!”
Communication and teamwork are the backbone of flight safety and an essential component of airline training.
But sometimes issues can impede When the aircraft took off, it was unable to n these days of locked cockpit doors, communication between cabin and cockpit. In gain altitude and crashed into trees near the communication between flight and cabin CRM Advocate, Lucy Young from US Air says I runway killing 24 of the 69 people on board. crew has never been so important.With most they can include: “complacency, distraction, contact between the flight deck and cabin via confusion, fatigue, peer pressure, poor CASE STUDY 2: Two flight attendants the interphone, CASA cabin safety inspector situational awareness, ‘significant others’, travelling at the back of an aircraft realised Susan Rice says pilots and cabin crew should stress or supervisory pressure.” consider the effectiveness of how they are there was something wrong on takeoff and decided to go to the front (to respect communicating which each other. Young calls these problems “barriers” because interphone silence) to see whether it had been “they can distort or block information noticed. When they got there the purser was “Being mindful of each spoken word and how transfer, or cause communication not to be already in contact with the captain who it may be interpreted is something that must initiated at all.” be recognised as a vital component of crew informed them there were some problems on the flight deck and he would let cabin crew coordination and effectiveness,” she says. However, she has a solution. “Any of these know as soon as possible what was happening. can be overcome by interaction with other “Most airline operators in Australia have crew members who can, through teamwork, In the ensuing five minutes the flight implemented their own crew resource bring the original crew member back into the attendants focused on staying relaxed and management (CRM) programs in recent years. loop or help them advocate their concern to alert and revised their emergency procedures. A vital tool in building these sessions is to utilise the captain.” the findings that have resulted from incidents The passengers became aware that the that have occurred within their companies. The captain’s reaction to the cabin crew’s aircraft was going around in circles so the approach is important, as can be seen with purser made an announcement informing This can provide valuable lessons for all case study 1. In this incident, the flight that the captain would speak as soon as he aircrew and highlight any problems that are attendant decided not to tell flight crew could, which he did straight away. impeding communication.” about snow on the wings because of bad experiences in the past when she had In a clear and reassuring way he told CASE STUDY 1: A commercial flight was approached pilots with her concerns. taking off in the early morning in a cold passengers there was a problem and the flight would need to return to the airport. He then climate. From the cabin, a flight attendant Young says the best captain is “authoritative asked cabin crew to prepare the cabin for a noticed heavy snow build-up on the wings. enough to command the flight effectively, yet heavy landing. seeks input from other crew members.” However, the flight attendant did not speak to The aircraft landed safely and engineers fixed the pilot-in-command about her observation She recommends crew briefings as an the problem. because on previous occasions when she’d effective way to establish clear leadership and brought concerns to flight crew in the same authority, while giving cabin crew the Cabin crew were given an extensive company, she had been rebuffed and made to opportunity to participate in the discussion. feel stupid. debriefing so they understood what had
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“Assertiveness with respect, not acted as a filter, deciding whether the ■ Extreme temperature change insubordination, is the goal for the ‘followers’ information was important enough to disturb ■ De-ice problem in the crew,” Young says. the pilots. ■ Suspicious, unclaimed bag, package ■ When aircraft is moving on the ground, In their paper “Shall We Tell the Pilots?” “The flight attendant probably found it easier call cockpit if emergency conditions exist published in The International Journal of Aviation to communicate with the flight engineer, such as unusual bangs, scraping sounds, Psychology, Rebecca Chute and Earl Weiner whom she might expect to be less judgmental, smoke, fire etc. quoted from an aviation safety reporting system owing to his relatively lower status in a highly report filed by a flight attendant following an hierarchical cockpit,” they wrote.“Furthermore, Incidents when it was not acceptable to incident in the United States: his physical proximity to the cockpit door breach the sterile cockpit rule included: made communication easier. Interrupting his “After being on the ground in Denver duties was not seen as a problem.” ■ Non-safety related logbook duties approximately 1/2 hour, passengers and flight ■ Temperature (i.e. too hot/cold) attendants began to notice snow and ice Knowing when it is acceptable to disturb a ■ Entrée preferences mounting on the wings. The captain was pilot is an important judgement call and one ■ Gates information asked three times about deicing. He claimed it that is particularly crucial during the sterile ■ Misconnected baggage was not necessary. More time passed and cockpit periods of takeoff and landing. ■ “How much time do we have?” more snow and ice became visible on the Although all ‘nonessential’ communications ■ Catering problems wings.” Eventually the captain listened to the between the cabin and cockpit crew are ■ Obnoxious but not dangerous passengers concerns and commenced de-icing. banned, if the cabin crew knows of anything that could affect flight operations, they must “Bear in mind that this extract is taken from an While this incident shows that certain inform the pilots. American situation and there may be some personalities can make it hard to forge a cultural differences involving language and working relationship, cabin crew need to be An example of this was an incident near interpretation. You will make your own sure of their own abilities and judgement and Orlando, Florida. The commercial airliner had assessment as to suitability and effectiveness,” feel confident to raise concerns either with encountered severe turbulence but the rest of Sue Rices advises. their supervisor or the pilots if they ever have the flight and the landing were normal. doubts about something. However, when the aircraft landed, a flight It’s always worth telling your company when attendant told the pilots that both cabin you have any concerns or observe something A tragic crash at Kegworth in 1989 occurred attendants and some passengers had been that could be a potential problem as training when the pilots shut down the wrong engine injured in the turbulence. But because the and procedures are developed from people’s before their emergency landing. The No. 1 pilots were in a sterile cockpit, the attendants reactions to reallife incidents. (left) engine had failed, but the pilots thought they shouldn’t disturb them. mistakenly throttled back and then shut down “The industry is constantly challenging and No. 2. By the time the mistake was The problem was if any emergency had raising its standards to improve procedures. discovered, it was too late to restart the developed during approach and landing, the Nothing is ever static in the arena of training operational engine. pilots wouldn’t have been aware that the and education, for operational personnel, flight attendants might have been too injured inclusive of maintenance engineers, ground The Boeing 737-400 crashed into a field, then to perform their usual emergency functions. staff and aircrew.” onto the M1 motorway. Forty-seven people died and 74 were severely injured. In a paper published in CRM Advocate, Tom Cabin crew should use this training as well as Chidester and Laura Vaughn of American their experience to guide them on whether Investigators found that three cabin Airlines had some suggested guidelines for they should alert other cabin crew or the attendants and several passengers had communicating with the sterile cockpit either pilots to a potential problem. As aviation observed flames coming from the No. 1 in person or on the intercom. professionals, their knowledge is invaluable engine but did not inform the flight crew. The and a vital cog in the systems safety machine. accident report recommended the Incidents when it was acceptable to breach introduction of training exercises for flight and the sterile cockpit rule were: Reprinted with kind acknowledgement to cabin crew to improve coordination between Flight Safety Australia them in the event of an emergency. ■ Fire in the cabin ■ Exit door ajar In “Shall We Tell the Pilots?” Chute and ■ Burning odour in the cabin Weiner note that the improvements in ■ Medical emergency aircraft technology and design that have ■ Cart stowage problem made flight engineers redundant have ■ APU torching contributed to changes in cabin and flight ■ Fuel spilling from the aircraft crew interaction. The flight engineer often ■ Passengers moving or standing
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Monitoring Flight Levels
ew more stringent ICAO height The International Civil Aviation Organization monitor an individual aircraft during normal Nmonitoring requirements are (ICAO) has introduced a requirement that operations without the need to fly over a effective from November 2010. aircraft operating in RVSM airspace be height monitoring unit. There are no height monitored to ensure the continued accuracy monitoring units in Australia anyway. It goes without saying that accurate altitude of altimeter systems. keeping is vital in commercial aviation, For the small proportion of the monitored particularly in the thin cold air where altitudes While no accidents have been attributed to fleet that flies internationally, this is not a become flight levels. the introduction of RVSM (the system was huge problem – they can fly over HMUs in developed to a safety standard of 2.5 Europe or the US and be checked by them. The reduced vertical separation minimum accidents per billion flying hours) extensive (RVSM) has been one of the success stories of monitoring in North America and Europe has A third way conducted by the Australian international air transport since its introduction revealed a loss of accuracy of hundreds of feet Airspace Monitoring Agency (AAMA), an ICAO in the 1990s. It has been progressively in the altimetry systems of some aircraft. In a designated agency operated by Airservices introduced globally; nearly all the world’s recent example, one aircraft had a measured Australia, monitors using automatic airspace will be operating with RVSM by the error of minus 800ft. Because of the nature of dependent surveillance - broadcast (ADS-B). end of 2011.With RVSM the minimum altitude types of altimetry errors, pilots of these The system broadcasts an aircraft's call sign, gap between aircraft flying between flight aircraft would be unaware that they were GPS-derived position and altitude, velocity levels 290 and 410 is 1000 feet. Flight level 290 flying higher or lower than other aircraft and other data, more than once a second. is approximately 29,000 feet, based on a reporting the same flight level. Additionally Australia leads the world as the first country standardised altimeter QNH setting of ATC is unable to observe the error. to have full ADS-B coverage for FL300 and 1013.25 mbar. After RVSM was introduced in above. The national network of ADS-B ground Europe delays to scheduled flights fell by 40 per While it’s tempting to quip that if this aircraft stations became fully operational on 23 cent.The system frees up airspace by increasing were to encounter another with a comparable December 2009. the number of usable flight levels between altimetry system error the respective crews FL290 and FL410 from seven to 13. It has also would be close enough to wave to each other, As a GNSS satellite-based system, ADS-B been found to reduce fuel consumption – and the reality of a 900kt-plus closing speed calculates altitude geometrically, like a GMU. therefore greenhouse gas emission – by more makes this a very serious situation, with only The ADS-B transmissions contain aircraft flight than one per cent. That may not sound like traffic collision avoidance system (TCAS) as level measured from barometric pressure. By much but it’s a big deal over years of operating the last line of defence. Unfortunately, the converting the flight level to a geometric aircraft whose fuel capacities are measured in commonly-used TCAS II bases its altitude height using meteorological data, the AAMA tonnes rather than litres. calculations on reported flight level and so can compare the two heights and calculate an would not recognise even a very large altimetry system error. The AAMA is But there is a cost involved. The technical altimetry system error. collaborating with the US Federal Aviation requirements for operating in RVSM airspace Administration to make this data processing as are stringent. To conduct regular operations To ensure accuracy of altimeters in RVSM accurate and efficient as possible. there an aircraft must have: aircraft, ICAO’s more stringent global longterm height monitoring requirements The AAMA will be able to retrieve data for any 1) Two independent altitude measurement become effective from November 2010. At a flight of an ADS-B-approved aircraft in RVSM systems; minimum they require two of each aircraft airspace since 23 December 2009, and derive 2) An altitude alerting system; type that an operator flies to have their an altimetry system error for the airframe. 3) An automatic altitude control system; and height-keeping performance monitored, at Aircraft not equipped with ADS-B will need to 4) A secondary surveillance radar transponder least once every two years or every 1000 be monitored with a portable GMU. As ADS-B with altitude reporting system that can be flight hours per aircraft, whichever period is equipped aircraft replace older types in RVSM connected to the altitude measurement longer. However, within the Asia/Pacific operations ahead of the 2013 mandate for system in use for altitude keeping. Region, as in other regions, some aircraft types ADS-B carriage in RVSM airspace, the ability will require up to 60 per cent of an operator’s of the AAMA to efficiently monitor altimetry Typically, RVSM airspace is managed on an fleet to be monitored. ICAO requirements will systems increases. With increased data exclusive basis, with aircraft only being able to require monitoring of 143 aircraft on the processing power the future will be a safer flight plan and operate in the airspace if they Australian register. one of seamless and frequent checking of hold state-issued RVSM airworthiness and altimetry systems for commercial aircraft that operational approval. Australian airspace is Monitoring can be done in three ways: aircraft ply their trade high in the thin cold air. managed on a nonexclusive basis where the can fly over a height monitoring unit (HMU, 1000ft minimum will only be applied between also known as an aircraft geometric For more information aircraft holding the required RVSM approvals. measurement height measurement or www.airservicesaustralia.com/.../RVSM_ However, clearance at RVSM levels for non- AGHME) that accurately determines its minimum_monitoring_requirements.pdf RVSM approved aircraft is subject to height; or it can be temporarily fitted with a disposition of traffic and RVSM aircraft priority. portable GPS monitoring unit (GMU). The main advantage of a GMU is the ability to
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Members List
Members of The United Kingdom Flight Safety Committee
FULL MEMBERS AVISA DHL Air Phil Stuckle Shayne Broad Chairman Monarch Airlines BA Cityflyer Eastern Airways UK Ltd Capt. Tony Wride Alan Taylor Capt. Jacqueline Mills
Vice-Chairman BAA Ltd easyJet RTI Tim Hardy Capt. Chris Brady Steve Hull BAE SYSTEMS Reg. A/C Flight Data Services Ltd Treasurer Alistair Scott Capt. Simon Searle Air Contractors Capt. Anthony Barrett-Jolley Baines Simmons flybe. Bob Simmons Neil Woollacott Executive Board CAA Rep CAA BALPA Gael Ltd Mark Chesney Carolyn Evans Craig Baker
Non Executive Board Member Belfast Intl. Airport GAMA Aviation CTC Aviation Services Ltd Alan Whiteside Nick Mirehouse Robin Berry bmi regional GAPAN Acropolis Aviation Alistair Stenton Capt. Alex Fisher Phil Breeze-Lamb British International GATCO A|D|S Justin Wood Shaneen Benson Mel James CargoLux Airlines GE Aviation Aegean Airlines Mattias Pak Mike Rimmer Capt. Vassilis Anadiotis Cathay Pacific Airways Global Supply Systems Aer Arann Rick Howell John Badley Stuart Dobbyn Cello Aviation Goodrich Actuation Systems Ltd Aer Lingus Stephen Morris Gary Clinton Capt. Conor Nolan Charles Taylor aviation Gulf Air Co Airbus S.A.S David Harvey Capt. Khalil Radhi Christopher Courtenay Chartis Europe Ltd Independent Pilots Association Airclaims Jonathan Woodrow Peter Jackson John Bayley CHC Scotia Irish Aviation Authority Air Contractors Mark Brosnan Capt. Harry McCrink Capt. Anthony Barrett-Jolley CityJet Jet2.com Air Mauritius John Kirke David Thombs Capt. Francois Marion City University London JRA Aerospace Air Seychelles Cenqiz Turkoglu Andy Evans Annie Paul Cobham Aviation Services Loganair Air Tanker Services Ltd Capt. Gary Wakefield Robin Freeman James Davis Cranfield Safety & London City Airport ALAE Accident Investigation Centre Gary Hodgetts Ian Tovey Dr. Simon Place Lufthansa Consulting GmbH Astraeus Ltd CTC Aviation Services Ltd Ingo Luschen Tanya Fenn Robin Berry
Atlantic Airlines Cyprus Airways Alex Wood Andreas Georgiou
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Malaysia Airlines Thomson Airways RAeS Eng. Ooi Teong Siew Martin Ring John Eagles
Manchester Airport plc Titan Airways TAM Brazilian Airlines Rory McLouglin Pavan Johal Capt. Geraldo Costa de Meneses
Monarch Airlines Virgin Atlantic Airways TAM Executiva Usman Hussain Rob Holliday Capt. Castro
Navtech (EAG) Vistair Stuart Mckie-Smith CO-OPTED ADVISERS Max Harris
AAIB Panasonic Avionics GROUP MEMBERS Capt. Margaret Dean Bob Jeffrey bmi CAA PrivatAir Jeffery Thomas Sean Parker - Grp. Safety Services Tom De Neve Graham Rourke - Airworthiness bmi Eng. Simon Williams - Flight Operations Policy Pen Avia Ian Johnston Garth Gray – Flight Operations Brad Preston bmi baby CHIRP QBE Aviation Nicole Stewart Peter Tait Jerry Flaxman Bond Offshore Helicopters GASCo RTI Tony Duff Mike Jackson Steve Hull Bond Offshore Helicopters (Maint) Legal Advisor Rolls-Royce Plc John Crowther Edward Spencer Phillip O’Dell Holman Fenwick Willan LLP Bristow Helicopters Ryanair Capt. Adrian Bateman NATS Capt. George Davis Karen Bolton Bristow Helicopters Eng. Suckling Airways Brian Bolda Royal Met. Society Rob Seaman Nigel McClure MOD Representatives Capt Al Clark (RN) - MAA Deputy Head Ops UK Airprox Board Shell Aircraft Intl. Group, Flt Ops Division Air Cdre. Ian Dugmore Jacob Van Eldik Wg Cdr Andrew Tait - MAA Flt Ops Div Cdr Mark Leaning - Royal Navy Superstructure Group Lt Col Chris Hyslop - Army Eddie Rogan Gp Capt. Simon Brailsford - RAF
TAG Aviation (UK) Ltd QinetiQ Malcolm Rusby Flt. Lt. Bryan Tennant
Teledyne Controls QinetiQ Eng. Mark Collishaw Phil Bevan
Thomas Cook Airlines RAeS Terry Spandley Peter Richards
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