AeroSafety world
PILOT MULTITASKING Risks real, benefits few THE PROMISE OF ASIAS System-level safety data arrive OUTSIDE THE BOX Deployable CVR/FDR modules ARFF RESOURCES Upgrades tough to justify RUNWAY EXCURSIONS KEEPING IT ON THE PAVEMENT
The Journal of Flight Safety Foundation AUGUST 2009 “Cessna is committed to providing the latest safety information to our customers, and that’s why we provide each new Citation owner with an FSF Aviation Department Tool Kit.” — Will Dirks, VP Flight Operations, Cessna Aircraft Co.
afety tools developed through years of FSF aviation safety audits have been conveniently packaged for your flight crews and operations personnel.
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Additional bonus CDs include the Approach and Landing Accident Reduction Tool Kit; Waterproof Flight Operations (a guide to survival in water landings); Operator’sMEL Flight Safety Handbook; item Turbofan Engine Malfunction Recognition and Response; and Turboprop Engine Malfunction Recognition and Response.
Here’s your all-in-one collection of flight safety tools — unbeatable value for cost. FSF member price: US$750 Nonmember price: US$1,000 Quantity discounts available! For more information, contact: Namratha Apparao, + 1 703 739-6700, ext. 101 e-mail: [email protected] President’sMessage
AGAINST The Tide
know that a lot of people turn to this page You also can expect to see your Foundation looking for some insight or inspiration about cited in the press more than ever. Many members aviation safety. I hate to disappoint, but at least have asked us to be the voice of reason for the once a year, I believe I should give you some international media, so we work daily with ma- Iinsight into this organization, letting you know jor media outlets around the world to help them what you can expect from us. produce better-informed aviation safety stories. This is the toughest economic climate the Foun- In the first six months of the year, the Foundation dation has endured since it started in 1947. The good has been quoted in various news media more than news is that in spite of the tough times, we are sur- 10,000 times and in more languages than we can viving while at the same time preparing to grow. By count. Our head office may be in the United States, the time you read this, you should be able to use our but our voice is heard all over the world. I hope it new Web site. It is part of an effort to modernize our is the voice of reason. infrastructure with a new generation of communica- It takes money to keep these things happening. tion tools. Travel will be tough for safety professionals We have been blessed with a few major contributions for a long time, but with these new electronic tools, over the last several years, but we can’t leave future the Foundation, I hope, will remain a place where the contributions to chance. For that reason, Susan aviation safety community comes together. Lausch has joined us as our new director of develop- If you have not already noticed, our reach has ment. It will be her job to communicate the value of been steadily expanding. A team of volunteers for the Foundation to economic decision makers and months now has been producing a Chinese language donors. It also will be her job to listen to you and edition of this magazine, which is available for keep us technical people going in the direction the download on our Web site. Some articles also are members need us to go. You can help the Foundation being translated into Russian, and we hope to see a by helping her. Please let her know how the Founda- Spanish version in the not-too-distant future. Recent tion earns your membership and the things it needs economics may have caused the industry to contract, to do to appeal to more people and add more value. but the Foundation’s reach has been extended. You can contact Susan at development@flightsafety. It is not enough to build new communication org. She will be looking forward to hearing from you, channels; we have to have something to say. Some and I will be grateful for your support. of you who are International Air Transport As- sociation members probably have seen the newly minted IATA/FSF Runway Excursion Risk Reduc- tion Toolkit. Even if you are not an IATA member you will be able to get this information from FSF and IATA. Also, an updated Approach and Landing William R. Voss Accident Reduction Tool Kit will be available from President and CEO the Foundation in the coming months. Flight Safety Foundation www.flightsafety.org | AeroSafetyWorld | August 2009 | 1 AeroSafetyWorld
contents August2009 Vol 4 Issue 8
features Memory unit
Battery Antenna Antenna 12 CoverStory | Keeping It on the Runway 12 18 HumanFactors | The Perils of Multitasking 24 AccidentInvestigation | Thinking Outside the (Black) Box
28 CausalFactors | Idle Approach
32 StrategicIssues | Latest ASIAS Results
38 HumanFactors | Stressed Out
43 AircraftRescue | Unjustified Resources 18 47 InSight | Fogbound departments
1 President’sMessage | Against the Tide
5 EditorialPage | Virtual Face
6 AirMail | Letters From Our Readers 28 7 SafetyCalendar | Industry Events
2 | flight safety foundation | AeroSafetyWorld | August 2009 32 43
38
AeroSafetyWORLD telephone: +1 703.739.6700 9 InBrief | Safety News William R. Voss, publisher, FSF president and CEO [email protected] 49 DataLink | More Accidents, Fewer Fatalities J.A. Donoghue, editor-in-chief, FSF director of publications 53 InfoScan | More Accidents, Less Oversight [email protected], ext. 116 Mark Lacagnina, senior editor [email protected], ext. 114 57 OnRecord | Question of Command Wayne Rosenkrans, senior editor [email protected], ext. 115 Linda Werfelman, senior editor [email protected], ext. 122 Rick Darby, associate editor [email protected], ext. 113 Karen K. Ehrlich, webmaster and production coordinator [email protected], ext. 117 Ann L. Mullikin, art director and designer [email protected], ext. 120
About the Cover Susan D. Reed, production specialist Report details excursion risks and prevention tools. [email protected], ext. 123 © John Wollwerth/Dreamstime.com Patricia Setze, librarian [email protected], ext. 103
We Encourage Reprints (For permissions, go to
HIGH RISK
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Safety Management • Safety reporting module integrates incident data across all departments • Risk assessment calculates and guides decision-making to resolve incidents • Automatically trigger corrective actions from incidents • Schedule and execute safety audits (IOSA) across multiple departments • Consolidate and standardize document control and training across the organization Quality Management • Risk assessment determines critical vs. non-critical events, guides decisions • Schedule and track maintenance and equipment calibration • Powerful reporting tool with over 50 reports out-of-the-box • Over 20 integrated modules available: • Incidents • Document Control • Employee Training • Corrective Action • Audits • Calibration & Maintenance • Centralized Reporting... and more! Supplier Management • Foster collaboration with suppliers and contractors • Create visibility into supplier quality and supplier safety • Supplier rating automatically updates scorecards based on quality/safety events Integrated Approach • Integration of Quality, Safety, Environmental, and Supplier data across the enterprise • Holistic Integrated Airline Management System
v i s i t o u r w e b s i t e fo r a f r e e a u t o m a t e d d e m o c a l l fo r a f r e e l i v e d e m o n s t r a t i o n w w w. e t q . c o m / a i r s a f e t y Editorialpage
Virtual Face
uch of what Flight Safety Foun- Foundation. In this issue, you can find the old style menus. At the top of the page dation does is related to com- material from all three sources. is information about the Foundation and munications, the gathering The Foundation’s Web site, however, various ways to communicate with us. and retransmitting of safety- has lagged, presenting the same FSF face And the middle dark blue bar has buttons enhancingM information to the global to the world for nearly a decade in an era leading to information on joining Flight aviation community. Our ability to fulfill when a Web site three years old is thought Safety Foundation, our store and a place this function is directly related to our to be antique. The material on the site has where those considering donating to our ability to be effective in reducing the risks evolved with the workings of the Founda- safety cause can examine the contribution of accidents. tion, but getting to that material has not options available. A little more than three years ago, the been easy, with the viewer forced to work At the center bottom of the home Foundation took a big step in changing through the pages covered in dense text page is an innovation for the Foundation, how it communicates by creating this to find the correct links. a news section, featuring aviation safety journal. The combination of seven spe- Beginning in September, however, news from our associate Aviation Safety cialist publications into a single colorful, the Foundation will present a new virtual Network, plus general media stories from glossy magazine signaled a change in face to the world as the new FSF Web site respected aviation specialist journalists. attitude. The previous publications’ style is launched. To the left of the news is a listing of those reflected the engineer-driven birth of the The home page announces the change elements of the site viewed by the largest Foundation. Eventually, some members immediately, with a wide view and an number of visitors; on the bottom right of the Foundation’s board of governors uncluttered design colored from a palette are our upcoming seminars and what is began to believe that a change was needed keyed to our new logo. The site focus is new at the Foundation. in the style of the FSF publications, which based on what people historically have We hope, once you have had time to led to my joining the organization and the come to
Optional Ob/Gyn Items in not reflect what is federally mandated Emergency Medical Kit in EEMKs. While U.S. air carriers may hank you for your very informative very well carry these items in addition to article, “Special Delivery” (ASW, the EEMK, they are not required to do encourages 5/09). The article is wonderfully so. The FAA’s complete list of required AeroSafety World T comments from readers, and will well written and researched. I enjoyed EEMK items can be found at
Europe, Central USA, Latin America AeroSafetyWorld advertising Joan Daly, [email protected], tel. +1 703.983.5907 Northeast USA and Canada Your advertisement in AeroSafety World goes a long way. You’ll reach nearly 40,000 Tony Calamaro, [email protected], tel. +1 610.449.3490 primary readers in the global aviation industry, 120,000 including pass-along readers. Asia Pacific, Western USA And it reaches the top floors, cruising altitude for executive decision makers. Pat Walker, [email protected], tel. +1 415.387.7593 Regional Advertising Manager Arlene Braithwaite, [email protected], Call or e-mail our advertising representatives for further information. tel. +1 410.772.0820
6 | flight safety foundation | AerosafetyWorld | August 2009 ➤ safetycalendar
AUG. 18–19 ➤ GA Flight Data Monitoring SEPT. 8–10 ➤ Asia Pacific Aviation Training SEPT. 28–OCT. 1 ➤ 13th Annual Safety Conference. Embry-Riddle Aeronautical Symposium. Halldale Media. Hong Kong. Jeremy Standdown USA. Bombardier, National University, University of North Dakota and CAP Humphreys,
www.flightsafety.org | AeroSafetyWorld | August 2009 | 7 Serving Aviation Safety Interests for More Than 60 Years
Officers and Staff light Safety Foundation is an international membership organization dedicated to Chairman, the continuous improvement of aviation safety. Nonprofit and independent, the Board of Governors Amb. Edward W. Stimpson FFoundation was launched officially in 1947 in response to the aviation industry’s need President and CEO William R. Voss for a neutral clearinghouse to disseminate objective safety information, and for a credible General Counsel and knowledgeable body that would identify threats to safety, analyze the problems and and Secretary Kenneth P. Quinn, Esq. recommend practical solutions to them. Since its beginning, the Foundation has acted in the Treasurer David J. Barger public interest to produce positive influence on aviation safety. Today, the Foundation provides leadership to more than 1,170 individuals and member organizations in 142 countries. Administrative
Manager, Support Services Linda Crowley Horger MemberGuide Flight Safety Foundation Financial Headquarters: 601 Madison St., Suite 300, Alexandria, VA, 22314-1756 USA tel: +1 703.739.6700 fax: +1 703.739.6708 Chief Financial Officer Penny Young www.flightsafety.org
Membership
Director of Membership Ann Hill Seminar and Exhibit Coordinator Namratha Apparao Membership Services Coordinator Ahlam Wahdan
Business Development Member enrollment ext. 102 Director of Development Susan M. Lausch Ahlam Wahdan, membership services coordinator [email protected] Seminar registration/Exhibitor opportunities ext. 101 Communications Namratha Apparao, seminar and exhibit coordinator [email protected] Director of Seminar sponsorships ext. 107 Communications Emily McGee Penny Young, chief financial officer [email protected] Donations/Endowments ext. 112 Technical Susan M. Lausch, director of development [email protected] FSF awards programs ext. 105 Director of Ann Hill, director of membership [email protected] Technical Programs James M. Burin Technical product orders ext. 101 Technical Namratha Apparao, seminar and exhibit coordinator [email protected] Programs Specialist Norma Fields Library services/seminar proceedings ext. 103 Technical Specialist/ Patricia Setze, librarian [email protected] Safety Auditor Robert Feeler Web site ext. 117 Karen Ehrlich, webmaster and production coordinator [email protected] Manager of Aviation Safety Audits Darol V. Holsman Regional Office: GPO Box 3026 • Melbourne, Victoria 3001 Australia Telephone: +61 1300.557.162 • Fax +61 1300.557.182
Past President Stuart Matthews Paul Fox, regional director [email protected] Founder Jerome Lederer Amy Beveridge, event manager [email protected] 1902–2004
flight safety foundation | AeroSafetyWorld | August 2009 Safety News inBrief Pitot Probe Replacements
he European Aviation Safety Agency during flights at high altitudes in which improves A320 airplane airspeed (EASA) has proposed requiring op- inclement weather. Indications are that indication behavior in heavy rain condi- Terators of Airbus A330s and A340s the crew of an Air France A330 was tions,” the agency said. “This same pitot to replace the airplanes’ Thales Avionics experiencing such problems before probe standard has been made available pitot probes. the airplane crashed into the Atlantic as optional installation on A330/A340 The EASA said, in Proposed Air- Ocean on June 1, 2009, during a flight airplanes, and although this has shown worthiness Directive (PAD) 09-099, from Rio de Janeiro, Brazil, to Paris. an improvement over the previous … that the action followed reports of All 228 people in the airplane were standard, it has not yet demonstrated “airspeed indication discrepancies” killed. The investigation of the ac- the same level of robustness to with- by flight crews of A330s and A340s cident is continuing. stand high-altitude ice crystals as the A330s and Goodrich … probe.” A340s equipped The EASA said it would accept with Thales pitot comments on the PAD until Sept. 7, probes “appear 2009. The PAD did not indicate how to have a greater soon after that a final airworthiness susceptibility to directive would be issued but said that adverse environ- within four months after issuing the mental condi- final directive, Goodrich pitot probes tions” than those (part no. 0851HL) must be installed at equipped with pitot the captain and standby positions in probes manufac- place of the older Thales pitot probes tured by Goodrich, (part no. C16195AA). Probes at the first the EASA said. officer position also must be replaced, “A new Thales either with the same Goodrich probe or pitot probe … has with a new Thales pitot probe (part no. Brazilian Navy been designed C16195BA).
Obstacle Avoidance Ice Protection
he ground-based Obstacle Colli- ew U.S. certification standards sion Avoidance System (OCAS) have been adopted to require Thas been approved by the U.S. N a more timely activation of Federal Aviation Administration (FAA) ice protection systems on transport as the first audio-visual warning system category airplanes. to be used in U.S. airspace to warn The new standards implemented pilots against potential collisions with by the Federal Aviation Administration obstacles. (FAA) will require new transport air- OCAS Inc. said that its system craft designs to have either automati- Ann Mullikin uses a “low-power ground-based cally activated ice protection systems or radar” to track an aircraft’s proximity a method of alerting pilots to activate enough to warrant turning on their to an obstacle such as a power line, them. After their initial activation, the ice protection equipment,” said FAA tower or wind turbine. The system, systems must either operate continu- Administrator Randy Babbitt. which is installed on an obstacle, can ously, turn on and off automatically, or The rule applies only to designs for detect an aircraft’s proximity and alert pilots to cycle them. new transport category airplanes and to track and, if a collision is likely, can The certification change adds significant changes in current designs warn the pilot with flashing lights “another level of safety to prevent that “affect the safety of flight in icing and an audible alert. No additional situations where pilots are either conditions,” the FAA said. The agency equipment is required to be installed completely unaware of ice accumu- is considering further rule making that in an aircraft. lation or don’t think it’s significant would cover existing airplane designs.
www.flightsafety.org | AeroSafetyWorld | August 2009 | 9 inBrief
English Training Guidelines Hard Landings
wo international organizations are pilot-controller communications in finalizing guidelines for programs 2003 and defined six levels of language Tthat teach aviation English. proficiency — from “pre-elementary” at The International Civil Aviation Level 1 to “expert” at Level 6. Require- English Association (ICAEA) is working ments call for pilots and controllers to with the International Civil Aviation Or- demonstrate at least “operational” Level ganization (ICAO) to develop guidelines 4 proficiency to be permitted to be in- that recognize that training in aviation volved in international flight operations English “has specific objectives, content, after March 2011. criteria of proficiency, conditions of use, The ICAO Journal article quoted and professional and personal stakes ICAEA President Philip Shawcross as which set it apart from the teaching of saying that when the ICAO requirements language in any other area of human were introduced in 2003, they “essen- activity,” ICAO said in the ICAO Journal tially required that an entire new train- who were having to seek out suitable (Volume 64, No. 3). ing sector be established in a very short programs in the training marketplace.” Until now, there has been “no formal period of time. We began to see materi- The ICAEA guidelines will empha- system of accreditation or qualification als and techniques being employed that size the importance of “plain language for schools or teachers developing and were not necessarily appropriate to the in an operational context [as] the prime delivering aviation English training,” ultimate objective, and so it became focus of aviation English training,” as ICAO said. an early goal for us not only to provide well as the need for lesson content that is ICAO formally designated Eng- information and guidance to educators relevant to the pilot or controller group
lish as the language for international but also to the aviation decision makers being trained. Kaspar© iStockphoto/Andreas
Learjet Design Change Sought
ombardier should be required to change the design of the were stowed.” The NTSB said that the findings prompted thrust lever system in its Learjet 60 in the aftermath of a concern about “safety issues involving inadvertent stowage of Bfatal Sept. 19, 2008, crash, the U.S. National Transporta- the thrust reversers.” tion Safety Board (NTSB) says. “In March 2009, Learjet published a Federal Aviation Ad- Both pilots and two of the four passengers in the Global ministration (FAA)-approved temporary flight manual (TFM) Exec Aviation Learjet were killed in the late-night crash, in change in procedures, which described improved methods which the airplane overran the runway during departure from for quickly recognizing and handling situations when inad- Columbia, South Carolina, U.S. vertent stowage occurs,” the NTSB said. “However, the NTSB The NTSB investigation of the accident is continuing, is concerned that Learjet 60 pilots are not sufficiently trained but an examination of the engines found “evidence consistent to recognize that a failure could occur during takeoff as well with high thrust … and indicated that the thrust reversers as landing phases of flight and could subsequently result in the loss of system logic control requirements for maintaining deployed thrust reversers during a rejected takeoff.” The NTSB issued six safety recommendations to the FAA, including a call for the agency to require the design change “so that the reverse lever positions in the cockpit match the posi- tions of the thrust-reverser mechanisms at the engines when the thrust reversers stow.” Another recommendation said the FAA should require training for Learjet 60 pilots “for takeoff as well as landing phases of flight on recognizing an inadver- tent thrust reverser stowage, including the possibility that the stowage can occur when the requirements for deploying thrust reversers are not fully met, such as when the air/ground sensor squat switch circuits are damaged.” Bombardier
10 | flight safety foundation | AeroSafetyWorld | August 2009 inBrief
Hard Landings
perators should provide more training in procedures for The “primary trigger” for a hard/heavy landing report reporting suspected hard landings, the U.K. Civil Aviation should be the aircraft commander’s subjective evaluation of OAuthority (CAA) says in a new flight operations division the event, the report said, adding, “It must be clear to crew and communication. maintenance staff that all suspected hard/heavy landings must The communication was issued as a result of the U.K. Air be reported before further flight to permit a full investigation Accidents Investigation Branch (AAIB) report on the hard land- and determination of continued airworthiness.” ing of an Airbus A321 at Manchester Airport on July 18, 2008. The AAIB said that the airplane was “not flared sufficient- ly” and the subsequent landing was “severe hard.” Neverthe- less, the AAIB said, “the possibility of a landing parameter exceedance was not reported by the crew following discussion with ground engineers who had been on the flight. The pres- ence of a landing parameter exceedance report was identified after a further two sectors had been flown, when an unrelated inspection of the landing gear found a crack in a wing rib gear support lug.” The CAA said that data systems in this particular A321 were not configured to automatically generate exceedance re- ports; instead, the data management unit (DMU) had to be in- terrogated manually. The pilots believed that, because the DMU had not produced a report, there had been no hard landing. The CAA said operators should “provide clear guidance and training to all staff to enable them to correctly report a suspected hard/heavy landing to enable investigation prior to any further operations.” Satyajit © D.
Wind Farms vs. ATC In Other News …
urocontrol is developing guidelines A comment period will continue he International Air Trans- for the assessment and mitigation of through January 2010. port Association has signed a Ethe effects of wind farms on air traf- Tmemorandum of understand- fic control surveillance systems. ing with India to “enhance the “Wind turbines can potentially have skills and knowledge of Indian a detrimental impact on the performance civil aviation personnel to sup- of surveillance systems used for air traffic port the development of In- control,” Eurocontrol said. “A wind farm dian aviation.” … The Australian could cause the loss or corruption of the Civil Aviation Safety Authority declared aircraft’s position, or may create (CASA) has begun a campaign false targets. These create additional to ensure that operators of model work for air traffic controllers and may aircraft and rockets comply with also result in safety issues.” safety rules that require them to The proposed guidelines were remain away from airports and developed in consultation with civil and below 400 ft in controlled airspace, military providers of surveillance systems unless they have CASA’s approval. in Europe, with input from Australia, The campaign follows an incident Canada, Japan, New Zealand and the involving a model aircraft being United States. flown near the Perth airport. © Tore Johannesen/iStockphoto
Compiled and edited by Linda Werfelman.
www.flightsafety.org | AeroSafetyWorld | August 2009 | 11 Coverstory Keeping It on the Runway
BY RICK DARBY
A new product combines findings and tools developed by the Runway Safety Initiative for reducing runway excursions.
he long, straight pavement lies ahead, involving commercial jets worldwide The RSI report, “Reducing the Risk waiting to launch an airplane into were runway excursions, four occurring of Runway Excursions,” summarizes the the sky or welcome it to the ground. on takeoff (ASW, 2/09, p. 18).2 findings of two and one-half years of A runway is an invitation. A new joint product from Flight industry effort. The RSI effort brought TThe invitation is accepted, the meet- Safety Foundation and the International together disciplines that included aircraft ing takes place and nearly always every- Air Transport Association (IATA), the manufacturers, operators, management, thing goes well. But nothing in takeoffs Runway Excursion Risk Reduction Toolkit, pilots, regulators, researchers, airports or landings is guaranteed. When an promises to significantly help operators and air traffic management organizations. airplane rolls past the end of the runway reduce the risk of runway excursions. The team initially studied the data — an overrun — or off the side — a The compact disc combines the final on three kinds of runway risk: runway veer-off — the runway excursion puts report of the FSF Runway Safety Initiative incursions, runway excursions and its occupants at risk.1 James M. Burin, (RSI) and material from IATA. The tool runway confusion. It found that both Flight Safety Foundation (FSF) direc- kit is available from the Foundation and incursion and confusion accidents had tor of technical programs, reported that IATA; check the FSF Web site for order- higher fatality rates than excursions.
in 2008 six of the 19 major accidents ing information. However, the proportion of excursions © Chris Photography Sorensen
12 | flight safety foundation | AeroSafetyWorld | August 2009 coverStory
among runway-related accidents far exceeded aviation equivalent of automobile fender bend- those for incursion and confusion accidents ers. However, every excursion has the potential (Figure 1). As a result, the number of fatal ex- for serious consequences. From 1995 through cursion accidents was substantially greater than 2008, of 417 runway excursions by commercial the number of fatal incursion and confusion transport aircraft, 34 involved fatalities and 712 accidents (Figure 2). The RSI team decided that people were killed.3 it would be most useful to focus its efforts on Although no accident can strictly be de- reducing excursion accidents. scribed as typical, an excursion that occurred on Excursions are little noted in mainstream Sept. 19, 2008, gives an idea of what lies behind news media unless they involve fatalities or the statistics. A safety recommendation letter by extensive injuries, or present spectacular photo the U.S. National Transportation Safety Board and video opportunities. Perhaps there is a (NTSB) to the U.S. Federal Aviation Administra- perception that excursions are not “crashes” tion (FAA) described the occurrence.4 but just low-consequence careless driving, the “A Bombardier Learjet 60 … overran Runway 11 while departing Columbia Metropolitan Air- Proportions of Runway-Related Accidents, port, Columbia, South Carolina,” the letter said. 1995–2008 “The pilot, copilot and two of the four passen- gers were killed; the two other passengers were Confusion — turboprop seriously injured. The aircraft was destroyed by Incursion — turboprop postcrash fire. … “According to witness interviews and the Excursion — turboprop cockpit voice recorder transcript, the beginning Excursion — jet of the takeoff roll appeared normal. However, Incursion — jet sparks were observed as the airplane traveled Confusion — jet along the runway. The airplane continued be- yond the runway and through the approximately
Note: Data represent commercial transport aircraft 1,000-ft [305-m] runway safety area and, beyond worldwide. that, struck airport lighting, navigation facilities, Source: Runway Excursion Risk Reduction Toolkit a perimeter fence and concrete marker posts. The airplane then crossed a roadway and came Figure 1 to rest when it struck an embankment across the road from the airport.”5 Proportions of Fatal and Nonfatal Runway Accidents, 1995–2008 Sifting the Data Fatal accidents Runway confusion Nonfatal accidents The RSI team studied a database of excursions to identify high-risk areas. The entire study, in- cluding the study basis, data set and constraints, Runway incursion can be found in a “Report on the Design and Analysis of a Runway Excursion Database,” an
Runway excursion appendix to the RSI report. Among the findings were that landing excur- 0 50 100 150 200 250 300 350 400 450 sions outnumbered takeoff excursions by about Number of accidents four to one; almost two-thirds of the takeoff
Note: Data represent commercial transport aircraft worldwide. excursions were overruns; landing excursion
Source: Runway Excursion Risk Reduction Toolkit overruns and veer-offs occurred at nearly the same rate; and turboprops were involved in the Figure 2 highest percentage of takeoff excursions. In www.flightsafety.org | AeroSafetyWorld | August 2009 | 13 Coverstory
landing excursions, jets were involved in more crew; and failure to provide timely or accurate excursions than turboprops. runway condition information to the crew. The data were analyzed to determine the Airport. Runways that are not constructed prevalence of various risk factors associated and maintained to maximize effective fric- with takeoff excursions (Figure 3) and landing tion levels and drainage; incorrect or obscured excursions (Figure 4). runway markings; failure to allow use of the “Multiple risk Risk factors were not confined to pilot ac- optimal runways for the prevailing wind; and an tions or airplane mechanical problems. The inadequate runway end safety area (RESA) or factors create a following is a selection from the list — given in equivalent deceleration system. full in the RSI report section of the tool kit — of Regulators. Lack of a regulatory requirement synergistic effect.” other factors boosting the odds of an excursion: to give flight crews takeoff and landing data for Air traffic management. Late runway all runway conditions in a consistent format. changes during the approach, such as after the final approach fix; failure to provide timely or Double Trouble accurate wind and weather information to the Risk factors for excursions can be compounded. Two, or even more, sometimes coexist in a take- off or landing. Takeoff Excursion Risk Factors “Multiple risk factors create a synergistic effect (i.e., two risk factors more than double
RTO: initiated after V1 the risk),” the report says. “Combining the ef- Pilot directional control fects of the risk indicators via a proper safety
RTO: before V1 management system (SMS) methodology could
No rotation — below VR effectively identify increased-risk operations.” Noncompliance with SOPs Risk factors that showed up in the database Rotation: no attempt analysis were cross-tabulated for veer-offs and Crew resource management overruns, both in takeoffs and landings. Four Degraded engine performance tables in the report show the degrees of interac- Tire failure tion among factors. Unable to rotate “The small number of events comprising Weight calculation error Sudden engine power loss the takeoff excursions data set — made even RTO: no time smaller when considering only veer-offs — lim- Thrust asymmetry its our ability to know whether differences in the tabulated values are significant,” the report Rotation: above VR RTO: not considered says. “However, it is interesting to note where Pilot technique: crosswind there are associations of factors that may war- PIC supervision rant further, more detailed study. For instance,
Improper checklist use aborts [rejected takeoffs] at or below V1 often
Rotation: below VR still resulted in a veer-off when there was an 0 10 20 30 40 50 engine power loss, a runway contaminant or a Percentage of accidents crosswind. There is also some indication that in which risk factor was present the increased risks created by crosswinds and
CRM = crew resource management; PIC = pilot-in-command; RTO = rejected takeoff; tail winds are magnified when gusts, turbulence SOPs = standard operating procedures or wind shear is present.” Note: Data represent commercial transport aircraft worldwide. A single excursion could have In the table showing takeoff overrun factor more than one risk factor. interactions, “the numbers in these data suggest Source: Runway Excursion Risk Reduction Toolkit that there might be interesting associations Figure 3 between engine power loss and aborts initiated
14 | flight safety foundation | AeroSafetyWorld | August 2009 coverStory
above V1, as well as an association between Landing Excursion Risk Factors these high-speed aborts and the presence of runway contaminants,” the report says. Observations about risk interactions for Go-around not conducted landing excursion veer-offs and landing excur- Touchdown: long sion overruns were based on a larger sample. Ine ective braking: runway contamination Landing gear malfunction The cross-tabulations showed that “the landing Approach: fast excursion data have some strong associations Touchdown: fast between pairs of factors,” the report says. “For Touchdown: hard instance, … for veer-offs, the factor(s) ‘touch- Crew resource management down long/fast’ have little association with the Pilot directional control other listed factors. However, … ‘touchdown Noncompliance with SOPs hard/bounce,’ shows strong associations with Wheels: aymmetrical deceleration malfunction many of the other factors.” Approach: high Landing gear damaged Adopting Mitigations Pilot technique: attitude control Following the descriptions of the research Touchdown: bounce findings, the report delivers its payload: recom- Pilot technique: speed control mended mitigations. The prevention strategies Pilot technique: crosswind embrace five stakeholder groups: flight opera- Pilot technique: are tions, air traffic management, airport operators, Touchdown: o -center Reverse thrust: asymmetric aircraft manufacturers and regulators. 0 10 20 30 40 Here are samples, from an extensive list, in Percentage of accidents each category: in which risk factor was present Flight operations. “Operators should define criteria that require a go-around”; “Operators SOPs = standard operating procedures should define and train the execution of the Note: Data represent commercial transport aircraft worldwide. A single excursion could have more than one risk factor. RTO [rejected takeoff] decision.” Source: Runway Excursion Risk Reduction Toolkit Airport operators. “Define criteria to deter- mine when to close a runway to prevent runway Figure 4
A Bangkok Airways ATR 72 skidded off the runway while landing in heavy rain on Aug. 5, 2009. The captain was killed and 11 occupants were injured. © Apichart Weerawong/Associated Press Weerawong/Associated © Apichart
www.flightsafety.org | AeroSafetyWorld | August 2009 | 15 Coverstory
excursions”; “Ensure that runways indicate the degree of risk severity This appendix puts excursion risk are constructed and maintained to for each factor. “Elements of this tool factors under the microscope, dealing ICAO [International Civil Aviation should be integrated, as appropriate, with specifics such as “wheel factors.” Organization] specifications, so that with the standard approach and depar- It was found, for example, that “tire effective friction levels and drainage ture briefings to improve awareness of failures are often a consequence of are achieved (e.g., runway grooving, factors that can increase the risk of a rejected takeoffs, but 13 of the 16 ‘tire porous friction overlay).” runway excursion,” the RERAT says. failure’ citations in this field occurred Air traffic management. “Ensure all “Runway Excursion Risk Reduction during the takeoff roll and motivated ATC/ATM [air traffic control/air traffic Strategies” are included in a condensed the takeoff abort. The other three oc- management] personnel understand format so that the RERAT can be used as curred during the abort process and the concept and benefits of a stabilized a stand-alone tool when appropriate. The contributed to the aircraft departing approach”; “Encourage joint familiar- document includes the recommended the runways.” ization programs between ATC/ATM elements of a stabilized approach, which Appendix IV, “Selected Flight Safety personnel and pilots.” are discussed in detail in the RSI report. Foundation Publications,” includes Regulators. “Develop a policy to articles — mainly published in the past standardize takeoff and landing data for- Briefing Notes four years — bearing on the subject. mat as a function of runway condition.” Appendix II of the RSI report consists They are all available on the Web site Aircraft manufacturers. “Manu- of “Approach and Landing Briefing
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From Deliberation to Product discussions amongst the team members the RSI team was successful in identify- “We knew we were going to concentrate resulted in subgroup proposals which ing key areas and finding solutions for on runway safety, but deciding to focus in turn were discussed in plenary ses- given problem areas. The Foundation on runway excursions actually took sions with the other groups.” did an outstanding job in raising world- a few meetings of deliberation by the The group studying approach risk wide awareness for runway excursions. team members,” said Glenn Michael of factors had a head start because of the “I daresay that the awareness has the FAA, who was involved in the Run- work that had been done in connection reached the critical point, meaning that way Safety Initiative from its beginning. with the FSF ALAR Tool Kit. The runway it is in so many heads now that runway “Once the decision was made to work group was faced with a “zillion years of safety will be addressed almost as a self- on excursions, the team was divided history,” as van Eekeren put it, on brak- propelling process. This will undoubt- into functional groups to address spe- ing action problems. The airport study edly lead to a process where we will see a cific causal factors of runway excur- group started from ICAO Annex 14 reduction in the runway safety risk in the sions. Mitigation strategies were then recommendations for airport design. next five to 10 years. However, since there constructed to address risks associated “The challenge now was to go beyond is no global coordination point or glob- with runway excursions.” existing material and produce new ideas ally accepted plan, it might be expected Rob van Eekeren, a captain repre- and initiatives which could make a dif- that some runway safety measures will be senting the International Federation of ference,” van Eekeren said. “That takes done with the best intentions, but will fail. Air Line Pilots’ Associations, recalled, time. The representatives also had to ad- Others might prove highly successful.” “The process involved industry partners dress their normal day-to-day jobs, and Notes as well as international organizations, only as an RSI meeting approached was all with their own interests and agendas. there significant activity. Even a special 1. The FSF Runway Safety Initiative defined a runway excursion as “when an aircraft on Four meetings per year were scheduled Web-based page created by the Founda- the runway surface departs the end or the with a two-year time frame. It proved tion for communicating and posting side of the runway surface. Runway excur- to be an interesting challenge to get ideas could not overcome this. It must sions can occur on takeoff or landing.” everybody focused on a common goal. be said, however, that inside each orga- 2. A major accident, which Flight Safety This goal could not be and was not nization the subject of runway excur- Foundation believes is the primary accident reached in one meeting alone. In fact, it sions became prominent in its own right. criterion for safety purposes, is defined took almost 18 months.” The allotted time limit was pressing and as an accident that meets any of three conditions: First, the aircraft is destroyed or It was agreed to work along a data- a leap forward was achieved during the sustains major damage; second, there are driven approach. “Although in potential last formal meeting in Brussels in 2009. multiple fatalities; third, there is one fatality a lot of data were available — a runway A final meeting at the FSF office brought and the aircraft is substantially damaged. excursion is always an incident and the final result.” 3. “Reducing the Risk of Runway Excursions,” thus recorded — it had never been Glenn Michael said, “This was an from the Runway Excursion Risk Reduc- compiled in the runway safety field,” outstanding group of experts to work tion Toolkit. van Eekeren said. “So the Foundation with and once we defined our goal, Jim 4. NTSB. July 17, 2009. Available via the In- contracted with a data specialist. Dur- Burin and [FSF Fellow] Earl Weener ternet at
BY LOUKIA D. LOUKOPOULOS, R. KEY DISMUKES AND IMMANUEL BARSHI
As we started the taxi, I called for the taxi checklist but became confused about the route and queried the first officer to help me clear up the discrepancy. We discussed the route and continued the taxi. ... We were cleared for takeoff from Run- way 1, but the flight attendant call chime wasn’t working. I had called for the ‘Before Takeoff’ checklist, but this was inter- rupted by the communications glitch. After affirming the flight attendants were ready, we verbally confirmed the ‘Before Takeoff’ checklist. On takeoff, rotation and liftoff were sluggish. At 100–150 ft, as I continued to rotate, we got the stick shaker. The first officer noticed the no-flap condition and placed the flaps to 5. … We wrote up the takeoff configuration warning horn but found the circuit breaker popped at the gate.1
s this an example of recklessness? from Birmingham (England) Interna- [stabilizer trim set for takeoff] to go Complacency? Absent-mindedness? tional Airport at 155 kt after finding it unchecked.”2 Complex operating conditions? Com- impossible to rotate the aircraft. The Are these incidents exceptions to plicated operating procedures? Insuf- investigation revealed that “a number usual practice or symptoms of wider- ficientI crew experience? Or something of distractions, combined with unusual spread vulnerability? What do they say as subtle as multitasking? demands imposed by the poor weather, about the progress of an industry that During another flight, in Febru- led to a breakdown of normal proce- has suffered at least three catastrophic ary 2009, a crew rejected their takeoff dures and also allowed a missed action accidents when a takeoff configuration
The Perils of Multitasking Pilots overestimate their abilities, as well as the benefits of doing several things at once. © Chris Photogtaphy Sorensen
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warning system failed to alert the crew (FAA) to characterize the nature and pieces of information from external that they were attempting to take off demands of routine flight operations. sources. In the ideal world, everything without having set the flaps?3,4,5 Preliminary findings13 raised red flags occurs at specific, predictable moments In reviewing categories of accidents for an industry that, like many others, as the taxi phase of flight unfolds. for 2008 — spurred in part by the fatal had unsuspectingly accepted multitask- This is the way activities are laid Aug. 20 crash of a Spanair McDonnell ing as a normal state of affairs. out in the manuals, the way cockpit Douglas MD-82 during an attempted We argued that commercial and tasks are taught in training, and the way takeoff from Madrid, apparently with public pressures, organizational and pilots are expected to perform, on the improperly set flaps, according to pre- social demands, and the increase in line. The activity-tracing exercise can liminary reports6 — Flight Safety Foun- air traffic, mixed with a healthy dose be repeated for every phase of flight, dation decried the “unwelcome return of pilots’ overestimation of their own and in each case, the ideal perspec- of the no-flaps takeoff” and concluded abilities, were creating situations that tive portrays crew activities as linear, that “we are not making much progress were considered routine, although they or following a prescribed sequence; in reducing the risk of these [types of concealed appreciable risk. predictable; and under the moment-to- loss of control] high-fatality accidents” Our research at the Flight Cogni- moment control of the crew. (ASW, 02/09, p. 18). tion Laboratory at NASA’s Ames Re- The real world is not as straight- A quick search of the U.S. National search Center in California is based on forward. Observation of flight crews, Aeronautics and Space Administra- a combination of methodologies that from the vantage point of the cockpit tion (NASA) Aviation Safety Reporting through the years have included labora- jump seat, helps us understand the System (ASRS) database reveals more tory experiments, structured interviews full ramifications of that. During our than 50 reports of attempted no-flaps and surveys, in-depth analyses of flight observations, we recorded every event takeoffs in the last decade, as well as manuals, participation and observation that caused some perturbation — or reports of incorrectly set trim, airspeed of ground and flight training, incident disruption — of the ideal sequence of and heading bugs; cockpit windows not and accident report analyses, and many activities of the two pilots. It did not latched; and other omissions. In many hours of cockpit jump seat observations take long to realize that the real opera- of these events, the crew was saved by during passenger-carrying operations. tional world is more complex and more the proverbial bell — a takeoff configu- Taking advantage of these sources of dynamic than represented in writing ration warning horn. That bell cannot data, we systematically analyzed and and in training. be relied on to always work, however. contrasted cockpit operations in theory Let’s look at the taxi phase of flight What leaves expert, conscientious and in reality.14 in more detail, as it often unfolds in the pilots — and their passengers — hang- Take any carrier’s flight operations real operating environment. The base ing by the thread of a last line of defense, manual (FOM) and draw out the flow layer (grayed-out and in the background such as a warning horn or a checklist? of activities required of each pilot from of Figure 2, p. 21) is the ideal representa- Articles abound in the daily news moment to moment while the aircraft tion depicted in Figure 1. Another layer about a multitasking society and the is taxied from the gate to the run- has been added, formed by some of the dangers inherent in our natural drive way for takeoff, and you will see the many disruptions that were observed to have more than one thing going on theoretical, “ideal” taxi phase of flight from the jump seat during routine at once.7,8,9,10 Most people know they (Figure 1, p. 20). flights. Ovals contain some of the pos- should not talk on their cell phone while The crew’s activities can be traced sible, additional demands that are not driving, although many do it anyway.11,12 from the moment the captain requests explicitly expressed in the FOMs. But what does multitasking have to do that the first officer obtain taxi clear- The disruptions listed in each oval with pilots on an airline flight deck? ance until the aircraft is lined up with carried additional task demands for the runway centerline, ready for takeoff. attention and action. Ice or snow on Complex Operations There are a number of procedures the ground meant that the captain In 2000, we embarked on a research that pilots conduct individually, two deferred calling for flaps prior to taxi to project sponsored by NASA and the checklists conducted by pilots together, avoid contaminating the wing surfaces U.S. Federal Aviation Administration monitoring requirements and other with slush, continued with other taxi www.flightsafety.org | AeroSafetyWorld | August 2009 | 19 humanfactors
activities, performed the taxi checklist is considerably more work than the Limitations calling for verification of the flaps set- ideal perspective suggests. But it is People often feel they are perfectly ting, and remembered to set the flaps not just a question of workload quan- capable of performing several tasks right before takeoff. Encountering a tity. It is also a question of workload simultaneously. There seems to be a busy frequency meant that the first of- management. Responding to the mul- popular myth that humans are good ficer had to continue monitoring all ra- tiple, concurrent demands of flight multitaskers. In reality, however, human dio calls in order to “jump in” when the operations requires interweaving ability to process more than one stream frequency became available, all while new activities with old ones, defer- of information at a time and respond monitoring the captain, maintaining ring or suspending some tasks while accordingly is severely limited. Truly situational awareness and carrying out performing others, responding to un- simultaneous performance is possible other pre-taxi preparations. expected interruptions and delays and only when tasks are highly practiced Again, the exercise can be repeated unpredictable demands imposed by and rehearsed extensively together. for each phase of flight. The resulting external agents — all while monitor- Performance in this situation becomes “real” picture reveals activities that are ing everything that is going on. This largely automatic, making few demands much more fluid, convoluted and vari- is multitasking in a pilot’s world. on the brain’s limited capacities for able than in theory: Activities are dynamic ‘Ideal’ Taxi Phase of Flight1 and not so linear, are
unpredictable, and are Monitor not fully under the Monitor ATC (ground), Captain ATC (ground) company First o cer control of the pilots. Request taxi clearance Obtain clearance Taxi clearance Pilots are routinely (taxi) Taxi Procedure Taxi Procedure forced to deviate Recall Check xxxx xxxxx xxxx x from their linear, xxxx xxxxxx Flight controls Check Flaps (green light) xxxx xxxx xxxx well-practiced and xxxx xxxx xxxx Flaps (green light) xxx xxxxx xxxx xx xxxx xx xxxx xxxxxxxxx habitual execution of Cabin door Lock Monitor procedures. Neither xxxx xx xxxx xxxxxxxx captain taxiing Takeo brie ng Review the nature nor the Ask for checklist Begin checklist Taxi Checklist timing of tasks and xxxx xxxxx xxxx x events can be antici- Flight controls Checked xxxx xxxxx pated with certainty. Flaps Set, green light Takeo brie ng Completed Essential information xxxx xx xxxx xxxxxxxxxx (at or near runway) Checklist complete and/or the individuals Before Takeo Procedure Before Takeo Procedure Engine start switches CONT xxx xxx xxxxxxx xx xx x required to perform Takeo clearance Landing lights and As FMC position update As desired strobe light switches desired some activities are not Transponder On xxx xxxxxx xxxx xx always available when Ask for checklist Begin checklist Before Takeo Checklist expected. Tasks often xxxxx xxx xxx xx Packs Set must be initiated Transponder TA/RA earlier or later than Master caution Checked xxx xxxxxx xxxx xx Checklist complete planned. Pilots must Line up with runway continually find ways to fit more than the “ideal” activities into ATC = air traffic control; CONT = continuous; FMC = flight management computer; TA/RA = traffic advisory/resolution advisory the allotted time. 1. The ‘ideal’ phase represents that described in a flight operations manual. Source: Loukopoulos, L.D.; Dismukes, R.K.; Barshi, I. The Multitasking Myth: Handling Complexity in Real-World Operations. Burlington, Vermont, U.S.: Ashgate One implica- Publishing Co. 2009. tion of the real picture is that there Figure 1
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attention and working memory. But human information processing attri- ad hoc, inventive ways. Too many of these when an individual tries multitasking butes, and the experience, skill and goals seemingly benign situations bore a strik- in a situation that involves novel tasks, of the individual — always within the ing resemblance to stories recounted by complex decision making, monitoring, context of prevailing standard operating pilots in incident reports or that we read or overriding habits, it all falls apart. procedures and operational restrictions. about in accident reports.15 In principle, pilots, like all people, However, the approach people take to For example, the crew cited in the have limited choices when called to multitasking demands is not necessarily first paragraph of this article received a multitask: They can interweave steps deliberate or well thought out. stick shaker warning after rotation and of one task with steps of other tasks, During our observations, we spent realized they had inadvertently omitted or defer one task until the other task is many hours watching pilots handle rou- setting the flaps to the takeoff posi- completed, or even purposefully omit tine multitasking situations, apparently tion. This crew had been multitasking, one task. The choice and the degree to without much effort or many errors — attempting to concurrently address a which any of these proves successful but we became increasingly uneasy with discrepancy in their route and an inop- depend on the interaction of the char- the risks they were unknowingly accept- erative call chime. acteristics of the tasks being performed, ing each time they were called to react in The crew in the Birmingham event rejected their takeoff, after finding it impos- ‘Real’1 Taxi Phase of Flight sible to rotate the air-
Monitor craft, because they had Monitor ATC (ground),Busy frequency Ask first officerATC (ground) to set flaps company inadvertently omitted Captain Defer communication First o cer Request taxi clearance Obtain clearance setting the stabilizer Taxi clearance Monitor frequency and (taxi) Verify ramp contact when available clear area trim for takeoff. This Taxi Procedure Taxi Procedure Acknowledge clearance Recall Check Ice/snow xxxx xxxxx xxxx x crew was also multi- xxxx Deferxxxxxx setting flaps Consider need for de-icing Flight Confirmcontrols Checkcaptain’s understanding tasking: They had to FlapsRemember flaps(-, before green light) takeoff De-icing checklist xxxx xxxx xxxx System configuration? (APU, packs) Unfamiliar with xxxx xxxx xxxx Flaps (green light) deice the aircraft, were Monitor airport/taxi route xxx xxxxx xxxx xx Remember/identify xxxx xx xxxx xxxxxxxxx airport traffic Review charts Monitor preoccupied by the Cabin door Lock turns/intersections Monitor xxxx xx xxxx xxxxxxxx hold-short instruction taxi progress captain taxiing visual “clear” turns weather conditions, Takeo brie ng Review aircraft to follow Ask for checklist Delay (traffic) Begin checklist were trying to meet a Consider shuttingTaxi down Checklist one engine New/additional First officer busy Restart enginexxxx before takeoffxxxxx xxxx x taxi instruciton takeoff time constraint, Defer checklist Flight controls Checked After start checklist Acknowledge instructions and were focused on Perform checklist as soon as possible xxxx xxxxx Interruption Verify understanding Flaps Set, green light remembering (which RespondTakeo to interruption brie ng Completed Verify captain’s understanding Resumexxxx checklist xx xxxxSwitch xxxxxxxxxx to tower frequency they did) to set the (at or nearRunway runway) change Checklist complete Monitor flaps, which they BeforeConsider Takeo feasibilityProcedure tower frequency Before Takeo Procedure Engine start switches CONT xxx xxx xxxxxxx xx xx x Consult charts/performance data Takeo clearance Just-in or revised load data had deferred earlier Landing lights and As FMC position update As desired strobe lightBrief switches new runwaydesired Calculate new performance data Transponder On because of the slushy xxx xxxxxx xxxx xx Reprogram new data Have captain verify new entries Ask for checklist Begin checklist conditions. Before Takeo Checklist Continue to monitor captain xxxxx xxx xxx xx Inform company The Madrid ac- Packs Set Transponder TA/RA cident apparently re- MasterVisually caution “clear”Checked runway sulted from the crew’s xxx xxxxxx xxxx xx First officer’sChecklist turn to complete fly Line up with runway inadvertent omission Take control of aircraft while finishing checklist of setting the flaps for takeoff, coupled APU = auxiliary power unit with the failure of the 1. The ‘real’ phase represents the findings of jump seat observers. takeoff configura- Source: Loukopoulos, L.D.; Dismukes, R.K.; Barshi, I. The Multitasking Myth: Handling Complexity in Real-World Operations. Burlington, Vermont, U.S.: Ashgate Publishing Co. 2009. tion warning system. Was this crew also Figure 2 multitasking? There www.flightsafety.org | AeroSafetyWorld | August 2009 | 21 humanfactors
are indications that the crew was distracted by often so busy that it is extremely difficult for pilots an overheating probe, and had to return to the to pause long enough to review whether they have gate for maintenance, receive additional fuel, completed deferred or interrupted tasks. and start the engines anew. Pilots also are highly vulnerable to errors of Our research has focused on key aspects of omission when they must attempt to interweave human cognition that lie at the heart of multitask- two or more tasks — performing a few steps of a ing, namely remembering to perform tasks that task such as flight management system (FMS) data must be deferred (prospective memory), auto- entry, switching attention to another task such as matic processing and switching attention between monitoring taxi progress, back and forth. Much tasks. There is considerable scientific evidence of the time pilots can interweave tasks without that pilots, like all people, are highly vulnerable to problems, but if one task becomes demanding— inadvertent but potentially deadly omissions when the FMS does not accept the input, for example a situation leads them to defer a task that nor- — their attention is absorbed by these demands, mally is performed at a particular time and place. and they forget to switch attention to other tasks. Deferring a task breaks up the normal sequence of Monitoring, a crucial defense against threats and habitual actions and removes environmental cues errors, often falls by the wayside when pilots must that help pilots remember what to do next. interweave it with demanding tasks. In fact, moni- Interruptions create especially dangerous toring is far more difficult to maintain consistently prospective memory situations — by requiring than most pilots realize, as evidenced by studies of pilots to remember to resume the deferred, inter- automation monitoring.16,17 rupted task — but are so commonplace that pilots may not recognize the threat. Interruptions typi- Dispelling the Myth cally disrupt the chain of procedure execution so There is no single best technique to manage the A crane lifts the abruptly that pilots turn immediately to the source challenges posed by multitasking in flight opera- wreckage of a of interruption without noting the point where tions, but we have suggested various things that Spanair McDonnell the procedure was suspended, without forming an pilots and organizations can do.18 First, we must Douglas MD-82 that explicit intention to resume the suspended pro- dispel the myth that multitasking comes easily to crashed in August cedure, or without creating salient cues to remind humans, especially to pilots with “the right stuff.” 2008 during takeoff themselves to resume the interrupted task. Certain We must help pilots recognize typical multitask- from Madrid. phases of flight such as taxi-out and approach are ing situations that create vulnerability to error even in the most routine aspects of operations. Organizations must take a close look at the dif- ference between the ideal perspective and the real nature of actual flight operations and adjust pro- cedures, training and expectations accordingly. Fortunately, both individual pilots and or- ganizations can reduce the peril of multitasking. Pilots can treat interruptions, suspending tasks, deferring tasks or performing tasks out of normal sequence as red flags. When interrupted, they can reduce vulnerability by pausing momentarily to mentally note the point at which the procedure is interrupted and by reminding themselves to return to that place later, before addressing the interrup- tion. When suspending or deferring tasks, they can identify when and where they intend to perform © Associated Press the task; create salient reminder cues, such as
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putting an empty coffee cup over Immanuel Barshi is a research psychologist 9. Wallis, C. (2006, March 19). “The the throttles when they have deferred at the Human-System Integration Division at Multitasking Generation.” Time, March setting the flaps to their takeoff position; NASA Ames Research Center. 19, 2006.
BY LINDA WERFELMAN
he fruitless search for the flight re- A330 and a Yemenia Airways A310 that “If anything, it’s fire that did the re- corders from the Air France Airbus crashed in the Indian Ocean on June 30, corders in,” Cash said. “We’ve never lost A330 that crashed into the Atlantic 2009,2 the search has gone on for weeks one because of impact damage, but … Ocean on June 1 has stirred new or months — continuing even after older, tape-based units were more easily Tinterest in the development of alternate the end of the 30-day period in which damaged by fire.” methods of delivering vital black box underwater locator beacons, or “pingers,” data to accident investigators.1 transmit signals to alert searchers to the Closer Look One alternative — the deployable location of the boxes. Current standards call for large com- flight incident recorder — has been in Historically, most accidents in mercial airplanes to be equipped with use for decades on military aircraft; the which flight recorders have been an FDR and a CVR installed separately future of a second alternative — trans- pronounced “not recoverable” have not — not in a single combined unit. mission of flight data to a ground station been in water but rather in “unusually In the aftermath of the Air France — is intertwined with technological ad- inhospitable terrain, such as mountain- crash, however, some in the industry vances that are improving computer data tops,” Angers said. pressed for a closer look at other methods transmission between air and ground. Years ago, recorders sometimes of collecting flight data and of recovering “Both ideas have advantages and dis- were so badly damaged by post-impact the information in the event of a crash. advantages that must be carefully evalu- fire or by water that some of their in- The deployable flight recorder (Fig- ated,” said Sandy Angers, a spokeswoman formation was irretrievable. In recent ure 1, p. 26) was developed in response for Boeing Commercial Airplanes. years, however, as solid-state digital to a suggestion made in the 1960s In almost all crashes, the flight media have replaced tapes, this has by the National Research Council of data recorder (FDR) and cockpit voice happened less frequently, said James Canada, which expressed concerns recorder (CVR) are recovered without Cash, the U.S. National Transportation about locating aircraft that crashed much difficulty. But on some occa- Safety Board’s (NTSB’s) chief technical in remote areas and proposed “some sions, as in the case of the Air France adviser for recorders. form of detachable and automatically
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A deployable flight recorder — which incorporates a flight data recorder, cockpit voice recorder and emergency locator transmitter — is automatically ejected when sensors detect that the aircraft is crashing.
activated ELT [emergency locator identification number and its longitude “The standards for the fixed and transmitter] system.”3 and latitude to the Cospas-Sarsat Pro- deployable components of the system Deployable recorders were devel- gramme, the international network that should be compatible to optimize the oped and have evolved into combined coordinates the detection of distress probability of recovery of recorder in- FDR/CVR units that incorporate an signals. If the aircraft crashes in water, formation from one of the two systems ELT. Such units have been installed the airfoil unit floats. under any conceivable crash scenario,” for 25 years in military aircraft and in Connolly noted that the concept of Austin said. helicopters used in North Sea energy installing deployable flight recorders in Boeing’s experience with deployable exploration. In that time, about 110 commercial aircraft had been the sub- flight recorders on military 707s identi- military aircraft equipped with deploy- ject of considerable discussion after the fied several issues requiring further able recorders have crashed, and all 110 July 16, 1996, crash of a Trans World consideration, Angers said, such as recorders have been recovered for use Airlines 747 into the Atlantic Ocean how to prevent a recorder from being by accident investigators, said Peter minutes after takeoff from Kennedy ejected into the ground if the airplane Connolly, vice president and general International Airport in New York.4 is in a vertical attitude, how to avoid manager of DRS Technologies, which Three years later, P. Robert Austin, injuring anyone on the ground when manufactures the devices. a DRS senior systems engineer, told an a recorder deploys and how to avoid The recorders are housed in an international transportation recorder accidental deployment. airfoil unit that is automatically ejected symposium that proposals to modify Even if deployable recorders when on-board sensors determine that flight recorder standards by requiring are installed in an aircraft, Boeing’s the aircraft is crashing. the installation of dual combined re- position is that the aircraft also must “That’s the smart part — it goes corder systems in commercial transport be equipped with standard, fixed away from the crash,” Connolly said. aircraft should include a provision recorders. The deployable recorder’s ELT that one of the systems be a deployable Michael Poole, chairman of the 5 © DRS Technologies © DRS immediately transmits the aircraft FDR/CVR recorder. International Society of Air Safety
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Investigators (ISASI) working group on flight “Various technical means for reinforcing recorders, agreed. flight data recovery and data transmission to Poole, a former member of the Transporta- ground centers are principally available,” said tion Safety Board of Canada, said that he would Airbus President and CEO Tom Enders. “We encourage the use of deployable recorders — but will now study different options for viable only if the deployable unit was installed in an commercial solutions, including those where airplane that also was equipped with a tradi- our experience with real-time data transmis- tional fixed recorder. sion from our own test aircraft could support Poole noted the higher cost of installation the further development of such solutions.” and maintenance of deployable recorders, in Airbus said that retrieving flight recorder comparison with standard, fixed recorders, and data after an accident is a challenge for the avia- said he could foresee events — such as some tion industry, in part because the air-to-ground types of runway overrun accidents — in which data links used by aircraft communications deployable recorders might fail to deploy away addressing and reporting systems (ACARS) to from the crash scene. transmit maintenance data “do not offer the bandwidth that would be needed for a fully real- Manufacturer Initiatives time transmission of all the data stored in the Both Airbus and Boeing have been examining [digital] FDR and CVR.” the use not only of deployable recorders but Angers said that Boeing recognizes similar also of other alternative technologies for col- difficulties. lecting flight data. “Although real-time data streaming is pos- Soon after the Air France crash, Airbus said sible, an enormous amount of data is collected it had begun a study to “reinforce flight data by flight data recorders,” she said. “Current recovery capability,” including an examination regulations require FDRs to record a minimum of the feasibility of extended data transmission.6 of 88 parameter groups. To meet this require- ment, all current production airplanes record more than 1,000 individual parameters. Also, Deployable Flight Recorder consider the fact that there are tens of thousands of commercial transport jets flying today. The current satellite system and ground architecture would be unable to support a large number of airplanes continuously streaming data.” Memory unit Memory unit Poole added that if CVR data were transmit- ted along with FDR information, bandwidth requirements would be even greater. Battery Battery Antenna Antenna In addition, in some situations, especially those involving aircraft in unusual attitudes, it could be difficult, if not impossible, to maintain Beacon transmitter a constant link between an aircraft and a satellite, assembly he said. Satellite transmissions also are affected by bad weather, and if a satellite went out of service for any reason, data would be lost, he added. Other issues include where data would be Cover includes keeper and breakaway connector stored, who would have access to it, how it would be maintained and by whom, and how to Source: DRS Technologies protect the privacy of pilots whose communica- Figure 1 tions would be included in data transmissions.
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“The concept sounds really el- egant,” Poole said. “But there are a lot of impediments.” Poole said that, although he does not believe the constant transmission of data from all large com- mercial airplanes can replace flight recorders, he would encourage the industry to imple- ment a system that would allow satellite transmission of data from “an airplane in distress.” In these situ-
ations, data transmis- © Associated Press sion might be triggered Brazil, to Paris. All 228 passengers and crew were by a pilot’s “mayday” call, or by some on-board killed. The investigation of the accident is continuing. Workers in Recife, Brazil, unload conditions that indicated the airplane was expe- 2. Aviation Safety Network. Accident Descrip- debris from an Air riencing difficulty — as was the case for the Air tion. < http://aviation-safety.net/database/record. France A330 through ACARS messages — or by php?id=20090630-0>. The Yemenia Airways A310- France A330 that some other action by the crew or air traffic control. 300 crashed off the coast of the Comoros Islands crashed into the “You don’t need all that bandwidth being used during an approach to the Mitsamiouli airport after Atlantic Ocean up with constant data transmissions, but with any a flight from Yemen. All but one of the 153 people during a flight from in the airplane were killed. The wreckage sank in airplane in distress, it’s not a bad idea to send the Rio de Janeiro to waters up to 4,000 ft deep, and at press time, news Paris on June 1. data real-time going forward and transmit the reports said that the airplane’s flight recorders had recorded data back in time,” Poole said. been located but not recovered. The airplane’s flight recorders have not Nevertheless, the NTSB’s Cash said that 3. Austin, P. Robert. “The Use of Deployable Flight the eventual alternative to the traditional black Recorders in Dual Combi Recorder Installations.” been located. box most likely would involve some method of Presentation to the International Symposium on real-time data transmission, perhaps an event- Transportation Recorders, Arlington, Virginia, U.S. triggered transmission of data to a ground station. May 3–5, 1999. “Data link is going to get more attention,” 4. The NTSB said the probable cause of the accident Cash said, noting the technological develop- was “an explosion of the center wing fuel tank result- ing from ignition of the flammable fuel/air mixture ments in recent years that have provided pas- in the tank.” The explosion probably was caused by a sengers with Internet access. “Airplanes already short circuit outside the tank that “allowed excessive are being equipped with the hardware.” voltage to enter it through electrical wiring associ- Notes ated with the fuel quantity indication system,” the report said. The FDR and CVR were recovered one 1. The second phase of the search for the A330’s flight week after the crash by U.S. Navy divers. recorders ended in late August. At press time, the 5. Austin. French Bureau d’Enquêtes et d’Analyses (BEA) was considering organizing a third search phase. The 6. Airbus. Airbus Launches Initiative to Reinforce Flight airplane crashed during a flight from Rio de Janeiro, Data Recovery Capability. July 2, 2009.
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BY MARK LACAGNINA
The 737 stalled after the autothrottles disengaged without notice. Idle Approach
either pilot was aware that As airspeed had decreased, the autopi- None of the 132 passengers or five the autothrottle system had lot had increasingly trimmed the 737 crewmembers was injured, and there disengaged with the thrust nose-up to maintain the glideslope. The was no damage. The AAIB’s investiga- levers at idle during an instru- aircraft pitched up further as thrust tion of the Sept. 23, 2007, incident led to Nment landing system (ILS) approach to from the underwing-mounted engines recommendations to ensure that flight Bournemouth (Hampshire, England) increased as the commander advanced crews are effectively alerted to the disen- © Philippe Ballerstedt/Airliners.net © Philippe Airport. The Boeing 737-300 initially the thrust levers. gagement of an autoflight system and to decelerated according to the flight The combination of the nose-up clarify procedures for recovering from crew’s expectations. However, after final trim and the application of maximum an impending stall. flap extension, the commander noticed thrust “overwhelmed” the eleva- that indicated airspeed had dropped tor, the report said, but neither pilot Night Instrument Conditions 10 kt lower than the target speed. He considered retrimming the stabilizer. The aircraft was en route on a sched- was moving the thrust levers forward Both pilots were pushing their control uled flight from Faro, Portugal. The to initiate a go-around when the stall- columns against the stops when the commander, 56, had 11,280 flight warning system activated. aircraft finally stalled and descended hours, including 420 hours in type. He The flight crew’s subsequent ac- in a steep nose-up attitude. The com- had served as a 757/767 first officer for tions to avoid the impending stall were mander was able to recover from the the operator before upgrading as a 737 inadequate, said the U.K. Air Accidents upset only after reducing thrust to commander in 2006.1 The first officer, Investigation Branch (AAIB) in its the go-around setting, which restored 30, had 3,170 flight hours, includ- final report on the serious incident. elevator authority. ing 845 hours in type. He had flown
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twin-turboprop regional aircraft before being the pitch of the aircraft to minimize glideslope employed by the operator in 2006. deviation and adjusting the stabilizer angle to “Before departing Faro, the crew discussed keep the aircraft in trim.” the weather at Bournemouth, uplifted additional The report said that the approach was stable fuel to permit two approaches and decided on a and that there was no sign the crew was “rushing full-flap (flap 40) landing,” the report said. the approach.” However, the pilots momentarily Night instrument meteorological condi- became distracted when the first officer increased tions prevailed at Bournemouth, which is on the the illumination of his map light to read a placard southern coast of England. Surface winds were showing the flap limit speeds before asking the from 220 degrees at 14 kt, visibility was 4,000 commander to select flap 40. About this time, m (2 1/2 mi) in light rain, and the ceiling was airspeed began to decrease rapidly. overcast at 400 ft. Cleared to conduct the ILS approach to Runway 26, the crew calculated a ‘I Have Control’ landing reference speed (Vref) of 129 kt and After selecting flap 40, the commander also se- decided to add six knots for the final approach. lected 135 kt — the planned Vref plus 6 kt final As the autopilot captured the glideslope at approach speed — on the MCP and completed 2,500 ft, the first officer, the pilot flying, asked the landing checklist. “The commander stowed the commander to extend the landing gear, the checklist on top of the instrument panel, and Idle Approach select flap 15 and begin the landing checklist. He when he looked down he saw an IAS [indicated also selected a lower speed on the mode control airspeed] of 125 kt,” the report said. “He called panel (MCP). The autothrottle system moved ‘speed.’ The [first officer] made a small forward The autothrottle (A/T) the thrust levers to idle to reduce airspeed to the movement with the thrust levers, and the com- annunciator flashes selected value. About 20 seconds later, the auto- mander called, ‘I have control.’” so often during throttles disengaged. “The disengagement was The aircraft was descending through 1,540 approach that it may neither commanded nor recognized by the crew, ft with a 12-degree nose-up pitch attitude and be perceived as a and the thrust levers remained at idle through- airspeed slowing below 110 kt when the com- nuisance message. out the approach,” the report said. mander moved the thrust levers full forward. Indicated air- As he did so, the stick shaker activated to warn speed initially of an impending stall (Figure 1, page 30). The decreased normally commander engaged the autopilot’s control at about one knot wheel steering mode and moved his control per second. “As the column forward, reducing the pitch attitude to speed decreased 5 degrees nose-up. “The stick shaker operation A/P A/T FMC P/RST P/RST P/RST below 150 kt, flap stopped, and the minimum airspeed was 101 kt,” 25 was selected,” the the report said. “A small, apparently unintended TEST report said. “The application of right aileron induced a right roll.”
autopilot tracked the As engine low-pressure rotor speed (N1) glideslope accurately, increased though 81 percent, the takeoff/go-
Susan Reed gradually increasing around (TOGA) mode activated. “The autopilot
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full forward. “Both Selected Plots From QAR Data pilots reported [dur- ing post-incident 200 Angle-of-attack interviews] that they Pitch attitude 180 had no pitch control Calibrated airspeed
Stick shaker Airspeed (kt) authority,” the report 160 said. 60 140 Calibrated air- speed (CAS) de- 40 120 Autothrottles disengaged creased below 107 kt 20 100 as the pitch attitude Degrees reached 36 degrees 0 80 and the left bank increased beyond 13 2247:00 2247:20 2247:40 2248:00 2248:20 2248:40 2249:00 2249:20 2249:40 degrees. The TOGA Coordinated universal time mode disengaged. A right rudder control QAR = quick access recorder input brought the Source: U.K. Air Accidents Investigation Branch wings level before Figure 1 the 737 stalled with a nose-up pitch attitude of 44 degrees. disengaged, the pitch attitude started to increase “With no change in elevator position, the again, and the stick shaker reactivated,” the pitch rate reversed from positive to negative al- report said. “A corrective roll input was made to though angle-of-attack continued to increase as bring the aircraft wings-level, and although the the aircraft started to descend,” the report said. control column was positioned fully forward, “Despite reducing pitch, the airspeed continued the nose-up pitch increased to 22 degrees.” to decrease for a further five seconds to a mini-
N1 increased to nearly 98 percent, which mum recorded CAS of 82 kt when the pitch was is above the rated go-around thrust setting of 33 degrees nose-up.” 94 percent. The pitch attitude stabilized briefly The commander regained control af-
at 22 degrees, and the stick shaker ceased as ter reducing N1 to 86 percent. Pitch attitude airspeed increased to 118 kt. However, the pitch decreased rapidly to 5 degrees nose-up, and attitude again began to increase when the crew airspeed increased to 147 kt. “The commander selected flap 15, the go-around setting. initially leveled the aircraft at 3,000 ft before “A small continuous left rudder input started climbing to 4,000 ft and self-positioning for a a left roll,” the report said. “As the flaps reached second approach,” the report said. The com- flap 15, the pitch angle was increasing through mander remained as pilot flying during the 27 degrees and the left roll was increasing second approach, which was conducted without through 7 degrees. The stick shaker reactivated, further incident with the autopilot and auto- full nose-down elevator was still being applied, throttles engaged. The 737 was landed at 2301 and the airspeed began to decay.” local time. After taxiing to a stand and shutting down ‘Full Forward Stick’ the engines, the commander told the operator’s The first officer called “high pitch,” and the base engineer that there had been an incident commander replied, “I have full forward stick.” and that, although he believed the aircraft was The first officer also held his control column serviceable, the operator likely would want to
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review the recorded flight data. “No The investigation did not resolve report said, noting that the 737 did not defects were entered in the technical why the autothrottle system disengaged have, and was not required to have, log,” the report said. “The engineer as- during the approach. Manual disen- an aural indication of autothrottle sured the commander that the opera- gagement is achieved by selecting the disengagement. tional flight data monitoring (OFDM) autothrottle switch on the glareshield As a result, AAIB recommended information was sent from the aircraft panel to “OFF” or by pressing a push- that Boeing and the U.S. Federal by an automatic mobile telephone- button on either thrust lever. The QAR Aviation Administration review the based data link.” data indicated that neither of these effectiveness of the autothrottle system actions had been taken. disengagement warnings in 300-, 400- Questions Unanswered The uncommanded disengagement and 500-series 737s and improve them The next morning, the commander of the autothrottle system could have if necessary. AAIB also called on the advised the operator’s safety depart- resulted from detection of an internal European Aviation Safety Agency to ment of the incident and completed fault by built-in test equipment. “Due to review Certification Standard 25 for an air safety report (ASR). The AAIB the delay in notification of the incident, transport category airplanes to “ensure report said that the ASR “contained the aircraft had completed more than that the disengagement of autoflight limited information” and “did not 10 flights, and therefore the fault his- controls, including autothrottle, is suit- depict the event accurately.” Not real- tory information from the incident had ably alerted to flight crews.” izing the seriousness of the incident, been overwritten,” the report said. Post- The incident investigation revealed the operator did not file a mandatory incident tests of the autothrottle system that the flight crew did not apply nose- occurrence report with the U.K. Civil revealed no faults that could cause an down trim to regain elevator author- Aviation Authority. uncommanded disengagement. ity. The flight crew training manual The OFDM analyst who read Why the pilots did not see the (FCTM) and the quick reference hand- the ASR was not a pilot and flagged flashing red light on the instrument book (QRH) for the 737-300 both say the event for further review by a panel that warns of autothrottle that the first action in response to a stall pilot representative. An OFDM pilot disengagement also was unanswered. warning or a stall is to apply full thrust. representative was on duty in the The annunciator is a small rectangular However, only the FCTM advises that safety department that day but was pushbutton lens in the upper center of the aircraft’s nose will pitch up as the too busy with other tasks to review the instrument panel. Labeled “A/T P/ engines accelerate and that the stabi- the incident aircraft’s flight data. The RST” —“autothrottle, push to reset” — lizer must be trimmed nose-down to report said that the seriousness of the annunciator also generates a flash- assist in pitch control. “The [QRH] drill the incident was not identified and ing amber caution light when airspeed does not mention the use of pitch trim,” appropriate action was not taken until is 10 kt above or 5 kt below the selected the report said. the next pilot representative came speed or decreases to “alpha floor,” or Based on this finding, AAIB called on duty again at the OFDM office 11 1.3 times the stalling speed. on Boeing to “clarify the wording of days later. “The autothrottle warning … flashes the approach-to-stall recovery [in the “[The aircraft] was not subjected amber routinely for extended periods QRH] to ensure that pilots are aware to an engineering examination to during the approach phase of flight,” the that trimming forward may be required ensure its continued airworthiness and report said. “It is likely that flight crews to enhance pitch control authority.” remained in service throughout this are subconsciously filtering out what is This article is based on AAIB Aircraft Accident period,” the report said. Data recorded perceived as a nuisance message.” Report 3/2009, “Report on the Serious Incident by the cockpit voice recorder and flight Investigators identified “a num- to Boeing 737-3Q8, Registration G-THOF, on data recorder during the incident were ber of other events” that involved Approach to Runway 26, Bournemouth Airport, overwritten, and the AAIB’s incident uncommanded and unrecognized Hampshire, on 23 September 2007.” investigation was limited to interviews autothrottle system disengagements and analysis of the flight data captured in 737s. “Consequently, the efficacy Note by the quick access recorder (QAR) for of the autothrottle warning became of 1. The operator was Thomsonfly, which the OFDM program. interest during the investigation,” the became Thomson Airways in 2008. www.flightsafety.org | AeroSafetyWorld | August 2009 | 31 n o i in s a g u rr in F e rt ta T o D X y p a e e S E- D v R A r t D y n A S u a e tr S t id Strategicissues C A e l a c a D n E m ic e I R o g c d T n I e lo n a G o ra nt M t e u e r G ss id o . A cc s p .S y A rt ir U it r po A l fo Re ua re lty Q nt u al e ffic n n C Di io io e at at ic r in erv pe d S dar O or ne Ra t Co rli te gh n Ai li ea n Rou F op E ase ur ram atab E og D Pr ident ad Acc fflo SB l O NT na atio A N FA ta am Da Progr ction fety A on Sa Aviati
By Wayne Rosenkrans ata System ent/Incident D Common ASIAS Accid ATC Nat ional Flow Data
Mode S Tra Cause nsponder Data
U.S. airline participation in ASIAS triples with the prospect of access to system-level safety intelligence.
s the Aviation Safety Information Analysis of understanding (MOU) that in effect enables and Sharing Program (ASIAS) approaches exchanges of de-identified safety data, and several its second anniversary in October, signa- have furnished subject matter experts to ASIAS tory airlines have come to represent a analytical working groups and to the develop- Asubstantial majority of commercial flights in the ment of safety enhancements under the Com- United States. The growth from seven to 22 par- mercial Aviation Safety Team (CAST). ticipating airlines — despite the tough economic One attraction for the airlines is exclusive environment — signifies a long-anticipated access to compelling ASIAS products. So far they advance in voluntary safety information sharing include a directed study of terrain awareness between the Federal Aviation Administration and warning system (TAWS) alerts, a directed (FAA) and air carriers, several representatives study of traffic-alert and collision avoidance
© Chris Photography Sorensen say. Each company has signed a memorandum system (TCAS II) resolution advisories (RAs); the
32 | flight safety foundation | AeroSafetyWorld | August 2009 n o i in s a g u rr in F e rt ta T o D X y p a e e S E- D v R A r t D y n A S u a e tr S t id C A e l a c Strategicissues a D n E m ic e I R o g c d T n I e lo n a G o ra nt M t e u e r G ss id capability to compare airline-level TAWS alerts we will have a 360-degree view — from the nar- o . A cc s p .S y A rt ir U it r po and TCAS RAs with experiences of the whole rative data — of the controller’s perspective, the A l fo Re ua re lty group — called benchmarking — and the capabil- pilot’s or copilot’s perspective and, where it is Q nt u al e ffic ity to benchmark specific airline versus aggregate relevant, the maintenance technician’s side of a n n C Di io io e experience of unstabilized approaches. particular issue,” Pardee said. The work has pro- at at ic r in erv pe d S dar “Two years ago, it was very hard to envi- duced various fusions of data, often computer- O or ne Ra t Co rli te sion that the program would get to this size and rendered as graphics that reveal safety insights, gh n Ai li ea n Rou level of participation,” says Don Gunther, vice such as the image on page 34. F op E ase ur ram atab president, safety, Continental Airlines; industry “We are developing the ability to see nation- E og D Pr ident co-chair of CAST; and co-chair of the ASIAS al-level trends either in flight operational quality ad cc o B A executive board. “Airlines finally see a process assurance [FOQA] data or aviation safety action Offl TS l N that is functioning as designed — not just in the program [ASAP] data,” Pardee said. “FOQA iona at analysis but in the development of safety en- databases have grown beyond 5 million flights, A N FA hancements that are meaningful for the whole and ASAP records exceed 50,000.” The sheer ta am Da industry. I can’t help but think that as ASIAS volume of flights by current ASIAS participants Progr ction matures, we will continue to reach out to the — about 75 percent of all 2008 flights in the fety A on Sa international community to determine areas of Aviati concern and try to reduce aviation risk around U.S. Airlines Participating in ASIAS, the world, not just within the United States.” The August 2009 airline participants (Table 1) represent a diverse AirTran Airways stem cross-section of U.S. major air carriers, regional t Data Sy Alaska Airlines ident/Inciden ASIAS Acc air carriers and cargo operators. American Airlines The central premise of ASIAS is that the American Eagle federal government and aviation stakeholders Atlantic Southeast Airlines Chautauqua Airlines — given a conducive environment and ground Compass Airlines ATC Nat rules — stand to benefit by cross-querying Continental Airlines ional Flow Data de-identified aggregate data distributed across Delta Air Lines airline network servers and associated data on ExpressJet Frontier Airlines government servers. This collaborative effort Mode S Tran Gulfstream International Airlines sponder Data includes airline pilot unions, air traffic control- JetBlue Airways © Nadia Prokhorova/iStockphoto ler unions, airframe manufacturers, avionics Northwest Airlines Republic Airways manufacturers, maintenance and repair organi- Shuttle America zations, aviation industry associations and the SkyWest Airlines Department of Defense. Southwest Airlines The focus has been on known-risk monitor- Sun Country Airlines United Airlines ing, directed studies, benchmarking, research UPS Airlines and development of analytical tools, and vulner- US Airways ability discovery, said Jay Pardee, director of ASAPs = aviation safety action programs; ASIAS = Aviation the FAA Office of Aviation Safety Analytical Safety Information Analysis and Sharing Program; FOQA = flight operational quality assurance; MOU = memorandum Services, and Michael Basehore, ASIAS pro- of understanding gram manager. The ASIAS Issue Analysis Team Note: Each airline has a FOQA program, or one or more — comprising FAA employees, contractors ASAPs, or both, and has signed an MOU with the Center for Advanced Aviation System Development at the MITRE and specialists lent by the industry — typically Corp., a federally funded research and development center, applies text-mining tools and data-mining tools to provide network access to its de-identified data and to receive analytical reports from ASIAS. to manually or automatically discover trends, Source: U.S. Federal Aviation Administration atypical events, exceedances and aberrations in the large network of databases. “By September, Table 1
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and TCAS alerts in either digital or narrative data. Being able to quickly pore through millions of records — that’s going to be key.” The program’s reputation was burnished last year by the directed study of alerts from TAWS equipment, such as the Honeywell en- hanced ground prox- Altitude (thousands of feet) imity warning system 0–5 15–20 30–35 (EGPWS). The study 5–10 20–25 35–40 10–15 25–30 40–45 (ASW, 5/08, p. 25) was initiated “based U.S. Federal Aviation Administration; MITRE Corp. Center for Advanced Aviation System Development on ASAP reports — ASIAS analysts National Airspace System — increases the FAA’s flight crewmembers expressing concern about plotted 38,100 TCAS confidence that issues discovered are likely to be the numbers of EGPWS alerts, particularly RAs from all sources comparable and relevant to all operations. Mode 2A [‘Terrain, Terrain’] alerts on approach in their network ASIAS analysts essentially add a new dimen- to mountainous-terrain airports,” Pardee said. of databases, sion to what airlines learn from their own analysis The study got the attention of airlines partly which at the time of data through the FOQA programs of routine because these data-driven processes proved contained data flight data monitoring, and the ASAPs designed up to the task of identifying issues that only from approximately for voluntary disclosure of safety issues by aviation the FAA could address. “Airline-level analy- 3 million flights, a professionals with non-punitive corrective action. ses of TAWS alerts would not have come up subset of all U.S. The Center for Advanced Aviation System with the issue of inaccurate minimum vector- flights in 2006–2008. Development at the MITRE Corp., a federally ing altitudes [MVAs]2 around our airports funded research and development center, provides … yet several MVAs were not appropriately the high-level architecture, synthesizes databases designed, and a couple of key elements weren’t and conducts airline data analysis as a trusted addressed,” Gunther said. “So the FAA is intermediary between the participating airlines reworking those MVAs to make them more ap- and the FAA. Twice a year, the FAA hosts FOQA/ propriate for the surrounding terrain.” ASAP Infoshare meetings that enable all interested FOQA and ASAP programs vary in their airlines to share and learn best practices. maturity, and all airlines should be open to con- ASIAS continues to evaluate advanced text- tinually improving them, he said. At Continental mining algorithms — such as the open source Airlines, better analytical tools and methods of Mariana software1 developed by the National deriving new data from actual FOQA parameter Aeronautics and Space Administration (NASA) data — to evaluate unstabilized approaches, for and other software used by participating airlines example — are welcome products from ASIAS. — for automatic classification of ASAP reports. “They might mean that we can do a better anal- “We are putting considerable energy and re- ysis and maybe refine some of our operational sources into advancing the science of text min- changes based on that analysis,” Gunther said. ing,” Pardee said. “Today we can detect TAWS Particularly for air carriers that have launched
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FOQA programs in recent years, “these MVAs at facilities with high numbers (ASDE-X), the local radar data from tools are going to be a tremendous of TAWS alerts.” the 39 largest air carrier airports. By the boost,” he said. The variations in arrival tracks end of 2010, ASIAS plans to downlink Nothing in the new ASIAS and — including vectoring of arriving TCAS RA data from 21 sensors located CAST processes diminishes an airline’s aircraft by FAA air traffic control at terminal areas throughout the United responsibility to implement corrective (ATC) — noted by ASIAS analysts also States to meet FAA safety management action with due diligence. “If we start have prompted the FAA to introduce system requirements related to TCAS to put out changes, change in itself is a airspace improvements based on more II Version 7.1 software implementation threat,” Gunther said. “We have to make precise navigation technology as a (ASW, 4/09, p. 34). sure there are no unintended conse- second safety enhancement. “One test quences. Every airline has to ensure airport, Oakland, showed the ben- TCAS Study Approved data integrity and, more importantly, efits of creating an area navigation In August, the ASIAS executive board look at proposed safety enhancements, [RNAV] approach, which was able to approved the report of the second and ensure it has thoroughly analyzed provide more repeatable routing and directed study, focused on TCAS and addressed all the associated issues.” more accurate approaches around the RAs. “We have looked at all the major high-terrain obstacles,” Pardee said. airports where airline concerns were ex- FAA Perspective “Our evaluations showed that airport pressed,” Pardee said. “We literally have ASIAS products in 2008 and 2009 equipage there would support RNAV.” mapped — for all the arrivals, all the have been used exclusively within the At other airports, the FAA has pur- departures and every runway end in the ASIAS executive board and CAST sued required navigation performance United States — all of the TCAS RAs under procedures and operations (RNP) approaches where supported by for a selected period of time, whether stipulations in the MOUs signed by the existing airport equipment. from ASAP data, FOQA data, radar the participating airlines and MI- In the third safety enhancement, the data archives or radar tracks. It has been TRE. Public release of more detailed FAA has urged air carriers to upgrade incredibly revealing. We also saw the ef- information might be authorized after their TAWS software — both system fects of closely spaced parallel runways CAST completes and officially issues logic and terrain database — to a and of interactions with general avia- its safety enhancements, Pardee said. minimum standard and install global tion, including helicopter operations As Gunther noted, one safety en- positioning system (GPS) receivers. and general aviation training bases.” hancement to reduce non-safety-critical Later this year, CAST plans to publish Developing mitigations for non- TAWS alerts aims to improve the FAA’s details of these safety enhancements as safety-critical TCAS RAs — especially calculation of MVAs at each location a solution set on Revision 14 of CAST’s in densely packed airspace in the North- where high numbers of TAWS alerts compact disc of resources. east — could prove far more challeng- have been documented. The FAA al- “In the interim, improved MVAs ing than TAWS alerts. “This one will be ready has searched all Federal Aviation and airspace procedures should serve hard,” Pardee said. “Short of redesigning Regulations Part 139 air carrier airports aircraft that can’t be upgraded to new the airspace, what other techniques or for the same “data fusion signature” TAWS software and GPS immediately, mitigation strategies might we have? first identified last year near Oakland, vastly eliminating the number of non- Where we had local peaks of TCAS California. safety-critical alerts,” Pardee said. “With RAs, can we do something locally? “We’ve identified other locations this solution set, we can eliminate more Is there a systemic solution? Can we that have similar issues, mountainous- than 98 percent of these alerts.” redesign the TCAS [II avionics] box? terrain approaches, that would benefit Two recent additions to ASIAS ana- Can we change things operationally or from the knowledge learned from the lysts’ data resources have been MITRE’s airspace management-wise?” initial study,” Pardee said. “We will capability to download en route radar The genesis of this study was the revisit those MVAs with some new track data on a daily basis from the concerns expressed during Infoshare tools that we developed in the process, FAA National Offload Program and the meetings. “We knew that several air- and the FAA Air Traffic Organization capability to receive data from airport lines had initiated TCAS RA studies on will check and revise as necessary the surface detection equipment, model X their own using FOQA data analysis,” www.flightsafety.org | AeroSafetyWorld | August 2009 | 35 Strategicissues
Infoshare meetings. ASIAS analysts worked with Example of ASIAS Benchmark for U.S. Airlines: airline specialists to develop and issue a set of Unstabilized Approach Criteria — Below 500 ft consensus definitions (Table 2) and common re- Approach Element Metric search methods as a starting point. “ASIAS tells Landing gear setting Down and locked the airlines what parameters are being analyzed Flap setting Any movement of flap setting greater than 2 degrees for an unstabilized approach, then enables them to calculate their own unstabilized approach Low thrust Less than 35% average N1 for five seconds or more Sink rate Greater than 1,500 fpm for three seconds or more metrics to compare against the aggregate of all participants’ values,” Basehore said. High-speed approach Greater than VREF plus 30 kt for three seconds or more ASIAS also has issued the first set of Low-speed approach Less than V for three seconds or more REF benchmarks, tailored to each participating Greater than one dot above glide slope centerline for five Above glide slope seconds or more airline, representing TAWS alerts, TCAS RAs and unstabilized approaches. The airlines have Greater than one dot below glide slope centerline for five Below glide slope seconds or more been asked to share with ASIAS, and their Greater than one dot deviation from localizer centerline counterparts, any safety lessons learned from Localizer deviation for five seconds or more considering the benchmarks and implementing ASAP = aviation safety action program; ASIAS = Aviation Safety Information Analysis and operational changes. Sharing Program; FOQA = flight operational quality assurance; N = engine compressor 1 “We also can look at whether the flight crew speed; VREF = reference landing speed Note: This subset of criteria for post-flight analysis was developed by ASIAS analysts and 22 actually went around if they did not meet the U.S. airlines. The airlines have provided access to their de-identified digital and narrative data criteria that we have mutually defined as a stabi- from routine flight operations. They, in turn, receive aggregate data from participating airline counterparts as benchmarks for airline-to-aggregate comparisons. lized approach,” Basehore said. ASIAS is taking
Source: U.S. Federal Aviation Administration a second look at the data to help airlines prepare for such assessments, he said. Criteria actually Table 2 used in airline flight operations — such as the Basehore said. “We also found that there were elements of a stabilized approach recommended some geographical areas where there were a by Flight Safety Foundation
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designing new approach areas, routes generated by their peers. Such prob- to make sure that when we come out within visual flight rules corridors lems would be more likely if the level of with a report on something as serious or IFR corridors, or similar kinds of FOQA program experience at an airline as TCAS RAs, we are definitely ac- fixes.” is below the average. If an airline does curate and the report is usable.” Southwest Airlines was among the not realize that some information in its False alerts and the frequent oc- ASIAS airline participants that received FOQA database is not valid, it cannot currence of alerts involving the same the first set of benchmarks. “We are convey that fact to others, Carter said. locations, flight phases or aircraft types still in the process of validating the data “This is something that airlines learn must be taken seriously no matter to be sure we are measuring the same over time,” he said. how good an airline’s safety record. “In thing on the same flights to get the Trend analysis by the Southwest areas where we got alerts, for example, same rates,” Carter said. Airlines flight data analysis program some Southwest crews were just saying, The company has taken more already had shown “very encouraging” ‘Well, it’s not a hazard right now, we time than expected to sort out valida- improvements in rates of stabilized are just going to continue,’” Logan said. tion and practical implications. “We approaches, reduction of non-safety- “They didn’t respond to the alert. The are learning that benchmarks are not critical GPWS alerts and correct flight areas may have been places where ATC as easy as people thought they were crew responses to GPWS alerts, Carter needs to route the airplanes around going to be,” Logan added. “I don’t said. “The thing that we have never so that when crews get an alert, it is a think people understood that if ASIAS known, and until now have had to real alert, and they react. ASIAS gives publishes a benchmark across the guess, is ‘Does the number that we have us the ability to know how often such industry, there are, first of all, different now indicate an extremely safe opera- alerts are happening, and that they are operators of different aircraft types, tion — which we think it does — or not just affecting one airline or one and different environments and qual- does it simply indicate safer than it type of airplane.” ity of data sets coming off aircraft or used to be, but there is still significant The airline industry and the FAA from ASAP. Even for a simple mea- room for improvement?’ Benchmarks may need periodic reminders to main- surement, such as whether or not there allow us to see if we want to focus on tain an unwavering system-level focus was a GPWS alert, there are difficulties previously identified issues or move on at ASIAS, however, he added. “We have because different systems have differ- to others more critical for us.” to stick to our guns to keep a methodi- ent data issues.” The ASIAS airline participants cal process of detailed analysis,” Logan Airlines know from experience to have been careful about manag- said. “Following every accident, the in- discard the data if a GPWS or TAWS ing their own expectations of the dustry seems to react a little bit, but this terrain alert was not a real alert, and program and influencing those of program is not going to solve some- ASIAS analysts who aggregate FOQA companies that have not signed up. thing at the push of a button. We need data have to take such false alerts into “We have been very deliberate in to keep the discipline and make sure account so that they are not inadvertent- indicating that this requires a lot of that political pressures don’t push us ly included in aggregate data, he said. manpower, a lot of good hard analysis into an area that system-level analysis Similarly, airline FOQA analysts because we spend most of our time was really not designed to do.” have learned to assume that the quality validating that what we are seeing is of narrative-text information in ASAP the true picture and actually rep- Notes reports varies and especially does resents a safety issue,” Logan said. 1. NASA said, “Mariana is an algorithm not accurately represent the quantity “Usually, when we get to that point, that can be applied to the text portion of of events. “We can only look at the however, the answer — or at least reports, determining the likely categories that each report falls into, and calculating aggregate, long-term trends to see if the direction to go look — is pretty a confidence for each classification.” we’ve got an increase or a decrease,” obvious. There has been a lot of angst 2. An MVA on an air traffic controller’s Logan said. among others in the industry asking display is a predetermined altitude, Another issue that participating ‘Why has this taken so long?’ It has based only on a required 1,000 ft or airlines keep in mind is the possibility taken so long because it is a new pro- 2,000 ft obstruction clearance, shown in of problems with the validity of data cess, and we are trying to do it right an airspace sector. www.flightsafety.org | AeroSafetyWorld | August 2009 | 37 HumanFactors
Second of two parts Stressed Out
BY CLARENCE E. RASH AND SHARON D. MANNING
A range of physical and emotional factors can interfere with a pilot’s cognitive process and degrade his decision-making skills.
henever pilots step onto a factor that degrades any portion of endocrinologist Hans Selye. He identi- flight deck, they should ask the cognitive process ultimately will fied what he believed was a consistent themselves if they are fully degrade decision-making skills. When pattern of mind-body reactions that he capable of making the right considered in the context of their effect called “the nonspecific response of the Wdecisions during the upcoming flight on cognitive function in the operational body to any demand.”5 He later referred and taking the actions required in case flight environment, these factors often to this pattern as the “rate of wear and of an emergency. are referred to as “stressors.”4 tear on the body.” Decision making — the final step in The definition of stress is necessari- the cognitive process1 — is a factor in ‘Wear and Tear’ ly broad: Stress is a normal, nonspecific 30 to 40 percent of all commercial and The term “stressor” is derived from physical, psychological and physiologi- general aviation aircraft accidents.2,3 “stress,” a concept first identified in cal response of the body to any demand
Any physical, physiological or emotional the early 20th century by Austrian placed upon it. © iStockphoto
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Prolonged stress may affect cognition — Lockheed L-1011 in the Florida Everglades. the process of perception, attention, memory, The three-member flight crew declared a knowledge, problem solving and decision mak- missed approach because they had no indica- ing — just as it affects emotions and behavior. tion that the nose landing gear had extended, This is a serious issue for pilots, because prob- and then became so engrossed in identifying lems with judgment, attention or concentration the problem with the position light system that present a great risk to the aircraft and the people they failed until seconds before the crash to in it. For example, under high-stress conditions, notice that their airplane was no longer in level there is a tendency to oversimplify problem flight at 2,000 ft.6 solving and decision making and to ignore In addition to affecting memory, judgment important, relevant information —to “take the and attention, stress also can decrease hand-eye easy way out.” coordination and muscle control. Many individuals under high-stress condi- It is important to control stress by identifying tions tend to forget learned procedures and and managing potential stressors. Stressors often skills and revert to old habits that may not be are categorized as either external or internal.7 appropriate. For example, they apply the tech- External stressors originate outside the indi- niques and knowledge acquired during previous vidual and may be divided further into environ- training in other aircraft types. mental and psychosocial subcategories (Table 1). Another stress-related cognitive error is per- In aviation, examples of environmental stressors ceptual tunneling — in which a pilot or an entire are adverse flight conditions, cabin temperature aircrew under high stress becomes focused on one extremes, glare or insufficient lighting, high stimulus, such as a warning signal, and neglects to noise levels and altitude effects. Psychosocial attend to other important tasks or information. stressors relate to events or conditions that are Perceptual tunneling was at the heart of the linked to individual and family social char- Dec. 29, 1972, crash of an Eastern Air Lines acteristics, positions and roles, and include workplace conflict, a Classifying Stressors feeling of a lack of support from cowork- External Internal ers, and family-related Environmental Psychosocial Physiological Cognitive stressors such as Poor flight conditions Workplace conflicts Poor diet (Nutrition) Lack of information spousal conflict, prob- Extreme heat or cold Family conflicts Tobacco Information overload lems with children, High noise level Insufficient flight time Muscular fatigue Mental fatigue and illness or death of Excessive vibration Low job satisfaction Sleep deprivation Fear a relative. Altitude effects Feeling of lack of support Alcohol Feeling of helplessness Internal stressors Crowded space Lack of control High blood pressure Boredom originate within the Air pollution Spousal conflict Prescription or over-the- High workload individual and typi- Humidity extremes Family illness or death counter medications cally are considered to Unrealistic expectations Caffeine be within the indi- Financial problems Decreased vision vidual’s control. They Loneliness Hearing loss may be divided into Devalued self-worth Diseases physiological and cog- Hunger nitive subcategories. Thirst (Dehydration) Physiological stres- sors include poor diet, Source: Clarence E. Rash and Sharon D. Manning tobacco use, mus- Table 1 cular fatigue, sleep
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deprivation, alcohol use and hearing loss. Cog- dehydration; tobacco use; exposure to heat and nitive stressors include boredom, high workload, cold; noise; and vibration. As a result of their information overload, a lack of information and exposure to these factors, pilots may not be emotions such as fear and hopelessness. at their best while flying. Consequently, in an emergency, pilots may be unable to respond Making Rules with the necessary reaction time, hand-eye co- A few of these stressors have long been recog- ordination, communication skills or decision- nized for their degrading effects on cognitive making ability. function and, therefore, on decision-making Poor nutrition and lack of exercise are stress- Regulatory bodies skills. For this reason, civil aviation regulatory ful and make it more difficult to deal with other bodies have established rules regarding some of stresses. A proper diet provides the body with have established the more obvious stressors, including alcohol the essential vitamins and minerals and helps rules regarding some consumption and drug use, and continue to maintain cognitive function. wrestle with the best methods of handling oth- of the more obvious ers, such as fatigue. Medication In the past, fatigue was addressed almost Most civil aviation regulations prohibit flying stressors, including exclusively with rules limiting the number of while taking any medication that might affect alcohol consumption hours worked in a given period. In recent years, pilot performance and flight safety. Medical however, specialists have begun to recognize conditions and medications — even those that and drug use, and other equally important contributors to fatigue present no problems on the ground — can have such as inadequate sleep time, poor sleep quality, adverse side effects that may vary with altitude. continue to wrestle disruption of circadian rhythms, irregular work Many common over-the-counter medica- hours and the effects of commuting time. tions can significantly impair cognition, judg- with the best methods Fatigue typically causes an increase in reac- ment or sensory inputs. For example, some of handling others, tion time, a decrease in accuracy and a reduc- medicines for colds and allergies contain ingre- tion in attention. Fatigued pilots may exhibit a dients that can cause drowsiness, short-term such as fatigue. tendency to overlook or misplace sequential task memory loss and blurred vision. Pilots should elements, such as leaving out items on a check- ask aeromedical specialists about the appropri- list, or become so preoccupied with a single task ateness of medications for use during flight and that they neglect more critical tasks. read all labels carefully. Fatigue also impairs memory. Although When researchers from the U.S. Federal long-term memory is reasonably well preserved Aviation Administration (FAA) Civil Aero- in the presence of fatigue, short-term memory medical Institute (now the Civil Aerospace and cognitive processing capacity are greatly Medical Institute) examined pathology reduced.8 Communication also is impaired by samples from 1,683 pilots killed in aviation fatigue; speech may become less clear, and fa- accidents from 1994 to 1998, they found over- tigued pilots may be prone to misunderstanding the-counter medications more frequently than messages. Fatigue invariably degrades decision- any other drugs.9 Over-the-counter drugs making skills, sometimes resulting in incorrect were found in 301 samples, and prescription responses to emergency situations. drugs in 240.
Hidden Stressors Smoking A host of other factors — often misunderstood The use of tobacco is widespread, although or ignored — have more subtle effects on numerous studies have demonstrated an as- cognitive performance. These factors include sociation between smoking and cardiovascular inadequate nutrition and exercise; use of disease, various cancers, pulmonary disease and 10 prescription and over-the-counter medications; other ailments. Illustration:Photo © Chris Photography; Diane Diederich/iStockphoto Sorensen
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As a stimulant, nicotine has been found to The first common indication of dehydra- improve cognitive performance on attention tion is thirst. By the time an individual senses and memory tasks,11,12 and it appears to im- thirst, however, he or she already is about 1.5 prove visual attention — both important in avia- qt (1.6 L) low on water — or about 2 percent tion.13 Other studies have shown that nicotine dehydrated — and more if he has been drink- may improve the ability to focus on auditory ing caffeinated beverages or if he consumed information and filter out background noise.14,15 alcohol the previous day. At a dehydration level However, other studies have found that: of 3 percent, he may experience sleepiness, nausea, mental impairment, and mental and • Cigarette smoking contributes to hy- physical fatigue. poxia — a problem that increases with altitude. Three cigarettes smoked at sea Psychosocial Stressors level increase the physiological altitude Psychosocial stressors are those that involve to between 5,000 and 8,000 ft. At altitude, relationships, career and finances, as well as the complex tasks requiring decision making, factors that influence these three areas, such use of mental strategies and memory re- as physical health. Psychosocial stress can be tention can be more difficult than they are either positive — such as a promotion at work, at sea level; for a pilot who is at an artifi- marriage or the birth of a child — or negative — cially high physiologic altitude because of such as divorce or separation, death of a loved smoking, the problem is compounded.16 one or illness or injury to self or family. Good • Smoking reduces visual acuity at night, psychological health enhances pilot perfor- and the effect increases with altitude. mance, and the presence of negative stressors Night vision has been reported to decrease affects performance. These stressors are distrac- by 5 percent at 3,500 ft, by 20 percent at tions and can slow reaction times in assessments 10,000 ft and by 35 percent at 13,000 ft, if of critical situations and decision making. 17 supplemental oxygen is not provided. While some stressors are well known to • Cigarette smokers are nearly two times pilots, others go unrecognized. Civil aviation more likely than nonsmokers to expe- authorities and others have developed a number rience hearing loss, especially at high of personal checklists to aid pilots in evaluating frequencies.18 themselves for stressors. For example, the FAA has developed an “I’m Safe” checklist for pilots • The nicotine in cigarettes also is associ- to evaluate their readiness for flight (Table 2).21 ated with transient dizziness and nausea, which can be aggravated by motion.19 ‘I’M SAFE’ Checklist Dehydration Illness Do I have symptoms of an illness? Dehydration is a major contributor to fatigue and an accompanying decrease in mental and Medication Have I been taking prescription or over-the-counter drugs? physical performance, and dehydrated pilots are Stress Am I under psychological pressure from the job? at a higher risk than others for decompression Alcohol Have I been drinking within eight hours? Within 24 hours? sickness, spatial disorientation, visual illusions, airsickness and loss of situation awareness.20 Fatigue Am I tired and not adequately rested? Pilots with health problems and those in Eating Have I eaten enough of the proper foods to keep adequately small aircraft without air conditioning are most nourished during the entire flight? susceptible, but the problem also can affect Source: U.S. Federal Aviation Administration; Clarence E. Rash and Sharon D. Manning pilots who operate on the low-humidity flight decks of air carriers. Table 2 www.flightsafety.org | AeroSafetyWorld | August 2009 | 41 HumanFactors
The mnemonic stands for being unimpaired by 8. Cognitive neuroscientists consider memory to be illness, medication, stress, alcohol, fatigue or divided into three types, or storage systems: Sensory eating (inadequate nourishment). memory, a copy of what is seen and heard, lasting Dozens of stressors — originating from a less than two seconds; short-term memory, lasting variety of environmental, psychosocial, physiologi- for less than a minute; and long-term memory, cal and cognitive sources — may degrade cognitive which is relatively permanent storage. processes and jeopardize decision-making skills. 9. Canfield, D.V.; Hordinsky, J.; Millett, D.P.; Endecott, Vigilance by pilots can help prevent these stressors B.; Smith, D. “Prevalence of Drugs and Alcohol in from putting flight operations at risk. Fatal Civil Aviation Accidents Between 1994 and 1998.” Aviation, Space and Environmental Medicine, Clarence E. Rash is a research physicist with 30 years expe- 72(2), 120–124. 2001. rience in military aviation research and development. He 10. Haddock, C.K.; Klesges, R.C.; Talcott, G.W.; Lando, H.; has authored over 200 papers on aviation display, human Stein, R.J. “Smoking Prevalence and Risk Factors for factors and protection topics. His latest book is Helmet- Smoking in a Population of United States Air Force Mounted Displays: Sensation, Perception and Cognition Basic Trainees.” Tobacco Control, 7, 232–235. 1998. Issues, U.S. Army Aeromedical Research Laboratory, 2009. 11. Levin, E.D.; McClernon, F.J.; Rezvani, A.H. “Nico- Sharon D. Manning is a safety and occupational health tinic Effects on Cognitive Function: Behavioral specialist at the Aviation Branch Safety Office at Fort Characterization, Pharmacological Specification, Rucker, Alabama, U.S., and has over 20 years experience and Anatomic Localization.” Psychopharmacology in aviation safety. (Berlin), 184(3–4), 523–39. 2006.
Notes 12. Levin, E.D.; Rezvani, A.H. “Nicotinic Treatment for Cognitive Dysfunction.” Current Drug Targets — 1. The cognitive process is discussed in Part 1 of this CNS and Neurological Disorders, 1(4), 423–31. 2002. series in ASW, 7/09, p. 16–21. 13. Kumari, V.; Gray, J.A.; Ffytche, D.H.; Mitterschifftha- 2. Shappell, S.A.; Wiegmann, D.A. Human Error and ler, M.T.; Das, M.; Zachariah, E.; Vythelingum, General Aviation Accidents: A Comprehensive Fine- G.N.; Williams, S.C.R.; Simmons, A.; Sharma, T. Grained Analysis Using HFACS. 2005.
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Unjustified By Wayne Rosenkrans Accident analysis yields few cost-benefit insights into ARFF Resources enhancements at U.S. airports.
roposals to increase aircraft rescue and fire fighting (ARFF) capability at most air carrier airports in the United States ideally would sail through government reviews.P Missing so far, however, is sufficient confidence that lives would be saved by invest- ing, for example, $3 billion initially and then spending $1 billion more per year than currently is budgeted. U.S. air carrier accident data from the past 11 years provide little guidance for de- ciding which international standards to adopt as new ARFF requirements, according to a report prepared for the U.S. Transportation Research Board (TRB) of the National Academies.1 “It is difficult to suggest what might happen in terms of future accidents,” said the report, de- signed to supply recent accident survivability data and analyze the predominant ARFF cost factors. “With the very small number of accidents in pas- senger air carrier operations and the multiplic- ity of causes and outcomes, it is not possible to reach a conclusion from past accidents about how improved ARFF response times and capabilities would reduce accident mortality. However, the review of accidents … suggests that enhanced ARFF standards may have made a difference in the outcome for at most one individual.” A resolution of the U.S. Congress early this year called on the Federal Aviation Administra- tion (FAA) to more closely align Federal Aviation Regulations (FARs) for ARFF with 2009 global consensus standards — especially NFPA 403, Standard for Aircraft Rescue and Fire-Fighting Services at Airports, 2009 Edition, published by the National Fire Protection Association (NFPA), © Chris Photography Sorensen www.flightsafety.org | AeroSafetyWorld | August 2009 | 43 AircraftRescue
and Annex 14, Aerodrome Design and airport is located or the airport opera- other required vehicles. This time period Operations, of the International Civil tor has adopted those standards. … has been interpreted to mean with direct Aviation Organization (ICAO). The The FAA and the NFPA have worked routes, dry pavement and good weather. research for TRB was limited to a repre- together to adopt common standards The NFPA standard requires the sentative sample of fire stations, ARFF whenever possible; however, there are first vehicle to reach any point on the vehicles and firefighters located at 476 areas where the FAA and NFPA differ operational runway in two minutes U.S. airports categorized as Class I, II significantly.” or less with good visibility and sur- or III by FARs Part 139, Certification of The major drivers of cost are the face conditions. The ICAO standard Airports, based on the seating capacity of number of firefighters, airport fire sta- requires the first ARFF vehicle to reach aircraft typically operating at the airport tions and ARFF vehicles that enable fire- any point on each operational runway and whether the air service is scheduled fighters to achieve a specified response within three minutes in optimum vis- or unscheduled. Table 1 shows the scale time for the first ARFF vehicles to arrive ibility and surface conditions. of ARFF operations for these classes. at designated points on runways and The elements of any standard “While the average airport has 26 begin applying extinguishing agents. adopted become critical in building and firefighters and three vehicles, Class IA The FARs specify three minutes for staffing airport fire stations. The key airports have 10 firefighters and two the first vehicle to arrive at the mid- finding of the 2009 research therefore vehicles, and Class IE airports have point of the farthest air carrier runway was that “the NFPA two-minute run- 115 firefighters and seven vehicles,” the or other specified point of comparable way response requirement could more report said. “NFPA standards apply to distance on the movement area available than double the number of firefighters airport operators if the state where the to air carriers, and four minutes for all and ARFF vehicles at the 476 Part 139 airports considered in this study.” Current Firefighters and ARFF Vehicles at U.S. Air Carrier Airports1 FAA, ICAO and NFPA also have standards for minimum ARFF vehicles FAA Airport Class and ARFF Index2 on duty, and at least general guidance IIIA/IIA IA IB IC ID IE Total on the basis for determining the num- Airports 99 131 111 78 33 24 476 ber of firefighters per shift. Neither the 3 Firefighter count 60 103 193 256 215 460 1,287 FAA nor ICAO specifies the number of 4 Average firefighters 8 10 15 28 43 115 26 firefighters on duty per shift, except to 5 Estimated firefighters 743 1,349 1,648 2,219 1,419 2,760 10,137 require a sufficient number of trained 3 Vehicle count 10 17 22 38 22 29 138 personnel as determined by the number 4 Average vehicles 1 2 2 3 4 7 3 of fire stations and ARFF vehicles to 5 Estimated vehicles 124 202 188 247 145 174 1,080 achieve the minimum response time FAA = U.S. Federal Aviation Administration; ARFF = aircraft rescue and fire fighting adopted. In contrast, NFPA standards Notes specify minimum shift-staffing require- 1. The table is based on 53 interviews completed during a February 2009 survey of airports regulated ments based on the class of airport under Part 139, Certification of Airports, of U.S. Federal Aviation Regulations. 2. U.S. airports serving air carriers are certificated in one of four classes based on the passenger seating (Table 2). capacity of the typical aircraft and the scheduled or unscheduled nature of these flight operations. Generally, a Class I airport can serve all sizes of passenger aircraft, and a Class III airport can provide scheduled and unscheduled services for aircraft that have 30 or fewer seats. FAA ARFF indexes Few Relevant Accidents subdivide the Class I airports by the length of the longest aircraft conducting more than five scheduled The researchers studied 23 FARs Part departures per day (A less than 90 ft [27.4 m], B 90 ft but less than 126 ft [38.4 m], C 126 ft but less than 159 ft [48.5 m], D 159 ft but less than 200 ft [61 m] and E longer than 200 ft). Class II and III airports 121 air carrier aircraft accidents and 13 meet ARFF Index A as a minimum, and Class II airports may qualify for alternative means of compliance Part 135 commuter aircraft accidents using local community fire fighting capability. Class IV airports were excluded from this study. 3. The count was provided during interviews with airport managers or other representatives. during scheduled operations in the 4. The average was the number of firefighters/vehicles counted divided by the number of airports in the period Jan. 1, 1997, through Dec. 31, study sample. 2007. Three accidents in the Part 121 5. Total firefighters and ARFF vehicles for all 476 airports were extrapolated. record and three accidents in the Part Source: Richard Golaszewski, Benedict Castellano and Robert E. David 135 record were considered relevant to Table 1 ARFF response issues.
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had to evacuate the aircraft immedi- Applying Unmet ICAO and NFPA Standards for ately and, in the second case, the ARFF ARFF Response to U.S. Airports response team would have had to enter Airport Class and ARFF Index1 the aircraft instead of first suppressing IIIA/IIA IA IB IC ID IE Total the fire,” the TRB report said. Airports 99 131 111 78 33 24 476 Faster ARFF response would Effect of ICAO three-minute runway response standard2 not have altered the outcome in the Additional fire stations 50 24 34 46 13 24 190 Charlotte accident because NTSB Additional vehicles 25 12 94 78 26 48 283 “determined that all 21 people on board Additional firefighters 124 83 589 559 198 420 1,973 the aircraft died from ‘multiple blunt 3 Effect of NFPA minimum vehicles and firefighters standard injuries due to an airplane crash,’” the Additional vehicles 0 60 60 13 0 0 132 report said. Among passengers who Additional firefighters 371 1,691 3,057 1,950 363 210 7,642 survived the crash impact forces but Effect of NFPA two-minute runway response standard4 died from smoke inhalation or ther- Additional fire stations 85 131 111 117 58 90 592 mal injuries in the Lexington accident, Additional vehicles 42 107 222 351 116 180 1,018 Additional firefighters 509 1,905 3,244 2,802 908 1,680 11,047 “the NTSB found it was not possible to Effect of NFPA three-minute movement area response standard5 determine how long these passengers Additional fire stations 28 24 43 46 25 60 225 survived, but noted that all of the pas- Additional vehicles 0 71 102 124 33 120 450 sengers were found close to their seats,” Additional firefighters 283 1,870 3,099 2,152 330 960 8,694 the report said. “The accident site was ARFF = aircraft rescue and fire fighting; ICAO = International Civil Aviation Organization; not directly accessible to ARFF vehicles NFPA = U.S. National Fire Protection Association; RRA = rapid response area from the runway end. It took the ARFF Notes vehicles approximately 11 minutes to 1. Table 1 (p. 44) explains FAA airport classes and ARFF indexes. The analysis in the study assumed that standards discussed would apply to ARFF satellite stations at Index D and Index E airports. travel about 2.0 mi [3.2 km] by public 2. The ICAO standard requires that the first ARFF vehicle reach any point on an airport runway within roads, a dirt road with a significant three minutes. incline and off-road terrain to reach 3. NFPA 403, Standard for Aircraft Rescue and Fire-Fighting Services at Airports, 2009 Edition, sets the following minimum numbers of ARFF vehicles: one or two for the equivalent of FAA ARFF Index A, the site.” The Lexington accident site was two for Index B, three for Index C and Index D, and four for Index E. The standard requires airports to outside NFPA’s proposed rapid response have the following number of ARFF firefighters per shift: four or five for the equivalent of FAA ARFF Index A, six for Index B, seven for Index C, eight for Index D, and nine or 10 for Index E. area (RRA, Figure 1, page 46). 4. NFPA 403 requires the first ARFF vehicle to reach any point on an airport runway within two minutes and any point in the RRA within 2.5 minutes. Cost Perspectives 5. NFPA 403 requires the first ARFF vehicle to reach any point on an aircraft movement area beyond the runways or the RRA within three minutes. The sample comprised 11 percent of
Source: Richard Golaszewski, Benedict Castellano and Robert E. David all Class I, II and III airports, and was selected for geographic and airport size Table 2 diversity. Data were collected about The air carrier accidents of the U.S.; and Comair Flight 1591 on Aug. direct and indirect costs of enhancing period most relevant to ARFF response 27, 2006, a Bombardier CRJ-100 that their response capability, including fac- issues were American Airlines Flight crashed during takeoff from the wrong tors such as training more firefighters. 1420 on June 1, 1999, a McDonnell runway at Lexington, Kentucky, U.S. Data then were extrapolated to all 476 Douglas MD-82 that overran Run- The report cited a finding by the airports to estimate nationwide costs. way 4R at Little Rock, Arkansas; Air National Transportation Safety Board “It was not possible to estimate Midwest Flight 5481 on Jan. 8, 2003, a (NTSB) that, although the Little Rock all costs; the most significant of these Raytheon Beech 1900D that struck a accident potentially was survivable for is the requirement to make the en- maintenance hangar and terrain during two fatally injured passengers, faster tire RRA accessible to ARFF vehicles takeoff with an incorrectly rigged eleva- ARFF response would not have made within two minutes,” the report said, tor control system at Charlotte-Douglas the difference in saving their lives. “In citing construction and station reloca- International Airport, North Carolina, one case, the passenger would have tion costs even when the airport owns www.flightsafety.org | AeroSafetyWorld | August 2009 | 45 AircraftRescue
U.S. airport managers, fire chiefs Rapid Response Area and other officials expressed logisti-
1,650 ft cal and safety concerns about adopt- (503 m) Not to scale ing RRAs at their airports. The main concerns were geographic obstacles, 500 ft (152 m) including existing major roadways, and 9
Runway 27 safety issues created by driving ARFF Runway safety area 500 ft (152 m) vehicles at least 37.5 mph (60.4 kph) NFPA rapid response area across unpaved surfaces of an RRA to meet a response standard. ARFF = aircraft rescue and fire fighting; NFPA = U.S. National Fire Protection Association; “Almost 75 percent of the [pro- RRA = rapid response area Note posed] RRAs at the airports inter- In NFPA’s proposal, any point in the RRA located on airport property must be accessible to ARFF viewed (95 of 129 runways) cannot vehicles. The first responding ARFF vehicle must be able to reach these points within 2.5 minutes during meet the two-minute accessibility conditions of optimum visibility and surface conditions, and other required ARFF vehicles would arrive at 30-second intervals. The dimensions of the RRA are the same for every runway regardless of the requirement as configured today,” the aircraft type used to determine the airport’s ARFF index. report said. “The data gathered did not Source: Richard Golaszewski, Benedict Castellano and Robert E. David permit us to make an estimate of the Figure 1 costs needed to make the on-airport RRA specified by NFPA fully accessible sufficient land beyond the runway firefighters. “The 592 additional stations to ARFF vehicles.” safety area. “Firefighter salaries repre- are estimated to cost $2 billion and the The TRB also considered the dif- sent the largest annual cost impact.” 1,018 vehicles are estimated to cost $708 ferences in standards for quantities of Twenty airports in the sample million,” the report said. “The largest in- fire-suppressing agents, which were could not meet the ICAO three-minute crease in annual operating cost is $776.3 less significant. The researchers also response standard. Projected costs na- million for additional firefighters.” estimated the costs of all enhancements tionwide just to meet this standard were The NFPA three-minute move- per enplaned passenger at each of the $36 million initially for ARFF vehicles, ment-area response standard would representative airports. equipment and training with recurrent require 225 new or relocated stations The report notes that its cost annual costs of $16.5 million. costing $823.3 million, 450 new ARFF estimates inevitably would vary from Projected initial costs for additional vehicles costing $310 million and 8,694 actual costs of proposed enhance- ARFF vehicles, stations and firefighters additional firefighters at an annual cost ments because of unknown variables, to comply with unmet ICAO or NFPA of $635.4 million, the report said. including assumptions about the future standards represent a small fraction Adopting the NFPA standard for regulatory environment. “The actual of the total cost impact over time. For ARFF vehicles alone would generate increase in ARFF costs experienced by example, “the NFPA two-minute runway a requirement for an additional 132 any airport would be based on the spe- response standard has the highest costs, vehicles, primarily at Class IA and cific changes to Part 139, because FAA with initial costs of $2.9 billion and an- IB airports. “The initial costs of the has the latitude to adopt all, some or nual operating and depreciation costs of vehicles are estimated at $67.1 million, none of the other industry standards,” $1 billion,” the report said. “The NFPA while the costs of firefighter equipment the report said. three-minute response to taxiways, and initial training are $76.4 million,” Note ramps and aprons (maneuvering area) the report said. The NFPA staffing has initial costs of $1.2 billion and an- requirement — typically adding four 1. Golaszewski, Richard; Helledy, Gregson; nual operating and maintenance costs of firefighters at Class IIA and IIIA air- Castellano, Benedict; David, Robert E. “How Proposed ARFF Standards Would $747.8 million.” ports and more than 20 at Class IB and Impact Airports.” Airport Cooperative Adoption of the NFPA two-minute IC airports — alone would generate Research Program, U.S. Transportation response standard would require the added costs of $545.7 million annually Research Board of the National most ARFF stations, ARFF vehicles and in firefighter salaries and benefits. Academies. June 17, 2009.
46 | flight safety foundation | AeroSafetyWorld | August 2009 insight © Sam Chui/Airliners.net
Fogbound BY LESLIE JOSEPHS A CAT III landing system provides hope for keeping InSight is a forum for Peru’s key airport open during the busy tourist season. expressing personal opinions about issues of importance to aviation safety and for dense fog blanketed most of Peru’s nighttime temperatures begin to dip significant- stimulating constructive coastal capital in early May. Lima’s Jorge ly in May, the days are still warm and sunny. It is discussion, pro and con, Chávez International Airport was shut this gap in daytime and nighttime temperatures about the expressed opinions. down for at least six days — four of them that generates the fog, which generally burns off Send your comments to Aconsecutively — grounding hundreds of flights, by midday. J.A. Donoghue, director of publications, Flight Safety rerouting others and stranding thousands of The density of the fog is sufficient to bring Foundation, 601 Madison passengers, many of them tourists who had trav- operations at the airport to a halt. With only a St., Suite 300, Alexandria eled long distances to see the country’s treasures. Category (CAT) II instrument landing system VA 22314-1756 USA or Although usually not as severe, fog is al- (ILS) in place, requiring a runway visual range [email protected]. ways expected as Peru’s autumn begins. While of no less than 350 m (1,200 ft) and allowing
www.flightsafety.org | AeroSafetyWorld | August 2009 | 47 insight
aircraft to descend no lower than 100 the zero-zero landing equipment. “Now more than ever, Peru needs to ft without the appropriate references The Ministry of Transportation and try to show the world that we’re able to in sight, flight cancellations and delays Telecommunications says that the CAT propel more air transit,” Maslucán said. sometimes persist for days on end. IIIC landing system should be up and Travel to Peru has indeed increased Lima’s airport has long needed a running by May 2010. in recent years. The country’s tour- CAT IIIC landing system, which would The Peruvian Airport and Com- ist destinations, particularly the no. 1 allow suitably equipped aircraft and mercial Aviation Corp., or CORPAC, tourist site, the pre-Columbian Inca specially trained flight crews to land in the government company that equips citadel of Machu Picchu, continue to zero visibility, at least partially alleviat- Peru’s airports and oversees air traf- draw hordes of visitors. Foreign visi- ing the seasonal logjam. The sluggish fic, estimates that the system will cost tors to Peru nearly doubled from 1.1 pace of the Peruvian government’s about $3.5 million, including training million in 2002 to 2.1 million last year, investment in the country’s principal for airport staff — a modest investment according to Peru’s Foreign Trade and airport has proved to be a major head- for the region’s so-called rising star. Tourism Ministry. ache for travelers and airlines alike. Peru had the highest economic growth The economic impact of the sea- No other airline has suffered more rate in Latin America in 2008 — 9.8 sonal fog that had virtually closed Jorge than Chile’s LAN Airlines, whose local percent. The country has one of the few Chávez International Airport for hours subsidiary LAN Peru controls 80 percent economies in the region that is expect- and days on end has not been quanti- of the domestic market and whose ed to grow this year. fied. Around 230 flights typically go in domestic and international flights com- Nevertheless, lagging investment in and out of Jorge Chávez every day. This prise more than half of Jorge Chávez’s infrastructure is a common complaint in year, the fog could not have rolled in air traffic. “There’s a lot of things that Peru, where the government is scram- at a worse time. Between April 30 and Peru should have but doesn’t,” said Jorge bling to draw investment in the construc- May 4, 56 flights were canceled because Vilches, general manager of LAN Peru. tion and improvement of roads and ports. of the fog. Friday, May 1, was a bank “It’s something they’re working on.” “The government has not acted op- holiday and nearly all domestic flights Indeed, the Peruvian government portunely in implementing technology were sold out. The airport was again has now committed to purchasing that is more efficient to allow planes to closed for several hours each day on land in difficult conditions,” said José May 5–7. Because flights were unable to Maslucán, a congressman who heads come in from Peru’s interior provinces, the Transportation Committee. operational delays snowballed into half- Peru is eager to position itself as a day lags in departures. prime destination for foreign capital The modest investment required and foreign visitors. Despite the slow for the CAT IIIC equipment at Jorge pace in approving the installation of a Chávez International Airport promises landing system that will enable year- to save the country from near-chaos
round operations, the government has and embarrassment when the tourist © Karel Pardo Navarro big plans for Lima’s airport. It wants to season begins next year. have a second runway operating there Leslie Josephs is a freelance journalist and for- within the next five years. mer travel agent based in Lima, Peru.
48 | flight safety foundation | AeroSafetyWorld | August 2009 DataLink
More Accidents, Fewer Fatalities
Runway excursions were prominent in 2008 commercial jet accidents worldwide.
BY RICK DARBY
unway excursions, the focus of There was little change in accident accidents resulted in 356 on-board the FSF Runway Safety Initia- numbers in any category compared with fatalities (Table 2, p. 50) versus 576 tive and the Runway Excur- the 1998–2007 period, but the number in 2007. In 2006, there were 28 ac- sion Risk Reduction Toolkit of on-board fatalities in all passenger op- cidents and 498 on-board fatalities. R(p. 12), were prominent among erations decreased from 5,105 to 4,670, a Although the summary did not offer worldwide commercial aviation 9 percent reduction. The improvement a breakdown of accidents by country accidents in 2008, according to the was more pronounced in charter opera- of registry, a letter accompanying the latest data from Boeing Commercial tions, from 57 in 1998–2007 to four in publication said, “U.S. airlines had Airplanes.1,2 Initial approach, final 1999–2008, a 93 percent reduction. On- one on-board fatality in 2008, com- approach and landing continued to board cargo flight fatalities were down pared to their average of 44 on-board be the most accident-prone phases of 12 percent, from 42 to 37. fatalities per year for the preceding flight. The 2008 accident total for all 10-year period.” Boeing’s data include accidents types of operations was 53, com- Of the 53 accidents, 16 — 30 percent involving commercial jet airplanes pared with 2007’s 38, but last year’s — were runway excursions. Three of the heavier than 60,000 lb (27,216 kg) maximum gross weight, and exclude Accidents, Worldwide Commercial Jet Fleet, by Type of Operation types manufactured in the Russian Fed- eration or the Soviet Union. Limited On-board Fatalities All Accidents Fatal Accidents (External Fatalities)* data are presented for the most recent Type of operation 1959–2008 1999–2008 1959–2008 1999–2008 1959–2008 1999–2008 year, 2008, but more extensive data are Passenger 1,287 283 471 76 27,443 (776) 4,670 (175) supplied for trailing periods beginning Scheduled 1,184 265 426 74 23,330 4,666 in 1999 and 1959. The second period Charter 103 18 45 3 4,113 4 covers roughly the entire commercial Cargo 231 79 69 13 238 (329) 37 (78) jet transport era. Maintenance test, ferry, 112 8 42 2 196 (66) 10 (0) positioning, training There were 283 accidents involving and demonstration passenger airplanes in the world com- Totals 1,630 370 582 91 27,877 (1,171) 4,717 (253) mercial jet fleet in 1999–2008 (Table 1). U.S. and Canadian 513 73 174 14 6,154 (448) 366 (83) That compared with 286 in 1998–2007 operators and 285 in 1997–2006. Fatal accidents Rest of the world 1,117 297 408 77 21,723 (723) 4,351 (170) — 76 in the most recent 10-year period Totals 1,630 370 582 91 27,877 (1,171) 4,717 (253) — represented an improvement for *External fatalities include ground fatalities and fatalities on other aircraft involved, such as helicopters or small general aviation airplanes, that are excluded. this type of operation over 1998–2007, Source: Boeing Commercial Airplanes when there were 78. But they exceeded the 75 in 1997–2006. Table 1 www.flightsafety.org | AeroSafetyWorld | August 2009 | 49 DataLink
2008 Airplane Accidents, Worldwide Jet Fleet
Fatalities On-board Major Date Airline Model Accident Location Phase of Flight Description Damage (External) Accident Jan. 2 Iran Air F-100 Tehran, Iran Takeoff Struck ground Destroyed ● Jan. 3 Atlas Blue 737-400 Deauville, France Landing Overrun Substantial Jan. 8 Aigle Azur A321 Algiers, Algeria Landing Hard landing, tail strike Substantial Jan. 9 Blue Air BAe 146 Bacau, Romania Landing Nose landing gear collapse Substantial Jan. 15 Air France A300-600 Paris Landing Veered off runway Substantial Jan. 17 British Airways 777-200 London Final approach Landed short Destroyed ● Jan. 28 Merpati Nusantara 737-300 Merauke, Indonesia Landing Struck cow on landing roll Substantial Airlines Feb. 1 Lloyd Aereo Boliviano 727-200 Near Trinidad, Bolivia Final approach After fuel exhaustion, landed in field Destroyed ● Feb. 2 Atlas Air 747-200 Lome, Togo Climb Cargo shifted, damaged aft Substantial pressure bulkhead Feb. 7 Airlink QantasLink 717-200 Darwin, Australia Landing Hard landing Substantial Feb. 25 Aeromexico 777-200 Mexico City Taxi Wing struck light pole Substantial March 1 Dragonair 747-400 Manchester, England Landing Engines struck ground Substantial March 10 Adam Air 737-400 Batam, Indonesia Landing Landing gear collapsed, Substantial veered off runway March 10 Saudi Arabian 777-200 Near Riyadh, Saudi Final approach Landing gear failure — Airlines Arabia March 14 Air Algerie 737-800 Setif, Algeria Landing Hard landing Substantial March 24 Aerosvit Airlines 737-200 St. Petersburg, Russia Taxi Struck tug Substantial March 25 Saudi Arabian 747-300 Dhaka, Bangladesh Landing Engine fire Substantial Airlines April 15 Hewa Bora Airways DC-9 Goma, Zaire Takeoff Overrun Destroyed 3 (37) ● April 22 Carpatair BAe 146 Bucharest, Romania Landing Veered off runway Substantial May 4 Airblue Limited A321 Quetta, Pakistan Landing Tail strike Substantial May 16 Asia Pacific Airlines 727-200 Pohnpei, Micronesia Landing Departed wet runway Substantial May 24 Air Ivoire A321 Cotonou, Benin Landing Hard landing Substantial May 25 Kalitta Air 747-200 Brussels Takeoff Overrun Destroyed ● May 30 TACA International A320 Tegucigalpa, Landing Overrun Destroyed 3 (2) ● Airlines Honduras June 6 Aerocondor 737-200 Near Pucallpa, Peru Climb Damaged horizontal Substantial stabilizer and elevator June 10 Sudan Airways A310 Khartoum, Sudan Landing Overrun Destroyed 33 ● June 14 FedEx DC-10 Near New York City Descent Airspeed loss, excessive-maneuver Substantial damage June 18 Comair 737-200 Durban, South Africa Landing Veered off side of runway Substantial June 19 China Eastern A319 Near Changsha, China Cruise Cargo hold fire Substantial Airlines June 28 ABX Air 767-200 San Francisco Parked Fire Substantial
July 2 Pakistan International 777-200 Near Milan, Italy Descent Severe hail damage Substantial Airlines July 6 USA Jet Airlines DC-9 Saltillo, Mexico Final approach Crashed and burned Destroyed 1 ● July 7 Kalitta Air 747-200 Near Bogota, Initial climb Engine failure Destroyed (2) ● Colombia July 14 Chanchangi Airlines 737-200 Port Harcourt, Nigeria Landing Overrun Substantial July 25 Qantas 747-400 Near Manila, Cruise Depressurization Substantial Philippines Aug. 5 Lufthansa A320 Manchester, England Taxi Struck by taxiing airplane Substantial Aug. 15 Jet2 737-300 Near Bergamo, Italy Final approach Hail storm damage Substantial Aug. 20 Spanair MD-82 Madrid Takeoff Crashed and burned Destroyed 154 ● Aug. 24 ITEK AIR AirCompany 737-200 Near Bishkek, Final approach Crashed and burned Destroyed 64 ● Kyrgyzstan
Table 2 (continued next page)
50 | flight safety foundation | AeroSafetyWorld | August 2009 DataLink
2008 Airplane Accidents, Worldwide Jet Fleet
Fatalities On-board Major Date Airline Model Accident Location Phase of Flight Description Damage (External) Accident Aug. 27 Sriwijaya Air 737-200 Jambi, Indonesia Landing Overrun Substantial Aug. 30 CONVIASA 737-200 Near Latacunga, Descent Crashed in mountainous terrain Destroyed 3 ● Ecuador Sept. 1 HeavyLift DC-8 El Fasher, Sudan Landing Hard landing Substantial International Airlines Sept. 14 Aeroflot-Nord 737-500 Near Perm, Russia Initial approach Crashed in darkness and poor Destroyed 88 ● weather Sept. 22 ICARO F-28 Quito, Ecuador Takeoff Overrun Destroyed ● Oct. 1 KD Avia 737-300 Kaliningrad, Russia Landing Gear-up landing Substantial Oct. 7 Qantas A330 Near Learmonth, Cruise Autoflight-commanded pitch-down — Australia Oct. 16 Rutaca Airlines 737-200 Caracas, Venezuela Landing Veered off Substantial Oct. 27 Cargo B Airlines 747-200 Brussels Takeoff Tail strike Substantial Nov. 10 Ryanair 737-800 Rome Final approach Multiple bird strikes Destroyed ● Nov. 27 XL Airways Germany A320 Near Perpignan, Initial approach Broke up and struck sea Destroyed 7 ● France Dec. 15 Mesa Airlines CRJ-700 Chicago Landing Left main landing gear retracted Substantial Dec. 20 Continental Airlines 737-500 Denver Takeoff Veered off Destroyed ● Dec. 26 American Airlines MD-83 Los Angeles Taxi Collision with tug Substantial 53 total accidents 356 (41) 17
Note: Airplanes manufactured in the Commonwealth of Independent States or the Soviet Union are excluded because of lack of operational data. Commercial airplanes used in military service are also excluded.
Source: Boeing Commercial Airplanes
Table 2
10 accidents with onboard fatalities, or Accidents, by Injury and Damage, Worldwide Commercial Jet Fleet 30 percent, were runway excursions. Six excursions were classified as major ac- 1959 through 2008 Total 1,630 cidents, a category that partially overlaps 582 fatal accidents 1,048 non-fatal accidents the fatal accident category.3 (36% of total) (64% of total) 471 accidents with hull loss 409 hull loss accidents Thirty-one accidents, 58 percent 24 accidents with of the total, occurred in the initial substantial damage 596 substantial damage 87 accidents without 43 accidents without substantial approach, final approach or landing substantial damage damage (but with serious injuries) phase. The accidents included six fatal 0 100 200 300 400 500 600 700 800 900 1,000 1,100 1,200 1,300 1,400 1,500 1,600 1,700 and six major accidents. Number of accidents 1999 through 2008 Total 370 In the most recent 10-year period, 91 fatal accidents 279 non-fatal accidents fatal accidents accounted for 25 percent (25% of Total) (75% of Total) 75 accidents hull loss 132 hull loss without fatalities of the total (Figure 1). The fatal- 3 fatal accidents with accident proportion of all accidents substantial damage 138 substantial damage without fatalities 13 accidents without 9 accidents without substantial was 36 percent for the 1959–2008 span. substantial damage damage (but with serious injuries)
The number of fatal accidents without 0 100 200 300 400 substantial airplane damage was 14 Number of accidents percent and 15 percent of the total of Note: Airplanes manufactured in the Commonwealth of Independent States or the Soviet Union are fatal accidents in the past 10 years and excluded because of lack of operational data. Commercial airplanes used in military service are also from 1959 onward, respectively. excluded. Source: Boeing Commercial Airplanes Among nonfatal accidents, those in- volving substantial damage represented Figure 1 www.flightsafety.org | AeroSafetyWorld | August 2009 | 51 DataLink
49 percent in 1999–2008 and 57 percent flights — had a fatal accident rate of 0.63 an improvement on 1997–2006, when in 1959–2008. Thirteen fatal accidents per million departures. on-board CFIT fatalities totaled 1,655. in the most recent 10‑year period, 14 Tabulating fatal accidents by the It appears that industry efforts to reduce percent of the fatal-accident total, were U.S. Commercial Aviation Safety Team CFIT can claim a degree of success. not accompanied by substantial damage. (CAST)/International Civil Aviation The number of on-board fatalities Nine nonfatal accidents with serious Organization (ICAO) taxonomy, “loss of in the next-largest category for 1998– injuries, but no substantial damage, control in flight” was the dominant cat- 2007, “system/component failure or represented 3 percent of the nonfatal- egory in 2008 and the trailing nine years malfunction (non-powerplant),” was accident total for this period. (Figure 2).4 Loss of control accidents also reduced from 655 to 426 in the lat- For the 10 years ending in 2008, the resulted in 1,926 on-board fatalities, est 10-year period. fatal accident rate for scheduled commer- more than double the 961 for “controlled Notes cial passenger operations worldwide was flight into terrain” (CFIT). The dif- 0.45 per million departures. All other op- ference widened since the 1998–2007 1. Boeing Commercial Airplanes. Statistical Summary of Commercial Jet Airplane erations — charter passenger and cargo, report, when the numbers were 1,984 Accidents: Worldwide Operations 1959– scheduled cargo, maintenance test, ferry, and 1,137 respectively. The CFIT data 2008. Available via the Internet at
2. An airplane accident is defined as “an oc- Fatalities by CAST/ICAO Taxonomy Accident Category, currence associated with the operation of Worldwide Commercial Jet Fleet, 1998–2007 an airplane that takes place between the time any person boards the airplane with 2,200 1,926|65 On-board fatalities [Total 5,147] the intention of flight and such time as all 2,000 External fatalities [Total 261] such persons have disembarked, in which 1,800 death or serious injury results from being 1,600 in the airplane; direct contact with the 1,400 airplane or anything attached thereto; or 1,200 direct exposure to jet blast; the airplane 961|0 sustains substantial damage; or the 1,000 Fatalities airplane is missing or completely inacces- 800 sible.” Occurrences involving test flights 600 408|23 426|4 or resulting from hostile action such as 400 156|69 146|69 193|10 sabotage or hijacking are excluded. 200 123|3 125|0 120|0 107|1 23|0 0|7 2|2 1|0 3. Boeing defines a major accident as one 0 LOC-I CFIT RE- SCF-NP MAC RE- RI-VAP OTHR LOC-G UNK WSTRW FUEL RAMP SCF-PP F-NI in which any of three conditions is met: Landing + Takeo ARC + USOS the airplane was destroyed, or there were Number of fatal accidents multiple fatalities, or there was one fatality (91 total) 22 17 15 5 2 4 4 5 1 2 2 1 1 7 3 1 and the airplane was substantially damaged. Flight Safety Foundation supports the use CAST = U.S. Commercial Aviation Safety Team; ICAO = International Civil Aviation Organization; ARC = abnormal runway contact; CFIT = controlled flight into terrain; F-NI = fire/smoke (non-impact); FUEL of this term to designate the most severe = fuel related; LOC-G = loss of control – ground; LOC-I = loss of control – in flight; MAC = midair/near accident category, in place of the tradi- midair collision; OTHR = other; RAMP = ground handling; RE = runway excursion; RI-VAP = runway tional term hull loss, which the Foundation incursion – vehicle, aircraft or person; SCF-NP = system/component failure or malfunction (non- powerplant); SCF-PP = system/component failure or malfunction (powerplant); UNK = unknown or believes is more significant for insurance undetermined; USOS = undershoot/overshoot; WSTRW = wind shear or thunderstorm. actuarial purposes than as a measure of risk. No accidents were noted in the following principal categories: aerodrome, abrupt maneuver, air traffic management/communications, navigation, surveillance, cabin safety events, evacuation, fire/smoke Substantial damage is “damage or failure (post-impact), ground collision, icing, low altitude operations, runway incursion – animal, security which adversely affects the structural related, turbulence encounter. strength, performance or flight charac- Note: Principal categories are as assigned by CAST. Airplanes manufactured in the Russian Federation or teristics of the airplane, and which would the Soviet Union are excluded because of lack of operational data. Commercial airplanes used in military normally require major repair or replace- service are also excluded. ment of the affected component.” Source: Boeing Commercial Airplanes 4. The taxonomy is described at
52 | flight safety foundation | AeroSafetyWorld | August 2009 InfoScan
More Accidents, Less Oversight U.S. on-demand operations, with a far higher accident rate than scheduled commercial carriers, receive less attention from the FAA.
REPORTS says. “In contrast, a [FARs] Part 121 operator Counting Seats Is Not What Counts with 10 aircraft, overseen by the same FAA over- sight office, received 199 inspections in 2008.” On-Demand Operators Have Less Stringent Safety Requirements and Oversight Than Large Commercial The report’s findings are summarized under Air Carriers three major headings. U.S. Department of Transportation, Office of Inspector General. AV- First, “On-demand operators have less 2009-066. July 13, 2009. 25 pp. Available via the Internet at
ON-DEMAND OPERATORS HAVE LESS STRINGENT SAFETY REQUIREMENTS AND payload under U.S. Federal Aviation Regulations “Current requirements for maintenance OVERSIGHT THAN LARGE COMMERCIAL AIR CARRIERS Federal Aviation Administration Report Number: AV-2009-066 (FARs) Part 135. On-demand includes unsched- focus on the number of passenger seats [as a cri- Date Issued: July 13, 2009 uled passenger flights, cargo operations, com- terion for safety inspection] rather than the risk mercial sightseeing, and air medical missions factors in an aircraft’s operating environment,” such as emergency medical services. the report says. For example, unlike Part 121 “The operators comprising the on-demand carriers, on-demand carriers are not required industry segment can range from a company to have a maintenance program that includes with one pilot and one aircraft to a company required inspection items and a continuous with over 600 aircraft,” the report says. “On- analysis and surveillance system. demand aircraft range from small, two-seat pis- Crew resource management (CRM) training ton engine aircraft to helicopters to turboprops is not required for on-demand operators. “CRM and jets with 10 or more seats.” for on-demand operators is one of the NTSB’s As an example of the leaner oversight given [U.S. National Transportation Safety Board’s] six to on-demand companies, the report cited an most wanted aviation safety improvements,” the operator that offered “dozens of flights daily report says. during the summer” for glacier viewing, in the The FAA has issued a notice of proposed rule course of which the aircraft landed and took off making that would expand CRM training require- on skis. “This operator flies 17 aircraft and was ments to Part 135 operators (ASW, 6/09, p. 45). inspected eight times by FAA [the U.S. Federal Other areas noted by the report under this Aviation Administration] in 2008,” the report heading are the lack of required safety training www.flightsafety.org | AEROSafetyWorld | August 2009 | 53 InfoScan
for cabin attendants if the aircraft carries 19 or they fly at lower altitudes, on-demand aircraft fewer passengers; the lack of a requirement for are more vulnerable to sudden weather changes dispatchers who follow the flight and can inform or other obstacles,” the report says. “We note the flight crew of conditions that might affect that the high-end jet aircraft flown by some safety, such as adverse weather; no required on-demand operators have the same advanced aging-related aircraft inspections in on-demand electronics as commercial aircraft. Many of the service, although according to an FAA study, 60 smaller operators, however, still have very basic percent of the on-demand passenger and cargo equipment in their cockpits.” fleet is over 20 years old; that maintenance re- On-demand operators have more fatal ac- quirements for on-demand aircraft seating nine cidents as a result of the higher risks involved, or fewer passengers are less demanding than the report says: “Between 2000 and 2008, the those for larger aircraft; and that recommenda- fatal accident rate for on-demand operators was tions to strengthen Part 135 oversight, submit- 50 times higher than that of commercial carri- ted in 2005 by the FAA Aviation Rulemaking ers. Since January 2003, on-demand operators Committee (ARC), have not resulted in any final have been involved in 95 fatal accidents, which rule making by the agency. resulted in 249 deaths. … The most fatalities for “We found that 16 NTSB recommendations the period 2003 through 2008 occurred in the resulting from on-demand operator accident in- states of Alaska and Hawaii and in the Gulf of vestigations issued since June 2002 also remain Mexico. In both Alaska and Hawaii, air tours are open,” the report says. “For example, the NTSB common, and small planes are a major source of has been concerned about the safety effects transportation for people and cargo. In addition, of fatigue on flight crews since 1989, and has there are numerous helicopter operations in the recommended that operators set working-hour Gulf of Mexico delivering crews and supplies to limits for flight crews based on fatigue research. oil rigs [platforms].” “FAA lacks a risk- … Another key NTSB concern is reducing The report lists other problems under the dangers to aircraft flying in icing conditions; heading “FAA lacks a risk-based oversight strat- based oversight this has been on the NTSB’s most wanted avia- egy for on-demand operators.”
strategy for on- tion safety improvements list since 1997. FAA’s The FAA Air Transportation Oversight response to this has been classified as ‘unaccept- System, based on data-driven risk assessment, demand operators.” able’ by the NTSB.” is the agency’s primary tool for overseeing com- The FAA has recently amended the air- mercial carriers. But, the report says, “oversight worthiness standards applicable to transport of on-demand operators is primarily based category airplanes certificated for flight in ic- on required, pre-determined inspection items ing conditions. The rule, effective Sept. 2, 2009, assigned to inspectors on a nationwide basis. requires either that ice protection systems be These items are focused on compliance with automatically activated or that a means be regulations rather than where risk dictates.” provided to tell pilots when they should be Required inspections, called “R-items,” for activated. on-demand operators are based on the National The second major heading for the report’s Program Guidelines (NPG), assigned nationally findings is “on-demand operators have more without regard to specific operator factors. “In- inherent risks in their operations and more fatal spectors must complete all R-items and may add accidents than commercial operators.” other inspections to their work plan (planned The report says that on-demand operators or P-items) for operators that they feel need have more takeoffs and landings per aircraft; additional oversight,” the report says. “However, fly to many airports lacking control towers; use some of the inspectors we spoke with did not pilots who may be unfamiliar with routes; and complete P-items because they only had time to have smaller aircraft than airlines. “Because complete the R-items on their programs.”
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Inspections are spread thinly, the report says: Handle With Care “Operations inspectors must conduct a ramp Musculoskeletal Ill-Health Risks for Airport Baggage Handlers: inspection on a minimum of 10 percent — a Report on a Stakeholder Project at East Midlands Airport minimum of 25 percent for the Alaska region — Oxley, Laraine; Riley, David; Tapley, Sarah. Health and Safety Executive (HSE), United Kingdom. RR675. 106 pp. Available via the of all on-demand operators that are certificated Internet at
Health and Safety tors must be rotated from year to year, meaning ccording to the results of an HSE question- Executive Musculoskeletal ill-health risks for an operator could receive a ramp inspection naire, 73 percent of airport baggage han- airport baggage handlers Report on a stakeholder project at East Midlands Airport from an operations inspector as seldom as once dlers reported having lower back trouble, 51 Prepared by the Health and Safety Laboratory A for the Health and Safety Executive 2009 every 10 years.” percent reported knee problems and 43 percent The operators flying the smallest aircraft get reported shoulder trouble in the previous three less attention. The report says, “We found that 78 months. “Compared to other data from physically percent of all fatal on-demand accidents between demanding tasks, baggage handling produced the 2003 and 2008 involved aircraft seating nine or highest prevalence rates for trouble experienced fewer passengers. Yet, the NPG require inspections in the last three months/year,” the report says. RR675 Research Report for aircraft seating 10 or more passengers that are The report describes work undertaken to bet- not required for aircraft seating nine or less. Single- ter understand musculoskeletal risks of baggage engine aircraft and single-pilot operations have handling and to appraise the efficacy of new ex- even fewer required inspections than operators tending belt loader (EBL) technology. Data were categorized as [having] nine or fewer seats.” collected on site visits to East Midlands Airport, A new, risk-based oversight method, the Bristol Airport and Stansted Airport, England. System Approach for Safety Oversight (SASO), Loading baggage onto aircraft is performed is under development. But the FAA plans to wait according to two basic methods: direct-to-hold, until SASO is up and running — not expected where the baggage is transferred manually from a before 2013 — rather than implement any cart to the hold door, and mechanically assisted, interim prioritization process for on-demand using some form of equipment, mainly belt load- aviation, the report says. ers. Unloading uses similar methods in reverse. The report recommends that FAA revise its In its recommendations, the report says that regulations and practices by: “EBL-type technology significantly reduces mus- culoskeletal risks through the mechanization of the • “Establishing milestones to track the imple- transfer of bags down the hold and improvements mentation of recommendations made in posture and lifting.” It adds, “For the external by the ARC and the NTSB that would on- and off-load of bags, the vertical level and lift enhance the safety and oversight of on- distance of the bags is more favorable when using a demand operators and reporting annually belt loader … compared to direct-to-hold loading on progress toward those milestones to from the ramp.” the Office of Inspector General; — Rick Darby • “Implementing an interim risk assessment oversight process for on-demand opera- WEB SITES tors until the risk-based SASO approach is Flu Planning implemented; [and,] Pandemic Influenza: Preparedness, Response, and Recovery Guide for Critical Infrastructure and Key Resources. • “Considering the inherent operational Annex: Aviation Sub-Sector Pandemic Influenza Planning risk factors in on-demand operations in Guidelines,
Identify and assess essential services, supporting Pandemic Influenza governments provide Preparedness, Response, and Recovery information and guid- functions and processes. How can your business Guide for critical infrastructure and key resources ance to individuals adapt to support a community or the nation? and businesses about Review assets and equipment critical to support
Preparedness, Response, and Recovery Guide planning and opera- essential functions. Unlike a natural disaster, a tions in anticipation health pandemic will not directly damage physi- of, and during, an cal assets and infrastructure, but could recur- outbreak. The U.S. ring maintenance requirements be met during a Department of Home- pandemic lasting three months? Annex: Aviation Sub-Sector Pandemic Guideline land Security (DHS) Review materials and supplies to sustain func- issued an 84-page tions and equipment for up to 12 weeks. How guide in 2006 saying, would critical materials such as parts and fuel “Eighty-five percent of critical infrastructure be affected? How vulnerable are contractors resources reside in the private sector, which gen- and suppliers? erally lacks individual and systemwide business Identify types and numbers of workers needed to continuity plans specifically for catastrophic sustain essential functions; policies and procedures health emergencies such as pandemic influenza.” that ensure safe workplaces and minimize disease DHS said that most existing contingency plans transmission; and actions to protect and sustain for businesses are tailored for diverse natural essential workers. “A severe pandemic influenza and manmade disasters that “do not account scenario may result in absentee rates as high as for the extreme health impact assumptions and 40 percent among all worker groups,” says the containment strategies projected for a severe DHS. pandemic influenza.” Identify interdependent relationships and actions In March 2008, DHS issued a 16-page an- to sustain mutual support. Which businesses does nex to the initial report, tailored specifically to your organization most depend upon (such as aviation. “Organizations that fail to prepare for communications, food, power generation or such a prolonged and potentially catastrophic trucking), inside or outside of aviation? event may find themselves without the staff, Identify regulatory and government policy issues equipment or supplies necessary to continue that may affect business operations. What issues providing essential transportation services might arise for your business if temporary regu- for their customers and the nation,” the annex latory waivers or new government restrictions says. are imposed? The annex is a non-prescriptive reference Identify and assess consequences resulting from to help owners, operators and planners evalu- community mitigation strategies. How will local ate and augment their emergency response community quarantines and nonessential travel plans to include pandemic health events. DHS restrictions affect your business? identified seven key areas of vulnerability The annex and the initial report con- with related questions and actions to consider. tain numerous references and links to other Noting that individual airports, airlines and resources, documents and Web sites with other aviation businesses will be affected dif- information on influenza; occupational health ferently in a pandemic environment and act or and safety; public and media relations; internal react differently, the annex says guidelines “are communications; and other aspects of response designed simply to represent a starting point planning, preparation and recovery. The initial to stimulate thinking about further actions and report may be accessed directly at
56 | flight safety foundation | AEROSafetyWorld | August 2009 OnRecord Question of Command In the absence of SOPs, authority for a land/go-around decision was uncertain.
BY MARK LACAGNINA
The following information provides an aware- precision markings that were in good condition. ness of problems in the hope that they can be It was equipped with a precision approach path avoided in the future. The information is based indicator [and] a medium-intensity approach on final reports by official investigative authori- lighting system with sequenced flashers.” ties on aircraft accidents and incidents. Weather conditions included surface winds from 270 degrees at 7 kt, scattered clouds at Jets 1,800 ft, broken clouds at 2,500 ft and an over- cast ceiling at 3,800 ft. Reported visibility was 1 Captains Did Not Designate a PIC 1/4 mi (2,000 m) in light rain and mist. How- Israel Aircraft Industries Astra SPX. Substantial damage. One minor injury. ever, the visibility decreased to 1/2 mi (800 m) in heavy rain and fog as the pilots conducted the oth pilots conducting the business flight ILS approach. from Coatesville, Pennsylvania, U.S., to The Astra was descending on the glideslope BAtlanta the evening of Sept. 14, 2007, were when the PM announced that he had the ap- qualified as captains in the Astra. They routinely proach lights in sight. The PF replied that he took turns flying the airplane from the left seat; also had the lights in sight and disengaged the however, they did not formally decide who had autopilot. “The [PF] then attempted to continue authority as pilot-in-command (PIC) for each and land visually, though they were flying in flight, said the report by the U.S. National Trans- moderate to heavy rain,” the report said. portation Safety Board (NTSB). The PF told investigators that he initially The right-seat pilot, the pilot monitoring had “good visual contact” with the approach (PM), was the aviation department’s chief pilot. lights but lost sight of the lights shortly after He held type ratings in several business jets and activating his windshield wiper. The PF said that had 10,800 flight hours, including 2,200 hours he announced this to the PM and considered in the Astra (now called the Gulfstream G100). initiating a missed approach but did not go The left-seat pilot, the pilot flying (PF), also held around because the PM replied that he still had several business jet type ratings and had 16,042 the approach lights in sight. (The Astra has two flight hours, including 1,500 hours in the Astra. windshields, each with its own wiper.) As the airplane neared Atlanta’s DeKalb- Cockpit voice recorder (CVR) data indicated Peachtree Airport, the pilots were cleared to that the PM then began to direct the PF, saying, conduct the instrument landing system (ILS) “Just follow the glideslope … little bit to the approach to Runway 20L, which is 6,001 ft right, little to the right. … There it is. You got (1,829 m) long and 100 ft (30 m) wide. “The it?” The PF replied, “Yep, I got it.” Seconds later, threshold was displaced 1,000 ft [305 m] due to however, the PM again began providing direc- obstructions,” the report said. “The runway had tions, saying “Okay, to the left, left, left, left.” The www.flightsafety.org | AEROSafetyWorld | August 2009 | 57 OnRecord
PF asked, “I’m on the runway now, right?” The The CVR then recorded the sounds of the PM replied, “Yeah. … I got it.” lavatory smoke detector and the fire warning The PM took control of the airplane, but bell. The first officer reported the fire to air traffic both pilots realized that there was only about control (ATC) and requested aircraft rescue and 1,000 ft of runway remaining. “We’re not going fire fighting (ARFF) service. Unable to use the to make it,” said the chief pilot, now the PF. The main door or service door because of the proxim- other pilot said, “I don’t know what to do.” ity of the intensifying smoke and flames, the pilots The Astra was substantially damaged when it evacuated through their cockpit window exits. overran the runway, struck the localizer antenna The NTSB report said that ARFF personnel Both pilots realized complex and traveled several hundred feet be- arrived about four minutes after the first offi- fore coming to a stop near the airport fence. The cer reported the fire. They were unable to open that there was only chief pilot sustained minor injuries; the left-seat the airplane’s doors because of fire damage and pilot and the two passengers were not hurt. initially used skin-penetrating nozzles to fight about 1,000 ft of Investigators found that the Astra’s wind- the fire. The fire was contained within about 25 runway remaining. shields had not been maintained in accordance minutes and extinguished about 18 minutes later. with the manufacturer’s recommendations to Examination of the airplane revealed preserve their water-shedding coating. The extensive thermal damage to the cockpit, the report said that this contributed to the left-seat entrance/service compartment and the two pilot’s loss of visual references after activating forward cargo containers in the main deck cargo his windshield wiper. compartment. “[The operator] reported that the The report said that during post-accident substantial damage to the airplane resulted in a interviews, when queried about who was in hull loss,” the report said. command, “the [chief pilot] stated that he was Investigators determined that the fire most confused as to who was the PIC and that he and likely began when a short circuit in adjacent the [left-seat pilot] were ‘co-captains.’ When electrical wiring penetrated the hose for one of asked about standard operating procedures the three supplemental oxygen masks stowed in (SOPs), the [chief pilot] advised that they [i.e., the entrance/service compartment and ignited the aviation department] did not have any. They a metal spring inside the hose. The oxygen and had started out with one pilot and one airplane, the polyvinyl chloride hose material, a plastic and they now had five pilots and two airplanes. that chemically decomposes when exposed to “The [chief pilot] later stated that they prob- heat, fueled the fire. ably should have gone around when the flying NTSB concluded that the probable causes of pilot could not see out the window.” the accident were the design of the supplemental oxygen system hose and “the lack of positive Short Circuit Breaches Oxygen Hose separation between electrical wiring and electri- Boeing 767-200. Substantial damage. No injuries. cally conductive oxygen system components.” he freighter had been loaded, and the pilots The investigation generated several recom- were preparing to start the engines for depar- mendations regarding aging oxygen hoses, the Tture from San Francisco International Airport proximity of oxygen system components to elec- the night of June 28, 2008, when they heard a loud trical wiring, smoke detection systems in cargo pop and hissing sounds. The first officer said, aircraft, and other issues (ASW, 7/09, p. 10). “Hey, there’s something going on in the back.” He opened the cockpit door and saw black smoke Wind Shear Strikes on Short Final and flames near the ceiling of the entrance/service Boeing 747-400. Substantial damage. No injuries. compartment, which is between the cockpit and isual meteorological conditions (VMC) the main deck cargo compartment. He told the prevailed at Manchester (England) Airport captain, “We’ve got a fire … a big fire.” Vthe night of March 1, 2008, but the surface
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winds were strong and gusty. The flight crew of on the runway. Investigators traced the tire the 747, inbound on a cargo flight from Dubai, failure to a malfunction of an anti-skid control was cleared to conduct the ILS approach to valve that had prevented the wheel brake from Runway 23R. The automatic terminal informa- releasing. tion system reported winds from 280 degrees at “There were no abnormal indications on the 25 kt, gusting to 42 kt, and moderate to severe engine instruments, and after an external check turbulence on approach to Runway 23R. by the airport fire fighting and rescue service, The aircraft did not encounter signifi- the aircraft taxied on to a stand,” the report said. cant turbulence during the approach, but the enhanced ground-proximity warning system Engine Cowling Separates, Strikes Tail (EGPWS) generated a wind shear warning Canadair CRJ200. Substantial damage. No injuries. when the aircraft was 500 ft above ground level hile holding for takeoff from Capital (AGL). The crew conducted a go-around and City Airport in Lansing, Michigan, U.S., requested and received ATC radar vectors for Wthe night of April 7, 2007, the flight another ILS approach. “The second approach crew received indications that the left thrust was described as smoother but still with a reverser was unlocked. “The captain cycled the strong wind from the northwest, resulting in reverser and had decided to return to the gate a crosswind from the right which was close to when the messages cleared,” the NTSB report the operator’s limit for landing this aircraft,” said. “With the issue apparently resolved, he said the report by the U.K. Air Accidents Inves- elected to take off.” tigation Branch (AAIB). The crew felt a slight vibration during The report said that the second approach climb-out and suspected that it was caused by was stable until the commander disengaged the thrust reverser. Later, during cruise flight at the autopilot and autothrottle system at 220 ft 16,000 ft, the crew heard a loud bang, and the AGL. The aircraft drifted above the glideslope airplane pitched up and rolled left. “The auto- and right of the localizer. The commander was pilot disengaged and the left thrust lever moved correcting when the wind shifted to a direct to idle during the event,” the report said. “The right crosswind and increased in velocity. “The first officer ran the checklist to stow the reverser. aircraft started yawing right and rolling right,” The captain decided to continue to the intended the report said. “Left control wheel and rudder destination because the thrust reverser messages The crew heard a inputs were made, slowing the rate of roll to the had cleared and the vibrations had stopped.” The right but not stopping it before touchdown.” airplane was landed at Chicago O’Hare Interna- loud bang, and the Meanwhile, airspeed had decreased 20 kt tional Airport without further incident. airplane pitched within one second and then increased 23 kt Examination of the CRJ revealed that the within the next four seconds before touchdown. translating cowling for the thrust reverser sys- up and rolled left. Rate of descent increased from 700 fpm to tem on the left engine had separated and struck 1,400 fpm but was reduced to 300 fpm before the empennage, causing the loud bang heard by touchdown. the crew. “The inboard leading edge of the left The aircraft was drifting left of the runway horizontal stabilizer was dented and crushed aft, centerline and was banked nearly 10 degrees consistent with impact damage,” the report said. right when it touched down on the right main “The left side skin of the vertical stabilizer was landing gear. The no. 4 engine nacelle struck the punctured immediately forward of the center runway and was substantially damaged. The 747 s p ar.” then rolled left, and the no. 1 and no. 2 engine The report said that inadequate maintenance nacelles scraped the runway. A tire on the left by the operator had contributed to the accident. main landing gear burst as the crew stabilized “Damage to the thrust reverser components was the rollout and brought the aircraft to a stop consistent with prior operation with the reverser www.flightsafety.org | AEROSafetyWorld | August 2009 | 59 OnRecord
out of alignment and jamming of the translating The tug driver was working a double shift structure,” the report said. “Review of the aircraft’s and had been on duty for nearly 14 hours when maintenance records revealed a history of anoma- the collision occurred. The headset opera- lies related to the left engine thrust reverser.” tor had worked a 16-hour night shift and had about 12 hours off before reporting back on SOPs Neglected in Taxiway Collision duty less than an hour before the collision. Airbus A321, Boeing 777. Substantial damage. No injuries. “The pushback crew’s working-time records for fter landing at London Heathrow Airport the preceding four weeks showed that working- on July 27, 2007, the A321 flight crew was hours rules had not always been adhered to,” Ataxiing the aircraft to the assigned stand the report said. “Both crewmen had worked when they noticed that the electronic stand in excess of the permitted 72 hours per week entry guidance system had not been activated. for at least part of the four-week period. … “The Airbus commander stopped his aircraft The possibility that fatigue played some part about 50 m [164 ft] short of the intended parking in the ground crew’s performance cannot be position,” the AAIB report said. “It was aligned discounted.” with the stand centerline but with about half the aircraft protruding into the taxiway behind.” Attention Diverted During Close Call The A321 commander attempted to es- Boeing 737-700, Airbus A330-200. No damage. No injuries. tablish radio communication with the airport ight VMC prevailed on July 2, 2008, when ground traffic controller, but the frequency was the airport traffic controller cleared the congested and his call was not acknowledged. NA330 flight crew for takeoff on Runway Meanwhile, the controller had approved the 34R at Seattle–Tacoma International Airport 777 flight crew’s request for pushback from an and shortly thereafter told the flight crew of the adjacent stand. 737, which had been landed on Runway 34C, to The 777 pushback crew consisted of a tug exit on high-speed Taxiway F, which is near the driver and a headset operator, both of whom end of the runway, and to hold short of Runway were in the tug’s cab when the collision oc- 34R. The 737 captain, the PM, acknowledged curred. The tug driver initially did not see that the instruction. the A321 was partially obstructing the taxiway “The first officer steered the airplane onto behind the 777. “The tug driver reported that he the taxiway, gave control to the captain, ran … applied the vehicle’s brakes but was too late the ‘After Landing’ checklist and shut down the The tug driver had to prevent the collision,” the report said. The right engine,” the report said. “During this time, collision damaged the 777’s left aileron and wing the captain was consulting his airport diagram been on duty for panel, and the A321’s vertical fin and fairing. while taxiing.” “The accident occurred primarily because The controller asked the 737 crew to verify nearly 14 hours. the Boeing 777 pushback was not conducted in their hold-short clearance, and the first officer accordance with the aircraft operator’s normal acknowledged. “The hold-short markings, in- operating procedures and safe practices,” the pavement lights and elevated guard lights were report said. The tug had a radio capable of visible and illuminated, but the flight crew of receiving and transmitting messages on the the Boeing 737 did not notice them,” the report ground controller’s frequency, but the radio said. had not been turned on. Although it was The airport surface detection equipment standard practice for the headset operator to generated aural and visual warnings when the walk alongside an aircraft during pushback, he 737 was taxied onto Runway 34R at a ground- remained in the tug’s cab; he was not aware of speed of about 12 kt. The A330 flew over the the collision until the 777 commander asked 737 at 425 ft AGL. There were 314 people what had happened. aboard the two airplanes.
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The report said that the probable cause of contributing factor was “the captain’s inadequate the incident was the 737 flight crew’s “diverted post-maintenance preflight check.” attention during taxi.” Skydiving Flight Encounters Icing Antonov An-28. Substantial damage. Two minor injuries. TURBOPROPS he aircraft, a turboprop version of the An-14, was being used for skydiving Elevator Trim Rigged in Reverse flights from an airstrip in Osterdalen, Convair 580. Destroyed. Three fatalities. T Norway, on July 16, 2004. After conducting he flight crew was conducting the first flight six drops, the aircraft was refueled in prepara- in the cargo airplane following maintenance tion for the next flight with 20 parachutists Tthat included rigging of the flight controls. who were to jump in two groups, said the The captain, a check airman for the com- report issued recently by the Accident Investi- pany, had more than 16,000 flight hours. The gation Board of Norway. post‑maintenance test flight from Columbus, The flight crew flew the aircraft to 15,000 ft Ohio, U.S., to Mansfield, Ohio, the afternoon and maintained a southerly course over the drop of Sept. 1, 2008, also was intended as a training zone — the airstrip — where the first 10 para- flight for two newly hired pilots: the first officer, chutists jumped. “The aircraft continued on that who had more than 19,000 flight hours, and the course for a short time before turning through observer, who had about 500 hours. 180 degrees and getting ready for the next drop VMC prevailed when the airplane departed at the same location on a northerly course,” the from Runway 05L at Rickenbacker International report said. Airport. CVR data indicated that neither the VMC prevailed, but a large cumulonimbus captain nor the first officer called for the landing cloud was nearing the drop zone from the north. gear or flaps to be retracted, or for the power “To reach the drop zone above the runway, the to be reduced from the takeoff setting. About a aircraft had to fly close to this cloud,” the report minute after takeoff, the first officer requested said. “[A videotape] showed that the parachut- and received clearance to return to the airport. ists became covered in a layer of white ice The NTSB report said that during the within 2–3 seconds of leaving the aircraft. The 2-minute 40-second flight, the captain repeated ice on the parachutists only thawed once they the instruction “pull” 27 times. At one point, had descended to lower altitudes where the air the observer said, “Come back on the trim?” temperature was above zero.” The CVR then recorded the sound of the eleva- As the commander made a turn away from tor trim wheel in motion and the captain reply- the cloud, still maintaining the low power set- ing, “There’s nothing anymore on the trim.” ting and airspeed used for the drop, the first Recorded ATC radar data indicated that the officer saw that ice had formed on the wind- airplane entered a downwind leg for Runway shield. He engaged the anti-icing system without 05L at 900 ft AGL and turned to a base leg at informing the commander of his action. The about 187 ft AGL. The Convair then descended anti-icing system uses engine bleed air, and steeply to the ground about a mile southwest of the An-28 manual warns that fuel flow to the the airport. engines will be shut off automatically if the anti- The report said that the probable causes ice system is selected when engine compressor of the accident were “the improper (reverse) speed is low. rigging of the elevator trim cables by com- Both engines flamed out when the first pany maintenance personnel and their sub- officer engaged the anti-ice system, and the sequent failure to discover the misrigging propellers were feathered automatically. The during required post-maintenance checks.” A first officer made several unsuccessful attempts www.flightsafety.org | AEROSafetyWorld | August 2009 | 61 OnRecord
to restart the engines using a checklist that did burned. “The debris path was along a magnetic not specify that if the autofeather system had en- bearing of 270 degrees,” the report said, noting gaged, the propeller-feathering levers had to be that both engines were producing power on moved fully aft and then fully forward to recycle impact. the system; the engines cannot be started unless The pilot had a private license and 1,177 the autofeather system is armed. flight hours, including 286 hours in the E90 and With no hydraulic pressure to extend the 268 hours of instrument flight time. flaps, the commander had to maintain a rela- tively high airspeed on approach to the 600-m (1,969-ft) runway. “The final approach was fur- PISTON AIRPLANES ther complicated because the [commander] had Fuel Quantity Indications Neglected to avoid the last 10 parachutists who were still in Piper Navajo. Destroyed. One serious injury. the air and who were steering toward a landing area just beside the airstrip,” the report said. he pilot had flown five passengers from The An-28 touched down about halfway Mount Isa to Century Mine, both in Queen- down the runway. The commander realized Tsland, Australia, the morning of July 27, that he would not be able to stop the aircraft on 2008, and was returning alone to Mount Isa. He the runway and lifted off to clear a 2.5-m (8.2- had conducted the takeoff and climb to cruise ft) embankment about 60 m (197 ft) beyond altitude with the inboard wing fuel tanks selected, the end of the runway. The aircraft cleared the as required by the aircraft operating manual, and embankment but struck a ditch and flipped had selected the outboard fuel tanks prior to level- over while rolling out in a marshy area. ing off at cruise altitude. However, the pilot did Noting that the crew had not used supple- not monitor fuel quantity during the flight and mental oxygen while flying the unpressurized neglected to switch from the outboard tanks to the aircraft at 15,000 ft, the report said that their inboard tanks during descent, said the report by performance might have been affected by hy- the Australian Transport Safety Bureau (ATSB). poxia. “The fact that the first officer switched on The Navajo was descending through 3,000 the anti-icing system without asking the com- ft about 33 km (18 nm) from Mount Isa when mander first indicates that crew collaboration the left engine lost power. The right engine lost was not functioning at its best,” the report said. power shortly thereafter. The pilot, who had 470 flight hours, including 30 hours in type, mistak- Instrument Takeoff Goes Awry enly believed that the engines were still produc- Beech King Air E90. Destroyed. Two fatalities. ing power and did not feather the propellers or isibility was 1/4 mi (400 m) in fog when switch fuel tanks. the King Air departed from Runway 24 at The aircraft descended rapidly at a low VMcClellan/Palomar Airport in Carlsbad, airspeed. “The aircraft impacted the ground at California, U.S., for a business flight to Tucson, an angle of approximately 30 degrees left-wing- Arizona, the morning of July 3, 2007. The air- down and 30 degrees nose-down,” the report port is on a plateau surrounded by lower terrain, said. Investigators found signs that the flaps according to the NTSB report. were retracted and the landing gear was partially The pilot apparently did not achieve a extended during the forced landing on sparsely positive rate of climb or track the extended wooded terrain. centerline of the runway. The King Air struck a ATSB concluded that the engines had lost power line about 90 ft (27 m) below field eleva- power because of fuel starvation and that power tion and 2,500 ft (762 m) beyond the end of could have been restored if the pilot had selected the runway. The airplane then struck a trans- the inboard tanks, which contained sufficient mission tower, crashed on a golf course and fuel to complete the flight. Alternatively, if the
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pilot had feathered the propellers after losing heating system as a possible source,” the AAIB power and maintained control of the aircraft, report said. he might have been able to land the Navajo on a The helicopter was about 15 nm (28 km) highway 4 km (2 nm) from the accident site, the from Coventry when the cockpit began to fill report said. with smoke and the copilot felt heat begin to build near his seat. “Given the increasing levels of Control Lost During Split-Flap Takeoff smoke in the aircraft, the crew considered mak- Beech Duke. Destroyed. One fatality. ing an emergency landing but decided it was safer flight instructor who saw the Duke in the to reach the airfield, where full fire cover had run-up area near Runway 27 at New Castle been placed on standby,” the report said. A(Delaware, U.S.) Airport the morning of The smoke and heat intensified significantly. Dec. 4, 2007, said that the run-up appeared The crew landed the helicopter near the fire normal, except that it was performed with the crew and evacuated quickly. “Eventually, the flaps extended. Before takeoff, the pilot of the smoke and heat dissipated, and the aircraft was Duke requested and received clearance from declared safe,” the report said. ATC for a right-turn departure. During initial Examination of the S-76 revealed that the climb, however, the airplane banked left at about auxiliary electric heater had overheated and had 50 ft AGL. The left bank steepened, and the melted the plastic ducting between the cabin airplane stalled at about 300 ft AGL and spun to and the cockpit. “The electronic control box the ground. for the heater was removed and subsequently The NTSB report said that when the pilot confirmed to have failed, probably disabling the attempted to retract the flaps before takeoff, overheat protection and cockpit controls for the the left flap retracted but the right flap re- system,” the report said. mained fully extended. Examination of the wreckage revealed that a component in the Brownout Causes Spatial Disorientation right-flap drive mechanism had fractured in Eurocopter AS 350B-3. Substantial damage. Three serious injuries. overload. “The pilot could have identified this ark night VMC prevailed when the pilot, condition prior to takeoff, either visually or by flight nurse and paramedic were dispatched means of the flap indicator, which received its Dto the site of a motorcycle accident near Ash input from the right flap actuator,” the report Fork, Arizona, U.S., on June 27, 2008. The pilot, said. who was using night vision goggles, conducted A study performed by the manufacturer said an approach to the landing zone over a sparsely that control of the airplane in the split-flap con- vegetated dirt field, the NTSB report said. figuration and with full power could have been “Halfway through the approach, the flight maintained, “though marginally,” at airspeeds as encountered brownout conditions, and the pilot low as 70 kt. began to perform a go-around,” the report said. “He reported being confident that he had initi- ated a climb, but shortly thereafter the helicopter HELICOPTERS impacted the ground.” Overheated Heater Fills Cabin With Smoke NTSB determined that the probable cause of the accident was “the pilot’s spatial disori- Sikorsky S-76B. Minor damage. No injuries. entation resulting in his failure to detect and he flight crew was conducting a positioning compensate for an unintentional descent during flight from Denham, England, to Coven- a go-around.” The report said, “Contributing to Ttry the night of Nov. 22, 2007, when they the accident were the pilot’s inadequate choice detected an unusual odor. “The crew began to of landing approach, reduced visibility from troubleshoot the problem and switched off the brownout conditions and the dark night.” www.flightsafety.org | AEROSafetyWorld | August 2009 | 63 OnRecord
Preliminary Reports, June 2009
Date Location Aircraft Type Aircraft Damage Injuries June 2 Halavelhi Resort, Maldives de Havilland DHC-6 destroyed 7 minor The float-equipped Twin Otter flipped over while landing on a lagoon during a charter photography flight. June 3 Santa María de Caparo, Venezuela Bell 407 destroyed 5 fatal The helicopter crashed in mountainous terrain. June 6 Sittwe, Myanmar Fokker F28-4000 substantial NA Three of the 68 occupants sustained unspecified injuries during a runway-excursion accident on landing. June 7 Port Hope Simpson, Labrador, Canada Britten-Norman Islander destroyed 1 fatal Visibility was limited by fog when the airplane struck a hill on approach during an emergency medical services (EMS) positioning flight. June 7 Anchorage, Alaska, U.S. de Havilland DHC-2 destroyed 4 minor The float-equipped Beaver struck a fence during takeoff from Lake Hood and crashed in a garden. June 9 near Santa Fe, New Mexico, U.S. Agusta A109E destroyed 2 fatal, 1 serious The police helicopter was on a search-and-rescue mission when it struck a ridge in night instrument meteorological conditions (IMC). June 10 Coomera, Queensland, Australia Bell 206B-II destroyed 2 serious, 3 none The JetRanger struck the ground and rolled over after the engine failed on final approach. June 12 Bridgeport, Connecticut, U.S. Pilatus PC-12/47 substantial 7 none IMC prevailed when the airplane touched down about halfway down the 4,677-ft (1,426-m) runway and struck a blast fence. June 13 Orange, Virginia, U.S. de Havilland DHC-6 none 1 serious The Twin Otter was making a low pass over a landing area when it shredded a skydiver’s parachute canopy. The skydiver was seriously injured. June 14 Tanah Merah, Indonesia Dornier 328 substantial 33 none After landing, the airplane veered off the right side of the 950-m (3,117-ft) gravel runway. June 15 Rapid City, South Dakota, U.S. Beech King Air B100 none 1 serious, 4 minor The patient was seriously injured when the airplane encountered clear air turbulence on descent during an EMS flight. June 18 Newark, New Jersey, U.S. Boeing 777-200 none 1 fatal, 237 none The first officer took control when the captain became incapacitated during a flight from Brussels, Belgium, and landed the 777 without further incident in Newark. June 18 Fort Worth, Texas, U.S. Learjet 45 substantial 2 none The airplane was being taxied to a run-up area following engine maintenance when it struck an embankment and a hangar. June 22 Mollet del Vallès, Spain Aerospatiale AS 350-B3 destroyed 2 fatal The helicopter crashed after dropping water on a forest fire. June 23 Barcelona, Spain Partenavia P-68 destroyed 2 fatal The airplane crashed in a garden after an engine failed during a training flight. June 24 Holbrook, Arizona, U.S. Beech Travel Air destroyed 4 fatal Witnesses said that the pilot appeared to be ill before departure and that the airplane appeared to be turning back to the airport when it banked steeply and descended to the ground. June 25 Maryland Heights, Missouri, U.S. Piper Cheyenne substantial 2 none The airplane was on a positioning flight when it overran the runway while landing at Creve Coeur Airport, traveled down a ravine and came to a stop in a cornfield. June 25 Caticlan, Philippines Xian MA60 substantial 55 none The twin-turboprop airplane had a tail wind when it was landed long, overran the runway and came to a stop in a drainage ditch. June 29 Wamena, Indonesia de Havilland DHC-6 destroyed 3 fatal The Twin Otter was on a cargo flight from Dekai when it struck a mountain at 9,600 ft during approach to Wamena. June 30 Moroni, Comoros Airbus A310-300 destroyed 152 fatal, 1 serious Strong winds prevailed when the flight crew of the A310, inbound from Yemen, conducted a go-around during a night approach to the island airport. The airplane subsequently stalled while turning base and crashed in the sea.
NA = not available
This information, gathered from various government and media sources, is subject to change as the investigations of the accidents and incidents are completed.
64 | flight safety foundation | AEROSafetyWorld | August 2009 “Me m b e r s h i p i n Fl i g h t Sa f e t y Fo u n d a t i o n i s a s o u n d i n v e s t m e n t , n o t a n e x p e n s e .” dave barger, ceo, jetblue airways
For Eurocontrol, FSF is a partner in safety. In these times of economic restraint, it makes excellent sense to combine scarce resources and share best practices.
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FSF membership has made a real difference for the Johnson Controls aviation team. Having access to the Foundation’s expert staff and its global research network has provided us with an in-depth understanding of contemporary safety issues and the ability to employ state-of-the-art safety management tools, such as C-FOQA and TEM. All of which has been vital to fostering a positive safety culture.
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For membership information, contact Ann Hill, director of membership, +1 703.739.6700, ext. 105, or [email protected]. November 2–5, 2009 2–5, November To sponsoran event atthe seminar, contact Penny Young, ext.107; e-mail:[email protected]. contact Namratha Apparao, tel:+1703.739.6700, ext.101;e-mail:[email protected]. For seminarregistration and exhibitinformation, Beijing, China Joint meeting of the FSF 62nd annual International Air Safety Seminar IASS, IASS, Seminar Safety Air International annual 62nd FSF the of meeting Joint IFA 39th International Conference, and IATA and Conference, International 39th IFA IASS Hosted by
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