AeroSafety world STARTLED AND CONFUSED Fatigue plays role in Q400 crash RAISING THE BAR Setting a new audit standard EASS REPORT Criminalization a major focus ETHNIC FRICTION AFTERMATH Expatriates vs. locals OPTIMIZING RESCUE RESOURCES
The Journal of Flight Safety Foundation March 2010 55th annual Corporate Aviation Safety Seminar CASS
May 11-13, 2010 Tucson, Arizona For seminar registration and exhibit information, contact Namratha Apparao, +1 703.739.6700, ext. 101; [email protected].
© Jimsphotos/Dreamstime To sponsor an event, contact Ann Hill, ext.105; [email protected]. President’sMessage Building on the Basics ately, several high-profile accidents and operational quality assurance (FOQA) programs, incidents have involved violations of basic and new Congressional legislation may make these sterile cockpit procedures. This troubles programs mandatory. But many of these programs me, and I know that I am not alone. The are still in their infancy, and some of the airlines LU.S. National Transportation Safety Board re- that need them the most are lagging. cently suggested that monitoring of cockpit Would a FOQA program have prevented the voice recorders (CVRs) should be considered lack of cockpit discipline that preceded the Colgan to keep crews on their toes and discourage this crash? Maybe not, but it might have prevented the sort of unprofessional behavior. I have not been accident. I am sure that crew was not the first one very supportive of that position, and I should to be surprised by an unexpected stick shaker with explain why. the deicing system activated. That sort of problem, To be honest, it is painful to think that things or a hundred other training deficiencies, would have slipped so far that we have to consider this have been flagged if FOQA had been in place. It option. I worry this will demoralize good profes- might have even told us about an accident that sionals who have already endured a thousand hasn’t happened yet. When crews know a FOQA other indignities. But at the end of the day, I get it. program is in place, they operate differently. They Lives are at stake. If this is the only answer, we will know odd excursions will be questioned. They have to seriously consider it, but I would suggest report mistakes, because they would rather admit that we don’t run off in this difficult new direction them under a reporting program than wait for the until we have the other basic safety building blocks chief pilot to ask. in place. We have to consider the opportunity cost We know FOQA programs work. They have of the CVR monitoring. There has never been a been an international requirement since 2005. time when safety resources were stretched so thin, We know they help drive voluntary reporting. We or when safety was less a priority. Everyone’s first also know that FOQA plus voluntary reporting worry is the economy, then security, then the plus line operations safety audits provide a very environment, and then maybe safety. To some complete picture of risk in the operation. Am I extent, this is due to a safety record that is pretty fundamentally against using data from the CVR? good; there is no crisis. The best we can hope for Not really, but I am against diverting resources is a zero-sum game. In this environment, safety from the things that are needed and the things that priorities have to be set carefully. are proven. Let’s get the basics in place first. So let me discuss the pieces I think have to be put in place before we take on something as diffi- cult as monitoring CVRs. This discussion is being led from the United States, and there we are still missing a vital piece of the puzzle. In response to a recent call to action from the administrator of the William R. Voss U.S. Federal Aviation Administration, many U.S. President and CEO regional airlines have committed to voluntary flight Flight Safety Foundation www.flightsafety.org | AeroSafetyWorld | March 2010 | 1 AeroSafetyWorld
March2010 Vol 5 Issue 2 11contents features
11 InSight | Mixed Culture
14 SafetyStandards | Raising the Bar
20 CausalFactors | Startled and Confused 14 26 CoverStory | Mutual Aid 32 RunwaySafety | Line Up and Wait
36 MaintenanceMatters | Gear Collapse
40 SeminarsEASS | Combining Resources
44 CargoSafety | Battery Rules 20 departments 1 President’sMessage | Building on the Basics
5 EditorialPage | Unintended Consequences
7 SafetyCalendar | Industry Events
2 | flight safety foundation | AeroSafetyWorld | March 2010 26
32 44
AeroSafetyWORLD telephone: +1 703.739.6700 8 InBrief | Safety News William R. Voss, publisher, FSF president and CEO [email protected] 47 DataLink | By the Book J.A. Donoghue, editor-in-chief, FSF director of publications 52 InfoScan | A Code Shared Accident [email protected], ext. 116 Mark Lacagnina, senior editor [email protected], ext. 114 57 OnRecord | Takeoff Rejected Well Above V1 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 Coordinating the response Susan D. Reed, production specialist to an off-airport crash. [email protected], ext. 123 © Gary Wiepert/Reuters Patricia Setze, librarian [email protected], ext. 103
We Encourage Reprints (For permissions, go to
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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JetBlue Airways considers that membership in Flight Safety Foundation is a sound investment, not an expense. Membership brings value, not just to our organization, but to our industry as a whole.
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Cessna has worked with FSF for a number of years on safety issues and we especially appreciate that it is a non-profit, non-aligned foundation. Its stellar reputation helps draw members and enlist the assistance of airlines, manufacturers, regulators and others. We supply the Aviation Department Toolkit to customers purchasing new Citations and it’s been very well received. Our association with FSF has been valuable to Cessna.
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For membership information, contact Ann Hill, director of membership, +1 703.739.6700, ext. 105, or [email protected]. Editorialpage
Unintended Consequences
ockpit failures that contributed to At first blush this seemed to be a House repassed its bill with the pilot- the crash of a Colgan Air Q400 boon to the sophisticated flight schools, experience part changed only in giving near Buffalo, New York, U.S., early the Mercedes/Cadillac-level folks like FAA some wriggle room. The last chance last year have moved the U.S. Con- the University of North Dakota, Embry- for a good outcome for this mess is in Cgress to action. Whenever legislative Riddle Aeronautical University or even the conference committee that will try bodies start writing aviation operating my smaller alma mater further down the to smooth out the differences between rules I get nervous, and this time my beach, Florida Tech, which could cash in the two bills. unease is fully justified. Generally, when on this sudden need for ATP tickets. But The growing worldwide shortage of that happens, bad comes out along with then the broader, longer-term picture trained aviation professionals, already the good, and we hope that calm heads began to take shape, and the outlook for set to accelerate as economies recover, will rule the day. This time, however, the these grade-A flight schools appeared will be severely strained if this part of the bad may prevail. fairly grim. bill is adopted in the final version. Given Members of Congress, alarmed by These schools do a lot of business that the House bill also requires non-U.S. the Colgan captain’s poor piloting skills, pumping out well-educated pilots with a repair stations working on U.S.-registered compounded by a relatively inexperi- fresh commercial pilot license and around aircraft to have direct FAA inspections enced first officer’s response, are legislat- 250 hours, financed by student loans and/ twice a year — an internationally con- ing a solution. or parents’ support, positioning these tentious rule that has no foundation The initial bill, passed last year in graduates to go directly into a Part 121 in reality — and that airlines get fresh the House of Representatives, would operation. Suddenly that track would be government approval for their alliances require both pilots in a Federal Aviation closed. Now, fledgling pilots could not af- every three years, it is clear that the House Regulations Part 121 operation to have ford to build their needed time in a classic doesn’t mind creating chaos in the avia- air transport pilot (ATP) certificates, aviation university and would have to hold tion world so long as its motivation at which means each will have at least 1,500 down costs to acquire more time on their least appears righteous. hours of flight time. When this was an- own while competing for the few com- nounced, I imagined crew-scheduling mercial jobs that would help accumulate officials across the land, especially those the needed experience, and the grade A working at regional airlines, clutching schools would become much less valuable their chests, fighting for breath as they to prospective students. imagined how hard it would be to keep The recently passed Senate bill re- their airline flying anything close to a duced that needed flight time to 800 J.A. Donoghue reasonable schedule with such an experi- hours, and obviously shelved the ATP Editor-in-Chief ence investment in each cockpit. requirement, but as this is written the AeroSafety World www.flightsafety.org | AeroSafetyWorld | March 2010 | 5 Serving Aviation Safety Interests for More Than 60 Years
Officers and Staff light Safety Foundation is an international membership organization dedicated to Chairman, Board of Governors Lynn Brubaker the continuous improvement of aviation safety. Nonprofit and independent, the President and CEO William R. Voss FFoundation was launched officially in 1947 in response to the aviation industry’s need General Counsel for a neutral clearinghouse to disseminate objective safety information, and for a credible and Secretary Kenneth P. Quinn, Esq. and knowledgeable body that would identify threats to safety, analyze the problems and Treasurer David J. Barger recommend practical solutions to them. Since its beginning, the Foundation has acted in the public interest to produce positive influence on aviation safety. Today, the Foundation provides Administrative leadership to more than 1,040 individuals and member organizations in 128 countries. Manager, Support Services Linda Crowley Horger
Financial MemberGuide Chief Financial Officer Penny Young Flight Safety Foundation Headquarters: 601 Madison St., Suite 300, Alexandria, VA, 22314-1756 USA Accountant Misty Holloway tel: +1 703.739.6700 fax: +1 703.739.6708 www.flightsafety.org Membership Director of Membership Ann Hill Seminar and Exhibit Coordinator Namratha Apparao Membership Services Coordinator Ahlam Wahdan
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Communications Member enrollment ext. 102 Director of Ahlam Wahdan, membership services coordinator [email protected] Communications Emily McGee Seminar registration ext. 101 Namratha Apparao, seminar and exhibit coordinator [email protected] Technical Seminar sponsorships/Exhibitor opportunities ext. 105 Director of Ann Hill, director of membership [email protected] Technical Programs James M. Burin Donations/Endowments ext. 112 Technical Susan M. Lausch, director of development [email protected] Programs Specialist Norma Fields Manager of FSF awards programs ext. 105 Aviation Safety Audits Darol V. Holsman Ann Hill, director of membership [email protected] Technical Specialist/ Technical product orders ext. 101 Safety Auditor Robert Feeler Namratha Apparao, seminar and exhibit coordinator [email protected] Library services/seminar proceedings ext. 103 International Patricia Setze, librarian [email protected] Regional Director Paul Fox Web site ext. 117 Karen Ehrlich, webmaster and production coordinator [email protected] International Program Director Trevor Jensen 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 1902–2004
flight safety foundation | AeroSafetyWorld | March 2010 ➤ safetycalendar
CALL FOR PAPERS ➤ 41st Annual Seminar MARCH 31–APRIL 1 ➤ Aviation Human APRIL 25–27 ➤ Asia Pacific ANSP of the International Society of Air Safety Factors and SMS Wings Seminar. U.S. Conference. Civil Air Navigation Services Investigators. Sapporo, Japan, Sept. 6–9. Bob Federal Aviation Administration Wings Pilot Organisation. Hua Hin, Thailand. Marc-Peter Matthews,
MARCH 28 ➤ IS-BAO Workshop. National APRIL 20–21 ➤ Risk Management Course. Business Aviation Association. New Orleans. ScandiAvia. Stockholm. Morten Kjellesvig, Jay Evans,
he U.S. National Transportation Safety Board (NTSB), citing an Oct. 21, 2009, incident in which the pilots of a TNorthwest Airlines Airbus A320 were out of contact with air traffic control (ATC) for more than one hour as they flew past their destination airport, is recommending new proce- dures for documenting radio communications. The NTSB said in its final report that the pilots failed to maintain radio communications because they were distracted by “a conversation unrelated to the operation of the aircraft.” After they re-established radio communications, they returned to their destination airport in Minneapolis and landed the airplane. © Ivan Cholakov/Dreamstime “The investigation found that the pilots had become engaged in a conversation dealing with the process by which on the FAA to “require air traffic controllers to use standard pilots request flight schedules, and during the conversation, phraseology, such as ‘on guard,’ to verbally identify transmis- each was using his personal laptop computer, contrary to sions over emergency frequencies as emergencies.” company policy,” the NTSB said. “The pilots were not aware of The other said the FAA should “establish and imple- the repeated attempts by air traffic controllers and the airline ment standard procedures to document and share control to contact them.” information, such as frequency changes, contact with pilots The NTSB said that the investigation identified “deficien- and the confirmation of the receipt of weather information, cies in ATC communications procedures” — ATC procedures at air traffic control facilities that do not currently have such for documenting communication with flight crews and for a procedure.” The NTSB said these changes “should provide identifying emergency communications. visual communication of at least the control information that As a result, the NTSB issued two safety recommendations would be communicated by the marking and posting of paper to the U.S. Federal Aviation Administration (FAA). One called flight-progress strips.”
Surface Vehicle Safety SMS for FAA
he Australian Civil he U.S. Federal Aviation Ad- Aviation Safety Au- ministration (FAA) Air Traffic Tthority (CASA) has TOrganization has adopted a safety proposed new regula- management system (SMS) that the tions to govern vehicles agency says provides for managing that operate on aircraft risks associated with changes in the maneuvering areas at national airspace system. several major airports. FAA Administrator Randy Babbitt There are no current said the new SMS enables the agency to regulations governing manage “the challenges of introducing the entry, movement and new technology into the national airspace
surveillance of vehicles in © Graça Victoria/Dreamstime system. Practically speaking, SMS is as these areas. The proposed important as the new technology itself.” regulations would give CASA the authority to designate airports that would be As an example, he said that SMS required to have advanced surface movement guidance and control systems. would provide a framework for The regulations would require that vehicles operating at those airports be conducting a risk analysis as NextGen equipped with radios and electronic devices compatible with surface surveil- technology is introduced into the lance. They also would prohibit unequipped vehicles from entering aircraft system. Such an analysis was conducted maneuvering areas “without a close escort, and require vehicle drivers to moni- on automatic dependent surveillance– tor and communicate with air traffic control,” CASA said. broadcast (ADS–B) equipment before it The regulations would affect operations at airports in Sydney, Brisbane, Mel- began operating in the Gulf of Mexico, bourne and Perth. he said (ASW, 2/10, p. 14).
8 | flight safety foundation | AeroSafetyWorld | March 2010 inBrief
Million-Dollar Penalty Proposal
he U.S. Federal Aviation Administration (FAA) has proposed penalties totaling more than $1 million against TAmerican Airlines for four maintenance violations (“Over- sight Overlooked,” p. 54). The largest of the four proposed penalties is $625,000 and stems from an April 2008 case in which the FAA says that American Airlines maintenance personnel diagnosed problems in a McDonnell Douglas MD-82’s central air data computer (CADC) but, instead of replacing the unit, they improperly deferred action under the minimum equipment list (MEL). Wikimedia However, the MEL “does not allow deferral of an inopera- tive CADC,” the FAA said. “The airline subsequently flew the meteorological conditions without flight into known or forecast plane on 10 passenger flights before the computer was replaced. icing conditions or visible moisture. During this time, flight crews were led to believe that both A $75,000 penalty was proposed for what the FAA described computers were working properly.” as the airline’s failure to correctly comply with an airworthiness The FAA also proposed a $300,000 civil penalty for a Feb. 2, directive for the inspection of Boeing 757 rudder components. 2009, case in which the airline’s maintenance personnel deferred The FAA proposed an $87,500 fine for a case involving what maintenance on an MD-82 under the MEL because a “pitot/stall the agency said was the return to service of an MD-82 although heater light OFF light on the aircraft’s annunciator panel was inop- records indicated that several steps of scheduled B-check main- erative.” The following day, technicians determined that the inop- tenance were not checked as completed and replacement of a erative part was not the light but the captain’s pitot probe heater. landing gear door was not noted in aircraft logbooks. The MEL provides for deferred maintenance on pitot In each instance, the airline had 30 days to respond to the probe heaters only if flights are restricted to daytime visual FAA’s proposal.
Transfer of Oversight
ransport Canada plans to resume its complying with maintenance require- seriously injured (ASW 12/09–1/10, p. control of the certification and over- ments, and Transport Canada will 18 and p. 22). Tsight of business aircraft — func- continue to assess their compliance. In the report, the TSB said that the tions that currently are performed by the On April 1, 2010, and through- accident “needs to be considered in the Canadian Business Aviation Association out the year preceding the transfer of context of a relatively new and evolving (CBAA). certification and oversight responsi- safety regulatory environment” featur- The change, which takes effect April bilities, Transport Canada said, it will ing safety management systems (SMS). 1, 2011, will include the issuance of “begin enhancing surveillance of the The principles of SMS, which were be- operating certificates and the process- association’s certification and oversight hind the CBAA’s development of safety ing of changes in existing certificates. functions” and “conduct a complete standards for business aviation, gave Operators will remain responsible for review of its surveillance and regula- the operators “significant responsibil- tory structure for business aviation ity for safety management” but also left operations.” them “twice removed from Transport Transport Canada’s announcement Canada’s scrutiny,” the TSB said, noting follows criticism of its arrangement that SMS is a “useful and practical tool with CBAA by the Transportation … [that] requires the development of Safety Board of Canada (TSB) and an appropriate balance between the others. The TSB’s comments were responsibilities of the regulator, the included in its final report on the Nov. operator and (in this instance) the 11, 2007, crash of a Bombardier Global delegated agency.” In this case, the TSB 5000 at Fox Harbour Aerodrome in said, the appropriate balance “has not Nova Scotia in which two people were been established.” Transportation Safety Board of Canada
www.flightsafety.org | AeroSafetyWorld | March 2010 | 9 inBrief
Canadian Watchlist
he risk of collisions on runways is “Given the millions of takeoffs and among the most critical safety issues landings each year, incursions are rare,” the Tin Canada’s transportation system, the TSB said. “However, the consequences can be Transportation Safety Board (TSB) said in catastrophic. The Board is concerned that releasing its “Watchlist” of nine items that incursions and the risk of collisions will re- © Mtoumbev/Dreamstime present the greatest risks to Canadians. main until better defenses are put in place.” “There is no higher priority” than The TSB reiterated its past recommenda- Canada that resulted in 128 fatalities. the listed items, said TSB Chair Wendy tions calling for improved procedures and the Past TSB recommendations have in- Tadros. “It’s time for industry and regu- use of enhanced collision warning systems. cluded a call for ground proximity warn- lators to step up and tackle these nine Two other aviation issues were ing systems in smaller aircraft. “Without critical issues.” included on the Watchlist: this technology, passengers and crews Tadros said the list was developed after • Collisions with land and water continue to be at risk,” the TSB said. TSB analysts identified “troubling patterns” that occur while aircraft are under The TSB said that, to reduce the in their accident investigation work. crew control — a risk typically risk of landing accidents and runway “Many times, we arrive on the scene of classified as controlled flight into overruns, pilots need timely information an accident and see the same safety issues — terrain (CFIT); and, about runway surface conditions, and issues that we have raised before,” she said. airports must extend safety areas at the The TSB said that, from 1999 to • The risk of collisions on runways. end of runways “or install other engi- 2007, some 3,831 runway incursions The TSB said that, between 2000 and neered systems and structures to safely were reported at Canadian airports. 2009, there were 129 CFIT accidents in stop planes that overrun.”
Low Approaches In the News …
urocontrol says that one European “Consequently, air traffic control- he SESAR Joint Undertaking — nation — which it does not name lers are not aware of such limita- the technological arm of the Single E— has failed to establish operat- tions (i.e., that for each instrument TEuropean Sky project — says it has ing minimums for its airports, causing approach at a particular aerodrome, spawned nearly 300 separate programs pilots of some aircraft to conduct there is a minimum which no opera- intended to modernize air traffic approaches and land when the runway tor should go below),” Eurocontrol management throughout Europe. A task visual range (RVR) is below the ap- said. “Furthermore, the controllers force is scheduled to report later this year plicable minimum. do not have in place a procedure(s) on how to implement the programs. …
© Eurocontrol to act as a safety check when a com- The Civil Aviation Safety Authority and mander decided to commence an the Australian Transport Safety Bureau approach to land when the re- have signed an agreement clarifying ported RVR is less than the specified their complementary roles in enhanc- minimum.” ing aviation safety in Australia and European regulations say that pledging to make the most effective use minimums adopted by individual of accident investigation findings. … The operators must not be lower than those International Civil Aviation Organization specified in the European Aviation (ICAO) has offered to help coordinate Safety Agency’s EU OPS 1. reconstruction of the civil aviation in- Eurocontrol asked air navigation frastructure in Haiti, which was heavily service providers and aircraft operators damaged in the January earthquake. to comment on what actions control- ICAO Secretary General Raymond lers should take if a captain indicates Benjamin said the goal is to reconstruct a that he or she plans to begin an ap- system that conforms to ICAO standards proach when the RVR is below the and avoid duplication of efforts by donor lowest minimum for that airport. nations and organizations.
Compiled and edited by Linda Werfelman.
10 | flight safety foundation | AeroSafetyWorld | March 2010 insight
By Joshua Amara
Strained relationships between Nigerian and expatriate maintenance technicians interfere with common safety objectives.
here is no valid reason why avia- indeed, in many parts of sub-Saharan benefit European colonial masters, the tion maintenance technicians of Africa — a peculiar condition persists. old system’s legacy still has a negative different races, tribes and cultures This condition originated partly influence on aviation safety culture cannot learn to work together in from the historical inequalities of the from the perspective of human factors. aT friendly environment, enjoying equal labor system passed down from the Nowadays, the norm for aviation career opportunities within the mainte- time of British colonial rule, which professionals in the most developed nance, repair and overhaul facilities in lasted from the 19th century until Nige- countries is to work in harmony with
© Ken Iwelumo–Global Images/Airliners.net Aviation Nigeria. However, in my country — and, rian independence in 1960. Created to colleagues from different parts of the
www.flightsafety.org | AeroSafetyWorld | March 2010 | 11 insight
world. The working conditions are ex- largely on a person’s origin, not just a checks occur because of the “direct” pected to be the same for all to ensure person’s competence. It is also sad to or “literal” translations between the optimal performance and productivity note that the present compensation of maintenance technician’s first language of every employee. the locals is much lower than their for- and English. This is quite visible when The contrast in Nigeria is that eign counterparts, even if an expatriate going through maintenance entries in maintenance technicians tend to be has less qualification and experience. technical logbooks. arbitrarily categorized and subcatego- This is a great setback — one that, I be- Language “barriers” become an rized. This troubling division separates lieve, ultimately detracts from the safety excuse for staff to separate by ethnicity/ the workforce into expatriate personnel of both the maintenance performed language when possible during work and indigenous Nigerian citizens, who and flight operations. sessions and breaks. Employees and are differentiated as indigenes or locals. The emphasis on qualifying expatri- supervisors also form teams limited to Moreover, the indigenes in these facili- ates to work in Nigeria diverts limited people from their category. I have even ties create divisions among themselves resources from training Nigerian staff. come across a conflict where expatri- on the basis of their majority or minority Company executives who set the pri- ates chose to use different languages to ethnic/tribal affiliation. The expatri- orities must realize that some Nigerian write their job-sheet handover notes, ates also tend to subdivide themselves maintenance technicians have worked with the team on one shift writing into staff of Western European origin for years without opportunities for addi- something in the technical logbook and — including those from North America tional qualification or refresher training. the next team unable to read what was — and staff from places such as Eastern At my airline, we have tried as much recorded about task status. Europe, Russia, Asia and Latin America. as possible to ensure that there is no Maintenance technicians often Today’s system impedes both the difference in treatment, that it doesn’t face unfamiliar standards. This occurs advancement of individual Nigerian matter where you come from — it’s although most of the aircraft now aviation professionals and airline indus- only a matter of what you can offer. We maintained in Nigeria are Western- try progress by generating excessively also have been educating maintenance built types. For the maintenance high operating costs. The cost of keep- employees, preaching the message, “If technicians most familiar with Russian ing expatriate employees in the country you work with the expatriates, you’re airworthiness standards, today’s Nige- is much higher than otherwise should going to gain more knowledge, and the rian standards are significantly differ- be necessary, including costs of such more knowledge you have, the more ent, and their training time reflects this things as risk allowances for those who opportunity you will have to develop in difficulty. agree to stay and work, monthly round- your career here.” License endorsement/validation trip airfare to enable employee visits to In many places, however, several processes take too long. All expatri- their home countries during time off, problems are common. For example, ates must have their licenses endorsed local transportation with personal secu- cultural differences are not accommo- or validated by the Nigerian Civil rity services, and company payment of dated. Yet culture binds people as mem- Aviation Authority to be authorized to electric and communication utilities. bers of a group and provides key clues certify the airworthiness of Nigerian- It has become normal for rates of as to how to behave in both normal and registered aircraft. Those who have remuneration and incentive pay under unusual situations. licenses from the U.S. Federal Aviation contracts of employment to depend Communication is impaired. Due to Administration, however, require ad- both language and cultural differences, ditional testing to receive the aircraft InSight is a forum for expressing personal opinions there are bound to be not only errors type endorsements, a process lasting up about issues of importance to aviation safety in understanding but also some basic to three months or longer. and for stimulating constructive discussion, pro differences in the ways of reasoning. In If maintenance professionals per- and con, about the expressed opinions. Send Nigeria, English often is not the “moth- ceive unfairness, resentment can grow your comments to J.A. Donoghue, director of er tongue” (first language learned) of into hatred. A Nigerian saying is that publications, Flight Safety Foundation, 601 Madison St., Suite 300, Alexandria VA 22314- either locals or expatriates. two can work together only if they agree. 1756 USA or [email protected]. Language generates errors. Most As evidence, I have observed staff sitting errors discovered during maintenance down and waiting for a so-called expert
12 | flight safety foundation | AeroSafetyWorld | March 2010 insight
from a different category or subcategory to com- that locals cannot fill yet in some facilities. The mit errors rather than speaking up or interven- expatriates did not cause the infrastructural ing in the interest of safety. With such a strained deficiencies in the country, and they did not relationship, there is no safety synergy on the job. come to unfairly exploit their local colleagues One consequence has been unrest among or deny them job the labor unions representing maintenance tech- opportunities. nicians, an issue that today affects most airlines Employee con- in Nigeria. Sometimes the indigenes become sultative forums also Rosenkrans Wayne so hostile to their foreign colleagues that their have proved valu- unions demand forced repatriation of some of able for maintenance the staff from foreign countries. Outside the professionals of all workplace, in the worst cases, societal resent- nationalities, races, ment has been a factor in expatriates and locals ethnicities and first being targeted for kidnapping or robbery. languages to regu- Security concerns work against shared safety larly get together to culture. A group of expatriate specialists may arrive socialize, share ideas at work in large cars with security personnel, then and understand each after the day’s job is completed, security person- other better. nel gather them for the drive home. This does not My experience has create an avenue for colleagues to interact. If I’m been that foreigners working with somebody who doesn’t speak with who mix and relate Amara me, doesn’t joke with me, and the only interaction well with the locals we have is while doing the job together, that does have no reason to fear for their personal security. not encourage integration into one society. Life is better when people learn to live and reason So what is the way forward? In my company, together. Envy and hatred, however, pull down we are aiming to create a culture where every even the good structures that already exist. employee is part of the system, has a sense of be- The global aviation community already has longing and enjoys peaceful coexistence at work embraced principles of just culture, in which If maintenance and a sense of safety on the street. We began people are encouraged — even rewarded — for with a competency matrix and job placement providing essential safety-related information, professionals based on merit irrespective of factors such as with a clear line that differentiates acceptable race, ethnicity or geographical origin. from unacceptable professional behavior. Extend- perceive This means that for every position, there ing these principles to labor relationships can be unfairness, must be a written job description stating the en- accomplished by complying with labor laws that try requirements in support of equal employment ensure equal opportunity and on-the-job training resentment can opportunity. My company also has worked with for indigenes to grow in their profession. the Nigerian airline entrepreneurs, advising them For safety, efficiency, effectiveness and grow into hatred. not only to focus their resources on their expatri- harmony, there must be total commitment to ate staff for the short term, but also to develop change by government, airline management and the locals; otherwise entrepreneurs will never see all aviation stakeholders. If we are all thinking the long-term profits they intended to earn. in a productive way, these changes will happen Education includes social reorientation for gradually. I know they are not going to happen all subcategories of expatriate employees and all overnight. subcategories of indigene employees. Education Joshua I. Amara is manager of quality, airworthiness and helps locals understand that their counterparts safety for Nigerian Eagle Airlines and president of Global from outside Nigeria are not “enemies” in the Flight Safety Organization, a Nigerian affiliate of Flight workplace. Rather, they fill a temporary vacuum Safety Foundation. www.flightsafety.org | AeroSafetyWorld | March 2010 | 13 SAFETYStandards
viation operations associated with the personnel in the resource sector,” said FSF Interna- global mining and resource industry make tional Program Director Trevor Jensen, manager of hundreds of flights a day, often under chal- the BARS program. “Combined with the challeng- lenging conditions and in areas with inad- ing and often remote areas of operations, addi- equateA infrastructure, weak regulatory authorities tional variables increase the difficulty, including and inconsistent safety standards. the variety of aircraft types, adverse weather and Flight Safety Foundation’s new Basic Avia- terrain, wide number of aircraft operators and dif- tion Risk Standard (BARS) is intended to ad- fering levels of regulatory oversight.” dress the safety issues facing aviation operations Mining and resource companies use aircraft in the resource sector — a term that typically — from single-engine airplanes and helicopters encompasses mining and energy companies to airliners — in a wide range of activities, includ- with operations that are primarily onshore — by ing transportation of workers to remote mining establishing common safety standards.1 The operations, geological surveys, helicopter external BARS program also has attracted attention from load flights, photographic missions and medical others outside the resource sector, notably the evacuation flights. Although many operations United Nations World Food Program, which are small, others are substantial, Jensen said, uses many of the same aircraft operators. citing one operator in Western Canada that uses “Aviation risk management has always been a Boeing 737 to fly 1,000 employees to a remote one of the single greatest challenges to the safety of work site every day. Raising the Bar The new FSF Basic Aviation Risk Standard is designed to help mining and resource companies around the world develop common aviation safety standards.
BY LINDA WERFELMAN
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The absence of common safety consistency of audits that the sector Although many operators might standards for aviation operators under had sought, along with the elimination receive safety audits through the Inter- contract to resource companies has of unnecessary multiple audits, quality national Business Aviation Council’s troubled many in the resource sector assurance of the audit process, cost International Standard for Business for years, Flight Safety Foundation said efficiency, a centralized accident/inci- Aircraft Operations (IS-BAO), the BARS when BARS was introduced in February. dent database and a process to ensure audit “goes a little bit deeper” to address “The variety of safety standards that the industry standards reflect “the all threats in their operations, Voss said. among aviation providers and resource evolution of regulations, best practices He added that the BARS program companies has been a concern for the and identified needs of the sector.” represents a major change for the re- industry,” the Foundation said. “Be- David Jenkins, BHP Billiton vice source sector. fore the BARS program, there were no president for health and safety, praised “A major weakness of the old clear industry benchmarks for resource the program for its “potential to deliver company-specific standards was that companies when assessing the safety of a step-change improvement in global they tended to be prescriptive and reac- contracted aviation activity.” flight safety standards” in the resource tive to incidents,” Voss said. “The BARS As a result, aircraft operators often industry aircraft operations. program, on the other hand, is based on were subjected to multiple audits that “Flying remains one of the few ac- leading aviation industry risk manage- emphasized different sets of standards. tivities we all undertake which has the ment principles — analyzing possible Even though the audits often were potential for double-digit fatalities from points of failure and preparing for them. conducted by the same auditors, the a single event,” he said in an August “Global demand for a standardized resulting data were not shared. 2009 letter to industry colleagues. He risk-management approach has been Accident and incident data for noted that in 2008 and early 2009, the high in recent years, but it required an aviation operations associated with the resource sector experienced major acci- independent organization to man- resource sector are incomplete, and it is dents involving helicopters in minerals age it. Flight Safety Foundation has impossible to determine accident rates for and petroleum operations, adding that stepped into that role. Collaborating the sector. Compilation of data gathered the BARS program represents a “unique with industry leaders, we have created a through the BARS program eventually opportunity” to prevent such accidents solid standard that anticipates the risks will make possible that sort of analysis. in the future. rather than reacts to them, and can The program also has received the be applied to each company’s aviation Beginnings endorsement of the Minerals Council operations easily and cost-effectively.” Paul Fox, FSF regional director in of Australia, which passed a resolution Jensen described the four com- Melbourne, Victoria, Australia, said in December 2009 encouraging adop- ponents of the BARS program: the the BARS program developed from his tion of BARS by aircraft operators that standard; training the “aviation coor- conversations early in 2009 with safety serve that nation’s resource sector. dinators” — employees of the resource officials of BHP Billiton, one of the The program also has stirred inter- companies whose jobs include aviation- world’s major producers and suppliers est among relief organizations such as related responsibilities, even though they of coal, iron ore, oil and gas, and other the U.N. World Food Program, and may have no experience in aviation; the resources. The conversations centered peacekeeping groups, which contract audit program; and the development of a on the resource sector’s need for a with many of the same aircraft opera- central database that can be analyzed to single consistent set of safety standards, tors that serve the resource sector. identify safety trends. and a corresponding audit procedure. In many countries, especially devel- Flight Safety Foundation’s role has BHP Billiton and other leading oping nations in Africa, Asia and South included publishing and updating the resource companies — Lihir Gold, America, the companies that provide standard. Other companies have been Minerals and Metals Group (MMG), these aviation services are “a segment selected to develop training for aviation Rio Tinto and Xstrata — were among of the industry that’s neglected by the coordinators and for auditors, who the earliest participants in the new regulators,” said Foundation President must complete BARS auditor train- program, Fox added. He said that William R. Voss. “These operations are ing, pass their exams with a grade of
© Hafizov/iStockphoto BARS provides the standardization and not a high priority in many countries.” at least 90 percent and conduct at least
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one audit under an evaluator’s supervi- audits, conducted by three separate recommendations from the International sion before becoming qualified. Jensen audit companies, the Foundation said. Civil Aviation Organization (ICAO), typi- describes one of the Foundation’s roles “Multiple audits are unnecessary, cally expect industry sectors to exercise “a as to act as the “auditor of the auditors,” expensive and time consuming,” the greater responsibility for the day-to-day overseeing their work. Foundation said. “They neither enhance administration of their industry and its safety levels nor reduce risk.” routine surveillance.” Safety Culture The resource companies participat- The BAR standards are not in- The Foundation said that the resource ing in the BARS program have “a strong tended to override the requirements of sector and its individual companies commitment to and an immediate need regulatory authorities, manufacturers have for years had a strong safety for” the program, the Foundation said, or individual companies, “except to the culture. One element of that culture has noting that the need is “driven by the extent that the standards requirement been the frequent use of safety audits. individual corporate objectives of the is higher,” the Foundation said. “All the That frequency, however, has itself companies in respect [to] occupational standards are descriptive — versus pre- presented problems, Jensen said. safety and health, as reflected in their scriptive — of what is required rather Because of the absence of a single commitment to a ‘zero harm’ policy for than how the end is to be achieved.” set of standards applied to the entire all employees and their requirement to If there are differences among ICAO sector, individual resource companies lower exposure to aviation risk.” requirements, national regulations, adopted their own standards and ap- BARS and other specific requirements, plied them to the aircraft operators that Program Goals the highest standard always applies. worked for them. Goals of the BARS program include These multiple standards have creation of a single set of aviation safety Threats and Controls resulted in multiple safety audits each standards for the resource sector and The BARS program outlines 15 “com- year. During each audit, some aviation a single audit — the BARS Quality mon controls” that address all threats personnel are diverted from their regu- Controlled Audit — to ensure that the discussed in the overall standard, lar duties to concentrate on the audit, standards are being met. including that only appropriately Fox said, noting for some operators, Precedents exist for the use of a single licensed aircraft operators that have audit time amounts to as many as 28 industry standard for aviation operations. been “reviewed and endorsed for use by days a year. For example, the International Associa- a competent aviation specialist” should As examples, the Foundation cited tion of Oil and Gas Producers and the conduct flights for resource companies. the case of one unnamed helicopter International Airborne Geophysics Another control specifies minimum operator that experienced 14 separate Safety Association each have their own experience requirements for flight audits in one year, five of which were sets of aviation safety guidelines. The crewmembers, which vary according to conducted by the same audit company. Foundation said that national aviation au- the size of the airplane and the crew- An airplane operator experienced 11 thorities, in an approach consistent with member’s role as pilot-in-command
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(PIC) or copilot. For example, the weather-related issues. In addition, be- According to these controls, a pilot document says that the PIC of a fore a crewmember begins flight duties in a single-pilot operation should fly no multi-engine aircraft weighing 5,700 in a new location on long-term contract, more than eight hours a day and 40 hours kg (12,566 lb) or more should hold an he or she should receive a documented in any period of seven consecutive days, airline transport pilot license (ATPL) line check that includes orientation to and a pilot in a two-member crew should and have at least 3,000 flight hours, the local procedures and environment. fly no more than 10 hours a day and 45 including 2,500 hours as PIC and at The document includes similar hours in seven consecutive days. Duty least 500 hours as PIC in multi-engine requirements for maintenance per- days for flight crewmembers must be no aircraft. The copilot should have at least sonnel. For example, a chief engineer longer than 14 hours, the controls say, 500 flight hours, including 100 hours of (maintenance technician) should have although fatigue management programs multi-engine time and 50 hours in type, at least five years of experience, and a may be used instead of these limits if the and a commercial pilot license. line engineer, at least two years; both fatigue management program has been Crewmembers in all aircraft being should have an engine/airframe/avion- approved by the regulatory authority. flown for resource companies should ics rating, when appropriate, and both Maintenance personnel also should have at least 50 flight hours, including should have no record of involvement be subject to duty time limits, in ac- 10 hours in type, in the previous 90 days in a human-error accident for at least cordance with a fatigue management and at least three night takeoffs and the previous two years. program designed to “limit the effects landings. All flight crewmembers should Recurrent training must be pro- of acute and chronic fatigue,” the con- receive training every two years in crew vided by the operator or maintenance trols said. resource management and aeronauti- service provider at least every three Other controls call on all aircraft cal decision making, and they should years, and should include discussion of operators to conduct an operational have at least one year of experience in a human factors and company mainte- risk assessment before beginning topographical area similar to that where nance documentation and procedures. operations for “any new or existing they will work. They also should have Another of the document’s com- aviation activity,” and to implement a “two years accident-free for human error mon controls specifies a basic minimum safety management system, including a causes, subject to review by the resource equipment list — including a terrain provision to require an aircraft opera- company,” the document says. awareness and warning system (TAWS) tor to notify the resource company of Crewmembers also should receive and a traffic alert and collision avoid- any “incident, accident or non-standard the annual recurrent training speci- ance system (TCAS) — for all aircraft occurrence related to the services fied by the appropriate civil aviation used in resource company operations. provided to the company that has, or authorities, with at least one flight check Other controls require aircraft potentially has, disrupted operations or every six months for those who work in operators to institute drug and alcohol jeopardized safety.” “long-term contracted operations,” the policies and flight and duty time limits The last of the two common
© Weinelm/Dreamstime © document says. Training should include for flight crewmembers (Table 1, p. 18). controls discuss issues involving
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crewmembers in hostile environments Flight Time Limits also should wear survival vests equipped Single Pilot Dual Pilot with a voice-capable global positioning 8 hours daily flight time 10 hours daily flight time system emergency position-indicating 40 hours in any 7-day consecutive period 45 hours in any 7-day consecutive period radio beacon. Safety belts with upper- 100 hours in any 28-day consecutive period 120 hours in any 28-day consecutive period torso restraints should always be worn, 1,000 hours in any 365-day consecutive 1,200 hours in any 365-day consecutive period and passengers should dress for the period environment over which the aircraft
Source: Flight Safety Foundation is flown. Sideways seating should be avoided for takeoffs and landings unless Table 1 shoulder restraints are used. In addition, aircraft on long-term helicopters engaged in external load net climb gradient greater than the contract that seat more than nine pas- and offshore operations, and airborne takeoff path obstacle gradient.” sengers must be equipped with a cockpit geophysical operations. Crews of multi-engine airplanes voice recorder and flight data recorder, without appropriate performance company-owned or company-operated Specifics charts should limit their payload to airports and helipads should have a BARS also examines nine specific types ensure that, in case of an engine failure method of extinguishing a fire, and the of threats to aviation safety: runway after the airplane reaches best rate of contracting company should determine excursions, fuel exhaustion, fuel con- climb airspeed, “the net takeoff path the required level of insurance. tamination, controlled flight into terrain, clears obstacles by 35 ft up to a height incorrect loading, collision on ground, of 1,500 ft” above the airport with the Program Phases collision in air, structural or mechanical landing gear and flaps retracted and The BARS, published in late 2009 and failure, and weather. In each category, the the propeller feathered on the inopera- updated in February, is ready for adop- discussion also includes controls that can tive engine. tion by companies in the resource sector. be implemented to prevent accidents. Flight crewmembers also must Auditor training programs — designed For example, runway excursions can have a means of obtaining accurate for the large pool of auditors who cur- be addressed through six categories of weather information at company- rently are under contract to individual controls, including design considerations owned or company-operated airports, resource companies — are scheduled to in the construction of an airport or heli- the document says. begin in July. Actual audits are expected pad to be used in resource company flight to begin soon afterward, in the third operations (Figure 1). Accident Defenses quarter of 2010, Jensen said, and limited Another control says that company- The BARS program also prescribes de- data should be available by the end of owned or company-operated airports fenses that can limit deaths and injuries the year. and helipads should be subject to an in case of an accident. © Hevilift PNG operational control and safety review by For example, the document says, qualified specialists at least once a year, aircraft that are designed and built and landing sites should be assessed in accordance with the most recent before the start of operations. certification standards have “increased In addition, the controls call for crashworthiness and survivability all multi-engine airplanes to “meet characteristics.” balanced field requirements so that A carefully developed emergency- following an engine failure on takeoff, response plan, tested annually, can help, the aircraft will be able to stop on the along with installation of an aircraft remaining runway and stop-way, or emergency locator transmitter, use of continue (using the remaining runway flight-following systems, a survival kit, and clearway) and climb achieving a first aid kit and crash box. Helicopter
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Note sources are the Foundation’s Basic Aviation Risk Standard, Resource Sector Briefing, Feb. 23, 2010, and 1. Flight Safety Foundation. Basic Aviation Risk the Executive Committee Recommendation Resource Standard, Resource Sector. February 2010. Related Sector Basic Aviation Risk Standard, Sept. 1, 2009.
Aviation Risk-Management Controls
Threat Controls
Air eld Design Site Assessments Runway Excursions Air eld Inspections Destination Weather Reporting Balanced Field Length
Fuel Check IFR Fuel Plan Fuel Exhaustion Weather data VFR Fuel Plan Flight Plan Hot refueling
Fuel Testing Fuel Contamination Fuel Filtration Fuel Storage Drummed Fuel Fuel Sampling
Night/IFR Special VFR Controlled Flight Two Crew Stabilized Approaches Flight Data Monitoring Into Terrain (CFIT) Simulator Training Go-around Procedures Autopilot IFR Flight Plan CRM/ADM Training TAWS Approach/landing recency
Passenger Weights Passenger Brie ng Cargo Weights Manifest Incorrect Loading Multi-language Weight and Balance Dangerous Goods Calculations Brie ng
Passenger Terminal Rotors Running Load/Unload Collision on Ground Designated Freight Area Air eld Control Passenger Control Parking Apron Ground Procedures Perimeter Fence
TCAS Cruising Altitudes High Intensity Collision in Air Air eld Bird Control Radar Controlled Airspace Strobe Lights
Single-Engine Helicopter Vibration Minimum Equipment Structural/ Multi-Engine Monitoring List (MEL) Mechanical Failure Spare Parts Supply Engine Trend Sub-chartering Hangar Facilities Monitoring aircraft
VFR Minimums Weather Adverse Weather Policy Cold Weather Training Wind Shear Training Thunderstorm Avoidance Weather Radar
CRM/ADM = crew resource management/aeronautical decision making; IFR = instrument flight rules; TAWS = terrain awareness and warning system; TCAS = traffic alert and collision avoidance system; VFR = visual flight rules
Source: Flight Safety Foundation
Figure 1
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BY MARK LACAGNINA
he captain’s inappropriate response to a to monitor airspeed in relation to the rising stick shaker activation was the probable position of the low-speed cue [on their primary cause of an unrecoverable stall and the flight displays], the flight crew’s failure to adhere crash of a Colgan Air Bombardier Q400 to sterile cockpit procedures,1 the captain’s Ton approach to Buffalo Niagara (New York, failure to effectively manage the flight, and U.S.) International Airport the night of Feb. 12, Colgan Air’s inadequate procedures for airspeed 2009, according to the U.S. National Transporta- selection and management during approaches in tion Safety Board (NTSB). icing conditions.” All 45 passengers and four crewmembers Fatigue also was a likely factor, but investiga- in the airplane, plus one person on the ground, tors could not determine conclusively the extent to were killed, and the airplane was destroyed when which the pilots were impaired by fatigue or how it struck a house in Clarence Center, New York, it might have contributed to their “performance about 5 nm (9 km) northeast of the airport. deficiencies” during the flight, the report said. In its final report on the accident, NTSB said Fatigue was that the captain caused the airplane to stall by Flight 3407 Crew a likely factor pulling on his control column when the stick The airplane was being operated as Continental in the crash of shaker activated at an artificially high airspeed Connection Flight 3407 to Buffalo from Liberty this Q400. — a reaction that was consistent with “startle International Airport in Newark, New Jersey, and confusion” rather than with his training. the pilots’ home base. The report said that factors contributing The captain, 47, had 3,379 flight hours, in- to the accident were “the flight crew’s failure cluding 3,051 hours in turbine airplanes and 111
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A bad reaction to a Startled stick shaker triggered a stall. and Confused
hours in type. He was a Beech 1900D The report pointed out, however, report said. “His continued weaknesses first officer for Gulfstream Internation- that U.S. Federal Aviation Administra- in basic aircraft control and instru- al Airlines before being hired by Colgan tion (FAA) records showed that the ment flying were not identified and in September 2005. pilot had not passed initial flight checks adequately addressed.” He received a DHC-8 type rat- for an instrument rating in 1991, a The first officer, 24, worked as a ing — a rating common for the Q400 commercial license for single-engine flight instructor in piston airplanes and its predecessors — in November airplanes in 2002, a commercial license before joining Colgan in January 2008 2008. “The check airman who pro- for multiengine airplanes in 2004, and and received a DHC-8 second-in- vided the captain with his IOE [initial an airline transport pilot license in command type rating in March 2008. operating experience] described the 2007, while at Colgan. She had 2,244 flight hours, including captain’s performance as good and In addition, Colgan’s training 774 hours in type. indicated that his greatest strength was records showed that the captain had to One captain who had flown with being methodical and meticulous,” the be retested on normal and abnormal the first officer rated her as average to report said. procedures for a Saab 340 first officer above average for her level of experience. Q400 first officers who flew check ride in 2006 and had received “Other captains indicated that, because with the captain described him as unsatisfactory grades for a 340 recur- of her abilities, the first officer could have competent. “These first officers also rent proficiency check in 2006 and a upgraded to captain,” the report said. indicated that the captain created a 340 upgrade proficiency check in 2007. relaxed atmosphere in the cockpit but “The captain had not established a Commuting Pilots adhered to the sterile cockpit rule,” good foundation of attitude instrument The report characterized the flight
© Michael Fast/Airliners.net the report said. flying skills early in his career,” the crew as “commuting pilots.” The
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captain commuted to Newark from his home Both pilots often slept in the Colgan crew in Tampa, Florida; the first officer commuted room at Liberty International. The crew room from Seattle. had couches, recliners and a television. The The captain had told another pilot that he airline’s regional chief pilot said, however, that wanted to get a “crash pad” near Newark but was the crew room was intended as a place for crew- trying to avoid the expense of temporary lodging members to relax and that it was not adequate by bidding trips with overnights in hotels or end- for rest between trips. ing at locations with an easy commute home. The captain had commuted by airline to The first officer also tried to bid trips that Newark three days before the accident and had would facilitate her commute. rested in hotels during overnight trips. The first officer had arrived in Newark the morning before the accident. The night be- fore, she had occupied the jump seat of a cargo airplane that departed from Seattle at 1951 local time and arrived in Memphis, Tennes- see, at 2330 Seattle time, or 0230 Newark time. She slept for 90 minutes during the flight. “The captain [of the cargo airplane] stated that she seemed to be alert, well rested and in a good mood, and that she did not show any symptoms of being sick,” the report said. She then flew aboard another cargo air- plane that departed from Memphis at 0418 and arrived in Newark at 0623. “According to the captain of this flight, after the airplane landed the first officer told him that she had slept during the entire flight,” the report said. “The captain also stated that he asked her what she would be doing until her report time and that she responded that one of the couches in the crew room ‘had her name on it.’ [He] stated that she did not appear to be tired and showed no symptoms of being sick.” Both accident pilots were seen in the Col- gan crew room before their scheduled report time of 1330.
First Flights Canceled High winds and ground delays at Newark that afternoon prompted the cancellation of several Colgan flights, including the flight crew’s first two scheduled flights — to Rochester, New York, and return. The estimated departure time for Flight 3407 to Buffalo was 1917. The captain spent the afternoon doing office work — inserting revisions in airplane manuals
— and relaxing in the crew room. Press Duprey/Associated © David
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“The first officer’s specific activities on the day of the accident are not known, but several Bombardier Aerospace Q400 pilots reported seeing the first officer in the crew room watching television, talking with he Bombardier Q400 is the latest in the line of DHC-8, or Dash 8, other pilots and sleeping,” the report said. commercial twin-turboprops launched by de Havilland Canada in The cockpit voice recorder (CVR) picked up T1980. The Q400 entered service in 2000 with a stretched fuselage several sounds of the first officer sneezing and and seating for up to 78 passengers. sniffling. While waiting for takeoff clearance, The airplane has Pratt & Whitney Canada PW150A engines, each she told the captain, “I’m ready to be in the hotel flat-rated to 5,070 shp (3,782 kW), and Dowty R408 six-blade compos- ite propellers that turn at 1,020 rpm for takeoff and 850 rpm for cruise. room. This is one of those times that, if I felt like Maximum fuel capacity is 1,724 gal (6,526 L). this at home, there’s no way I would have come Maximum weights are 64,500 lb (29,257 kg) for takeoff and 61,750 lb all the way out here. … If I call in sick now, I’ve (28,010 kg) for landing. Sea-level field lengths at the maximum weights got to put myself in a hotel until I feel better. … are 4,265 ft (1,300 m) for takeoff and 4,223 ft (1,287 m) for landing. We’ll see how it feels flying. If the pressure’s just Maximum cruising speed is 360 kt. Maximum altitude is 25,000 ft, and too much I could always call in tomorrow — at service ceiling with one engine out is 17,500 ft. Maximum range with 70 passengers and reserves is 1,360 nm (2,519 km). least I’m in a hotel on the company’s buck — but Source: Jane’s All the World’s Aircraft we’ll see. I’m pretty tough.” The report concluded, however, that the first officer’s illness likely did not directly affect her performance during the flight.
Deicing Equipment On The crew received takeoff clearance at 2118 and activated the propeller and airframe deicing equipment while climbing to their assigned cruise altitude, 16,000 ft. “The cruise portion of flight was routine and uneventful,” the report said. “The CVR recorded the captain and the first officer engaged in an almost continuous conversation, but these conversations did not conflict with the sterile cockpit rule.” © Gerry Hill/Airliners.net Weather conditions at Buffalo included sur- face winds from 240 degrees at 15 kt, gusting to 22 kt, 3 mi (4,800 m) visibility in light snow and the approach and calculated a reference landing mist, a few clouds at 1,100 ft, a broken ceiling at speed (VREF) of 118 kt. 2,100 ft and an overcast at 2,700 ft. At 2156, the first officer said, “Might Reference Speed Riddle be easier on my ears if we start going down The crew set the VREF “bugs” on their airspeed sooner.” On the captain’s instructions, she indicators to 118 kt. This value was appropriate requested clearance to descend. The Cleveland for an uncontaminated airplane. However, when Center controller cleared the crew to descend the crew activated the deicing equipment during to 11,000 ft. departure from Newark, they also set the “REF The crew established radio communication SPEEDS” switch on the ice-protection panel to with Buffalo Approach Control at 2203 and were “INCR” (increase). told to expect the instrument landing system This action is required by the Q400 airplane (ILS) approach to Runway 23. They briefed for flight manual (AFM) before entering icing www.flightsafety.org | AeroSafetyWorld | March 2010 | 23 Causalfactors
conditions and results in activation of in icing conditions on her first day of airspeed is increasing from 260 kt and the stick shaker at a lower angle-of- [IOE] with Colgan than she had before will be about 278 kt in 10 seconds. attack — thus, at a higher airspeed. The her employment with the company,” the A red and black vertical bar appears AFM also specifies that on approach, the report said. next to the airspeed scale to warn that
flight crew must increase VREF by 15 to At 2212, the approach controller airspeed is too low. The stick shaker 25 kt, depending on flap setting, to re- cleared the crew to descend to 2,300 ft, activates when the indicated airspeed main above the stall-warning threshold. the initial approach altitude. “Afterward, drops below the top of the bar. In ad- Colgan’s company flight manual for the captain and the first officer performed dition, the displayed airspeed changes the Q400, however, provided inad- flight-related duties but also continued from white to red to provide another equate guidance for the use of the “REF the conversation that was unrelated to warning that airspeed is too low. SPEEDS” switch and did not require their flying duties,” the report said. These low-speed cues were present- crews to cross-check the switch posi- The crew conducted the descent ed on the PFDs “with adequate time for
tion against their VREF bugs on ap- and approach checklists while being the pilots to initiate corrective action, proach, the report said. vectored to the final approach course, but neither pilot responded to the The result during the approach to 233 degrees. presence of these cues,” the report said. Buffalo was that the stick shaker acti- The maximum allowable approach “The failure of both pilots to detect this
vated about 13 kt higher than the VREF speed was 138 kt, but airspeed was 184 situation was the result of a significant value set by the crew. kt when the crew was cleared for the ap- breakdown in their monitoring respon- proach about 3 nm (6 km) from the outer sibilities and workload management.” Unsterile Cockpit marker. “The captain slowed the airplane The approach controller cleared the by extending flaps to 5 degrees, reducing Seconds to Impact crew to 6,000 ft, and the Q400 de- power to near idle, extending the landing About 20 seconds after the first officer’s scended through 10,000 ft at 2206. gear and moving the condition levers to last radio transmission, the stick shaker “From that point on, the flight crew was maximum rpm,” the report said. activated and the autopilot automati- required to observe the sterile cockpit At 2216, the approach controller cally disengaged. When the stall warn- rule,” the report said. told the crew to establish radio commu- ing occurred, the landing gear was The crew received further descent nication with the Buffalo airport traffic extended, the flaps were being extended clearance to 4,000 ft. controller. The first officer’s acknowl- through 10 degrees to 15 degrees, and At 2210, the captain said that there edgement of the instruction was the last airspeed was about 131 kt. was ice on his side of the windshield communication between the crew and “The airplane was not close to stalling and asked the first officer if there was air traffic control. at the time,” the report said. “However, ice on her side. “Lots of ice,” she replied. because the ref speeds switch was selected The captain then said, “That’s the Missed Cues to the increase (icing conditions) posi- most … ice I’ve seen on the leading Neither pilot responded to cues of an tion, the stall warning occurred at an edges in a long time — in a while any- impending stall warning. Among the airspeed that was 15 kt higher than would way, I should say.” cues were indications on the primary be expected for a Q400 in a clean (no ice Despite these statements, the report flight displays (PFDs) of an excessive accretion) configuration.” said that recorded flight data showed nose-up pitch attitude. Flight data recorder (FDR) data the ice accumulation had a minimal ef- Other cues were provided by indicated that the captain increased fect on the airplane’s performance and the airspeed data on the PFDs. Each power as he pulled his control column did not affect the crew’s ability to fly display has a vertical airspeed scale back with 37 lb (17 kg) of force. “The and control the airplane. with a trend vector, a white arrow, captain’s inappropriate aft control The pilots continued their conversa- that indicates increasing or decreasing column inputs in response to the stick tion about previous experiences in icing airspeed. The tip of the arrow indicates shaker caused the airplane’s wing to conditions. “During that conversation, what the airspeed will be in 10 seconds stall,” the report said.2 Angle-of-attack the first officer indicated that she had if the trend continues. The trend vector increased to 13 degrees, load factor accumulated more actual flight time in Figure 1, for example, shows that increased from 1.0 g to about 1.4 g, and
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recommendations to the FAA. They in- Q400 Primary Flight Display cluded leadership training for upgrad- WNG LVL GA ing captains, fatigue risk management ALT SEL for commuting pilots, and improved 14000 stall recognition and recovery training 300 10 for pilots. 20 20 4 Indicated airspeed display 2 280 1 This article is based on NTSB Accident 10 10 Trend vector Report NTSB/AAR-10/01, “Loss of Control IAS 60 Current airspeed 260 5 40 on Approach; Colgan Air, Inc., Operating 20 as Continental Connection Flight 3407; 10 10 240 1 Bombardier DHC-8-400, N200WQ; Clarence 2 Center, New York, February 12, 2009.” The full Low-speed cue 20 20 4 220 0 0 report is available from the NTSB Web site, 1013 HPA
33 Part 121.542(b) and (c), which state: “No
S flight crewmember may engage in, nor
30
21 may any pilot-in-command permit, any
W ADF1 24 ADF1 activity during a critical phase of flight + – DME1H 92.1 NM DME2 92.1 NM which could distract any flight crewmem- ber from the performance of his or her
Vref = reference landing speed; Vga = go-around speed duties or which could interfere in any
Source: U.S. National Transportation Safety Board way with the proper conduct of those duties. Activities such as eating meals, Figure 1 engaging in nonessential conversations within the cockpit and nonessential airspeed decreased to 125 kt, the stall The first officer asked the captain communications between the cabin and speed under these conditions. if she should retract the landing gear. cockpit crews, and reading publications not related to the proper conduct of The airplane rolled left 45 degrees The captain replied, “Gear up,” and the flight are not required for the safe and was rolling back to the right when voiced an expletive. “The airplane’s operation of the aircraft. For the purposes 3 the stick pusher activated. pitch and roll angles had reached about of this section, critical phases of flight Airspeed was 100 kt when the 25 degrees airplane-nose-down and include all ground operations involving first officer retracted the flaps without 100 degrees right-wing-down, respec- taxi, takeoff and landing, and all other consulting the captain. The report said tively, when the airplane entered a steep flight operations below 10,000 ft, except cruise flight.” that this action was inconsistent with descent,” the report said. Colgan’s stall-recovery procedures and Among the last sounds recorded by 2. The report said that the Q400 is not training. the CVR were the captain saying, “We’re prone to tailplane stall and that it is “The roll angle reached 105 down,” and the first officer screaming. unlikely the captain was deliberately attempting to perform a tailplane-stall degrees right-wing-down before the The Q400 struck the house about 27 recovery. airplane began to roll back to the left, seconds after the first activation of the and the stick pusher activated a second stick shaker. There was a post-impact 3. The stick pusher activates when stall time,” the report said. “FDR data fire fed by fuel from the airplane and by angle-of-attack has been reached. The report said that it provides a tactile cue showed that the roll angle had reached natural gas from a severed pipe in the to push on the control column to gain about 35 degrees left-wing-down house (see article, p. 26). airspeed and alleviate the stall condition. before the airplane began to roll again Based on the findings of the The stick pusher also positions the elevator to the right.” investigation, NTSB issued 25 to 2 degrees nose-down. www.flightsafety.org | AeroSafetyWorld | March 2010 | 25 Coverstory
Mutual Aid By Thomas Chmielowiec Sr. When the Q400 struck a house and exploded, the volunteer fire chief pulled ARFF specialists into a massive response.
call from air traffic control All the firefighters went to their and wiped out a neighborhood. They did (ATC) captured the attention of trucks, but for about a minute they sat not know yet that the Colgan Air Bom- 10 firefighters on duty at Buf- idle in the firehouse with no place to go. bardier Q400 had struck only one house. falo Niagara (New York, U.S.) That gave them an eerie feeling, listening Between one and two minutes after AInternational Airport Fire Department to their radios as ATC repeatedly called the crash phone rang, one of the firefight- (BNIA-FD). The message for aircraft “Colgan 3407” and got no answer. The ers telephoned Amherst Fire Control, rescue and fire fighting (ARFF) at flight crew of a nearby airliner flying in the dispatch center for 15 local volunteer about 2220 on Thursday, Feb. 12, 2009, instrument meteorological conditions fire departments, to find out whether an said that a regional turboprop estab- had told ATC that the missing aircraft aircraft was reported down in its districts. lished on the localizer of the Runway could not be seen visually or on the The dispatchers said they were being 23 instrument landing system could be display of their traffic-alert and collision flooded with phone calls, and that they down somewhere between the outer avoidance system.1 had dispatched Clarence Center Volun- marker and Harris Hill, near Akron, Some of the firefighters anticipated teer Fire Company (CCVFC) to a specific approximately 12 nm (22 km) northeast the possibility that the aircraft had trav- address in Clarence Center for a “possible
of the airport (see p. 20). eled thousands of feet along the ground aircraft into structure” call. Press Duprey/Associated © David
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experience as a picture-perfect firefighting op- eration by all the fire companies involved. At BNIA, the full airport emergency plan was put into place. Christopher Putney, fire chief of BNIA-FD, was in command of airport response, ARFF on-scene and off-scene operations and keeping the airport functional during the emer- gency. With the help of four captains, he safely coordinated crew involvement in all activities, including sending firefighters as standby emer- gency medical technicians to the center where family members received official information and counseling during the unfolding tragedy. My crash-related duties began just after mid- night at the BNIA-FD firehouse, and my first shift at the scene was Friday 0700–1100 as the captain on the third ARFF relief crew. My understand- ing of the firefighting response reflects personal experience; published accounts from a few key participants such as David Case, then chief of the CCVFC and incident commander, and Timothy Norris, the assistant chief and first firefighter to reach the crash site; findings of the U.S. National Transportation Safety Board (NTSB); and record- ed ATC and fire service radio communications. The firefighter then asked the First Arrivals dispatchers, “Would This event happened on Long Street just 525 you like us to start ft (160 m) from the CCVFC firehouse, shortly rolling toward that after a few firefighters had returned from an site just in case?” By emergency medical services call. BNIA weather two minutes after conditions included near-freezing temperature, the initial alert from winds west–southwest at 14 mph (23 kph) with ATC, one of the light snow and mist, the NTSB said. three BNIA-FD crash From inside their own houses, Norris trucks — supported and Case heard a loud but muffled impact of
Firefighters by one structural pumper with foam capability the aircraft with the house. Running outside, 2,3 from 17 fire and extra hoses — responded with full ARFF they heard an explosion and saw a fireball. departments, crews and a captain. They arrived at the scene Seconds later, at 2219, their signal emitters most volunteers, 12 minutes later. sounded with the alarm from Amherst Fire responded to So began 11 days of ARFF mutual aid to Control, Case recalled. the scene. various stages of firefighting, crash site recovery Norris drove his fire command truck and accident investigation in Clarence Center, three blocks from his house to the location in a village surrounded by the Town of Clarence. about 15 seconds, and Case arrived in his fire There probably were some flaws somewhere command car after driving about 0.5 mi (1 along the line, but, at least to me, they were km) from his house as a wall of flames about © David Duprey/Associated Press so unnoticeable that I will remember this 60 to 70 ft (18 to 21 m) high lit up the village.
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The aircraft fuel Fire Departments Respond to Colgan Air Flight 3407 tanks were ruptured by the impact, and Crash site 2 mi Total individual emergency responders = 1,060 5 km burning Jet A fuel (from re departments, law enforcement and all other agencies) was concentrated Rapids RVFC in the basement of the crushed house. Burning natural gas from a household NFAFRS meter broken in 990 GFC Akron half — with its valve NFC AFC CCFVC left in the full-open North Clarence EC-MCC position — also fu- Tonawanda 290 Center CFD 5 eled the flames, thick BFD5 smoke and radiant TCA AFCD 90 Amherst NAFD heat. The flames MTFC HHVFC EAFD were going straight SFC BVFC 33 up; the wind was not 33 BNIA-FD a factor. Bu alo Niagara 90 International Airport The fire area was RMMS Alden OFPC BFD EC-EOC LVAC MVFD confined to part of 20 Bu alo the residential lot. Firefighters ordered the shutdown of all Fire Incident Command, Communication and Documentation utilities as part of AFCD = Amherst Fire Control (Dispatcher) EC-EOC = Erie County Emergency Operations Center their standard operat- CCVFC = Clarence Center Volunteer Fire Company EC-MCC = Erie County Mobile Command Center (Clarence Town Hall) ing procedures, yet Mutual Aid Fire Departments a continuing flow of (Fire, emergency medical services, hazardous materials and/or scene recovery) natural gas feeding AFC = Akron Fire Company MTFC = Main Transit Fire Company the fire was not recog- BFD = Buffalo Fire Department MVFD = Millgrove Volunteer Fire Department nized for a while. BFD5 = Brighton Fire District No. 5 NAFD = North Amherst Fire Department The fire chief and BNIA-FD = Buffalo Niagara International Airport Fire Department NFAFRS = Niagara Falls Air Force Reserve Station BVFC = Bowmansville Volunteer Fire Company NFC = Newstead Fire Company assistant fire chief CFD = Clarence Fire District No. 1 OFPC = Office of Fire Prevention and Control (New York) sized up the situa- EAFD = East Amherst Fire Department RMMS = Rural/Metro Medical Services tion, including the GFC = Getzville Fire Company RVFC = Rapids Volunteer Fire Company protruding aircraft HHVFC = Harris Hill Volunteer Fire Company SFC = Swormville Fire Company vertical stabilizer, LVAC = Lancaster Volunteer Ambulance Corps TCA = Twin City Ambulance and confirmed Sources: U.S. National Transportation Safety Board, David Case, Thomas Chmielowiec Sr. on Amherst Fire Figure 1 Control’s designated radio channel for on- While driving to the location, Case asked Am- scene operations that a relatively large airplane herst Fire Control to dispatch heavy rescue had struck the house, and the house was fully vehicles from two nearby volunteer fire com- involved. BNIA-FD simultaneously got this panies with full crews, a water-cascade system information by telephone from Amherst Fire and shoring materials to support search and Control, and confirmed the crash and its loca- rescue (Figure 1). tion to ATC.
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Fast Attack Around this time, he requested one (6 m) to the north never caught fire, Some firefighters who arrived with the crash truck from BNIA-FD to help despite exposure to radiant heat from first CCVFC and mutual aid fire en- extinguish the fire with aqueous film- approximately 5,800 lb (2,631 kg) of gines were assigned to do a systematic forming foam and the Erie County burning fuel. At the brick house, there 360-degree perimeter check, searching mobile command unit. The two ARFF was heat damage, such as the plastic and listening for any sound of survi- crews already were en route, however. globe of the electric meter and vinyl vors,4 as close to the fire as possible and “We quickly refocused our atten- electric-service entrance cable melting, in surrounding areas including trees tion to fire-suppression operations as and minor damage from flying debris. and roofs. Other CCVFC firefighters we started to gain headway,” Case said. The crash truck, equipped with a simultaneously laid in about four or “The Erie County mobile command roof turret operated from the cab, had a five 1.75-in (4.45-cm) hoses and estab- unit arrived. Inside the command post, capacity of 3,000 gal (11,356 L) of water lished a water supply from a hydrant we tried to determine how many people and 412 gal (1,560 L) of foam concen- in front of their firehouse. Unlike most were on the plane and the quantity of trate. This water tank can be refilled four calls in which firefighters can don their fuel. Originally, we thought just a crew times with water before exhausting one standard structural turnout gear — that was bringing the plane in.” He learned tank of foam concentrate. The pumper, is, protective clothing — and self- from emergency medical technicians equipped with a bumper turret operated contained breathing apparatus (SCBA) that two of the three occupants of the from the cab, carried 750 gal (2,839 L) en route, the first-arriving CCVFC house had escaped and survived. of water and 90 gal (341 L) of foam con- firefighters did this while on scene. The The wood-frame house struck by the centrate. ARFF personnel reported that first mutual aid fire company to arrive airplane initially was destroyed by the the bulk of the early fire extinguishment also established a water supply from a impact forces, not fire, and two vehicles took approximately 90 minutes. second hydrant near the house. burned next to it. Because curtains of “After crews searched the entire water from deluge and blitz guns quickly Natural Gas Threats area, it was finally determined there were applied, the garage building behind The NTSB determined that National were no survivors,” Case recalled. the house and the brick house 20 ft Fuel Gas, the utility company, was © Charles Anderson/Associated Press © Charles Anderson/Associated
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called at 2358 regarding blowing and In the meantime, a large number The relief crew after mine then burning gas, and its crew arrived on of people already were walking on flooded the area with approximately scene Friday at 0033. NTSB said, “The the crash site itself. One of the ARFF 9,000 gal (34,069 L) of water to ex- crew shut off the flow of gas at the firefighters on the crash truck looked at tinguish any debris left burning from homes on both sides of the accident the cab display of images from the roof- the underground fire and saturate the site. The crew was initially unable to mounted infrared camera. He told me, ground. All major firefighting was shut off the flow of gas at the destroyed “It’s a roaring furnace underground; look concluded at that point. home because the gas shutoff valve and what I’m picking up from 10 ft [3 m] We were advised Friday afternoon gas meter were directly in the fire area. down.” So I called over representatives by the NTSB that recovery would About 0130, after National Fuel [Gas] from the Federal Aviation Administra- start Saturday morning. The first had completed all of the work that it tion (FAA), Federal Bureau of Investiga- crews of the Buffalo Fire Department could safely accomplish, the incident tion (FBI) and NTSB. They hopped up Rescue 1, Engine 21 and Ladder 6 commander … requested that the crew in the truck cab to see the display, and vehicles arrived then as a specialty retreat from the site.” I told them, “If I were you, I would pull team. With ARFF support and under Gas company officials then deter- all of my people off the site. I don’t know the direction of then-Buffalo Fire mined that a system shutdown affecting what’s going on here yet but that may be Commissioner Michael Lombardo, about 50 homes would be required to natural gas burning underground.” They these crews spent three days help- stop the flow of gas at the fire scene. agreed to leave. “This delayed the NTSB ing the NTSB and the Erie County After consulting others about possible accessing the scene and beginning the Medical Examiner’s Office to separate evacuation of the residents in the early investigation,” Case recalled. the human remains, personal effects, morning hours and freezing tempera- The NTSB report said, “About 0855, wreckage, house and evidence for the tures, the CCVFC fire chief held off on the incident commander allowed Na- accident investigation. the shutdown, the NTSB said. tional Fuel [Gas] to enter the front yard When I arrived early Friday morn- of the destroyed home to secure the flow Minor Delay ing, I learned that one reason that the of gas at the home, which put out the Looking back at a few issues, the fact overall fire was not yet declared under natural gas fire.” This time, while digging that a lot of the Clarence Center streets control was an apparent magnesium fire up the affected area, the company’s crew initially were clogged with other fire creating a hot spot underground in the discovered that a short piece of PVC equipment meant that the first ARFF cockpit area. For unknown reasons, it (polyvinyl chloride plastic) pipe between crews had difficulties — for about 20 could not be knocked down with foam, the main line and the house shutoff minutes — trying to get the crash truck water or F-500.5 My crew came closer valve had been ruptured from the force and support truck to the locations with the crash truck and dumped 450 lb of the airplane impact. Once they sealed designated by the incident commander. (204 kg) of Ansul Purple-K6 down a vent off the pipe, the flame coming out of the Part of the access problem was tempo- hole. Each time I would dump some vent hole diminished. rary mass confusion, with many civil- Purple-K down there, the fire would go Working carefully so as not to ians crowding the area before arriving out. Then a few seconds later, it would disturb too much of the site after gas law enforcement secured the perimeter, erupt again with a “whoosh” sound. flow stopped, the ARFF crew noticed began evacuating residents and ordered At that point, I told the other fire- another small fire in part of the fuselage onlookers to leave. fighters, “We don’t just have magne- near the vent hole. I asked the NTSB Given the total fatalities on the sium down there, we have natural gas.” investigator-in-charge if we could aircraft, the destruction of the house They answered, “A gas company crew move this part closer to the road to get and the fire confined to that small was here last night, and we understood a better angle for extinguishment and area, the time lost was not of much they had shut off the gas from the street flood the area. The NTSB agreed, and concern. Case later noted that the to the house.” I replied, “Then we must a highway excavator was brought to BNIA-FD firefighters had to commu- have a broken line underground.” The the scene to lift up some of the rubble. nicate on radio frequencies that were incident commander then asked the gas That small fire and some hot spots were incompatible with the six channels company to do additional work. extinguished within 45 minutes. implemented by CCVFC and other
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after the alarm, he had established the location for the Erie County mobile command center at Clarence Town Hall and the news media staging area, enabling incident command officers to remain focused on scene safety, fire © Frank Franklin II/Associated Press II/Associated Franklin © Frank suppression and protecting exposed property from the fire and heat.
To read an enhanced version of this story, go to the FSF Web site
Thomas Chmielowiec Sr. retired as a captain in August 2009 after 28 years with the Buffalo Niagara International Airport Fire Department. Wayne Rosenkrans, an ASW senior editor, assisted in adapting and updating this story from the author’s 2009 ARFF Working Group Conference presentation.
David Bissonette, standing, Clarence disaster coordinator; and left-right, Sgt. Notes Bert Dunn, Clarence Police; Scott Bylewski, Clarence town supervisor; and Capt. 1. NTSB. Loss of Control on Approach. Steven Nigrelli, New York State Police, speak with news media on Feb. 14, 2009. Colgan Air, Inc. Operating as Continental Connection Flight 3407, Bombardier DHC- volunteer fire companies dispatched in their apparatus; even with NTSB assis- 8-400, N200WQ, Clarence Center, New by Amherst Fire Control. tance, firefighters at times had concerns York. February 12, 2009. Accident Report and difficulty accomplishing both fire NTSB/AAR-10/01. Feb. 2, 2010. Lessons Learned control and preservation of the accident 2. Case, David. “Response to Crash of Flight There really was no time to think about scene; the incident commander must 3407.” Fire Engineering. Aug. 1, 2009. what to do. Everything that firefight- ensure absolutely that utilities have been 3. Case, David. Telephone interview for ers are taught and trained to do kicked shut off completely; personal relation- Internet podcast by Bobby Halton, editor- in, and CCVFC and mutual aid did the ships developed earlier during joint drills in-chief of Fire Engineering, Feb. 16, 2009. right things automatically. among fire departments are an extremely 4. The NTSB final report said, “This accident Whether emergency calls occur on positive factor under such stressful was not survivable. … The Erie County Medical Examiner’s Office determined or off the airport, everybody in West- conditions; and the incident commander that the cause of death for the airplane ern New York’s ARFF and volunteer fire sometimes must turn down requests and occupants and the ground victim was mul- companies knows what they have to postpone decisions that can wait. tiple blunt force trauma.” do because of annual briefings, cross- I concur. Firefighters hear about it 5. Firefighters typically use F-500, produced training and drills. If a crash truck is if one responding agency doesn’t “click” by Hazard Control Technologies, for fuel ever needed, they know how to hook with another. From my personal per- fires. Unlike aqueous film-forming foam up the crash truck to hydrants, how to spective, we did not have conflicts at this that deprives a fire of oxygen, F-500 stops do hose layouts and connections, and scene. When a problem arose requiring combustion with encapsulating micelles, how to apply foam. a quick multi-agency decision, the co- described as “chemical cocoons around the hydrocarbon fuel neutralizing the fuel leg of Case, the incident commander, has ordinators got together and the problem the fire tetrahedron [the chemical reaction].” cited lessons from the overall experience: was rectified — usually in a few seconds. 6. Firefighters typically use Ansul Purple-K, a Firefighters may need drills to prepare On this topic, I learned much from potassium bicarbonate–based dry chemical for situations involving minimal/no time how David Bissonette, the disaster containing chemical additives, to extinguish en route to don turnout gear or mentally coordinator for Clarence, ran the burning flammable liquids, gases, greases rehearse what they will do while riding emergency coordination. By 30 minutes and/or energized electrical equipment.
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By Wayne Rosenkrans Line Up and SMS risk assessments convince the FAA that more of ICAO’s ATC clearance procedures and phrases canWait be adopted safely. lashing perspectives of U.S. progress “We were recently advised that the FAA soon in optimizing air traffic control (ATC) plans to adopt a single change, the use of ‘line procedures and phraseology to reduce up and wait’ instead of ‘position and hold’ to in- collision risks on airport surfaces struct pilots to enter a runway and wait for take- emergedC in December 2009 during the U.S. off clearance. … Some of the FAA’s responses [to Federal Aviation Administration (FAA) In- NTSB safety recommendations] have asked for ternational Runway Safety Summit in Wash- more time for further analysis.” ington. Time devoted to this issue paled in FAA publications in mid-2009 described comparison to other layers of defense on the pertinent changes in ATC procedures and agenda (ASW, 2/10, p. 14; 9/08, p. 46; 11/07, p. phraseology at various stages. “[The FAA] 44). Nevertheless, U.S. National Transporta- conducted a safety risk analysis of explicit taxi tion Safety Board (NTSB) and FAA talking clearance instructions, explicit runway cross- points at the summit suggested that since 2007, ing clearances, takeoff clearances and multiple a variety of new factors have persuaded the landing clearances (including landing clearances FAA to adopt elements of safety recommenda- too far from the airport),” the agency said. “We tions traceable to accident investigations more published and distributed detailed taxi instruc- than a decade ago. tions to the field in May 2008 with implementa- Deborah Hersman, NTSB chairman, criti- tion through the summer of 2008. … Among cized FAA progress in this area as too slow or related tasks to accomplish are to ‘Publish guid- unfinished. “In July 2000, the NTSB issued ance requesting positive clearance to cross any six safety recommendations to the FAA1 … to runway — all crossings of any runway must be amend various U.S. ATC procedures that, in confirmed via air traffic control clearance.’”3 the NTSB’s judgment, unnecessarily added to the risks associated with airport surface opera- Current FAA Activity tions,” she told summit attendees. “All but one of Michael McCormick, FAA director of terminal those six recommendations are still open, with safety and operations support, explained recent FAA responses in varying states of completion, FAA decision making on ATC procedures and and the remaining recommendation regarding phraseology as a panelist during the runway limitations on the use of ‘position and hold’ pro- safety summit’s closing session. “The first cedures2 has been [designated] ‘closed — unac- change that went into play [in 2008] was explicit ceptable action’ after the FAA declined to make taxi instructions or detailed taxi instructions the recommended changes. … to mitigate the risk of aircraft taxiing in the
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‘Detailed taxi wrong direction or wrong place,” he said. Input taxied onto the runway from which the aircraft from the Air Traffic Aviation Safety Action is going to be cleared for takeoff,” McCormick instructions … Program (ATSAP; ASW, 7/09, p. 12) already has said. “That mitigates the [possibility of the pilot] prompted reevaluation, however. misunderstanding and an aircraft turning onto mitigate the risk of “We are reanalyzing [although] we thought the wrong runway and actually taking off either aircraft taxiing in we had made a positive change in the system,” in the wrong direction or on the wrong runway. he said. “If there are unintended consequences Runways that are less than 1,000 ft [305 m] the wrong direction now, we need to … look at what additional risks apart are exempted from that procedure.” there are and how we mitigate, change or refine The third change, still in the works, would or wrong place.’ that process to make it work for everybody.” eliminate “taxi to” from ATC taxi instructions. The second change, implemented in August “Controllers will just issue the runway number, 2008, affected ATC clearances after crossing and then the instructions on how to get to the a runway. “[Controllers now] cannot issue runway,” he said. “That puts up an automatic a ‘cleared for takeoff’ clearance until after an ‘stop sign’ so that pilots can’t cross any runways
© Chris Photography Sorensen aircraft has crossed the active runway and because ‘taxi to’ … now authorizes the pilot to
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cross all runways and taxiways to get to As of December 2009, “line up and of completing a safety risk management the runway. When the change is imple- wait” was in the post-SRMD Panel stage. document … to explicitly require clear- mented, pilots will have to have a ‘green “[FAA] document change proposals ances to cross runways.” The plan to light’ [an explicit clearance] before they are already drafted, procedures already establish safety risk management work can cross any runways.” have been drawn up, and we are waiting groups by November 2008 was accepted The fourth change, still in devel- for the final approval,” he said. “Once by ICAO. opment, affects how ATC manages that is done, we are going to kick off at multiple runway crossings. “Controllers least a 150-day training period.” Long Evolution can only issue a clearance across one The February 2010 edition of its Most runway at a time, and then once the ICAO Audit Influence Wanted list indicates that the NTSB still aircraft is clear of that runway, the pilot In 2008, the International Civil Avia- urgently wants the FAA to “require spe- will be issued a clearance across the tion Organization (ICAO) audit of the cific [ATC] clearance for each runway next runway,” McCormick said. “[This] U.S. civil aviation system found that crossing” after more than nine years of would preclude pilots misunderstand- although the FAA Air Traffic Organi- correspondence and meetings between ing that they have been cleared to cross zation had a runway safety program, staffs of the two agencies. The pace of all intervening runways.” a safety management system (SMS) decision making has been attributed to The third and fourth changes have would not be fully implemented until several issues. been cleared by the FAA Air Traffic March 2010.4 Concerning the program, In April 2002, for example, the FAA Organization’s Safety Risk Management the audit finding said that a number told the NTSB that proposed changes Decision (SRMD) Panel, and final ap- of provisions in ICAO standards for in controller phraseology had been proval has been requested. The SRMD readback of clearances and procedures considered by a government-industry Panel had to resolve concerns about in- for aerodrome control service had not work group — using input from nine jecting more risk into the existing ATC been incorporated into this runway regional runway safety workshops and system, McCormick said. Examples of safety program but could “form part of a national summit on runway safety risks to accept or mitigate were multiple effective runway incursion prevention — and that the work group’s recommen- pilot-controller communications and measures.” dations were still being reviewed. additional coordination between the The audit finding added, “The FAA In January 2003, U.S. controllers tower local controller and the ground should revise its runway safety program implemented the shortened phrase controller. “After the pilot clears a run- to: require readback of clearances in “position and hold” to reduce radio way, and is going to be cleared onto the accordance with ICAO Annex 1 [ICAO frequency congestion and confusion for next runway, that requires another series Standards, 11.3.7.3]; apply clearances non-U.S. pilots unaware of the differ- of communications between a pilot and to land in accordance with Procedures ence between the ICAO phrase “taxi a controller, which increases the oppor- for Air Navigation Services–Air Traffic to holding position” (off the runway) tunity for an incorrect clearance or an Management [PANS–ATM] Chapter and the prior U.S. phrase “taxi into incorrect readback,” he explained. 7 [‘Procedures for aerodrome control position and hold” (on the runway). In To implement “line up and wait” in service,’ 7.9.2]; apply the phraseologies February 2004, the NTSB learned that the United States, the question of how for taxiing aircraft in accordance with the FAA work group had “determined to change the habits acquired by all U.S. PANS-ATM Chapter 12 [‘Phraseolo- that the surface phraseologies in FAA controllers and pilots became signifi- gies,’ 12.3.4.7 through 12.3.4.10]; and Order 7110.65, Air Traffic Control, and cant. “It probably took me just about [require] explicit clearances to cross ICAO [PANS–ATM] were as closely a week of feeling uncomfortable to get or hold short of a runway when a taxi matched as possible.” used to this phrase [taxiing in countries clearance contains a taxi limit beyond The work group advised the FAA that use ‘line up and wait’],” McCor- the runway in accordance with … that substituting “line up and wait” for mick said. “However, this is a dramatic PANS–ATM Chapter 7 [7.5.3.1.1.2].” “position and hold” in the United States change for the entire workforce of The FAA’s corrective action plan would be confusing for U.S. pilots [15,000] U.S. controllers and the flight in response to the audit finding also because “hold” in all other taxiing crews that will need to adjust.” said, “Currently, FAA is in the process instructions means stop the aircraft at a
34 | flight safety foundation | AeroSafetyWorld | March 2010 © Chris Sorensen Photography “the possibility of developing a human factors “These two phrases are equivalent in meaning and “The [SRMD Panel] process will permit us to to us permit will process Panel] [SRMD “The vice fromvice acontracted linguistics and phraseol- Panel] assessment of procedures the and FAA to reach adecision expected about ATC ceed anyceed or wait further for instruction. further conclude that risks from change the could be hazardsdefine and mitigate any safety risks changes to National the Airspace System. configurations that donot allow for an aircraft dure …excludes operators airport with airport clearance is issued,” FAA the proce said.- “This departure runway are crossed before atakeoff cies for issuing clearances, taxi and agency the requiring SRMD Panel analysis of proposed all intent,” FAA the said, agreeing to examine only ing eight mitigations. it had implemented runway-crossing anew to holding position.’” ty] recommendations,”ty] FAA the told NTSB. the to completely cross one runway and hold short managed at an acceptable level by implement- multiple landing clearances. audit and Air the Traffic Organization’s SMS as of 2007,however, October by ICAO the all runwaysall along route taxi the that to lead the and commitments the from 2007runway the ogy expert on “line up expert and wait”ogy and “taxi to of departure the runway.” of FAA and ICAO and phraseologies surface odology, ICAO the audit corrective actionplan holding position.” The effort was superseded particular pointparticular (as in“hold short”), donot pro- phraseology changes.”phraseology For example, as the - prior to implementation the of associatedphraseologies with [NTSB’s the safe- procedural changes and phraseology using ad- procedure. “Notice JO 7110.487…requires that study for adoption of ‘line up [and wait]’ and ‘taxi sessment of “line up and wait” led the FAA to the led wait” and up “line of sessment scheduled asix-monthscheduled SRMD Panel assessment safety summit of to led review expedited - poli www “Under the SMS, we will conduct [an SRMD SRMD [an conduct will we SMS, the “Under The convergence of FAA’s the SMS- meth In April that NTSB 2006,the learned the In August 2008,as noted, FAA the said that .flightsafety.org |
World World AeroSafety 5 | March 2010 March procedural/ 1. 4. 2. 3. 5. N otes “Final on Report Safety the Oversight Audit of “combine control alocal position only with another
35 MaintenanceMatters
An Avro 146’s nose landing gear failure can be traced to fatigue cracks in its main fitting, investigators say. Gear Collapse
BY LINDA WERFELMAN
ccident investigators blame the rough report by the U.K. Air Accidents Investigation finish on a landing gear part and the Branch (AAIB). incomplete performance of a corrective The scheduled flight from Amsterdam and airworthiness directive for a fatigue fail- the instrument landing system approach in Aure that caused the collapse of the nose landing London had been uneventful, the report said. gear on an Avro 146-RJ100 after touchdown at But then, “after touching down on the main London City Airport. wheels, the commander, who was the pilot Three passengers were treated for minor flying, lowered the nosewheel onto the runway,” injuries after the Feb. 13, 2009, accident, the report said. “As she did so, the aircraft which damaged the landing gear and the continued to pitch down until the fuselage
lower forward fuselage, according to the final contacted the surface. She then applied the © Kevin Rowett/Jetphotos.net
36 | flight safety foundation | AeroSafetyWorld | March 2010 MaintenanceMatters
wheel brakes fully as smoke started to ema- Initial examination of the broken landing nate from behind the instrument panel. This gear showed that it had fractured above its pivot, was followed by the illumination of the ‘ELEC near the top of the leg. SMOKE’ warning.” “Visual examination of the fracture surface The crew stopped the airplane on the runway, indicated several relatively small areas of crack declared an emergency and, after the engines had progression due to a fatigue mechanism, to- stopped, ordered passengers to evacuate. gether with a large area characteristic of a failure The pilots donned oxygen masks to operate in overload,” the report said. the engine fire handles, completed their “evacu- ation drills” and evacuated the airplane through Certification Tests the direct vision windows, the report said. A review of records showed that during the manufacturer’s certification testing of the nose Investigation landing gear main fitting, a test fitting complet- Investigators found scoring on the runway ed 360,532 flight cycles without failure. and a trail of hydraulic fluid, both of which “However, a subsequent [nondestructive test] indicated that the nose landing gear had inspection identified a fatigue crack in the upper broken soon after touchdown. The airplane section of the internal bore that had propagated stopped on the runway centerline about 500 partially through the radial wall,” the report said. m (1,641 ft) beyond the touchdown point. “The surface finish (roughness) of the inner bore The landing gear had “folded rearward and was confirmed as being within the limit speci- penetrated the forward equipment bay,” the fied at production of 3.2 microns.” report said, adding that the landing gear’s col- In a second fatigue test, a fitting failed at lapse caused the lower fuselage to scrape the 43,678 cycles without fracture, but a fatigue runway, resulting in damage to the nose land- crack was then found in the upper internal bore; ing gear doors, the fuselage skin and structure the crack had spread through the radial wall sec- immediately behind the landing gear bay, and tion, the report said. The surface roughness of the forward face of the lower section of the the internal bore was measured at 6.95 microns nose landing gear. — more than the production limit. “Examination of the two test specimens re- vealed that the high value of surface roughness The Avro 146’s present in the second specimen had resulted in lower fuselage was a significant reduction in the number of flight damaged after cycles required to initiate a fatigue crack in the the landing gear’s material,” the report said. collapse. Above, the As a result of the tests, in June 2000, Messier- accident airplane, Dowty, the manufacturer of the landing gear, photographed on issued service bulletin (SB) 146-32-149, which another day, at called for an ultrasonic inspection of the main London City Airport. fitting bore every 2,500 flight cycles after the fitting exceeded 8,000 flight cycles. Compliance subsequently was incorporated into the U.K. Civil Aviation Authority (CAA) airworthiness directive (AD) 002-06-2000. A second service bulletin, SB 146-32-150, called for a maximum surface roughness value of no more than 1.6 microns for the main fit- U.K. Air Accidents Investigation Branch ting internal bore, as well as shot-peening to www.flightsafety.org | AeroSafetyWorld | March 2010 | 37 MaintenanceMatters
“restore the fatigue life of the main fitting.” New cracks were found in the same groove and in main fittings were manufactured according to other nearby grooves. these specifications, and the specifications were “Examination of the inner bore confirmed “recommended to be [retroactively] embodied at that the shot-peening process had been carried Accident next overhaul for in-service main fittings,” the out, in accordance with the requirements of SB investigators found report said. 146-32-150, but that the surface roughness close fatigue cracks on “Incorporation of this SB terminated the to the origin of the fatigue cracks was 9.5 to 10.1 the fracture surface repetitive inspections introduced by SB 146- microns, in excess of the finish specified in the of the landing gear’s 32-149 and CAA AD 002-06-2000,” the report service bulletin,” the report said. main fitting. said, noting that the failed main fitting had Further examination showed that the land- been modified in ing gear actuator and torque link had failed as a accordance with SB result of the main fitting’s failure. 146-32-150. Accident investigators concluded that the Maintenance fracture of the main fitting caused the nose land- records showed that ing gear to collapse and to penetrate the lower fu- the nose landing gear selage, damaging the equipment bay and causing main fitting on the disconnection of the battery. When the landing accident airplane had gear penetrated the fuselage, hydraulic fluid was accumulated 18,299 released, causing smoke and fumes to enter the flight cycles, and that airplane. Because the battery was disconnected, U.K. Air Accidents Investigation Branch it had been over- the remote cockpit door release mechanism hauled at a Messier-Dowty facility in Sterling, could not be operated after the engines were shut Virginia, U.S., in January 2006 — 3,302 cycles down, forcing the pilots to evacuate through the before its failure. Both SBs had been in effect at cockpit direct vision windows. the time; therefore, additional repetitive inspec- tions of the main fitting were no longer required. Safety Actions In August 2009, Messier-Dowty issued SB Post-Accident Examination 146-32-174, describing a new ultrasonic After the accident, the nose landing gear was inspection technique for the nose landing removed from the airplane for analysis by the gear main fittings and prescribing a shorter AAIB and Messier-Dowty. re-inspection interval. The new service bul- The examination found no abnormalities in letin superseded SB 146-32-149. BAE Systems, material or microstructure of the main fitting. which holds the Avro 146 type certificate, Nevertheless, the report said that on the fracture subsequently issued alert service bulletin surface, there were three fatigue cracks that A32-180 (Revision 1), which introduced SB “had become conjoined to form a single crack 146-32-174 and canceled the requirements of extending 23.2 mm [0.9 in] around the cir- SB 164-32-149, and the European Aviation cumference of the upper section of the internal Safety Agency published AD 2009-0197-E, bore, with a maximum depth of 2.21 mm [0.09 which mandated compliance with the two new in].” The fatigue crack was located in the same Messier-Dowty and BAE bulletins. area where fatigue cracks were found in the two Messier-Dowty also issued SB 146-32-173 to fatigue tests. require borescope inspections of nose landing The fatigue cracks originated in “the trough gear main fittings that had been overhauled by of a fine circumferential machining groove” that its Sterling, Virginia, facility.
was in the bore when the fitting was manufac- This article is based on U.K. Air Accidents Investigation tured, and propagated for about 2,800 cycles Branch accident report no. EW/C2009.02/03, published in before the accident, the report said. Smaller February 2010.
38 | flight safety foundation | AeroSafetyWorld | March 2010 don’t run off
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CombiningEuropean seminar highlights strategies for safety improvement. BY ResourcesMARK LACAGNINA | From LISBON rgent calls for action in establish- was co-presented by the European unlikely to create any significant improve- ing binding obligations to block Regions Airline Association (ERA) and ment in air safety.” Its major drawback, he criminal prosecution of people Eurocontrol. said, is that it misses a major opportunity who provide safety informa- A regulation on aviation accident to strengthen occurrence reporting by Ution and in pooling the resources of investigation and occurrence reporting guaranteeing confidentiality for people member states to create a pan-European proposed recently by the European Com- who report safety-critical events and for air accident investigation board kicked mission (EC) was the focus of a discus- the people identified in the reports. off the Flight Safety Foundation (FSF) sion led by Mike Ambrose, ERA director Quinn said that there is an “increas- 22nd annual European Aviation Safety general, and Kenneth P. Quinn, FSF gen- ing tendency to turn accident sites into Seminar (EASS) March 15–17 in Lisbon, eral counsel and secretary, and a partner crime scenes” and discussed several Portugal. in the Washington law firm Pillsbury. investigations that were impeded by More than 200 aviation profes- Ambrose said that although well- prosecutors and police, resulting in re- sionals attended the seminar, which intentioned, the EC’s proposal “is very strictions of access to physical evidence
40 | flight safety foundation | AeroSafetyWorld | March 2010 seminarsEASS
and the refusal of individuals involved in the proposal, to ensure that aviation investigatory accidents to cooperate with investigators. agencies have priority over other agencies and to prohibit access by other agencies, the media and ‘Enough Is Enough’ the public to information gathered during an in- “The flow of important safety information is vestigation without guarantees of confidentiality. being hampered and delayed,” Quinn said. “Enough is enough. This prosecutorial abuse is ‘Obligations With Teeth’ directly putting safety on trial and the public at ERA and the Foundation have joined several risk, and it’s time to end that.” organizations in calling upon the International Regarding the current manslaughter trial Civil Aviation Organization (ICAO) to strength- of Continental Airlines and five individuals in en its protection of safety information sources. connection with the July 25, 2000, crash of Air Quinn said that ICAO Annex 13, which France 4590, a Concorde that received foreign- sets the standards and recommended practices object damage on takeoff from Paris, he said, “We for aircraft accident and incident investigation, at the Foundation believe that case is an utter “simply does not go far enough in protecting waste of resources and a great example of pros- sources of data and information that are abso- ecutorial abuse, and should be shut down now.” lutely critical to safety improvement. Ambrose and Quinn emphasized the impor- “Unless we foster a just culture environ- tance of time. “Accident investigation needs to ment, when we ask people to come forward with be rapid so that lessons are learned quickly and safety-sensitive information, we may inadver- are passed on to the operators,” Ambrose said. tently be setting them up for a loss of liberty. “It must not be jeopardized by judicial systems And that’s not fair. We need to make sure that Economic or other external agencies that seize some of the there are international obligations — with teeth concerns must not wreckage or some of the information.” — to protect these individuals.” outweigh safety, said ERA has called on the European Council Quinn noted that protection of safety- Lynn Brubaker. and Parliament, which are reviewing the EC information sources is among the topics on the agenda for the ICAO High-Level Safety Con- ference in Montreal from March 29 to April 1. “The Foundation embraces recommendations that ICAO form a multidisciplinary task force of legal experts from the aviation industry, law enforcement, judicial authorities and the public to achieve a balanced approach that is support- ive of blameless reporting and sharing of critical aviation safety information and the proper administration of justice,” he said.
‘Mandatory Club’ Ambrose and Quinn characterized as flawed a provision of the EC proposal to establish a “European Network of Civil Aviation Safety Investigation Authorities” comprising state investigatory agencies, the European Aviation Safety Agency (EASA) and EU judicial depart- ments, prosecuting offices and police that would operate under voluntary agreements to cooper-
Emily McGee ate in accident investigations.
www.flightsafety.org | AeroSafetyWorld | March 2010 | 41 seminarsEass
Ambrose said that by the Operators Guide to Human Factors the proposal for a in Aviation (OGHFA), a topic presented by “mandatory coopera- Jean-Jacques Speyer, a university professor and tive club … is a recipe retired senior director of flight operations and for costly inefficient training for Airbus. bureaucracy with no Speyer said that OGHFA, a product of the safety benefits.” FSF European Advisory Committee, comprises “Voluntary co- various materials addressing more than 100 operation is a recipe human factors topics. Available on the SKYbrary for no cooperation,” Web site, OGHFA is meant to supplement and Quinn said. “We need support threat and error management, he said. to have clear legal obli- gations.” He noted that ‘We Need New Ideas’ the Foundation sup- Concerns about the impact of the continuing Emily McGee ports a recommenda- economic downturn on safety efforts were voiced Kenneth Quinn tion by ERA to scrap the proposed network and by Lynn Brubaker, FSF board chairman, and by called for an end go forward with an option initially considered by David McMillan, director general of Eurocontrol. to the increasing the EC but rejected as “premature”: the creation “The industry must continue to research, tendency to turn of a European civil aviation safety board. investigate, innovate and educate on safety,” accident sites into “One of the reasons, we are told, that the Com- Brubaker said. crime scenes. mission has not gone down this road is that the “We must ensure that cutbacks do not have results from EASA have been less than satisfac- an effect on safety programs,” McMillan said. tory, and neither the Council nor the Parliament “We cannot afford to slow down our efforts. is consequently interested in establishing another Aviation safety in Europe, although improving, EU-wide institution,” Ambrose said. still has a long way to go.” Nevertheless, a multinational investigatory A rundown of accident statistics for world- agency would have significant advantages, he wide passenger and cargo airline operations was said. “It would permit the pooling of resources provided by David Learmount, operations and to provide improvements in training, facilities, safety editor for Flight International. He said that equipment and investigation techniques. We although the 28 fatal accidents and 749 fatalities would achieve collectively far higher standards last year were below the decade averages of 31 and of accident investigation.” 806, respectively, “traffic fell significantly in 2009, so the figures, when the rates have been finalized, ‘Spiral Dive’ will not look as good.” Further insight on how criminal prosecution Learmount discussed FSF data showing that impedes safety reporting was provided by Hans the serious accident rate among Western-built Houtman, consultant and former incident inves- jets in the 1990s dropped by nearly one-half this tigation coordinator for ATC The Netherlands. decade. He attributed this “giant leap in safety” “The open culture of reporting incidents has to the “harvesting of the fruits of the seeds sown become very fragile,” he said. in the 1980s and 1990s,” including the advent of Characterizing increased criminal prosecu- data-driven safety strategies, the Foundation’s tion as a “spiral dive that will be hard to stop,” efforts to reduce approach and landing accidents Houtman said that society must move away and controlled flight into terrain, and the global from the “old view that punishment is the best mandate of terrain awareness and warning way to eliminate errors and mistakes.” systems. Avoidance, detection and correction of hu- Since 2003, however, “there’s been no im- man error are among the key issues addressed provement at all in terms of accident numbers,”
42 | flight safety foundation | AeroSafetyWorld | March 2010 seminarsEASS
Learmount said. “Preventable accidents failures, directional control problems, Kenneth Neubauer, technical director are still happening, so there is still plenty noises/vibrations and bird strikes. for aerospace safety at Futron. of room for improvement. We need to Van Es said that in nearly one of Ed Pooley, principal consultant for come up with new ideas.” five occurrences, the RTO decision was The Air Safety Consultancy, discussed
Michel Tremaud, retired head of made before V1 but action to reject the the role of the safety pilot in augment- safety management for Airbus, said that takeoff was not taken until V1 was ex- ing and monitoring the flight crew safety can be improved if the industry ceeded. A possible factor is a standard during approach and landing. He noted does a better job of identifying accident/ operating procedure at most airlines that very little guidance exists for inter- incident precursors and utilizing the les- that requires the captain to call and vention by the safety pilot. sons learned from them. The best tool for perform an RTO. “This might involve a The importance of managerial com- this is flight data monitoring that includes transfer of control, causing difficulties munication to safety and strategies for interviews with the pilots, flight atten- and delays, if the first officer is the pilot improving it were presented by Randy dants, air traffic controllers, maintenance flying,” he said. Ramdass, senior director of technical technicians and others involved, he said. operations for Continental Airlines. Tremaud also cautioned that change ‘Train Like You Fly …’ Emma Romig, principal investigator should be viewed as a potential precur- Paul Miller, a member of the Indepen- for flight deck research and develop- sor. “Changes bring improvement, but dent Pilots Association safety commit- ment at Boeing, discussed the various they also carry their own risks,” he said. tee, and David Williams, a former line regulatory approaches to combating “We need to evaluate changes to iden- captain and check airman, explored fatigue. She also described a fatigue risk tify the risks they could bring.” the relationship between training and management system developed for the safety. Chinese civil aviation authority. Persistent Excursions Pointing to several recent major ac- Joseph Texeira, director of safety Jim Burin, FSF director of technical cidents, Williams said, “It is not poor pi- programs for the U.S. Federal Aviation programs, discussed the Foundation’s lots who are crashing airplanes but pilots Administration, described a new system effort to reduce runway excursion ac- who have been improperly trained. … developed by the agency to gather and cidents, which include overruns and You have to confirm that you train like analyze reports by air traffic controllers. veer-offs. He said that the frequency you fly and that you fly like you train.” He said that most reports to date have of runway excursion accidents has Miller said that the safety depart- identified “procedures that were not remained steady at about 30 per year. ment and the training department often working” and required correction. Data gathered by the Foundation are viewed by airlines as costs rather Ben Winfree and Ken Nagel, show that most landing accidents result than investments. “Every airline should partners at Alertness and Performance from unstabilized approaches and from be training at the same level,” he said. Management, presented the results of a not taking advantage of the opportu- Other presentations at EASS 2010 recent survey of 1,359 regional airline nity to go around, while most takeoff included a discussion by Alexander pilots. They said the results show the accidents result from takeoffs rejected Krastev, a Eurocontrol safety expert, of a need for education on fatigue risk man- above V1. wide-ranging program recently launched agement and for possible medical help The latter was the topic of a presen- by the organization to counter the rising for pilots suffering from chronic fatigue. tation by Gerard van Es, senior consul- trend in airspace infringements. Adrian Young, manager of quality tant on flight safety and operations for Thomas Lange, senior safety pilot for assurance for Denim Air, described the the NLR Air Transport Safety Institute. Boeing, presented the lessons learned hazards of operating in remote areas and
He said that although V1 is based on an about fuel system icing during the how his company meets the challenges engine failure, about 80 percent of the investigation of the Boeing 777 approach of maintaining a high level of safety. 135 high-speed rejected takeoffs (RTOs) accident at London Heathrow Airport. The final proceedings of EASS 2010, on CD, will in large commercial airplanes that led to The “Aerospace Performance Fac- be mailed to all FSF members. Information on accidents or serious incidents from 1980 tor,” a tool for integrating and monitor- purchasing a copy of the proceedings is available through 2008 resulted from other factors ing safety data gathered throughout an in the “Aviation Safety Seminars” section of the such as aircraft configuration, wheel/tire airline’s operations, was described by FSF Web site,
.S. transportation officials expect before the public comment period the changes are needed to reduce the to finalize new rules later this ended in mid-March. The Pipeline and chemical and electrical risks associated year for the air transportation Hazardous Materials Safety Administra- with lithium batteries. of lithium batteries and cells — tion (PHMSA) — the U.S. Department “This rule making is important for includingU those that are packed with or of Transportation agency that developed the protection of the traveling public and contained in equipment. the notice of proposed rule making many of those who work in the aviation Dozens of organizations submitted (NPRM) in cooperation with the Federal industry,” U.S. Transportation Secretary comments on proposed rules changes Aviation Administration (FAA) — said Ray LaHood said. “This rule will help
BY LINDA WERFELMAN Battery Rules U.S. officials are considering proposed changes in the requirements for transporting lithium batteries in cargo and passenger aircraft.
44 | flight safety foundation | AeroSafetyWorld | March 2010 CaRGOSafety
Proposed Changes ‘This rule will help us us achieve a safer aviation environment without imposing a ban on the transport of lithium bat- The changes proposed by PHMSA include the achieve a safer aviation teries by air.” following: The proposed rules, published in the Federal environment without Register on Jan. 11, 2010, apply to lithium batter- • “Eliminate regulatory exceptions for small lithium cells and batteries when included in imposing a ban on the ies and cells transported in cargo airplanes or in the cargo holds of passenger airplanes — not to an air shipment and require their transpor- 2 transport of lithium individual batteries carried on board by passen- tation as Class 9 materials, meaning they gers in their personal electronic equipment. could pose a hazard when transported; batteries by air.’ “If not safely packaged and handled, lith- • “Subject packages of small lithium batter- ium batteries can present a significant risk in ies to well-recognized marking and label- transportation,” PHMSA said in the proposed ing requirements for hazardous materials; rule. “Batteries which are misused, mishandled, improperly packaged, improperly stored, • “Require transport documentation to overcharged, or defective can overheat and accompany a shipment of small lithium bat- ignite, and, once ignited, fires can be especially teries, including notifying the pilot-in-com- difficult to extinguish. Overheating has the mand of the presence and location of lithium potential to create a thermal runaway, a chain batteries being shipped on the aircraft; reaction leading to self-heating and release of the battery’s stored energy.” • “Require manufacturers to retain results of PHMSA and the FAA have identified 44 satisfactory completion of United Nations air transport-related incidents since 1991 that design-type tests for each lithium cell and involved lithium batteries that overheated or battery type; short-circuited. The incidents “illustrate the • “Limit stowage of lithium cell and battery short circuit and fire risks … and the poten- shipments aboard aircraft to cargo locations tial for a serious incident,” the proposed rule accessible to the crew or locations equipped said. Of the 44 incidents, 23 occurred on cargo with an FAA-approved fire suppression aircraft, four in passenger aircraft cargo holds, system, unless transported in a container one in checked baggage and 16 in carry-on approved by the FAA administrator; and, items. In addition to these incidents, PHMSA • “Apply appropriate safety measures for noted that a United Parcel Service McDonnell the transport of lithium cells or batter- Douglas DC-8-71F and most of its cargo were ies identified as being defective for safety destroyed by a fire that was believed to have reasons, or those that have been damaged been caused by lithium batteries. The three or are otherwise being returned to the crewmembers in the airplane evacuated after manufacturer, and limit the transportation landing at Philadelphia International Airport; of defective or damaged cells or batteries all three received minor injuries from smoke to highway and rail.” inhalation (ASW, 4/08, p. 28).1 As a result of its investigation of that acci- Public Comments dent, the U.S. National Transportation Safety In comments submitted in response to the pro- Board (NTSB) issued a series of safety recom- posed changes, the Air Line Pilots Association, mendations, including requiring operators of International (ALPA) said it “has long voiced cargo airplanes to transport the batteries in concern that current provisions in the hazard- fire-resistant containers and/or to limit the ous materials regulations governing the trans- quantity of batteries at any single location on port of lithium batteries by air are inadequate
© Eugenp/Dreamstime.com an airplane. to protect crewmembers, passengers, cargo and
www.flightsafety.org | AeroSafetyWorld | March 2010 | 45 CargoSafety
the traveling public” and that the organization The Air Transport Association of America supports most sections of the NPRM. (ATA), noting that its member carriers transport ALPA specifically endorsed several provi- 90 percent of U.S. airline passenger and cargo sions, including the elimination of exceptions traffic, said the NPRM is “far more restrictive” for small lithium batteries, saying that the bat- than ICAO’s requirements. teries “present an unusual, significant risk “The measures proposed … are not likely in transportation, since nothing more to address the root causes of past or potential than a damaged package is necessary future incidents in air transportation but would to start a fire, possibly several hours certainly result in substantial processing and op- after the damage occurred.” erational delays that would disrupt the expedi- The organization also en- tious movement of goods along the supply chain dorsed provisions to strengthen and cause significant economic harm to a broad requirements for testing new spectrum of commerce,” the ATA said. “Such lithium battery designs and to revise disruptive impacts should be carefully consid- shipping names for lithium batteries to differen- ered along with a thorough and candid evalua- tiate between lithium ion batteries and lithium tion of the effectiveness of proposed changes.” metal batteries, which have different chemistries The Rechargeable Battery Association rec- and different fire characteristics. ommended that PHMSA abandon the NPRM in The International Federation of Air Line favor of the ICAO requirements. Pilots’ Associations (IFALPA) said that it also The association “remains strongly committed supports adoption of the NPRM, although “we to safety,” said Executive Director George Kerch- would prefer a globally harmonized approach” ner, “but this rule would not address the principal to regulating the transport of lithium batter- cause for concern — non-compliance by ship- ies. IFALPA is especially supportive of sections pers with existing transport regulations — while of the NPRM that would “align [U.S. regula- imposing unacceptable costs on all Americans.” ‘Nothing more than tions] with the provisions in the International In its public comment, the association added, Civil Aviation Organization (ICAO) ‘Technical “Billions of lithium ion cells and batteries have a damaged package Instructions for the Safe Transport of Danger- been shipped over the past decade, many repeat- ous Goods,’” and it cited provisions to “adopt edly, without a single fire on an aircraft attribut- is necessary new, proper shipping names for lithium ion and able to lithium ion cells, batteries or the products to start a fire, lithium metal batteries and to adopt a watt-hour into which they are incorporated where existing rating in lieu of equivalent lithium content.” U.S. regulations … were complied with.” possibly several The International Air Cargo Association said that portions of the NPRM “veer sharply away” Notes hours after the from the concept of international harmonization 1. NTSB. Accident Report NTSB/AAR-07/07: Inflight damage occurred.’ with “numerous regulations that would deviate Cargo Fire: United Parcel Service Company Flight 1307, significantly from international standards.” As an McDonnell Douglas DC-8-71F, N748UP, Philadelphia, example, the association cited provisions that devi- Pennsylvania, February 7, 2006. The NTSB was unable ate from ICAO’s “Technical Instructions” by “elim- to determine the cause of the fire because “potentially helpful evidence” was destroyed in the blaze. inating exceptions for most small, consumer-type batteries … and by restricting where such ship- 2. Class 9 materials are designated by the U.S. ments may be stowed aboard aircraft.” Department of Transportation as “miscellaneous The association said the “real problem … is dangerous goods.” lithium battery shipments that are not compli- Further Reading From FSF Publications ant with existing regulations. … This calls for better enforcement, rather than sweeping new Rosenkrans, Wayne. “Thermal Runaway.” AeroSafety
© Anton Starikov/Dreamstime.com © Anton regulations.” World Volume 3 (March 2008): 42–48.
46 | flight safety foundation | AeroSafetyWorld | March 2010 DataLink
BY HEMANT BHANA By the Book Good written guidance and procedures reduce pilots’ automation complacency.
s flight deck automation technol- automation activity, resulting in a fatal the nature of the airline’s fleet. Of the 273 ogy has advanced, most com- crash near Cali, Colombia.4 respondents, 87.8 percent were male. The mercial transport pilots have Against this backdrop, the author de- majority (54.4 percent) were between the transitioned from active partici- veloped a scale to measure automation ages of 41 and 50, with the next high- Apants in many processes to supervisors complacency–related behaviors as part est group between the ages of 51 and 60 of the automation. Unfortunately, this of a broader study on complacency and (28.2 percent). Examining their types of shift can lead to complacency. Avia- boredom.5 That broader study was based flight operations found that 64.3 percent tion-related automation complacency on ASRS reports from the 10-year pe- flew narrowbody aircraft in domestic occurs when a pilot over-relies on and riod between January 1999 and January U.S. operations plus Canada and Mexico, excessively trusts the automation, and 2009. The search criteria were restricted while 35.7 percent flew widebody aircraft subsequently fails to exercise his or her to anomaly reports from U.S. Federal in the international realm. Finally, 54.5 vigilance and/or supervisory duties.1 Aviation Regulations Part 121 opera- percent had flown their airplane type for Stated differently, “Pilots may tions, in which the causal factor category more than four years. The next highest become complacent because they are was flight crew human performance. group (22.3 percent) had flown their air- overconfident in and uncritical of the The search looked for any narrative plane type between two and four years. automation, and fail to exercise ap- or synopsis containing variations of the The “aircraft longevity” pilot groups of propriate vigilance, sometimes to the terms “FMC/FMS” (flight management one to two years experience and less than extent of abdicating responsibility to it computer/flight management system), one year experience comprised 9.9 per- [which can] lead to unsafe conditions.”2 “automation” and “complacency.” The cent and 13.4 percent of the sample, re- The U.S. National Aeronautics and search criteria revealed over 560 records, spectively. The sample group represented Space Administration Aviation Safety which the author cataloged and cat- 4.5 percent of the total pilot population Reporting System (ASRS) publication egorized. Those, in turn, were used to of the airline.6 Callback defines complacency through- develop questions probing the identified The term automation complacency out multiple issues as “the state of self- behaviors for the survey whose results are is interchangeable with automation satisfaction that is often coupled with shown here. The questions emphasized overconfidence, and broadly defined unawareness of impending trouble.”3 routine practices and the deliberateness as an operator no longer applying the These definitions imply that com- of a particular action (e.g., “How often do appropriate automation supervision placency occurs when the automation you deliberately … ”). Survey instruc- and monitoring. Examining the results supervisor is unaware of the current tions accentuated the need for honest from the ASRS data allowed a factorial or impending actions of the machine. answers and guaranteed anonymity. approach to the issue and revealed four Sometimes, this can have tragic results, Participants in the survey completed subcategories. Following each subcat- as evidenced in December 1995, when their responses online without time con- egory below are the related survey ques- an American Airlines crew flying a straints. Each pilot was experienced in tions and results. The results indicate Boeing 757 did not notice the aircraft’s advanced automated aircraft because of the frequency of the queried behavior as www.flightsafety.org | AeroSafetyWorld | March 2010 | 47 DataLink
a function of time. For example, a pilot The pilots reprogram the FMS with The pilots then fail to recognize any could report being engaged in a particu- new information during a mode change resulting improper automation modes. lar behavior between 31 and 45 percent (for example, the aircraft leveling after of the time. a descent or climb). The pilots do not No Cross-Checking notice the ensuing mode reversion, Pilots do not cross-check the automation Failure to Notice resulting in an altitude deviation; for the correct restrictions, route or infor- Pilots fail to notice the automation Pilots reprogram the FMS with a mation (cross-check failure complacency; mode or autopilot state after an FMS new lateral route and fail to notice that Table 2). Common behaviors include: reprogram or other distracting event the disruption in navigation informa- A pilot failing to ensure the FMS (distraction complacency; Table 1). tion has caused the automation to has the correct departure, en route or Common behaviors include: revert to HDG (heading) mode. This arrival route programmed, resulting in Air traffic control (ATC) issues causes the automation to follow head- a track deviation; a late runway change, causing pilots ing information instead of programmed Pilots receive a new routing from to reprogram the FMS. The pilots do track guidance, possibly resulting in a ATC, and subsequently fail to ensure the not notice that the descent mode has track deviation; and, FMS has activated the correct waypoint; changed or do not notice that the alti- The pilots experience an event that Pilots fail to program the correct tude crossing restrictions have dropped causes their workload to spike, such as altitude-and-speed crossing restrictions out. In both cases, an altitude-crossing a system failure or a procedure inter- in the FMS; deviation occurs; ruption caused by nonessential issues. Pilots enter a direct-to routing, and fail to ensure that the aircraft is Distraction Complacency, U.S. Airline Pilot Sample proceeding to the correct waypoint; Pilots fail to confirm that the 1. On the majority of your flights, if ATC issues a runway change or other event that selected arrival or departure procedure causes an FMS reprogram, how often do you deliberately check the automation mode (managed/VNAV PATH/open descent/level change, etc.)? waypoints and/or restrictions match the charted procedure; M = 5.03 0–15% 16–30% 31–45% 46–60% 61–85% 86–100% SD = 1.46 Pilots set the automation guidance 5.8% (16) 5.1% (14) 3.3% (9) 6.5% (18) 25.4% (70) 54.0% (149) N = 276 (FMS, instrument landing system [ILS], 2. On the majority of your flights, if ATC issues a runway change or other event that causes etc.) to the incorrect parallel runway, an FMS reprogram, how often do you deliberately check to ensure any altitude crossing resulting in inbound tracking of the restrictions are still programmed? incorrect runway; and, M = 5.11 0–15% 16–30% 31–45% 46–60% 61–85% 86–100% SD = 1.31 3.3% (9) 4.7% (13) 3.6% (10) 9.4% (26) 24.6% (68) 54.3% (150) Failure to Monitor N = 276 Pilots fail to notice incorrect per- 3. If you are interrupted by an event (such as a cabin issue, restroom break, etc.) how often do you deliberately check the aircraft’s automation mode after the event? formance information, resulting in M = 3.89 improper altitudes, speeds and weight- 0–15% 16–30% 31–45% 46–60% 61–85% 86–100% SD = 1.69 and-balance information. 12.7% (35) 13.0% (36) 12.7% (35) 15.6% (43) 25.7% (71) 20.3% (56) N = 276 Pilots fail to monitor the automation 4. When ATC issues a direct-to or a new flight plan routing or another lateral event that to ensure it is behaving as expected or requires an FMS reprogram, how often do you deliberately check to ensure the NAV mode is engaged? required (monitoring complacency; Table M = 5.37 3, p. 50). Common behaviors include: 0–15% 16–30% 31–45% 46–60% 61–85% 86–100% SD = 1.07 Pilots fail to monitor vertical 1.4% (4) 2.5% (7) 3.6% (10) 4.3% (12) 26.4% (73) 61.6% (170) N = 276 automation with raw data information ATC = air traffic control FMS = flight management system; M = mean; N = number of respondents; to ensure the aircraft will adhere to the SD = standard deviation altitude crossing restriction; Note: Pilots sampled were from a U.S. airline operating under U.S. Federal Aviation Regulations Part 121. Pilots fail to ensure the aircraft Source: Hemant Bhana automation is performing as expected Table 1 by failing to notice the aircraft has
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not acquired the top of descent point; Cross-Check Complacency, U.S. Airline Pilot Sample failing to notice the aircraft is not in the appropriate automation mode; and 5. On your flights, how often do you deliberately check that the FMS is programmed with failing to ensure proper navigation or the correct SID, en route path, and STAR against the flight plan and/or ATC clearance? M = 5.85 speed capture and hold; 0–15% 16–30% 31–45% 46–60% 61–85% 86–100% SD = 0.49 Pilots fail to monitor lateral auto- N = 276 0.0% (0) 0.4% (1) 0.4% (1) 2.2% (6) 8.0% (22) 89.1% (246) mation with raw data information to 6. When receiving a direct-to instruction or programming the FMS and more than one ensure the aircraft is on the correct waypoint with the same name is displayed, how often do you check the position navigation track; and, (frequency, distance, LAT/LONG) of the selected waypoint to ensure it is the desired one? Pilots fail to notice the automation M = 5.09 0–15% 16–30% 31–45% 46–60% 61–85% 86–100% has either overshot or undershot the SD = 1.48 5.4% (15) 5.1% (14) 5.4% (15) 4.3% (12) 18.8% (52) 60.9% (168) assigned altitude. N = 276 7. When issued a departure or an arrival route, how often do you check to ensure the Inappropriate Automation correct routing and/or altitude-crossing restrictions are programmed in the FMS against the Jeppesen or other kind of chart? Pilots use the automation inappropri- M = 5.60 0–15% 16–30% 31–45% 46–60% 61–85% 86–100% ately, or rely only on automation flight SD = 0.91 guidance, instead of exercising manual N = 276 0.7% (2) 2.2% (6) 1.4% (4) 4.3% (12) 14.5% (40) 76.8% (212) pilot skills or abilities (over-reliance 8. If ATC issues a “direct-to” instruction, how often do you switch to the plan view to ensure complacency; Table 4, p. 51). Common the aircraft is actually proceeding to the correct waypoint? behaviors include: M = 3.49 0–15% 16–30% 31–45% 46–60% 61–85% 86–100% Pilots attempt to use the automation SD = 2.21 38.0% 6.9% (19) 1.8% (5) 6.9% (19) 14.1% (39) 32.2% (89) to salvage a poor approach or a viola- N = 276 (105) tion of the FARs (such as exceeding the 9. When operating at an airport with parallel runways (for example, Runways 35L and 35R), how often do you deliberately check (during the approach briefing or any other time) to 250 kt indicated airspeed limit below ensure the correct runway and/or localizer frequency is programmed in the FMS and/or 10,000 ft); NAV radios? Pilots use the autopilot to capture M = 5.79 0–15% 16–30% 31–45% 46–60% 61–85% 86–100% the localizer and glideslope on the ILS, SD = 0.64 N = 276 0.4% (1) 0.7% (2) 0.7% (2) 1.8% (5) 10.1% (28) 86.2% (238) and do not manually take over when 10. When inputting performance data (such as V-speeds, center of gravity, and weight the aircraft does not capture the land- information), how often do you deliberately check the data for accuracy and/or ing guidance or behaves unexpectedly; reasonableness? Pilots fixate on programming the M = 5.57 0–15% 16–30% 31–45% 46–60% 61–85% 86–100% FMS during high-workload situations SD = 0.94 N = 276 1.4% (4) 1.1% (3) 1.8% (5) 5.4% (15) 15.2% (42) 75.0% (207) to the exclusion of monitoring the aircraft’s state; ATC = air traffic control; FMS = flight management system; LAT/LONG = latitude and longitude; M = mean; N = number of respondents; NAV = navigation; SD = standard deviation; Pilots exhibit poor flying skills SID = standard instrument departure procedure; STAR = standard terminal arrival procedure when the automation disengages with- Note: Pilots sampled were from a U.S. airline operating under U.S. Federal Aviation Regulations Part 121. out pilot action; and, Source: Hemant Bhana On an ILS, the pilots continue to Table 2 follow erroneous flight director guid- ance despite localizer and/or glideslope to standard operating procedures and automation mode awareness after a anomalies. good automation techniques. distraction (mean [M] = 3.89, stan- The results indicated good automa- This finding increases the impor- dard deviation [SD] =1.69). A pilot ex- tion practices by the sample group and, tance of having written and enforce- amining the airline’s operating manual by extension, the entire pilot popula- able guidance for pilots to follow. will find very limited guidance about tion. The automation practices, when For example, the results from ques- deliberately checking the aircraft’s au- viewed against the airline’s operations tion 3 show a wide distribution of tomation mode after an interruption. manual, indicated a strong adherence answers relating to the frequency of The closest analog in the flight manual www.flightsafety.org | AeroSafetyWorld | March 2010 | 49 DataLink
data not based on area navigation Monitoring Complacency, U.S. Airline Pilot Sample (RNAV) (M = 3.65, SD = 1.87). 11. When issued an altitude crossing restriction, how often do you monitor the aircraft’s The ASRS narrative data contained computed vertical path using mental math and/or raw-data information? multiple instances when pilots did not M = 5.42 0–15% 16–30% 31–45% 46–60% 61–85% 86–100% cross-check their LNAV data, result- SD = 1.03 N = 276 1.8% (5) 1.4% (4) 2.5% (7) 6.5% (18) 22.8% (63) 64.9% (179) ing in a lateral track deviation. Many 12. On the majority of your flights, when ATC issues an altitude crossing restriction, how of these deviations occurred when often do you deliberately monitor your proximity to the top of descent point, and, if the pilots did not have an adequate applicable, ensure the automation has captured the descent path? situational awareness of their current M = 5.68 0–15% 16–30% 31–45% 46–60% 61–85% 86–100% position during LNAV operations — a SD = 0.73 N = 276 0.4% (1) 0.4% (1) 2.2% (6) 3.3% (9) 15.9% (44) 77.9% (215) problem mitigated by referencing raw 13. For the majority of your flights, when conducting flight maneuvers (starting a descent, data information such as a radio mag- starting a climb, leveling off from a climb/descent, engaging NAV, etc.), how often do netic indicator needle for additional you deliberately monitor the aircraft’s mode to ensure it is doing what is desired? reference. The airline flight manual M = 5.69 0–15% 16–30% 31–45% 46–60% 61–85% 86–100% guidance issued to pilots on this topic SD = 0.61 0.0% (0) 0.0% (0) 1.4% (4) 3.6% (10) 19.2% (53) 75.7% (209) N = 276 is conditional, and only references 14. When issued a SID that is “navable” by the FMS (not an RNAV SID), how often do you certain conditions when flight crews deliberately back up your lateral guidance with raw-data information and/or mental are required to back up LNAV infor- computations? mation with radio-based raw data in- M = 3.65 0–15% 16–30% 31–45% 46–60% 61–85% 86–100% formation, despite anecdotal evidence SD = 1.87 N = 276 20.7% (57) 14.5% (40) 9.1% (25) 11.6% (32) 23.2% (64) 21.0% (58) of the benefits of radio-based raw data 15. For the majority of your flights, how often do you track the actual waypoint time and for additional situational awareness. fuel burn against the predicted values during cruise? Moreover, the language used to M = 4.45 advise pilots on this matter is complex, 0–15% 16–30% 31–45% 46–60% 61–85% 86–100% SD = 1.56 requiring high cognitive processing to N = 273 8.1% (22) 5.5% (15) 12.1% (33) 14.3% (39) 27.5% (75) 32.6% (89) understand. This example highlights the 16. On your flights, how often do you deliberately watch the altimeter to ensure the automation has captured the correct (assigned) altitude after a climb and/or descent? benefits of clear and concise language in the flight manual. When technical writ- M = 5.46 0–15% 16–30% 31–45% 46–60% 61–85% 86–100% SD = 0.94 ers create complex guidance stipulating 0.7% (2) 1.5% (4) 2.6% (7) 8.1% (22) 20.5% (56) 66.7% (182) N = 273 multiple conditions, they inadvertently ATC = air traffic control; flight management system; M = mean; N = number of respondents; cause inconsistency in pilot behavior. RNAV SID = area navigation standard instrument departure; SD = standard deviation In contrast, procedure description Note: Pilots sampled were from a U.S. airline operating under U.S. Federal Aviation Regulations Part 121. that is declarative, clear, concise and well Source: Hemant Bhana emphasized causes little variance in the Table 3 associated pilot behavior, as shown by the data for question 13. The airline’s flight describes procedures for handling a in the flight manual emphatically manual instructs pilots in boldface that checklist after a distraction. requires pilots to compare their rout- “during all phases of flight, both pilots However, question 5 results indi- ing with the pre-departure clear- must be aware of the [automation modes] cated a very narrow answer distribu- ance (PDC) and flight plan. Training and verify that they reflect the intended tion regarding cross-checking the FMS syllabi, evaluations and line checks autoflight modes.” In other sections of for route accuracy (M = 5.85, SD = further emphasize these practices. the manual, the guidance emphasizes this 0.49). The operational guidance in this As another example, the results on concept by further instructing pilots to case deliberately tasks each pilot with question 14 also indicated a wide distri- say aloud the automation mode during independently verifying the accuracy bution of answers, indicating variance specific phases of flight. of the FMS entries.7 Further written among the responses about how pilots The responses to question 13 guidance at several other locations cross-check lateral navigation (LNAV) indicated a strict adherence to this
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Despite advanced automation in Over-Reliance Complacency, U.S. Airline Pilot Sample modern airliners, the results of this 17. Think about the occasions where you have been “behind the airplane” with the survey indicate that sound standard autopilot on. For those times, how often did you turn the automation off when operating procedures that focus on the correcting (no autopilot or auto-thrust) versus keeping the automation on? fundamentals of aviation can mitigate M = 3.79 0–15% 16–30% 31–45% 46–60% 61–85% 86–100% SD = 1.61 many automation complacency– N = 273 12.8% (35) 12.1% (33) 12.8% (35) 22.3% (61) 24.9% (68) 15.0% (41) related behaviors. Creating an aware- 18. During high workload situations when FMS reprogramming is required, how often have ness of the potential pitfalls of modern you found yourself fixating on the FMS? automation through written SOPs and M = 2.92 0–15% 16–30% 31–45% 46–60% 61–85% 86–100% automation-focused training might SD = 1.31 prevent a future tragedy. N = 273 16.1% (44) 26.4% (72) 21.6% (59) 23.1% (63) 11.4% (31) 1.5% (4) 19. For the majority of your flights, how often have you found yourself focusing on the flight director to the exclusion of other guidance cues (LOG/GS indications, map view, References RMI, etc.)? M = 2.14 0–15% 16–30% 31–45% 46–60% 61–85% 86–100% 1. Parasuraman, R.; Riley, V. (1997). “Humans SD = 1.28 and Automation: Use, Misuse, Disuse, 41.0% (112) 28.6% (78) 14.3% (39) 8.8% (24) 6.2% (17) 1.1% (3) N = 273 Abu s e .” Human Factors 39: 230–253. 20. How confident are you in being able to turn off all the automation (autopilot and auto-thrust) and hand fly the aircraft in any weather condition, day or night, should the 2. Research Integrations (2007). ASRS automation start behaving unexpectedly? Incident Report Analysis. Retrieved September 2009, from Flight Deck M = 1.39 Somewhat A little Not confident Automation Issues:
Source: Hemant Bhana System,
A Code Shared Accident A television documentary finds the roots of the Colgan Air Flight 3407 accident in the changed structure of the U.S. airline industry.
AUDIO-VIDEO a dramatically changed airline industry, where regional carriers now account for half of the na- Regionals Under Scrutiny tion’s daily departures. The rise of the regionals Flying Cheap and arrival of low-cost carriers have been a huge Frontline. WGBH Boston. Producers: Rick Young and American boon to consumers, and the industry insists University School of Communication, Investigative Reporting that the skies remain safe. But many insiders are Workshop. Aired by Public Broadcasting System (PBS), Feb. 9, 2010. 56 minutes. Available on the Internet as a video, audiocast and DVD worried that now, 30 years after airline deregu- at
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“The Harrowing Crash of Continental a way of controlling costs,” Prater says. (Voss 3407” gives an overview of the flight and commented on cost controls and safety in begins to address issues identified in the NTSB ASW, 2/10, p. 1.) hearings and investigation. Clay Foushee, “The Life of a Regional Pilot” peers into the investigator for the U.S. Congress, says, “[The lives of regional pilots in which the workload is accident has] become a symbol of everything challenging, days are long, lengthy commutes to that’s wrong with the industry.” Foushee work are the norm, hourly pay is low, and time and the narrator refer to it as a “watershed on duty does not correspond to time paid, ac- accident.” cording to the program. Corey Heiser, a Colgan Air pilot from “Who’s Responsible for Safety” says, “Some 2005 to 2009, says, “We are only paid when major airlines don’t take responsibility for safety the door’s closed and the engines are running. of their regional partners — they rely on the … We may be on duty for 80 hours a week FAA. Is that agency up to it?” Congressional and get paid for 20 of it, if we’re lucky.” The hearings raised questions about who takes ‘The major airlines narrator and reporter, Miles O’Brien, says, responsibility for safety — major airlines or their created regional “Low pay and high living costs have created contractual regional airlines. Questions about an underground housing market in the airline the FAA’s mandate and its relationship with the airlines as a way of industry.” Chris Wiken, a former Colgan Air airlines it regulates are explored. pilot, says that “you can picture a one- and “A Decade of Missed Warning Signs” controlling costs.’ two-bedroom apartment with eight, 10, 12, 14 reveals documents, interviews and conver- guys in it, on roll-out mattresses and sleeping sations intended to support the program’s on the floor, sleeping on the couch, sleeping assertion that “the FAA was aware of signifi- in bunk beds, air mattresses, waiting in line cant and repeated safety concerns at Colgan for the shower.” Such quarters are known col- Air” and raises questions about safety culture loquially as “crash pads.” within the airline. Roger Cohen, speaking for the Regional “Raising Safety Standards at Regionals” Airline Association, responds: “Let’s get the discusses government and industry recommen- facts out on the table on this, Miles. The average dations and public comments that have resulted salary for a regional airline captain is $73,000. from the accident about pilot training and quali- The average salary for a first officer at a regional fications, pilot work rules, best practices, audits airline is about $32,000, $33,000 a year.” To and other safety issues. (Additional information O’Brien’s suggestion that regional airline pilots about the FAA’s “call to action” plans appear in paid less than the average are in “an untenable ASW, 2/10, p. 36.) position economically,” Cohen replies, “Abso- The video is accompanied by a companion lutely not, because there are many other people Web site produced by WGBH and contains who earn less money than that, who work more several special features that are not included days in these communities, that can afford it … in the program, such as two short videos and do it responsibly.” about work hours, rest/fatigue issues and “Growth of Regional Airlines” describes operational pressures on pilots of regional Colgan Air’s growth from a fixed-base operator carriers. There are expanded interviews to a charter company and, with deregulation with regional pilots, government regulators, of the airline industry, to a regional carrier. An industry representatives, family members of explanation of changes in the industry’s busi- victims, and others. A map of regional airlines ness model, the hub-and-spoke concept and flying into and out of major U.S. airports dis- development of code sharing leads to a discus- plays airline safety records. sion about financial pressures facing airlines. An online discussion includes extended “The major airlines created regional airlines as consideration of the issues raised by the Colgan www.flightsafety.org | AEROSafetyWorld | March 2010 | 53 InfoScan
Air Flight 3407 crash. Participants include Chris Additional maintenance-related complaints Wilken, former Colgan pilot; Loretta Alkalay, for- were submitted. mer FAA regional counsel; Mary Schiavo, former In response, the OIG audited the U.S. Federal inspector general, U.S. Department of Transpor- Aviation Administration’s (FAA’s) oversight of tation; Scott Maurer, father of Lorin Maurer, who American Airlines’ maintenance program be- was killed in the accident; and Rick Young, writer, tween June 2008 and December 2009. The audit producer and director of “Flying Cheap.” work was performed at FAA headquarters and For readers unfamiliar with PBS or Front- the FAA Certificate Management Office (CMO) line, the corporate facts section provided on the for American Airlines in Fort Worth, Texas. FAA PBS Web site,
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The OIG confirmed the allegation that was at a gate ready to depart with passengers.” maintenance deferrals had increased signifi- According to the report, American Airlines of- cantly. “From 2004 through the first five months ficials said that by December 2009, the airline of 2008, American’s number of open mainte- had implemented all but one SAT recom- nance deferrals increased by 32 percent, from an mendation; that recommendation was to be The airline average of 298 per day to an average of 394 per implemented in April 2010. day,” the report says. “Despite this increase, FAA The report says, “According to FAA’s princi- submitted at least only tracked the number of deferrals but did not pal maintenance inspector, FAA will continue identify the types of aircraft parts being deferred to monitor American’s compliance with RII 13 self-disclosures or the causes of the deferrals.” requirements until it is satisfied that a long-term concerning improper The report adds that from January 2007 to corrective action is in place. To date, however, the end of the study period, the airline sub- FAA’s actions have not elicited confidence that use or issuance of mitted at least 13 self-disclosures concerning its oversight is sufficient. For example, in re- improper use or issuance of minimum equip- sponse to the RII allegation, the CMO assigned minimum equipment ment lists (MELs). Examples included deferring one inspector to review only one MD-80 aircraft maintenance on a navigational component that — even though the MD-80 fleet is American’s lists (MELs). was not listed in an MEL, which therefore could largest, with 279 aircraft.” not legally be deferred. Finally, the report said, “We confirmed the The audit also “confirmed the allegation that allegation that American did not implement a American was not following procedures for re- Boeing service bulletin alerting carriers to prob- quired maintenance inspections. We found that lems with aircraft windshield heating systems FAA has not taken appropriate action to address that could cause the windshield to crack or shat- American’s longstanding failure to comply with ter if left uncorrected.” required maintenance inspection procedures.” The service bulletin, issued in 2006, con- The report cites the FAA’s failure to force cerned the Boeing 757 and instructed air carri- American Airlines to comply with procedures ers on how to correct the problem, which if not for required inspection items (RIIs): “Ameri- attended to could cause a component to over- can has a history of noncompliance with RII heat, possibly leading to smoke in the cockpit requirements. For example, in 2007, American and a cracked or shattered windshield. self-disclosed nine noncompliances — three “Although American took steps to imple- disclosures involved expired technician qualifi- ment the inspections, neither FAA nor the cations, and six disclosures related to RII inspec- carrier ensured the mechanics performed tions that were not conducted.” the work,” the report says. “For example: The In May 2006, a System Analysis Team engineer responsible for drafting the engineer- (SAT) formed of FAA and airline representa- ing change order — which is required to issue tives made 35 recommendations, including work cards to mechanics — left the company, promptly notifying employees whose qualifica- and the order was never released. Without the tions were about to expire. “Despite the SAT’s order, American personnel could not issue numerous recommendations, we confirmed the work cards instructing mechanics to perform allegation that an American Airlines techni- the work.” cian with an expired authorization performed The report points out that the service bul- an RII inspection on the fire-damaged MD-80 letin was not a requirement, and even had it [from the September 2007 engine fire] after been followed, correcting the identified prob- mechanics had performed significant repairs lem would not have prevented a January 2008 on the aircraft,” the report says. “American incident as the complainant alleged. In that did not discover the RII noncompliance until incident, a 757 crew made an emergency land- the aircraft had been returned to service and ing after the cockpit filled with smoke, and the www.flightsafety.org | AEROSafetyWorld | March 2010 | 55 InfoScan
inner pane of the copilot’s windshield shattered, review, [and] (b) coordinating all safety-re- blocking visibility. lated independent reviews conducted using “However, service bulletins often high- the IAC process through its new Office of light safety issues that lead to the issuance of Audits and Evaluations; [and,] an airworthiness directive,” the report says. • “Determine why FAA’s oversight did not “While an airworthiness directive has not been identify the weaknesses discussed in this issued, Boeing stated that the bulletin did have report and whether these are agency-wide safety implications based on prior incidents issues or limited to American’s CMO.” and that all carriers were expected to com- ply.” The report adds that “since the January The FAA concurred with the first five 2008 incident and subsequent February 2008 recommendations and partially concurred with allegations, American and FAA have initiated the last. or taken actions to address windshield heating — Rick Darby system concerns.” The FAA assembled an internal assistance BOOKS capability (IAC) team to review independently the February 2008 allegations and the CMO also It’s a Snap conducted a review. “However, neither review The Legacy of Flight: Images from the Archives of the Smithsonian National Air and Space Museum was comprehensive,” the report says. Romanowski, David and Melissa A.N. Keiser. Piermont, New Hampshire, The OIG recommends that the FAA: U.S.: Bunker Hill Publishing, 2010. 288 pp. Photographs, index. • “Begin a review of American’s CASS and hotography was well established by the be- reliability system to ensure that problems ginning of powered aviation, and the camera are identified and needed improvements has served the historical record. Early “flying are made; P machines” were sensational enough to attract the • “Conduct comprehensive inspections attention of any photographer who happened to of the allegations regarding operational be nearby, and many photographers ever since reliability, MELs, RII requirements and have found that aviation offers dramatic subjects. windshield inspections; • “Improve data analyses by requiring the CMO analyst and inspectors to regularly and thoroughly review available operational reli- ability data, track the types of maintenance items that are deferred, closely monitor trends in maintenance deferrals, and identify reasons for any significant negative changes in reliability or increases in deferrals; • “Issue the proposed airworthiness direc- tive that would require implementation of The Legacy of Flight includes 132 photo- the Boeing service bulletin on repairs to graphs that illustrate flight’s development, windshield heating components on 757s; through peace and war, into the space age. The • “Improve the independent review process emphasis is on people — both famous and by (a) performing verification work at air anonymous — as much as the equipment. An carriers rather than just reviewing FAA accompanying page of text offers commentary inspection records and ensuring that the re- about each photo. view results are shared with the office under — Rick Darby
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Takeoff Rejected Well Above V1 Incorrectly trimmed stabilizer resisted rotation.
BY MARK LACAGNINA
The following information provides an aware- The crew requested that the aircraft be ness of problems in the hope that they can be deiced before departure, and the deicing was be- avoided in the future. The information is based gun at 0659 local time. In the prevailing condi- on final reports by official investigative authori- tions, the Type 2 fluid had a maximum holdover ties on aircraft accidents and incidents. time of 65 minutes. Per company procedure, the 737 had been JETS parked overnight with the stabilizer at a nose- down trim setting. “It was normal practice Breaks in Routine Distracted Pilots during preflight preparations for the first officer Boeing 737-300. No damage. No injuries. to set the stabilizer trim to the takeoff position istractions and unusual situations that when the crew checked information from the interfered with normal routine led to a loadsheet,” the report said. “On this occasion, Dbreakdown of standard procedures that however, [the aircraft] was being deiced at the resulted in an attempted takeoff with an incor- time and the trim could not be set.” rect stabilizer setting and a rejected takeoff 29 After starting the engines, the pilots decided
kt above V1, according to the U.K. Air Accidents to leave the flaps up while taxiing on the slush- Investigation Branch (AAIB). covered taxiways. However, they did not check The serious incident occurred the morn- the stabilizer trim setting while conducting the ing of Feb. 6, 2009, at Birmingham (England) after-start checks. The required setting was 4.5 Airport. The 737 was scheduled for a round-trip units, but the stabilizer was set at 2.3 units — a flight to Edinburgh, Scotland. There were 100 nose-down setting that was within the allowable passengers and five crewmembers aboard for takeoff range of 1.0 to 6.3 units. the outbound sector. The first officer was desig- The loadsheet showed a takeoff weight of nated as the pilot flying. 46,766 kg (103,100 lb), or about 9,700 kg (21,385 The AAIB report said that both pilots were lb) below the 737’s maximum takeoff weight.
concerned about the weather conditions at The pilots had calculated V1 as 126 kt and VR, or Birmingham, which included 2.5 km (1.6 mi) rotation speed, as 132 kt.
visibility in snow, a broken ceiling at 2,600 ft, V1 is defined by regulations as “the maxi- surface winds from 350 degrees at 6 kt and a mum speed in the takeoff at which the pilot surface temperature of 0˚ C (32˚ F). must take the first action (e.g., apply brakes, “The first officer stated to the operator reduce thrust, deploy speed brakes) to stop the when interviewed that he was less comfort- airplane within the accelerate-stop distance” and able about the weather than the captain,” as “the minimum speed in the takeoff, following
the report said. “The captain, however, was a failure of the critical engine at VEF, at which the not sufficiently aware of the first officer’s pilot can continue the takeoff and achieve the concerns to decide to operate the outbound required height above the takeoff surface within
sector himself.” the takeoff distance.” VEF is the speed at which www.flightsafety.org | AEROSafetyWorld | March 2010 | 57 OnRecord
the critical engine is assumed during perfor- was incapable of flying] he made the decision mance certification to fail during takeoff. to reject the takeoff even though the speed was,
The report did not specify the calculated by then, well above V1.” takeoff distance. Runway 15/33 at Birmingham Tests in a flight simulator indicated that the
is 2,600 m (8,530 ft) long. nosewheel could have been raised at VR if the As the 737 was taxied to the runway, the copilot had pulled more forcefully on the con- snowfall intensity increased, and the captain de- trol column. “The results also showed that rota- cided to reduce the holdover time to 40 minutes, tion was achievable and that the aircraft could which would require that the aircraft be deiced have climbed away safely,” the report said. again if it did not depart by 0739. The captain told investigators that he felt pres- Glass Cockpit Darkens sure to depart before the deicing fluid holdover Dornier 328-300. Minor damage. No injuries. time expired. “This was compounded by the ATC nvestigators were unable to determine the [air traffic control] taxi clearance that required root cause for the failure of all five electronic them to taxi the longest route to the holding point Iflight displays during a ferry flight from Big- and caused the aircraft to be at the back of the gin Hill, England, to Southampton the afternoon queue on arrival,” the report said. “While they fo- of March 3, 2009. cused on selecting takeoff flap prior to departure, The AAIB incident report said that the air- they did not notice the incorrect trim setting.” craft had been stored in a hangar for about a year The takeoff was begun two minutes before after the tail section was repaired following an ac-
the holdover time expired. At VR, the copilot cident. It had been flown only three hours during applied normal rotation force on the control that time, although regular engine ground runs column. “He doubled his effort after his first and routine maintenance had been performed. attempt had no effect,” the report said. “The About 20 minutes into the ferry flight, the captain was aware that there was no rotation and Dornier was in instrument meteorological decided to stop the aircraft.” conditions (IMC) at 8,000 ft when the no. 1 The captain felt Airspeed was 155 kt when the pilots brought multifunction display failed. Over the next 15 the throttles to idle and proceeded with the re- minutes, the no. 2 multifunction display, both pressure to depart jected takeoff procedure. “The speed was under primary flight displays and the engine indicating control with 900 m [2,953 ft] of runway remain- and crew alerting system display went blank. before the deicing ing, which allowed braking to be reduced, and The flight crew used the standby instru- the aircraft vacated the runway at the upwind ments to conduct a localizer approach to South- fluid holdover end,” the report said. ampton Airport and landed the aircraft without time expired. Aircraft rescue and fire fighting personnel further incident. inspected the 737’s wheel brakes and, finding The display failures were traced to malfunc- no sign of fire, told the pilots that they could tions of the transformers in the high-voltage proceed to the stand. While taxiing, the pilots power supplies. “The transformers were epoxy- noticed the incorrect trim setting. encapsulated, and the potting around the They told investigators they had believed secondary winding [in each transformer] had that the inability to raise the aircraft’s nose- failed, most likely due to overheating, causing
wheel at VR was the result of a flight control the winding to short-circuit,” the report said. problem. “Both crewmembers were concerned To prevent damage from overheating, the about the weather conditions and taking off display manufacturer recommends avoidance of at the limit of the deicing holdover time,” the sustained operation when cockpit temperature report said. “When the captain saw the lack of exceeds 40˚ C (104˚ F). However, investigators rotation, his concerns about possible ice accre- concluded that it is unlikely the incident aircraft tion were reinforced, and [believing the aircraft had been exposed to such temperatures.
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The displays were replaced, and, follow- had occurred. The ground crew disconnected the ing no sign of recurrence of the problem, the tow bar and returned to the gate. aircraft was returned to service. The 757 crew observed, and cleared, a “Given the lack of any additional findings status message about the left elevator. They told Neither the flight from inspection of the incident aircraft, it has investigators that “everything appeared normal.” not been possible to determine a common Shortly thereafter, the ramp controller told the crew nor the trigger mechanism for the possible overheat crew that a collision had occurred. and breakdown of the [transformer] potting, Data from a security surveillance camera ground crew of although investigations into the failure of other showed that the 737 was stationary for 36 seconds the 757 realized units in the world fleet may lead to a definitive before the collision occurred. The airplanes, cause being identified,” the report said. which were operated by different airlines, both that a collision Similar display failures have occurred received substantial damage to their left elevators. recently in three other Dornier 328s during The probable cause of the accident was “the had occurred. ground operations. “All three aircraft had been failure of the tug operator and wing walker of subject to extended periods without airborne [the 757] to maintain clearance with the other operation,” the report said. airplane,” the report said. “Also causal was the ramp controller’s misinterpretation of the [737’s] Airplanes Backed Into Each Other gate location and her improper clearance for Boeing 757-300, 737-800. Substantial damage. No injuries. both airplanes to simultaneously push back ight visual meteorological conditions from nearly opposing gates.” (VMC) prevailed when the airplanes col- Nlided while being pushed back from gates Hard-Landing Damage Not Detected facing each other at Seattle-Tacoma (Washington, Airbus A321-231. Substantial damage. No injuries. U.S.) International Airport on Dec. 28, 2008. he A321 was inbound to Manchester, Eng- The 757 flight crew had requested and land, on a charter flight from Spain the night received clearance for pushback first, said the re- Tof July 28, 2008. The copilot, the pilot flying, port by the U.S. National Transportation Safety initiated the landing flare early, and the aircraft Board (NTSB). Shortly thereafter, the 737 crew began to float about 10 ft above the runway. requested clearance for pushback, reporting that “While in the float, the copilot’s sidestick they were at Gate 11. The ramp controller, how- moved to full forward then to full aft,” the AAIB ever, thought that the 737 crew had requested report said. “The aircraft reacted with a rapid clearance for pushback from Gate 14, and she nose-down pitch and touched down [nosegear- issued clearance for pushback. first] in a near-flat attitude. A significant bounce After pushback, the 737 was in the ramp occurred, which was controlled by the copilot; a alleyway facing north with the parking brake second touchdown and rollout ensued.” set. The flight crew was starting the no. 2 The commander taxied the aircraft to the engine and the ground crew was disconnect- stand, where the 159 passengers disembarked nor- ing the tow bar when they felt the airplane mally. “Three passenger service unit oxygen masks shudder. “The tug operator and [his] assistant had dropped from their stowages, but no other ef- immediately ran toward the rear of the 737 and fects of the landing were apparent,” the report said. observed [the 757] immediately behind the When the flight crew told a company en- 737,” the report said. gineer about the hard landing, they expressed The 757 was being pushed back into the alley- certainty that there had been some damage. way to face south when the flight crew “felt what However, the on-board data system had not appeared to be the nosewheel sliding slightly on generated a printed structural exceedance report the wet ramp,” the report said. Neither the flight based on recordings of excessive rate of descent crew nor the ground crew realized that a collision and vertical acceleration on touchdown. www.flightsafety.org | AEROSafetyWorld | March 2010 | 59 OnRecord
The engineer checked the data management landing and circled over the ocean to enter a unit (DMU) to determine if a report had been base leg. “As the aircraft was turned through the stored but not printed. “The DMU did not con- base leg and onto final approach, the visibility tain any such report; consequently, the engineer deteriorated, and a missed approach procedure concluded that the landing could not have been was conducted,” the report said. as hard as the crew suspected [and that] no While retracting the flaps, the crew felt a inspection was required,” the report said. high-frequency vibration and saw the control Nevertheless, because of the crew’s concern yokes deflect to the left. The control deflection about damage, the engineer performed a visual increased to about 40 degrees, and the autopilot inspection of the aircraft. He found no sign of disengaged automatically. damage, so the oxygen masks were restowed and “Controlled flight was maintained manu- the A321 was released for service. ally by the crew with difficulty,” the report said. Later that night, another flight crew was un- “There were no other cockpit indications to as- able to retract the landing gear while departing sist the crew to identify the problem. The cabin The engineer from Manchester. They returned to the airport crew reported that they also noticed that the and landed without further incident. aircraft was shaking and vibrating, similar to the concluded that the “Subsequent inspection of this defect effect of flying through cloud and turbulence.” landing could not identified internal damage to the nose landing The pilot-in-command (PIC) asked the cabin gear and a bent proximity switch link rod,” the manager to look out the cabin windows for any have been as hard as report said. “The [nosegear] was replaced and anomalies. The cabin manager reported that a extensive inspections were conducted before the leading-edge slat on the right wing was protrud- the crew suspected. aircraft was released to service.” ing at an unusual angle and showed the pilots a Among recommendations prompted by photograph made with a mobile telephone. the investigation, the AAIB called on Airbus The flight crew declared an urgency (pan) to review on-board data system parameters to and diverted to their designated alternate ensure that a report is issued whenever there is a airport at Nouméa, New Caledonia. Concerned potential for damage from a hard or overweight about controllability and the effects on perfor- landing, or from an abnormal landing such as a mance and fuel consumption from the aerody- nosewheel-first touchdown. namic drag created by the protruding slat, the PIC told the cabin crew to prepare the passen- Broken Slat Track Causes Control Problem gers for a possible ditching. Boeing 737-200. Substantial damage. No injuries. Lacking a checklist for the situation, the he 737 was en route the afternoon of Dec. 29, crew decided to cycle the flaps. This reduced 2007, from Brisbane, Queensland, Australia, the protrusion of the no. 4 slat; the vibration de- Tto Norfolk Island, where VMC with tempo- creased slightly, and performance and control- rary visibility and ceiling reductions was forecast. lability were improved. The 737 was landed in On arrival, visibility was 3,000 m (about 1 3/4 Nouméa without further incident. mi), the ceiling was at 500 ft, and surface winds There were no injuries during the flight, but were from the east at 20 kt, gusting to 35 kt. “a number of passengers reported psychological The flight crew conducted the VOR (VHF issues and resultant physical problems follow- omnidirectional radio) approach to Runway 11, ing the flight,” the report said. “That included according to the report issued in February 2010 by one passenger who suffered two seizures after the Australian Transport Safety Bureau (ATSB). disembarkation at Nouméa.” The aircraft was 2 nm (4 km) from the airport Examination of the 737 revealed that the when the crew established visual contact with the inboard main track for the no. 4 leading edge slat runway. They determined that excessive maneu- had fractured at mid-span. “An examination of vering would be required for a straight-in the failed track identified fatigue cracking that
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originated at the intersection of diverging ma- main landing gear was deflated and the wheel chining marks at the fracture site,” the report said. assembly was damaged. “The crew reported that there had been no TURBOPROPS prior indication of any problems with the aircraft, with normal handling during the landing and ‘Competing Tasks’ Cited in Control Loss taxiing phase of the flight,” said the ATSB report. Beech 1900C. Destroyed. One fatality. During an examination of the 340, main- MC prevailed for the single-pilot cargo tenance personnel found that about one-half flight from Honolulu, on the island of of the circumference of the wheel rim had VOahu in Hawaii, U.S., to Lihue, on Kauai, fractured but was still attached to the wheel as- the night of Jan. 14, 2008. The airplane was sembly. Damage to the axle and brake assembly nearing the destination from the south at 2,000 also was found, and replacement of the entire ft when ATC verified that the pilot had both the left main landing gear was required before the airport and a preceding Boeing 737 in sight. aircraft was returned to service. The controller then cleared the pilot to fol- The wheel had accumulated 252 hours of low the 737 for a visual approach, terminated service and 298 cycles since its last overhaul. In- radar services and told the pilot to change to vestigators found that the wheel design was being Lihue’s common traffic advisory frequency. phased out because of known fatigue cracking at Recorded ATC radar data “showed that the the rim bead seat area. “Both the manufacturer pilot altered his flight course to the west, most and the operator were aware of the increased fa- likely for spacing from the airplane ahead, and tigue susceptibility of the earlier wheel design and descended into the water as he began a turn had established increased inspection regimes for back toward the airport,” said the NTSB report. those wheels remaining in service,” the report said. The accident occurred about 6 nm (11 km) The investigation concluded that the fatigue south of the airport. Most of the wreckage sank crack likely was in the incipient stage and had in 4,800 ft of water and was not recovered. The not been detected during the last eddy current pilot was not located and is presumed to have inspection of the failed wheel. been killed. The report said that the pilot had been con- Gyro Problem Precedes Breakup fronted with the “competing tasks” of monitor- Jetprop DLX. Destroyed. Five fatalities. ing his airplane’s instruments, lining up with the he aircraft, a turboprop conversion of the runway and maintaining separation from the Piper Malibu, was en route on a private 737. This resulted in vulnerability to visual and Tflight from Edmonton, Alberta, Canada, to vestibular illusions, and reduced awareness of Winnipeg, Manitoba, the morning of March 28, his airplane’s attitude, altitude and trajectory. 2008. Shortly after the aircraft leveled off at its “The pilot most likely descended into the assigned altitude, Flight Level 270, ATC radar ocean because he became spatially disoriented,” showed that it was climbing. the report said. “Although VMC prevailed, no “When contacted by the controller, the pilot natural horizon and few external visual refer- reported autopilot and gyro/horizon problems ences were available during the visual approach.” and difficulty maintaining altitude,” said the report by the Transportation Safety Board of Undetected Crack Causes Wheel Fracture Canada (TSB). “Subsequently, he transmitted Saab 340B. Substantial damage. No injuries. that his gyro/horizon had toppled and could no uring a post-flight inspection of the air- longer be relied on for controlling the aircraft.” craft in Sydney, New South Wales, Austra- ATC radio and radar contact were lost after the Dlia, the afternoon of Feb. 9, 2009, the flight aircraft made several heading and altitude changes, crew noticed that the outboard tire on the left and began a steep descent that accelerated to more www.flightsafety.org | AEROSafetyWorld | March 2010 | 61 OnRecord
than 30,000 fpm. “On final descent, the ground- from Indore, India, to Shivpuri the morning of speed dropped [from 260 kt] to 100 kt, indicating a March 21, 2009. About 15 minutes after takeoff, a near-vertical flight path,” the report said. total electrical failure occurred, said the report by An emergency locator transmitter signal India’s Directorate General of Civil Aviation. was detected, and the Royal Canadian Mounted The aircraft was 30 nm (56 km) from Bhopal Police found the wreckage 16 nm (30 km) when the pilot told his passenger, the chief northeast of Wainwright, Alberta, about four instructor for the operator’s flight school, to use hours later. Examination of the aircraft showed his mobile telephone to inform the ATC facility that both wings and the vertical and horizontal at Bhopal Airport of their situation, their position stabilizers had failed in flight. and their intention of proceeding to Shivpuri. Investigators determined that the aircraft After receiving the information, ATC was about 712 lb (323 kg) over its maximum instructed the pilot to land at Bhopal, but there gross weight and that the center of gravity was was no reply. about 0.87 in (2.21 cm) beyond the aft limit The pilot used a hand-held global position- when the accident occurred. ing system receiver to navigate to the Shivpuri “The vacuum system appeared to have been airport, which is uncontrolled and has a 2,800-ft operating normally, although possibly at a lower (853-m) runway. On approach in VMC, he ex- setting than specified by the manufacturer due tended the landing gear manually but could not to an over-reading gauge,” the report said. extend the flaps. The 421 floated during the flare Before the accident flight, an instrument repair and touched down about 800 ft (244 m) from shop had recommended replacement of the at- the threshold. “At around 150 ft [46 m] from the titude indicator because of noisy bearings and un- runway end, the aircraft swung toward the left, stable output signals to the autopilot. The attitude probably due to pilot inputs,” the report said. indicator had been in service for 1,200 hours. The main landing gear separated, the The pilot, an executive for the company that nosegear collapsed and the engines and fuselage owned the airplane, had logged about 987 of his were damaged when the aircraft veered off the 2,200 flight hours in the Jetprop. He had passed runway and struck a ditch. There was no fire, an instrument proficiency check in December and the pilot and passenger escaped injury. 2007. Partial-panel exercises were not included, The report said that the electrical failure and were not required to be included, in the occurred because the pilot did not reset the check. Records indicated that the pilot’s last par- alternator circuit breakers before takeoff. With tial-panel training was conducted in May 2001. the alternators off line, the battery was drained Based on these findings, TSB said, “Many of charge. high-performance aircraft in Canada are oper- Lack of recent experience in the aircraft was ated in [instrument] conditions by single pilots. a factor in the accident, the report said. The The board is therefore concerned that with- pilot had logged 250 of his 11,600 flight hours out either additional instrument redundancy, in type. However, he had not flown a 421 during partial-panel currency, or both, there is a risk the 18 months preceding the accident and had that this type of accident will be repeated.” not received the required refresher training.
PISTON AIRPLANES Low Pass Ends With a Stall Piper Chieftain. Destroyed. One fatality. Electrical Failure Endangers Ferry Flight he pilot was conducting a VFR, single-pilot Cessna 421B. Substantial damage. No injuries. positioning flight from Sept-Îles, Quebec, he 421’s airworthiness certificate had expired, TCanada, to Wabush, Newfoundland and and the operator had received a permit to Labrador, for a medical evacuation flight the Tconduct a visual flight rules (VFR) ferry flight morning of April 1, 2007. About 30 minutes
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after departure, he turned off the route and flew The accident occurred at Galliano, Louisi- to Grand lac Germain, Quebec, where he made ana, U.S., the morning of March 2, 2009, follow- two passes between 100 and 300 ft over a lake- ing maintenance that included removal of the shore cottage inhabited by friends. tail rotor drive shaft from the coupling. “When The Chieftain was in a steep climbing the two components were reattached, the me- turn after the second pass when it stalled and chanic only hand-tightened the bolts, figuring descended onto the frozen lake. “The aircraft additional maintenance was still planned for the broke through the top layer of ice, which was gearbox,” the report said. about two inches thick, then bounced off the The mechanic reinstalled the drive shaft cover second layer of ice,” said the TSB report. but did not make a logbook entry indicating that the bolts [on the drive shaft and coupling] were Baggage Door Opens on Takeoff only hand-tight. “Another mechanic later per- Britten-Norman Trislander. Minor damage. No injuries. formed additional maintenance to the gearbox, he commander was rotating the aircraft for but the bolts were not checked since the mainte- takeoff from Jersey Airport, Channel Islands, nance manual did not require the removal of the Tthe morning of March 24, 2009, when he saw tail rotor drive shaft cover,” the report said. the nose baggage door warning light illuminate. The helicopter had been returned to service “He decided to continue the takeoff but, at around after an uneventful 12-minute maintenance 200 ft, saw the door open,” said the AAIB report. flight check. The accident occurred during the While the commander was turning the Tris- next engine start. lander back to the airport, the door separated and fell into the sea. “The commander contin- Selector Breaks During Gear Retraction ued the approach, and the aircraft landed safely,” Agusta A109A. Minor damage. No injuries. the report said. hile taking off from Manchester, Eng- The baggage door was not recovered, and in- land, for a flight to London on May 2, vestigators were unable to determine conclusive- W2008, the commander felt the landing ly why it opened. However, inspection of other gear handle rotate in his hand when he retracted Trislanders in the operator’s fleet showed that the gear. He asked the copilot to check the op- their door latching mechanisms were worn and eration of the gear system. that further wear could cause the door handles “When the copilot pulled on the handle prior to separate. The manufacturer subsequently to selecting the landing gear lever down, the issued a service bulletin recommending periodic handle and spindle became detached from the inspections of the latching mechanism. lever,” the AAIB report said. “Several attempts were made to lower the gear by pushing down on HELICOPTERS the visible stub of the lever, but it failed to move.” The commander diverted the flight to Red- Mechanic Left Drive Shaft Bolts Loose hill, where the helicopter was based. He flew the Bell 206L-3. Substantial damage. No injuries. 109 in a hover while discussing the situation with hortly after starting the LongRanger’s en- maintenance personnel. With fuel running low, gine for a ferry flight, the pilot heard a loud the commander disembarked the four passengers Sbang and felt a vibration. “He immediately while in a low hover, then flew to a remote area shut down the engine and exited the helicop- of the airport where he landed the helicopter on ter,” the NTSB report said. “Examination of the tires that had been placed in parallel rows. helicopter revealed that the tail rotor drive shaft Investigators determined that a circlip had and coupling had severed just forward of the not been inserted in its groove when the landing gearbox, which resulted in substantial damage gear selector assembly was reinstalled following to the tail boom.” an overhaul two years earlier. www.flightsafety.org | AEROSafetyWorld | March 2010 | 63 OnRecord
Preliminary Reports, January 2010
Date Location Aircraft Type Aircraft Damage Injuries Jan. 2 Kinshasa, Democratic Republic of Congo Boeing 727-200F substantial 3 none The flight crew turned back when a hydraulic problem occurred on departure in heavy rain. The freighter veered off the runway during the landing. Jan. 5 Auberry, California, U.S. Bell 206B-3 destroyed 4 fatal The JetRanger was on a wildlife-survey flight when it struck a power line and crashed on a hillside. Jan. 5 Prospect Heights, Illinois, U.S. Learjet 35A destroyed 2 fatal Day visual meteorological conditions (VMC) prevailed when the Learjet entered a steep bank, rolled inverted and crashed short of Runway 34 during a circling visual approach to Chicago Executive Airport. Jan. 6 Piajo, Botswana Cessna 208B destroyed 1 serious, 5 minor The Caravan flipped over during a forced landing on a wet flood plain after losing engine power on takeoff. Jan. 8 Vail, Colorado, U.S. Dassault Falcon 20 substantial 7 none The landing gear collapsed when the Falcon overran the runway during a takeoff that was rejected because of a burst tire. Jan. 8 Pierce, Idaho, U.S. Hughes 369D substantial 3 serious The helicopter touched down hard and rolled over during an autorotational landing following a loss of power during a wildlife-survey flight. Jan. 9 Kiev, Ukraine Ilyushin 76T substantial 13 NA The cargo airplane veered off the runway shortly after touching down. Jan. 10 San Lorenzo Acopilco, Mexico Agusta A109E destroyed 6 fatal The helicopter was on a night flight to Mexico City when it crashed in fog. Jan. 14 Beagle Bay, Australia Cessna 208B destroyed 1 minor The airplane stalled and crashed short of the runway during an emergency landing following a precautionary engine shutdown due to low oil pressure. Jan. 15 Kidlington, England Piper Navajo 31P destroyed 2 fatal The Navajo crashed in an open field soon after departing from Oxford Airport. Jan. 15 La Chaux-de-Fonds, Switzerland Beech C90GT King Air destroyed 2 serious, 2 minor The King Air overran the runway and struck the localizer antenna during a rejected takeoff. Jan. 18 Madison, Alabama, U.S. Beech B60 Duke destroyed 2 fatal The pilot was attempting to return to Huntsville after an engine failed on departure. The Duke struck treetops and crashed about 3 nm (6 km) from the airport. Jan. 18 Elyria, Ohio, U.S. Mitsubishi MU-2B-60 destroyed 4 fatal The MU-2 stalled and crashed short of the runway during an instrument landing system approach in instrument meteorological conditions (IMC). Jan. 19 Charleston, West Virginia, U.S. Bombardier CRJ-200ER minor 34 none The airplane came to a stop in an engineered material arresting system bed after overrunning the runway during a rejected takeoff (ASW, 12/09–1/10, p. 5). Jan. 21 Tijuana, Mexico Embraer 145LU substantial 39 NA The regional jet veered off the runway while landing in strong, gusting winds. Jan. 21 Luxembourg City, Luxembourg Boeing 747 minor 5 none The freighter was landed safely after its main landing gear struck and severely damaged a maintenance vehicle that was on the runway. Jan. 22 Sand Point, Alaska, U.S. Beech 1900C destroyed 2 fatal Night VMC prevailed with winds gusting to 26 kt when the cargo airplane crashed on takeoff. Jan. 24 Mashad, Iran Tupolev 154M substantial 46 serious, 124 none The landing gear collapsed when the airplane veered off the runway during a night landing in low visibility. Jan. 25 Senador José Porfirio, Brazil Embraer Bandeirante destroyed 2 fatal, 6 NA The Bandeirante crashed short of the runway during the third landing attempt. Jan. 25 Beirut, Lebanon Boeing 737-800 destroyed 90 fatal Night IMC prevailed when the 737 struck the Mediterranean Sea shortly after departing from Beirut. Jan. 27 Horten, Norway Robinson R44 Astro destroyed 4 fatal The R44 entered a spin at low altitude and plunged through the ice on a fjord. 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.
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