AeroSafety world
COUNTING THE HOURS Legislating pilot qualifications HELICOPTER SAFETY PROGRESS IHST midway to goal SMS TOOLS Corporate aviation’s 12 steps BEWARE OF AIRSTAIRS CLOSE CALL OVER IRELAND Falling threat is real FALSE COURSE HAZARD
The Journal of Flight Safety Foundation September 2010 BASS-Asia Business Aviation Safety Seminar-Asia November 9–11, 2010 Singapore Aviation Academy, Singapore
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Today’s best safety practices for the Asia Pacific region.
The rapid growth of business aviation in the Asia Pacific region represents opportunity for organizations and national economies.
As other regions have discovered, however, expansion is also a safety challenge. Fortunately, business aviation has already developed best practices that BASS-Asia can be applied in Asia Pacific.
is a new safety seminar, sponsored by four leading organizations to transmit practicable knowledge and techniques supporting safe flight.
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AVIATION AsBAA ACADEMY Asian Business Aviation Association Executive’sMessage Back To Where We Began hate to keep beating the same drum, but there mand for people was driven by retirement of the is one issue on which I will make an exception. baby-boomers; I don’t know about you, but I’m a We are still running out of people to run this few years older than when the recession began. business, and we still have not figured out how So, why do I think this is a safety problem? Ito ensure safety while dealing with a shortage of Because I keep seeing evidence that we don’t qualified personnel. I started talking about this have the systems and discipline required to face back in 2006, and I need to bring it up every now a sustained personnel shortage. During the last and then to remind everyone that the economic pilot shortage, the selection criteria went down downturn is transient and the personnel shortfall and the training departments were over-taxed. As is structural. I know people in the United States a result, a few years later, we are seeing accidents looking for a job are going to call me crazy, but that should never happen. Just read a few of the the fundamentals have not changed. recent headlines, or maybe review the accident re- Boeing ran the numbers again, and in mid- port from Cameroon in August’s AeroSafety World September reminded us that the industry will (ASW, 8/10, p. 24). If you think the Western world need to produce more than 1 million pilots and is immune, read the accident report on the Colgan maintenance personnel over the next 20 years. Air crash near Buffalo, New York (ASW, 3/10, p. That breaks down to 466,650 pilots and 596,500 20). It is clear we lack the systems to prevent hiring maintenance personnel. Almost 40 percent of that the wrong people, and to remove them when they number will be needed to handle growth in the can’t perform. China just came face to face with Asia Pacific Region. Growth in other developing one of these systemic weaknesses: After the most economies will account for another 20 percent of recent accident, investigators discovered that more the demand for new professionals. than 200 pilots had falsified their qualifications. The more mature aviation markets in North Anybody with three different colored pens and a America and Europe will see relatively little free afternoon can still fill out a logbook. growth but will have a lot of older people to Organizations that are focused on the next replace as they retire. Together, those regions quarter’s results must somehow find the time and will have to come up with about 450,000 new energy to deal with these long-term challenges. technical people. Aviation can’t go into this next era with rules Those are about the same numbers we heard written in the 1950s and record keeping that goes several years ago, unchanged because they were back to the technology of the quill pen. never driven by interest rates and stock markets — they were driven by demographics. There are still about 2 billion people expected to enter the middle class over the next 20 years, and they will want to fly places. The only thing that has changed William R. Voss is that those kids have finished a couple more years President and CEO of school. In the established aviation markets, de- Flight Safety Foundation www.flightsafety.org | AeroSafetyWorld | September 2010 | 1 AeroSafetyWorld
contentsSeptember 2010 Vol 5 Issue 8
MAX SPAN features 36M
12 SafetyRegulation | Minimum Flight Time
16 CoverStory | False Localizer Signal TL A BLUE TL A BLUE 12 22 HelicopterSafety | IHST Nears Mid-Point
28 AirportOps | Updating Markings
32 BusinessOps | SMS Tools for Corporate Aviation
38 GroundSafety | Airstair Vigilance
41 StrategicIssues | Safety Data Concerns 16 45 HelicopterSafety | Sightseeing Deviation departments
28 1 Executive’sMessage | Back to Where We Began
5 EditorialPage | Equip for the Future
6 AirMail | Letters from Our Readers
7 SafetyCalendar | Industry Events
9 InBrief | Safety News
2 | flight safety foundation | AeroSafetyWorld | September 2010 38
41 45
AeroSafetyWORLD telephone: +1 703.739.6700 20 FoundationFocus | Milan Agenda William R. Voss, publisher, FSF president and CEO [email protected] 40 FoundationFocus | BARS Training Begins J.A. Donoghue, editor-in-chief, FSF director of publications 49 DataLink | Australian Ground Operations [email protected], ext. 116 Mark Lacagnina, senior editor [email protected], ext. 114 53 InfoScan | Air France 447 Wayne Rosenkrans, senior editor [email protected], ext. 115 | 57 OnRecord Fumbled Numbers 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 Cracked windshield, Susan D. Reed, production specialist then a false course approach. [email protected], ext. 123 © Chris Sorensen Photography Patricia Setze, librarian [email protected], ext. 103
We Encourage Reprints (For permissions, go to
Editorialpage
Equip for the Future
ake no mistake, the effort to d’être is to cope with the crushing growth why, in tight money times, they decided catapult air traffic control tech- of operations expected in the next several to spend billions to benefit a bunch of nology to a revolutionary and decades, growth that surely will extend in jet-setters. vastly more capable level in the short order to the increasingly prosper- To that end, the NextGen Advisory UnitedM States and Europe is a very, very big ous developing world. But even at the Committee, an industry-government deal, not only in terms of scope and cost lowest level of implementation — ADS-B group chaired by David Barger, chief but also in terms of the consequences of Out as radar equivalent — the idea of executive officer of JetBlue and treasurer success or failure. controllers being able to monitor and of Flight Safety Foundation, has been There is a staggering amount of work accurately sequence precision approaches formed not only to keep development yet to be done, but in the United States there at remote airports is but one example of on an agreed path, but also to forge a also has been an impressive amount of the many safety benefits, or advances consensus business case that details why work completed, and the rate of implemen- such as the 4-D Weather Box, real-time this technology should be embraced. tation is accelerating. Clearly, the pressure weather data flowing into the aircraft in Several years ago, Southwest Airlines is on to make the two systems, NextGen in fairly early ADS-B In usage. was known to favor low-tech cockpits. the United States and Single European Sky Money, however, is and will remain Then came a fleetwide equipage with ATM Research (SESAR) in Europe, highly an obstacle. Much of the spending is the head-up displays, followed several years harmonized, not perfect clones, but close government’s, and anyone in the United later by avionics for RNP (required navi- enough to not get in the way. States tracking the ability of the Federal gation performance) operations. It has A possibly overly simplistic explana- Aviation Administration to get its budget been said SWA went the latter route tion of the difference between the two au- through Congress knows of the multiple because the carrier believed it could save tomatic dependent surveillance-broadcast built-in barriers in that process. one minute per flight. This is the sort of (ADS-B) modes that are the heart of this Users also will have to put up a fair vision managers need to develop today advance is this: ADS-B Out is the airplane chunk of cash to be part of the sys- to see the payoffs on the other side of signaling its global positioning system- tem. However, users are reluctant to the expense. derived position for the air traffic service equip their aircraft with even the well- provider to process as if it were advanced defined ADS-B Out without proof that radar with fantastic coverage down to the they’re not just buying a new box lacking ground; ADS-B In, on the other hand, is a net benefit for them. data flowing into the airplane from ground Despite the safety arguments for buy- facilities and other aircraft. ing into equipage, managers in today’s J.A. Donoghue To my mind, NextGen and SESAR are economic climate — and legislators — Editor-in-Chief safety systems, even though their raison must ask that question so they can explain AeroSafety World www.flightsafety.org | AeroSafetyWorld | September 2010 | 5 AirMail
Flow and Check or Do and Verify? military aviation to my current work n the July AeroSafety World cover as an MD-11 pilot, I have never been story [p. 12] on checklists and moni- tasked to do a second check of the same Itoring, the authors make the point item when, after completing the flow that the use of “flow and check” proce- part of the checklist from memory, I dures may increase the chance of pilots have then referred to the actual check- committing errors of omission. list to confirm that I have accomplished They specifically state that, in all the applicable items. at least one instance and presum- Instead of an attempt to get pilots ably more, “both pilots tasked with to “check things twice,” I feel that flow the flow procedure did not do it or and check is more “do and verify,” attended to only some of the flow and is very effective. True, there are items. As a result, most items were times when I’ve forgotten one of the performed only while using the flow items. But that is discovered checklist, eliminating the protective when I refer to the checklist and read redundancy designed into the flow through the items — verifying that and check procedure ... .” They also my memory did not fail in recalling argue that requiring pilots to “check them all. encourages things twice” in a short period of time I would not like to revert to a AeroSafety World comments from readers, and will (as I assume they feel is required in situation where I was required to do assume that letters and e-mails the flow and check procedure) is not a normal procedure, or an abnormal are meant for publication unless a good way to ensure the item is actu- procedure that required immediate ac- otherwise stated. Correspondence ally accomplished. tion to prevent the situation’s becom- is subject to editing for length Finally, they recommend that airlines ing worse, while I accessed a checklist and clarity. eliminate excessive repetition of items (cabin pressure loss comes to mind), on any flow and check procedure used. solely by taking out the checklist, read- Write to J.A. Donoghue, director The main disagreement I have with ing the first item, taking that action, of publications, Flight Safety their thoughts on flow and check pro- reading the second item, taking that Foundation, 601 Madison St., cedures is that they do not represent an action, etc. Suite 300, Alexandria, VA attempt to get pilots to check the same Thank you. 22314-1756 USA, or e-mail thing twice at all. Having used flow Alan Gurevich
6 | flight safety foundation | AerosafetyWorld | September 2010 ➤ safetycalendar
CALL FOR PAPERS ➤ 16th International SEPT. 26–27 ➤ ICAO/McGill University OCT. 9–10 ➤ Executive Aviation Safety Symposium on Aviation Psychology. Worldwide Conference and Exhibition: Air Symposium. University of Southern California Wright State University and Air Force Research Transport: What Route to Sustainability? Viterbi School of Engineering. Los Angeles. Laboratory Human Effectiveness Directorate. International Civil Aviation Organization and McGill
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 Executive Vice President Kevin L. Hiatt for a neutral clearinghouse to disseminate objective safety information, and for a credible General Counsel and knowledgeable body that would identify threats to safety, analyze the problems and and Secretary Kenneth P. Quinn, Esq. recommend practical solutions to them. Since its beginning, the Foundation has acted in the Treasurer David J. Barger public interest to produce positive influence on aviation safety. Today, the Foundation provides
Administrative leadership to more than 1,040 individuals and member organizations in 128 countries. Manager, Support Services and Executive Assistant Stephanie Mack MemberGuide Financial Flight Safety Foundation Headquarters: 601 Madison St., Suite 300, Alexandria, VA, 22314-1756 USA Chief Financial Officer Penny Young tel: +1 703.739.6700 fax: +1 703.739.6708 Accountant Misty Holloway flightsafety.org
Membership Director of Membership and Seminars Kelcey Mitchell Seminar and Exhibit Coordinator Namratha Apparao Membership Services Coordinator Ahlam Wahdan
Business Development Director of Development Susan M. Lausch Member enrollment ext. 102 Communications Ahlam Wahdan, membership services coordinator [email protected] Director of Seminar registration ext. 101 Communications Emily McGee Namratha Apparao, seminar and exhibit coordinator [email protected] Seminar sponsorships/Exhibitor opportunities ext. 105 Technical Kelcey Mitchell, director of membership and seminars [email protected] Director of Donations/Endowments ext. 112 Technical Programs James M. Burin Susan M. Lausch, director of development [email protected] Technical Programs Specialist Norma Fields FSF awards programs ext. 105 Kelcey Mitchell, director of membership and seminars [email protected] Manager of Aviation Safety Audits Darol V. Holsman Technical product orders ext. 101 Namratha Apparao, seminar and exhibit coordinator [email protected] Technical Specialist/ Safety Auditor Robert Feeler Library services/seminar proceedings ext. 103 Patricia Setze, librarian [email protected] International Web site ext. 117 Regional Director Paul Fox Karen Ehrlich, webmaster and production coordinator [email protected] 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 | September 2010 Safety News inBrief Fatigue-Fighting Proposals
he U.S. Federal Aviation Administration (FAA) has pro- posed a new rule to help prevent commercial pilots from Tflying while fatigued. The proposal would establish new limitations for flight and duty time, and new rest requirements — all based on fatigue science, the FAA said. “After years of debate, the aviation community is moving forward to give pilots the tools they need to manage fatigue and fly safely,” said FAA Administrator Randy Babbitt, noting that updated rules are needed because of changes in the operations of the global aviation system. The FAA said the proposed rule would establish a nine- hour “minimum opportunity for rest” before a duty period © DNY59/iStockphoto.com begins; current rules prescribe an eight-hour period. The notice of proposed rule making, published in Septem- The proposal also would “establish a new method for ber, will be subject to public comment for 60 days. The FAA measuring a pilot’s rest period so that the pilot can have the said it will issue a final rule by Aug. 1, 2011. chance to receive at least eight hours of sleep during the rest Pilot fatigue has been an issue for years, but the FAA period,” the FAA said. “Cumulative fatigue would be ad- designated it as a top priority after the Feb. 12, 2009, crash of dressed by placing weekly and 28-day limits on the amount a Colgan Air Bombardier Q400 during approach to Buffalo- of time a pilot may be assigned any type of duty. Additionally, Niagara International Airport in Buffalo, New York, U.S. All 28-day and annual limits would be placed on flight time.” 49 people in the airplane and one person on the ground were Under the proposed rules, air carriers could not assign killed, and the airplane was destroyed (ASW, 3/10, p. 20). pilots to work if they are fatigued; fatigued pilots also would be The U.S. National Transportation Safety Board said the prohibited from accepting a work assignment. probable cause of the crash was the captain’s inappropriate “In addition,” the FAA said, “a company employee who sus- response to a stick shaker activation, which resulted in an pects a pilot of being too fatigued to perform his or her duties unrecoverable stall. Fatigue was cited as a likely factor, al- during flight would be able to report that information to the though accident investigators said they could not determine air carrier so that the air carrier could make a determination of the extent to which the crew’s performance was affected by whether or not the pilot is too fatigued to fly.” fatigue.
Harmonized Pilot Licensing Category 1 for Nigeria
he European Aviation Safety Agen- igeria has earned a Category 1 safety rating from the U.S. Federal Aviation cy has proposed regulatory changes Administration (FAA), which means that its civil aviation authority meets the Tto extend the same pilot licensing Nsafety standards set forth by the International Civil Aviation Organization. requirements to all states represented in The rating, awarded under the FAA International Aviation Safety Assessment the European Commission (EC). (IASA) Program, followed a July review of Nigeria’s civil aviation authority. Air car- The proposal was the subject of riers in countries with Category 1 status may apply to operate flights to and from public comments from June 2008 until the United States. February 2009. It ultimately will be Harold Demuren, director general adopted by the EC, and will become of the Nigerian Civil Aviation Author- law by April 2012. ity, led the agency in a multi-year effort © Niko Guido/iStockphoto.com to upgrade the country’s aviation safety record. The effort began after a string of fatal accidents in 2006.
“Not only has the effort resulted in Ni- Adrian Pingstone/Wikimedia geria becoming the first African country in decades to achieve a new Category 1 rating, it also greatly improved Nigeria’s aviation safety record,” Flight Safety Foundation President and CEO William R. Voss said.
www.flightsafety.org | AeroSafetyWorld | September 2010 | 9 inBrief
New Magazine Expanded Blacklist Quality Control
he AviAssist he European Founda- Commission’s Ttion — the Tlist of airlines regional affiliate banned from operat- of Flight Safety ing in the Euro- Foundation pean Union has been for East and expanded to include Southern Africa Meridian Airways, — has published registered in Ghana. the first issue The updated of SafetyFocus, its quarterly journal on blacklist also placed African aviation safety. restrictions on a The magazine is a spinoff of second Ghanaian AeroSafety World, and more than 750 airline — Airlift © Meridian Airways African aviation safety professionals International — “We cannot afford any compro- “are now benefitting from the ASW which will be permitted to operate mise in air safety,” said Siim Kallas, wealth of articles,” said Tom Kok, direc- only one of its four aircraft into the European Commission vice president tor of AviAssist. European Union. responsible for mobility and trans- “By reaching out for industry The list now includes nearly all port. “Where we have evidence that support in the form of advertising, we carriers from 17 countries — although air carriers are not performing safe ‘Line Up and Wait’ are making this information available exceptions have been granted for 10 operations or where the regulatory largely for free,” Kok said. “Access to operators. In addition, the list bans authorities fail in their obligation safety information should not be lim- five air carriers headquartered in other to enforce the safety standards, we ited by the bandwidth of your connec- countries, and limits the operations of must act to … exclude any risks to tion or your ability to pay.” 10 additional carriers. safety.”
Proposed Penalty
he U.S. Federal Aviation Administration (FAA) has pro- posed the largest civil penalty in agency history — $24.2 Tmillion — against American Airlines for allegedly failing to comply with an airworthiness directive calling for specific inspections of wiring on McDonnell Douglas MD-80s. The FAA said that American “did not follow steps outlined in a 2006 airworthiness directive requiring operators to inspect wire bundles located in the wheel wells of MD-80 aircraft.” Under Airworthiness Directive (AD) 2006-15-15, opera- tors were required to conduct “a general visual inspection by Renee Schwietzke/Wikimedia March 5, 2008, for chafing or signs of arcing of the wire bundle The FAA said that it discovered the violations during for the auxiliary hydraulic pump.” Corrective actions also were March 25, 2008, inspections of two American Airlines MD- prescribed. 80s. In subsequent inspections, the FAA identified eight more The FAA said the actions required by the AD were MD-80s that did not comply with the AD. The airline began intended to prevent wires near the auxiliary hydraulic grounding all of its MD-80s on April 7, 2008, “to conduct new pump from shorting or arcing, which could cause a loss of inspections and redo work as necessary,” the FAA said. auxiliary hydraulic power or a wheel well fire. The AD also The FAA concluded that American operated 286 of its MD- was intended to “reduce the potential of an ignition source 80s on a total of 14,278 passenger flights while the aircraft were adjacent to the fuel tanks, which, in combination with the not in compliance with regulations. flammable vapors, could result in a fuel tank explosion,” the The airline has 30 days from its receipt of the penalty letter FAA said. to respond to the FAA.
10 | flight safety foundation | AeroSafetyWorld | September 2010 inBrief
Quality Control
he in-flight shutdown of an engine on a Japan Air Com- muter DHC-8 has prompted the Japan Transport Safety TBoard (JTSB) to recommend improved quality control in the production of an engine gear shaft. The JTSB said that Transport Canada should take steps to ensure that Pratt & Whitney Canada (PWC), which manu- factured the engine, makes “companywide efforts, including the management of the metal stock supplier and component manufacturer serving PWC, toward the improved quality con- trol concerning the production of the RGB [reduction gearbox] © contri/Flickr helical input gear shaft.” Fatigue failure of the RGB helical input gear shaft was In making its recommendation, the JTSB cited a March 25, “highly probable,” according to the JTSB report on the incident. 2009, incident in which the DHC-8 crew heard an “abnormal The agency said that the incident should be “reassessed noise” after takeoff from Tanegashima Airport and noted instru- from the viewpoint of the safety of the entire aircraft, and safety ment indications of an engine failure. They shut down the no. 1 en- improvement actions should be taken if the results of the reas- gine and conducted an emergency landing at Kagoshima Airport. sessment indicate this to be necessary.”
‘Line Up and Wait’ In Other News …
ecause of an official change in terminology, air traffic controllers at U.S. egardless of regulatory require- airports are about to begin telling pilots to “line up and wait” when it’s time to ments, all aircraft should be Btaxi onto a runway to await takeoff clearance. The change takes effect Sept. 30. Requipped with at least one The words “line up and wait” are prescribed by International Civil Aviation portable fire extinguisher “in a Organization guidelines and have been in use throughout the world. In the United place that is accessible to pilots,” the States, however, controllers have used the phrase “position and hold.” Civil Aviation Safety Authority of The U.S. Federal Aviation Administration (FAA) said that a safety analysis Australia (CASA) says. The hand-held performed by the agency’s Air Traffic Organization Terminal Services found that extinguishers should be “capable of using “line up and wait” would “eliminate confusion, particularly among pilots who controlled flow” and capable of being also fly overseas, and further reduce the risk of runway incursions.” operated by a single person, CASA The FAA said that the complete instruction to pilots will include the aircraft says. … The U.S. National Transporta- call sign, the departure runway and “line up and wait.” tion Safety Board (NTSB) is repeat-
© Ken Cole/Dreamstime.com ing its recommendation that the U.S. Federal Aviation Administration require separate seats for all aircraft passengers, including children under age 2 who currently may be held on an adult’s lap. These children “should be afforded the same level of protection as all other persons aboard air carrier airplanes,” the NTSB said. … Nearly half of all fatal general aviation acci- dents result from poor planning and decision making by pilots, according to a study by the Australian Transport Safety Bureau. Among the examples are failure to reject a takeoff despite poor engine performance and failure to check weather forecasts.
Compiled and edited by Linda Werfelman.
www.flightsafety.org | AeroSafetyWorld | September 2010 | 11 safetyregulation
A new law calls for an increase in the minimum flight time required of pilots hired by U.S. air carriers. Counting the Hours BY LINDA WERFELMAN
new law requiring pilots in U.S. Federal accumulated at least 1,500 flight hours and meet Aviation Regulations (FARs) Part 121 other specific criteria. The provision will take operations to have at least 1,500 flight effect in August 2013. hours might not have the safety- However, the act also says that the FAA may Aenhancing effects that its supporters had hoped allow “specific academic training courses … to for, some aviation safety specialists say. be credited toward the total flight hours,” if the Backers of the new law, however, say it will re- FAA administrator has determined that these sult in significant improvements in aviation safety. courses “will enhance safety more than requir- Provisions of the Airline Safety and Federal ing the pilot to fully comply with the flight Aviation Administration (FAA) Extension Act hours requirement.” of 2010, signed into law by President Barack “It remains to be seen how that exception Obama on Aug. 1, will require Part 121 pilots will be applied,” said Flight Safety Foundation to hold an airline transport pilot (ATP) certifi- President and CEO William R. Voss. “Over-
cate — which is issued only to those who have all, I can certainly understand the intent of © Chris Photography Sorensen
12 | flight safety foundation | AeroSafetyWorld | September 2010 safetyregulation
the 1,500-hour minimum to ensure that the them to obtain a type rating before being per- airlines are hiring pilots with more experience mitted to operate the controls while passengers and sharper skills, but I’m not sure this new are aboard their aircraft. The FAA currently requirement is going to have the effect that requires only captains to possess type ratings; was desired.” some large airlines, however, already require Instead, Voss said, airlines may be forced to type ratings for copilots. bypass pilots who possess excellent flight skills An FAA spokeswoman said the ARC’s rec- but lack the flight time requirement established ommendations would “help [the FAA] comply by the new law. with the recent safety bill and strengthen pilot “Ideally, we should be better able to under- experience.” The ARC’s recommendations will stand the skills that are needed and how to be used as the FAA drafts an NPRM dealing measure them,” Voss said. with pilot qualifications and training, she said. The ANPRM was published in the aftermath Dramatic Upgrade of the fatal Feb. 12, 2009, crash of a Colgan Air Rep. James Oberstar, a Minnesota Democrat Bombardier Q400 during approach to Buffalo who chairs the U.S. House Committee on Niagara (New York, U.S.) International Airport Transportation and Infrastructure, said the new (ASW, 3/10, p. 20). All 49 people in the airplane law will “dramatically upgrade the training and and one person on the ground were killed in the experience necessary to be an airline pilot.” accident and the airplane was destroyed.2 Obama signed the law as an FAA panel In the ANPRM, the FAA noted the first of- was considering public response to an advance ficer’s experience level — when hired by Colgan, notice of proposed rulemaking (ANPRM) on she had less than 1,500 flight hours, including six possible changes in regulations involving train- hours of actual instrument time and 86 hours of ing and qualifications of commercially rated simulated instrument time, although by the time copilots in Part 121 operations.1 In the ANPRM, of the accident, she had accumulated 2,244 hours published in February 2010, the FAA specifically — and said that the crash “focused attention on requested comments in several areas, including: whether a commercially rated copilot in Part 121 operations receives adequate training.” • Should all Part 121 air carrier pilots be required to hold an ATP certificate? Considering Options Counting the Hours • Should the FAA create a new endorsement When the ANPRM was published in February for “second-in-command (SIC)” privileges 2010, FAA Administrator Randy Babbitt said in in Part 121 operations? testimony before a congressional subcommittee • Should the FAA accept specific academ- that he did not believe “that simply raising … ic studies in lieu of some of the flight the total number of hours of flying time or expe- hours required before a pilot is issued an rience without regard to the quality and nature ATP certificate? of that time and experience is an appropriate method by which to improve a pilot’s proficien- • Should required training include “operat- cy in commercial operations.” ing experience in a crew environment, Instead, Babbitt said, the FAA planned to in icing conditions and at high-altitude consider other options. operations?” “For example, a newly certificated commer- The aviation rulemaking committee (ARC) that cial pilot might be limited to certain activities reviewed comments generated by the ANPRM until he or she could accumulate the type of was expected to recommend in late September experience deemed potentially necessary to that the FAA increase the training required for serve as a first officer for an air carrier. We are new Part 121 copilots — and perhaps require looking at ways to enhance the existing process
www.flightsafety.org | AeroSafetyWorld | September 2010 | 13 safetyregulation
for pilot certification to identify discrete areas that the current requirements are in need of an where an individual pilot receives and suc- overhaul and that simply increasing the mini- cessfully completes training, thus establishing mum required flight time for new first officers operational experience in areas such as the could prove counterproductive. multi-pilot environment, exposure to icing, high “The U.S. pilot training and assessment ‘The U.S. pilot altitude operations and other areas common system urgently needs an update … especially to commercial air carrier operations. We view in the field of multi-crew operations,” said training and this option as being more targeted than merely the International Air Transport Association increasing the number of total flight hours (IATA), calling for creation of a special panel assessment system required because it will be obvious to the carrier to “review current requirements and to include urgently needs what skills an individual pilot has.” best practices from other parts of the world, In comments submitted in response to the especially Europe.” an update.’ ANPRM, pilot organizations and airlines agreed Not all members of a Part 121 air carrier crew should be required to hold an ATP, IATA said. “For the SIC … it is sufficient to undergo a solid and structured training program that enables [him or her] to act safely as copilot in a multi-crew transport airplane environment in all regimes of flight,” the organization added. IATA endorsed a plan to introduce an “ATP– SIC” pilot certificate that, in most cases, would require applicants to have at least 750 flight hours. The Air Line Pilots Association, Internation- al (ALPA), which represents 53,000 pilots who work for 38 airlines in North America, agreed that current pilot training regulations “have failed to keep pace with the dynamic airline industry.” The current regulations “were first pub- lished in an era in which common business practices, driven not by regulation but by the supply of pilots and equipment in use, dictated that low-time, commercial-certificated pilots could only get airline jobs flying small, slow, propeller-driven aircraft and as flight engineers on jet transports,” ALPA said. “Pilots would traditionally fly several years and thousands of hours before even being given an opportunity to upgrade to first officers on high-perfor- mance jet transports. Today, it is not uncom- mon for new-hire pilots to be employed as first officers of high-altitude, high-performance aircraft carrying 50 or more passengers in highly complex Part 121 operations. This real- ity demands that airlines hire pilots with more
knowledge and greater skills than the new-hire © Chris Photography Sorensen
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airline pilots of the past, but in fact, in successful and competent comple- alternative path to produce a well-qual- just the opposite is happening at some tion of the job functions required of a ified SIC in a Part 121 program. This airlines.” second-in-command.” is preferred in lieu of simply requiring ALPA endorsed creation of a new more flight hours to meet the new re- “restricted” ATP certificate for other- No New Avenues quirement, which adds significant cost wise qualified pilots with fewer than Continental Airlines endorsed the to obtain the minimum qualification 1,500 flight hours or for those younger 750-hour minimum in the form of a without guaranteeing a commensurate than age 23. To be issued this new re- “commercial transport certificate” for safety enhancement.” stricted ATP, pilots should have at least Part 121 SIC pilots, adding, “We envi- In fact, Boeing cautioned, a move 750 flight hours, ALPA said. sion this to be a full certification effort to increase the minimum flight hours with detailed training requirements and might “adversely impact the flow of Exam Revision? formal knowledge and skills testing. We available pilots to support Part 121 JetBlue Airways said that all pilots in would expect it to be administered only operations and potentially negatively Part 121 operations should demon- by accredited aviation academic institu- affect the quality as well, as pilots strate the ATP knowledge requirements tions or by AQP [advanced qualifica- become more interested in acquiring described in the FARs and pass the tion program] qualified carriers.”3 flight time rather than ensuring the ATP written exam. The airline added, Continental said that a 1,500- value of the experience.” however, that the written exam is out- hour minimum for all Part 121 pilots Under the new law, the FAA has 36 dated and should be revised to “mirror is “unrealistic,” in part because of the months to issue a final rule spelling out the evolution of the industry.” limited opportunities for future pilots exactly how the training requirements “Fundamentally, JetBlue believes to accumulate flight time. will be implemented. The ARC’s input the correlation of knowledge and “Historically, commuter carriers on the ANPRM will be considered in experience to a pilot’s total flight time (now regionals) have been the primary drafting a final rule. is unjustified,” the airline said. “Our opportunity for a non-military pilot to FlightSafety International kindly provided proposal centers on the quality — not gain experience,” the airline said. “If access to simulators for ASW photographer quantity — of experience.” regional airline hiring minimums are Chris Sorensen. Any flight time requirement that raised significantly, another avenue Notes might be intended as an indication of must replace it. There simply isn’t one. strong aeronautical knowledge and expe- “The inference is made that a 1. FAA. “New Pilot Certification Require- rience is “without basis, and is merely an general aviation track pilot can achieve ments for Air Carrier Operations.” Federal unsound, arbitrary guess,” JetBlue said. the required 1,500 hours of experience. Register, Docket No. FAA-2010-0100. Feb. 8, 2010. The airline’s written statement said The reality is that there is simply not that a pilot with a commercial certifi- enough general aviation activity to pro- 2. NTSB. Accident Report NTSB/AAR- cate, an instrument rating, 500 flight vide 1,500 hours of experience for each 10/01, Loss of Control on Approach; Colgan Air, Inc., Operating as Continen- hours and 250 hours performing the of the potential number of non-military tal Connection Flight 3407; Bombardier duties of pilot-in-command “would pilots the industry will require.” DHC-8-400, N200WQ; Clarence Center, have a sufficient level of experience to Boeing, which endorsed “focused New York, February 12, 2009. The NTSB operate as second-in-command” in a training” to produce well-qualified SIC identified the probable cause as “the Part 121 operation, and therefore, those pilots and argued against specifying captain’s inappropriate response to the requirements should be imposed for an a minimum flight hour requirement, activation of the stick shaker, which led to an aerodynamic stall from which the ATP-SIC certificate for pilots in FARs estimated in mid-September that the airplane did not recover.” Part 121, 125 and 135 operations. commercial airplane industry in North JetBlue also challenged the current America will need 97,350 new pilots 3. Under an AQP, the FAA may approve what it considers “significant departures requirement that ATP applicants must over the next 20 years. from traditional requirements” for Part be at least 23 years old, noting that the The company added, “Focused 121 and Part 135 pilot training and airline “is not aware of any data that training in the form of targeted founda- checking, “subject to justification of an suggest that age is a contributing factor tional training and education offers an equivalent or better level of safety.” www.flightsafety.org | AeroSafetyWorld | September 2010 | 15 Coverstory
A business jet was in clouds when the pilots initiated a steep descent, following a spurious navigation signal toward high terrain.
False Localizer Signal BY MARK LACAGNINA
he flight crew initiated an emer- ground-proximity warning system situational awareness while attempting gency return to an Irish airport (EGPWS). to return to EIKY following a windshield after the Gulfstream IV-SP’s After climbing — and experiencing fracture encountered shortly after take- windshield cracked on takeoff in further navigational difficulties — the off.” The report said that the following Tinstrument meteorological conditions. crew landed the GIV. Neither the pilots were contributing factors: The aircraft was outside the localizer nor their lone passenger was injured, • “The crew made a number coverage area when the crew armed the but damage to the aircraft was substan- of rushed and inappropriate autopilot approach mode. As a result, tial, not only from the cracked wind- decisions during the flight, thus the autopilot captured a false localizer shield but from foreign object damage displaying poor crew resource signal. The crew then deviated from to the no. 1 engine that likely occurred management; the instructions they had received from after the aircraft was landed. air traffic control (ATC) and initiated In its final report, the Irish Air Acci- • “The first officer’s lack of recent a rapid descent while tracking the false dent Investigation Unit (AAIU) said that flying hours is likely to have con- signal. The aircraft was 702 ft above the the probable cause of the serious incident tributed to his loss of navigational ground and headed toward the high- — which occurred at (County) Kerry and situational awareness; est mountains in the country when Airport (EIKY) in Killarney the morn- the crew responded to warnings from ing of July 13, 2009 — was that “the crew • “A false localizer signal was re- ATC and from the on-board enhanced suffered a serious loss of navigational and ceived due to the approach mode
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being armed while the aircraft was outside He had 3,200 flight hours, including 200 hours the specific localizer coverage sector; in GIVs. The reported weather conditions at Kerry • “The captain commenced a descent with- Airport included calm winds, 8,000 m (5 mi) out having a valid ILS [instrument landing visibility in rain, scattered clouds at 1,000 ft and a © Chris Photography Sorensen system] signal and without cross-checking broken ceiling at 1,400 ft, and there was convec- other available navigational aids; [and,] tive activity in the vicinity of the airport. The windshield cracked shortly after the • “The situational awareness of the controller aircraft was rotated for takeoff from Runway in Kerry Tower was compromised by er- 08 at 0806 local time. The captain, the pilot roneous position reports from the crew and flying, told investigators that he then noticed noncompliance with his instructions, as abnormally high readings on the left-engine well as a lack of direct radar information.” vibration monitor. He said that he momentarily retarded the left thrust lever to idle, in accor- Trouble on Rotation dance with quick reference handbook guid- The GIV, built in 1999, was operated in the ance, and the indicated engine vibration level United States until it was registered by a private returned to normal. All other engine param- company in India in 2008. The crew for the eters also were normal. incident flight, with an intended destination of The captain was initiating a right turn to London Luton Airport, comprised a contract a southeasterly heading, in compliance with pilot serving as captain and a company pilot the standard instrument departure procedure serving as first officer. (SID), when the first officer radioed, “Sir, we The captain, 45, held a U.S. airline transport pi- have a cracked windshield. We’re leveling off lot certificate and an authorization by the Director- at three thousand. We’d like to come back to ate General of Civil Aviation in India to fly GIVs. Kerry.” The control tower at Kerry Airport was Electrical arcing He had 12,500 flight hours, including 2,600 hours not equipped with radar, and the airport traffic caused the GIV’s in Gulfstreams, with 1,027 hours in GIV-SPs. controller asked for a position report. The first windshield to The first officer, 38, held commercial certifi- officer erroneously replied that the aircraft was crack on takeoff. cates issued by India and by the United States. 35 nm [65 km] southeast of the airport. The report said that he likely mistook the indicated distance to Cork, the next navigational fix on the SID, for the distance from Kerry. The GIV actually was about 10 nm [19 km] southeast of the airport (Figure 1, p. 18). The controller asked the crew if they would prefer to navigate to INRAD, an intermediate fix for the ILS approach to Runway 26 — the only precision approach procedure available at the airport — or to navigate directly back to the airport and establish the aircraft outbound on the ILS. The first officer replied, “OK, confirm. Call you overhead at three thousand.” The first officer entered the airport waypoint in the flight management system (FMS), and the aircraft, which was being flown with the autopilot engaged, made a 180-degree turn and began to fly
Irish Air Accident Investigation Unit Investigation Irish Accident Air a northwesterly heading back to the airport.
www.flightsafety.org | AeroSafetyWorld | September 2010 | 17 COverStory
and the first officer said, “Turning back on the Flight Path localizer now; one … correction, niner miles U.S. National Aeronautics and Space Administration inbound now.” The controller then cleared the crew to conduct the ILS approach.
Confusion Reigns INRADINRAD VENUX The autopilot, which was maintaining the select- ed altitude of 3,000 ft, commanded a left turn to a southwesterly heading after capturing the false EIKY localizer signal. The first officer announced that the course deviation indicators were “alive” and LOC capture ON told the captain to begin a descent. The captain disengaged the autopilot and “commenced de- scent, in cloud on a track approximately parallel Mininum radar altitude, 702 ft to the ILS but 6 nm [11 km] south of it,” the report said. Killarney The localizer coverage area, as specified by the International Civil Aviation Organization, extends to a maximum of 35 degrees of the localizer centerline (Figure 2). The aircraft was EIKY = Kerry Airport; LOC = localizer at an angle of 43 degrees from the centerline Source: Irish Air Accident Investigation Unit when it intercepted the false localizer signal. Figure 1 Such signals — also called “false courses” — are normal byproducts of ILS signal generation and are created at various angles outside the cover- Localizer Coverage Area age area.1 False localizer and glideslope signals 35° also can be generated inside the coverage area during ILS maintenance and testing. At 0812, the tower controller requested
10° another position report. The first officer replied, “Coming up on the localizer, ah, seven DME” — that is, 7 nm [13 km] from distance measuring Localizer antenna equipment located near the approach threshold of Runway 26. 17 nm 25 nm
10° The report said that the tower controller should have realized that the crew’s position reports were inconsistent and inaccurate, and that they had deviated from his instructions. The con- 35° troller later told investigators that he recognized Source: Irish Air Accident Investigation Unit, Susan Reed the crew was under intense pressure and that he did not believe it was prudent to challenge them Figure 2 about their noncompliance with his instructions. At 0810, the controller again asked for a Both navigation displays were in the weather position report, and the first officer responded, radar map mode. The report said that if at least “Ah, we’re turning inbound now; one zero miles one of the displays had been in the EGPWS map inbound.” The controller asked him to confirm mode, the pilots might have realized that they that the aircraft was inbound on the localizer, were heading toward terrain rising above 3,000
18 | flight safety foundation | AeroSafetyWorld | September 2010 CoverStory
ft. “It is fortunate that the descent was “However, the aircraft did not turn windshield damage — the windshield made over ground that was relatively left toward VENUX or descend but had remained intact, and no fragments low-lying in comparison to much of maintained the heading of 350 [de- had been released. Laboratory analyses the terrain in the vicinity of EIKY,” the grees],” the report said. “As it passed indicated that the left engine had in- report said. through the localizer, it commenced a gested a round low-carbon-steel object right turn onto a heading of 010 [de- with a diameter of about 25 mm (1 in) ‘Climb Immediately’ grees]. This was followed by a left-hand after the aircraft was landed. Likely believing that he needed to orbit to the north of the localizer.” The report said that, despite the capture the glideslope from above, the At 0826, the crew reported that captain’s recollection of substantial captain established a descent rate of they were having problems with engine vibration after lift-off, recorded 1,300 fpm and then called for the land- the FMS and requested clearance to flight data showed no significant vibra- ing gear to be extended and the flaps to maintain their current position. The tion and that “the engine operated in a be extended 20 degrees. controller cleared the crew to circle, normal manner throughout the flight.” At 0812, a Shannon Center radar provided the ILS approach frequency The data, however, showed indications controller, who was monitoring the and offered radar vectors to the final of compressor stalls shortly before the flight but was not in radio communica- approach course. The crew accepted engine was shut down and later during tion with the crew, phoned the tower the offer, flew the ILS approach and the ground runs. controller and told him that the GIV landed the aircraft at 0834. Investigators determined that was about six miles south of the lo- the outer ply of the windshield had calizer at 1,600 ft. The radar controller Ground Runs cracked because of electrical arcing said, “Climb him now, please.” Later that morning, the crew taxied between a heating system bus bar and The tower controller advised the the aircraft to an unused taxiway and the anti-icing film covering the inner crew of their position and said, “Climb performed a ground run of the left surface of the outer ply. “The electri- immediately to 3,500 ft.” About the same engine that included a series of ac- cal arcing resulted when moisture time, the EGPWS generated an alert that celerations and decelerations. AAIU ingress was absorbed by the interlayer the GIV was at a radio altitude of 800 ft. inspectors arrived at Kerry Airport and caused degradation of the bus bar The aircraft was in a climb when the the next day. Their initial examination at the bottom forward corner of the tower controller handed off the flight to of the aircraft revealed that the left windshield,” the report said. a Shannon Center controller, who in- engine, a Rolls-Royce Tay 611-8, had Based on the findings of the inves- structed the crew to climb to 5,000 ft and received severe foreign object damage tigation, the AAIU recommended that issued a heading of 090 degrees at 0815. and required replacement. “Many of the Irish Aviation Authority (IAA) con- About six minutes later, the controller the fan blades had V-shaped nicks in sider installing ATC radar equipment issued a heading of 350 degrees, a vector their leading edges while a boroscopic at Kerry Airport. The report noted that toward the localizer course. examination of the forward stages of the IAA in November 2009 issued an The first officer, who had flown the compressor showed significant aeronautical information circular warn- only 1.4 hours in the preceding 28 days, blade damage,” the report said. ing pilots about the hazards of receiv- had difficulty in programming the The captain told investigators ing false localizer signals outside the FMS for the ILS approach. He initially that the company’s “senior manage- localizer coverage area. entered an approach to Runway 26 at ment” had instructed him to perform This article is based on AAIU Synoptic Report London Luton. the engine ground run to determine No. 2010-012. The full report is available at At 0823, the Shannon control- whether a ferry flight to a maintenance
“Commercial Aviation Safety Team (CAST), IASS International Update” — Glenn Michael, FSF 63r d a n n u a l manager, international operations, CAST, U.S. Federal Aviation Administration (FAA) In t e r n a t i o n a l Ai r Saf e t y Se m i n a r “European Commercial Aviation Safety Team (ECAST) — John Vincent, head, safety r e l i m i n a r y g e n d a P A analysis and research, European Aviation Safety Agency (EASA) 1200–1230 Questions and Answers 1230–1400 Lunch Tuesday,0900–1200 FSF InternationalNovember Advisory Committee 2 (IAC) Meeting Se ssi o n II Pr o f e ssi o n a l is m /Tr ai n i n g 1000–1700 Registration Session Chairman: H. Keith Hagy, director, 1000–1500 FSF Board of Governors Meeting Engineering and Air Safety Department, Air Line Pilots Association, International (ALPA) 1700–1800 Chairmen and Speakers Meeting for 1400–1430 “Professionalism in Aviation: Approaches to Wednesday presentations Ensuring Excellence in Pilot and Air Traffic 1830–1930 Opening Reception in Exhibit Hall Controllers’ Performance” — Roger Cox, senior air safety investigator, U.S. National Transportation Safety Board (NTSB) 1430–1500 “Building Tomorrow’s Professional Pilot Starts Today” — Charles Hogeman, chairman, 0730–1700 Registration Wednesday, November 3 Human Factors and Training Group, ALPA 0730–0830 Continental Breakfast in Exhibit Hall Executive Air Safety Committee
We l c o m e a n d Se m i n a r Op e n i n g 1500–1530 Refreshments in Exhibit Hall 0830–0930 Ho Ching-sheng (Danny C. Ho), executive vice 1530–1600 “Advanced Crew Competency Concepts for president, Safety and Security Division, EVA Air, Pilot Training” — Barbara Holder, associate and chairman, FSF IAC technical fellow/lead scientist, The Boeing Co. 1600–1630 “Aviation Safety: A Gap Analysis for Aviation William R. Voss, president and CEO, English” — Elizabeth Mathews, director, Flight Safety Foundation Elizabeth Mathews and Associates Keynote Address — David McMillan, 1630–1700 “Closing the Gap Between Accident Investigation director general, Eurocontrol and Training” — Mike Poole, executive director Italian Host Committee and chief investigator, CAE Flightscape Award Presentations 1700–1730 Questions and Answers 0930–1000 Refreshments in Exhibit Hall 1745–1815 Chairmen and Speakers Meeting for Thursday presentations Se ssi o n I Gl o b a l Up d a t e Session Chairman: Bill Bozin, vice president, safety and technical affairs, Airbus Americas, and member, FSF Board of Governors 0730–1700 Registration 1000–1030 “2010: The Year in Review” — James M. Burin, Thursday, November 4 director of technical programs, Flight Safety 0730–0830 Continental Breakfast in Exhibit Hall Foundation Se ssi o n III Op e r a t i o n a l Iss u e s 1030–1100 Hon. Debbie Hersman, chairman, Session Chairman: Capt. Mauro Schiro, U.S. National Transportation Safety Board aviation safety consultant, technical task force, Fondazione 8 Ottobre 2001 1100–1200 “Implementing the Global Aviation Safety Roadmap Worldwide: An Update” — Bill 0830–0900 “Operational Use of Flight Path Management Bozin, vice president, safety and technical Systems” — Kathy Abbott, chief scientist and affairs, Airbus Americas technical advisor, flight deck human factors, FAA
20 | flight safety foundation | AeroSafetyWorld | September 2008 FoundationFocus
0900–0930 “Departure Flight Into Terrain (D-FIT)” — 0730–0830 Continental Breakfast in Exhibit Hall Stewart Schreckengast, associate professor, Aviation Technology Department, Purdue Se ss i o n V Cu r r e n t Ch a l l e n g e s University Session Chairman: Robert MacIntosh, chief 0930–1000 “Go-Around Decision and Maneuver: How to advisor for international safety affairs, NTSB Make It Safer” — Capt. Bertrand de Courville, 0830–0900 “Volcanic Ash and Flight Safety: Spring 2010 corporate safety manager, Air France in Europe” — Capt. Ed Pooley, principal 1000–1030 Refreshments in Exhibit Hall consultant, The Air Safety Consultancy 1030–1130 “Stall Training, Approach-to-Stall Training, 0900–0930 “Influencing Safety Priorities: The Effect Impending-Stall Training” — Capt. David of the Media” — Kimberly Pyle, safety Carbaugh, chief pilot, flight technical and communications liaison, and Robert Tarter, safety, Boeing Commercial Airplanes Office of Safety Air Traffic Organizer, FAA “Stall Recovery Procedure” — Claude LeLaie, 0930–1000 “Degradation of Professional Piloting Skills”— senior vice president, product safety officer, Capt. Michael Gillen, integration team project Airbus S.A.S. manager, United Airlines “Best Practices Relating to Stall and Stick 1000–1030 Refreshments in Exhibit Hall Pusher Training” — Capt. David McKenney, 1030–1100 “What’s It All About? GNSS, GBAS, SBAS, human factors and training group, ALPA GLS, etc.” — James E. Terpstra, senior vice 1130–1200 Questions and Answers president–retired, Jeppesen; executive aviation consultant 1200–1330 Lunch 1100–1130 To be determined Se ss i o n IV Sa f e t y Ma n a g e m e n t Sy s t e ms 1130–1200 Questions and Answers Session Chairman: Capt. George H. Snyder, MBA, president and CEO, GHS Aviation Group 1200–1330 Lunch 1330–1400 “Measuring Safety” — David Mawdsley, aviation safety advisor, Superstructure Group Se ss i o n VI Ma n a g i n g Ri s k Session Chairman: Capt. Bill Curtis, Air Canada, 1400–1430 “Safety Culture in Air Traffic Management: and Presage Human Factors Risk Management A European Perspective” — Andrew Kilner, Group deputy lead, safety development, Eurocontrol 1330–1400 “Runway Incursions” — Massimo Garbini, 1430–1500 “Implementation of SMS in the Aviation director general, ENAV (Italian Company for Industry: Challenge and Success” — Peter Air Navigation Services) Müller, safety analyst, Federal Office of Civil 1400–1430 “Altitude Capture Enhancement to Prevent Aviation (FOCA) TCAS RAs” — Paule Botargues, multi-program 1500–1530 Refreshments in Exhibit Hall project leader–autoflight system, Airbus S.A.S. 1530–1600 “Integration Risk Management: The 1430–1500 Refreshments in Exhibit Hall Practical Approach for an Effective SMS” 1500–1530 “Designing and Implementing a Fatigue — Eddie Rogan, aviation solutions director, Risk Management System (FRMS)” — Peter Superstructure Group Simpson, manager air safety, deputy head of 1600–1630 “Safety by Design, an SMS Success Story” corporate safety, Cathay Pacific Airways — Philippe Pilloud, head of safety risk 1530–1600 “The Effects of Workload on Flight Crew management, easyJet Fatigue” — Capt. Kristjof Tritschler, flight 1630–1700 Questions and Answers safety manager, Germanwings, City University London, DLR 1715–1815 Chairmen and Speakers Meeting for Friday presentations 1600–1630 “Integrated Fatigue Modeling in Crew Rostering and Operations” — Suresh Rangan, technical principal, technology, FedEx Services 1630–1700 Questions and Answers Friday,0730–1700 Registration November 5 1700 Seminar Closing www.flightsafety.org | AeroSafetyWorld | September 2008 | 21 HelicopterSafety
Efforts of the International Helicopter Safety Team seem to be producing results. IHST Nears Mid-Point
By Douglas W. Nelms
n 2005, the global civil helicopter accident Aviation Safety Team (CAST) (ASW, 1/08, p. rate was at 9.4 per 100,000 flight hours; for 26), a government-industry group focused on the United States, with a little more than airline safety. While the two programs are now 14,000 civil helicopters — 41 percent of the fairly similar, the biggest difference between Iworld’s total — the rate was 9.1 per 100,000 CAST and IHST is that CAST currently bases its flight hours. These rates had held fairly level research on fatal accidents, while IHST consid- over the preceding five years, and this lack of ers all helicopter accidents. progress was judged to be unacceptable. In February 2006, IHST was officially In September of that year, the members of launched. In November 2006, the European the International Helicopter Safety Symposium Helicopter Safety Team (EHEST) was formed as (IHSS) met in Montreal and formed the Inter- the European component of the IHST. national Helicopter Safety Team (IHST), taking As of May 2010, approaching the halfway point on the goal of reducing civil helicopter acci- toward the IHST goal, helicopter accidents world- dents by 80 percent within 10 years. The IHST wide had dropped to 5.4 per 100,000 flight hours,
program was based on the U.S. Commercial while U.S. accidents dropped to 3.5 (Figure 1). © Chris Photography Sorensen
22 | flight safety foundation | AeroSafetyWorld | September 2010 HelicopterSafety
The relationship between the IHST’s efforts and the drop in accidents is, as yet, unproven,
said Matt Zuccaro, president of the Helicopter Donoghue J.A. Association International (HAI) and co- chairman of the IHST. “We can’t say there is a direct correlation, but we can’t ignore the trend. The simple fact that we are out there aggressively promoting a safety culture has created an industrywide heightened awareness for safety.” There is, he said, no “silver bullet” to en- hance helicopter safety. “It is the culture and actual mentality of the operators in the industry that is changing dramatically,” Zuccaro said. There is a commitment to safety, an economic commitment, a philosophical commitment: “Everybody from the owner of the company through the management team down to the pilot and maintenance and the support staffs are Zuccaro all in the same mindset of preventing accidents and being safety-aware.” operator did yesterday to satisfy the client may Zuccaro also noted that as part of the aware- not be appropriate today based on new informa- ness program, it is critically important that the tion obtained through the study of aircraft data, end user, the client, be educated as to what the sorted by mission type (Figure 2, p. 24). safety initiatives are, why the industry is promot- To develop an overall safety strategy, each ing this program, why operational procedures are region’s IHST has created sub-teams, the joint being changed and why something a helicopter helicopter safety analysis teams (JHSATs) to study and analyze hundreds of reports of IHST Review of Worldwide Helicopter Accidents helicopter accidents and incidents, and the joint helicopter safety implementation teams 10 9.4 (JHSITs) to turn the analyses into recommen- 9 dations to prevent accidents. 8 7 JHSAT studies have been completed by the 6 North American and European teams. Ad- 5 ditional regional teams are now collecting data 4 worldwide to increase the range of information 3 under study. 1.9 2 Canada, Brazil, India and Australia weren’t 1 fully on board the IHST program until 2007, flight hours per 100,000 flight Accidents 0 Middle East nations and Japan did not start 2001– 2006 2007 2008 2009 2010 2012 2014 2016 2005 May their regional JHSAT teams until 2009, and Rus- Year sia kicked off its program this year. The JHSAT phase, the analysis, is the lead- IHST = International Helicopter Safety Team Note: Data are through May 2010. ing edge of the IHST initiative, the engine that
Source: Helicopter Association International will drive down the accident rate “through in- troducing intervention strategies,” according Figure 1 to Duncan Trapp, EHEST Communications
www.flightsafety.org | AeroSafetyWorld | September 2010 | 23 HelicopterSafety
Sub-group leader and the safety and regula- Helicopter Mission Comparisons tory manager for CHC Helicopter—European Operations (Figure 3). 25 2000 A major step to improved safety in the 2001 2006 helicopter industry is the development of safety 20 management systems (SMS) by individual op- erators, with IHST and EHEST working through
15 their members to produce tool kits providing the road maps for meeting safety standards. Although not a required program for operators, 10 SMS is expected to become a regulatory require- ment for commercial helicopter operators in the Percent of operations, U.S. of operations, Percent 05 United States and Europe. To that end, the IHST initiative seeks to pro-
0 vide free, easy-to-use guidance material to get
EMS ENG operators to adopt the processes and principles Utility Air tour Business O shore Logging that are best practices elsewhere, and has created
Commercial Fire ghting External load an SMS tool kit which is available as a download Personal/private Law enforcement Observation/patrol Aerial applications from the HAI website
Percent of region’s total IR count total of region’s Percent Aviation Administration (FAA) and HAI have developed a joint program, providing mission- 0 Instruction/ Safety Maintenance Data/ Regulatory Systems and specific pilot-safety forums throughout the coun- training management information equipment try. “Right now, almost all pilot safety forums, Category and even the certificated flight instructor (CFI)
IHST = International Helicopter Safety Team; IR = intervention recommendation renewal programs, are fixed wing–oriented,” Zuc- caro said. “So we are going to go out and start a Source: Helicopter Association International whole new set of pilot safety forums.” Figure 3 Continued on p. 26
24 | flight safety foundation | AeroSafetyWorld | September 2010 “ At Honeywell, safety is our “ Our pilots want “ FlightSafety gives business, so FlightSafety is to train with me exceptional the natural and best choice FlightSafety, training that fits my for our aviation training.” and so do I.” demands as a pilot.” Dave Cote Steven R. Loranger Eric E. Schmidt, PhD Chairman and CEO Chairman, President and CEO Chairman and CEO Honeywell ITT Google Inc.
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New Initiatives
he worldwide helicopter industry is linking its for people to put these devices on their aircraft, particularly International Helicopter Safety Team (IHST) program to helicopters. What we did was to come up with some policy Ttwo initiatives that are organizationally separate from out of the Rotorcraft Directorate that allows these devices the IHST but are key program elements. to be installed with very little rigor as far as what normally The first initiative promotes the use of flight data moni- would go into an STC [supplemental type certificate]. We said toring devices, providing information useful in predictive that [FDMs] are non-operationally required safety-enhancing and reactive (accident investigation) safety programs. The equipment. So if the equipment doesn’t affect the operation second is the International Standards–Business Aircraft of the aircraft when it fails, let’s go ahead and get it installed.” Operations (Helicopter Edition), or IS-BAO (HE), an accredi- Somen Chowdhury, a member of the IHST execu- tation program to assist operators in developing a “best tive committee and manager, international research, Bell practices” safety program. Helicopter Textron, Canada, noted that in some countries, these recording devices are required. “But some national Flight Data Monitoring regulators such as the FAA don’t want to mandate them,” he In the perfect universe in which none of us live, helicopters said. “So IHST is taking is an educational approach. We are would have the same types of flight data recorders and going to put in a very simplistic system, with hardware nearly cockpit voice recorders that airlines use. However, the cost developed that will record the voice and instruments without and size of these units puts them beyond the reach of most intruding into the current certified system. It will not go into helicopter operators. the wiring system at all. Once you touch that, you have to As a result, the industry is looking for low-cost, low- re-certify the whole thing.” weight helicopter flight data monitors (HFDMs) that can Most helicopter manufacturers are working on finding provide data similar to those from the airlines’ “black boxes” FDMs for their aircraft. Lindsay Cunningham, senior accident and quick access recorders (ASW, 8/10, p. 28). The light heli- investigator for American Eurocopter, said the company is put- copter community is using the term “flight data monitors” for ting the Appareo Systems Vision 1000 on the AS-350. The sys- its hardware to differentiate it from the more complex flight tem, developed jointly by Eurocopter and Appareo Systems, is data recorders. a cockpit imaging and flight data monitoring device wrapped FDM analyses provide the information needed for both into a single unit to provide voice and video data, with a predictive and reactive safety efforts, HAI President Matt global positioning system that captures location. The cockpit Zuccaro said. The question is, he said, “How can you fix what imaging device takes photos of the instrument panel, flight you don’t know?” These safety data can be used to make controls and partial exterior views at four frames per second. It long-term safety improvements, to aid investigations into in- contains inertial sensors that include nano-gyros and acceler- cidents and accidents, and to add accuracy to discrepancy re- ometers to record basic flight parametric data. ports. Knowing more about what happens in flight will help In the event of an accident, investigators can zoom in improve training programs and fleet operation standards. on the gauges “and look at individual frames as necessary to The Global HFDM Steering Group was formed last April, determine what happened,” Cunningham said. with the goal of sharing “information with the intent of mak- Beyond accident investigation, however, “we want it ing HFDM easy for [all] operators to implement.” The steering available for training, flight testing, data monitoring, all group is co-chaired by Mike Pilgrim, a captain and FDM ad- of these uses that we hadn’t even anticipated,” American viser for CHC Helicopters’ European Operations, and Joseph Eurocopter’s Syslo said. Syslo Sr., manager–aviation safety for American Eurocopter, “One of the biggest issues coming out of JHSAT was the and includes 70 individuals from 48 organizations worldwide. lack of data … in the investigative reporting [of accidents] Syslo said that the steering group set up three sub- and the proactive use of data to stop accidents,” Cunningham organizations which deal with technical aspects; operational said. “The industry is running up against this brick wall. aspects; and a combination of communication, legal con- We know what is causing most of the accidents, but we’ve cerns and related matters. reached the point where we don’t have the data to support it The FAA says it is working to lessen barriers to opera- 100 percent. So people aren’t spending the money to move tors’ efforts to install FDMs on their aircraft. “We’re seeing a that forward.” The FDM will provide the data to allow both lot of emphasis put on [installing] fairly low-cost recording proactive and reactive data collection. devices on a voluntary basis,” said FAA’s Mark Schilling, IHST The system costs about $7,500, not including installa- co-chair. “The FAA has been very active in making it easy tion, and weighs only 300 g (0.66 lb). It comes with a secure
26 | flight safety foundation | AeroSafetyWorld | September 2010 HelicopterSafety
digital (SD) data card that can be taken out and put into a Duncan Trapp, safety and regulatory manager, CHC laptop that can transmit information about any flight to a Helicopter—European operations and communications data management system. Syslo noted that organizations sub-group leader for the European Helicopter Safety Team, offering a monitoring service for about $500 a year will log said that IS-BAO (HE) is being rolled out around the world as the information as it comes in and provide it to the customer a recognized standard with no planned differences between to look for trends. countries. “The aim is to set a baseline standard that said if Cunningham added that “the system is light enough and you’ve done all [the standardization work] and get IS-BAO low cost enough that you could put it on a Robinson R-22.” (HE) recognition, then you’ve covered to a good level all the She also noted that American Eurocopter President and CEO requirements in terms of safe operations.” Marc Paganini said the company will install the Vision 1000 HAI President Matt Zuccaro said that a working group system on all new production Eurocopter aircraft as an STC is being established “to look at the foundation document becomes available for each model. of IS-BAO, the accreditation document, and come up with “That’s where the some [manufacturers] are going … a helicopter addition to address helicopter operators who making it standard equipment,” Cunningham said. want to be IS-BAO accredited. That will be the basis of the HAI accreditation program.” IS-BAO (HE) HAI will actually be part of two accreditation programs, International helicopter organizations have signed an agree- its own and that of IS-BAO (HE). “We will be an agent of ment to create a new code of best practices for helicop- IS-BAO,” Zuccaro said. “We will be able to get [the helicopter ter safety, basing it on the fixed-wing corporate aviation operators] to the program and walk them through the pro- International Standard for Business Aircraft Operations cess. If you want to be HAI-accredited, we are going to send (IS-BAO). out one of our auditors who will be trained to do IS-BAO. So The new IS-BAO Helicopter Edition, or IS-BAO (HE), will it will be a one-shot deal.” provide a road map for helicopter operators to meet the new The difference between the HAI accreditation pro- standards and audits to achieve a certificate of registration. gram and IS-BAO (HE) is that “ours is IS-BAO plus mission- The agreement was ratified at the ILA Berlin Air Show specific,” Zuccaro said. “If you conduct ENG [electronic last June, signed by the European Helicopter Association, news gathering], we’re certifying you to IS-BAO standards Helicopter Association International (HAI), British Helicopter that we are going to develop for the helicopter world, and Association and the International Business Aviation Council. we are also going to certify that you meet the mission- The agreement will allow the formation of a steering com- specific standards that we have established for your ENG mittee responsible for developing international standards for mission. Just to have an accreditation program for a heli- operations, maintenance, training and related issues. It will copter operator is not really realistic or a true evaluation also provide linkage to the regulations and recommended of the operator. All the different missions that helicopters practices specified by the International Civil Aviation fly have different criteria requirements, operating environ- Organization and to national aviation regulations, the as- ments, different risks.” sociation said. — DWN
Sue Gardner, IHST program Gardner said. “They will have a day- pretty successful so far,” she said. The manager and a special assistant in the time meeting focused on helicopter FAA has worked closely with IHST on FAA’s Flight Standards General Avia- operators, and then an evening meet- the introduction of the tool kits, par- tion and Commercial Division, said ing that is specific to the individual ticularly in the training area, focusing that the FAA Safety Team (FAAST), helicopter pilot and flight instructor. on voluntary adoption. However, one along with working with HAI to pres- We are also working with an industry area that is in the regulatory realm, yet ent regional educational programs, is organization on developing a master is non-intrusive, is initial qualification developing products that are available CFI program specific to helicopters.” training, specifically the knowledge test through
ven when modern flight deck equipment Aerodrome Design Manual, Part 4 (Visual Aids). with moving maps is available, and even Those documents have detailed specifications with multilateration1 and automatic depen- for visual aids on runways and taxiways, but few dent surveillance–broadcast out supporting details can be found for aprons (ramps) — for MAX SPAN MAX SPAN Eair traffic control (ATC), safely navigating an example, markings for aircraft parking stands. 36M 36M aircraft on the ground is still a critical issue. In the absence of precise rules, airports have Airports are committed to providing suf- developed different markings. Despite some har- ficient navigation aids to maintain safety at the monization within a country or group of countries, required level. In addition to lighting systems pilots may be confronted with different apron and the support of controllers, surface markings markings almost every time they fly. These mark- are of great importance, especially in adverse ings may differ in shape, size, content and color. weather or critical lighting conditions. Airports Council International (ACI) has Major efforts have been made over the years recognized this problem and published in 2001 TL A TL A ORANGE by the International Civil Aviation Organization its first Apron Surface Markings and Signs hand- TL A BLUE TL A TL A BLUE (ICAO) to develop standards for visual aids to book. This handbook has been acknowledged by ORANGE TL A improve safety for moving aircraft on the ground. ICAO, in the remark that “additional guidance Requirements for visual aids such as light- on apron markings is given in the ACI/IATA ing, markings and signs can be found in ICAO [International Air Transport Association] Apron Annex 14, Aerodromes, and ICAO Doc 9157, Markings and Signs Handbook, which gives
28 | flight safety foundation | AeroSafetyWorld | September 2010 airportOPS
AIRPORTS COUNCIL INTERNATIONAL
Apron Markings and Signs
2nd Edition 2009
A new edition of the airport surface markings and signs handbook furthers standardization among airports.
BY GERHARD GRUBER Marking Time Again
examples of current best practices,” included in ICAO Doc 9157, Part 4, 2.1.2. The first edition of this handbook made a significant contribution to safer apron environ- MAX SPAN MAX SPAN ments, by fostering greater uniformity in the 36M 36M markings and signs provided by airport op- erators at airports worldwide. Since then, best practices have continued to evolve, and increas- ingly complex apron management requires more detailed regulations. Therefore, the ACI Safety and Technical Standing Committee determined that the first edition needed to be revised and requested the work to be done by the ACI Operational Safety TL A TL A ORANGE TL A BLUE Subcommittee. TL A TL A BLUE ORANGE TL A Within that committee, Vienna International Airport took the lead to redesign the handbook. In particular, the author and his team, Oliver Russ and Dietmar Schreiber, created the text and graphics and coordinated several drafts with
www.flightsafety.org | AeroSafetyWorld | September 2010 | 29 airportOPS
The handbook is intended for planners of apron areas, ground staff working on aprons, air traffic controllers, apron controllers and pilots. The change of surface markings and signs from an old system to the new specification cannot be completed overnight. Depending on size of the airport or budget, it will be done step by step. In Vienna we took several opportunities to introduce the new specifications, including the construction of new aprons, a scheduled repainting and a complete change of the stand numbering system. Using these opportunities minimized the cost of the project and complet- ed the change of markings within one year. The author has been involved in developing adequate surface markings for many years. Even before the publication of the first ACI handbook, experiments with various colors, shapes and sizes were made at Vienna International Airport in co- ordination with airports in neighboring countries. The author’s activity as a pilot on worldwide routes has been of great assistance in this task. Not a single flight takes place without the author having the camera ready to document both good and bad marking examples. Over the years, more than 1,000 photos have been taken, which were beneficial in developing the revised handbook. ACI before extensive industry consultation and Above, new Gerhard Gruber has worked for Vienna International Airport “alternative aircraft request for comments began. for 36 years, and has been the manager of airport opera- stand” taxi lane Comprehensive coordination with ICAO was tions since 1989. He has represented the airport at ACI since markings. Below, performed via the Visual Aids Working Group of the organization’s foundation in 1991. Gruber is an active airline transport pilot holding type ratings for the Dassault old “stand direction” the Aerodromes Panel, where ACI was represent- Falcon 900 and the Bombardier CRJ and Challenger 605, and marking. ed by Jean-Noel Massot of Aéroports de Paris. celebrates his 40th year of flying this month. The second edition of the handbook was published in 2009 and sent to more than 1,600 Notes ACI member airports in 179 countries. It has been significantly improved com- 1. Multilateration is a system in which the location of pared to the first edition, now including more an object is determined by computing the time dif- markings and their exact dimensions. It is also ference of arrival of a signal from that object to three or more receivers, or simultaneously from three or the first time that markings are shown in any more transmitters to a receiver in the object. worldwide publication for alternative aircraft stand taxi lanes. Such markings allow operations 2. Code-letter C airplanes have a wingspan up to but not including 36 m (118 ft); code-letter E airplanes on an apron taxi lane by either two code-letter have a wingspan up to but not including 65 m (213 2 C airplanes or one code-letter E or F airplane. ft); code-letter F airplanes have a wingspan up to but This has been applied and found to be both ef- not including 80 m (262 ft). The reference codes are fective and safe at a number of airports. contained in ICAO Annex 14, Table 1-1.
30 | flight safety foundation | AeroSafetyWorld | September 2010 ESCO-ZA_Aerosafety_World_Sept2010_Outlines.pdf 8/23/2010 2:39:40 PM
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Twelve steps to implementing a safety management system. BY JOHN SHEEHAN SMS Tools for Corporate Aviation 32 | flight safety foundation | AeroSafetyWorld | September 2010 BusinessOPS
ow that the International Civil and implement an SMS, a compact disc integrated team within the flight opera- Aviation Organization (ICAO) that contains an electronic copy of the tion — provide a rewarding return on has made it mandatory for booklet, and 18 tools and six reference the investment of the time and effort to international operators of documents in electronic format. There implement and maintain an SMS. largeN and turbojet-powered aircraft to are also hyperlinks to numerous other The naysayers who contend that “establish and maintain a safety man- related sources. Other aids to SMS their seat-of-the-pants brand of safety agement system (SMS) appropriate to implementation are also included. management is just fine without the the size and complexity of the opera- advantages of an SMS should ask the tion” after Nov. 18, 2010, implementa- Why an SMS? questions: Really, how safe is my opera- tion of the system is in full swing. We Most corporate and charter opera- tion? How can I know how safe it is if I at the International Business Avia- tors are aware of the existence of SMS, have no means of measuring the risks tion Council (IBAC) are pleased to but all may not fully appreciate the we encounter on a daily basis? note the great response by corporate rationale for its use and the advantages operators around the world, especially it brings to an operator. Most operators SMS in Brief those who choose to comply with this practice some form of overall safety The ICAO definition of SMS is “a mandate through International Stan- management, especially if they have systematic approach to managing safety, dard for Business Aircraft Operations an up-to-date flight operations manual including the necessary organization, (IS-BAO) registration. that contains policies, standards and structures, accountabilities, policies But experience has shown that both procedures that directly apply to their and procedures.” grasping the SMS concept and imple- operation. What is missing is the inte- IBAC defines SMS as “the system- menting it are not particularly easy gration of these elements into a system atic and comprehensive process for the tasks for corporate operators. The fully of interlocking policies and procedures proactive management of safety risks integrated approach to safety and the that considers all elements in concert. that integrates the management of diversity of missions and wide range of More important, an SMS forces operations and technical systems with flight department compositions make an operator to actively identify poten- financial and human resource man- a “one-size-fits-all” approach to SMS tial hazards, analyze them and create agement.” This definition goes a bit impossible. As a consequence, IBAC measures that will minimize the risks beyond the more fundamental ICAO over the years has provided increas- involved with the hazards. Further, the definition, but IBAC believes that the ingly detailed implementation guidance system provides for participation of concepts of risks, comprehensiveness, for SMS, culminating with the SMS all members of the flight operation proactiveness and integration are very Toolkit in 2009. in the SMS; teamwork is a welcome important. The most important advan- The SMS Toolkit was developed by result of this action in most operations. tages of an SMS over conventional, a working group comprising members The concept of constant improvement more fragmented safety programs of the IBAC staff and participants through a series of regular reviews of are the full integration of supporting from a number of IBAC’s 15 member the operation’s activities and compli- programs and the ability to measure associations to assist noncommercial ance with its own standards completes the degree of risk exposure. fixed- and rotary-wing aircraft opera- the action loop of hazard identification The component parts of an SMS in- tors, on-demand charter operators and and mitigation, active risk assessment, clude methods of creating and sustaining aerial work interests in developing managing organizational and environ- safety through: and implementing safety management mental change, internal evaluation and • Policies and objectives; systems that meet the ICAO standards program revision. and recommended practices, as well The resulting advantages — the • Risk management processes; as the requirements of major aviation ability to actively measure and mitigate • Assurance elements (Is it getting regulatory authorities. operational and organizational risks, done?); and, The tool kit consists of a 57-page better management practices, increased hard copy SMS Tools booklet that pro- customer confidence, loss prevention, • Education and promotion within vides a step-by-step process to develop preferred insurance rates, and a fully the organization. www.flightsafety.org | AeroSafetyWorld | September 2010 | 33 DEDICATED TO HELPING BUSINESS ACHIEVE ITS HIGHEST GOALS.
In your hands, a light airplane achieves significant things. The National Business Aviation Association exists to serve leaders like you, who fly their own course, their own way. Membership in NBAA gives you relevant, cost-effective tools that can help make flying solo the path to even greater opportunities. Flying solo doesn’t Learn more at www.flyforbusiness.org. mean you fly alone. BusinessOPS
The basic formula for achieving these objec- in your type of operation will prove quite tives is to: useful. • Identify hazards; 2. Obtain senior management commitment. This • Assess and measure risks created by the means “selling” the flight department man- hazards; ager/chief pilot on the merits of the program. But, whoever runs the flight department must • Eliminate the hazards or reduce risks to an also gain the support of corporate executives acceptable level; at the highest levels for the program to work. • Track and evaluate safety management activities for effectiveness; and, Corporate SMS Resources • Modify safety management activities as required. ore information about the International Business Aviation Council (IBAC) SMS Toolkit is available on the council’s “Safety Implementing an SMS MManagement” Web page at
Management personnel at all levels should be exploited. It relies heavily program to ensure that similar must stay actively involved. on checklists and processes to ensure events will not reoccur. compliance. 3. Establish an SMS team. A project 11. Conduct staff training and education. leader and representatives of the 7. Identify safety accountabilities. This Without training and constant hazard pilots, flight schedulers and mainte- determines who is in charge of the and risk education, the SMS probably nance personnel are essential. This is overall SMS program and, more im- will not be effective and might not truly a team effort; without a develop- portant, who is in charge of each even survive. Again, this is a team ment team, there may not be overall element of the program. Without effort, and the team must be kept in buy-in from the entire organization. designating a responsible individual the loop. If they don’t see both activity Many organizations also find that for each program task, the likelihood and results from the program, it will improved overall teamwork within of getting all the tasks done may be in be less effective. the organization is a consequence of doubt. And, don’t forget to designate 12. Track and evaluate safety manage- implementing an SMS. a due date or time interval for each ment activities. This aspect provides required action. 4. Conduct a gap analysis. This means answers to questions such as: “How taking one of the SMS checklists 8. Develop an ongoing hazard identifi- are we doing? Are we achieving our (see “Corporate SMS Resources,” p. cation and tracking system and risk goals and objectives? Are we becom- 35) and conducting an internal audit assessment procedures. This is a key ing more risk-aware? What can we of the organization to see what you feature of the program. The success do better?” already have that meets the criteria of an SMS depends on a constant for an SMS. The deficiencies noted flow of information regarding actual Continuing Process will provide a road map for your and anticipated hazards and methods The 12 steps described in this article implementation program. for dealing with them. Each primary form a process, one that will permit document listed in the sidebar to this 5. Conduct initial hazard identification your organization to recognize poten- article contains one or more methods and risk assessment, and develop a tial hazards; evaluate and mitigate the for accomplishing this critical ele- safety risk profile. This aspect asks related risks; and measure progress and ment of the program. key department personnel to iden- effectiveness. The result should not be tify the “standard” hazards they 9. Develop an emergency response plan. just another manual designed to meet a face on a daily basis and how they While we hope that no person or requirement imposed by someone else. handle them. It also asks what other aircraft within the organization will A well-developed and integrated SMS is hazards they may face based on the ever be involved in an incident or a continuing process designed to reduce variety of operations they perform. accident, having a plan for dealing the risks faced by your organization to Information on how to accomplish with the many consequences of such the lowest possible levels commensu- this also is available from the re- an event is essential. Without it, the rate with your type of operation. sources listed in the sidebar to this operator’s response to an incident or Ideally, practicing the process will article. The IBAC SMS Tools booklet accident is often chaotic and confus- lead to a positive change in the organi- is a good starting point. ing. It is essential to align the flight zation’s safety culture. Even better, the operation’s activities with those of the process will lead to a more effective, ef- 6. Develop safety management strate- main company or client to ensure a ficient and productive organization. gies and safety assurance processes. comprehensive response. This means that the organization John Sheehan is IBAC’s audit manager and must have a well-integrated plan 10. Amend programs, procedures and founder and president of Professional Aviation, to implement, sustain and measure documents as required. This is the an aviation safety consulting firm. This article was adapted from his presentation to the the overall SMS effort. Measuring feedback loop for the SMS. Once 2010 Corporate Aviation Safety Seminar, held the relative risk involved with haz- hazards and consequent risks are in Tucson, Arizona, U.S., by Flight Safety ards is one of the most important identified, how they are handled Foundation and the National Business Aviation features of the SMS concept and should be incorporated into the Association.
36 | flight safety foundation | AeroSafetyWorld | September 2010 groundSAFETY
A small child’s fall reminds adults of the need for close supervision and reveals inadequate updates to operators.
AirstairBy Wayne Rosenkrans Vigilance
3-year-old girl’s fall from the she held onto the lower handrail,” the boarding and disembarkation in place forward integral airstair of a report said. “When [the girl] reached of portable ground-based steps or an Ryanair Boeing 737-800 — an the top of the stairs, she turned towards airbridge, and safe operation depended approximate height of 8.5 to her mother, leaned backwards and fell on a combination of barriers, proce- A9.0 ft (2.6 to 2.7 m) — has prompted through the gap between the extend- dures and warnings on placards. “These the U.K. Air Accidents Investigation able handrail and the top of the airstair, airstairs include an integral two-rung Branch (AAIB) to issue several safety onto the hardstanding [ramp pave- handrail on either side,” the report said. recommendations, including one for ment] below.” Other passengers also “These [handrails] rise into position airstair modification. She was released were on the airstair at the time. during deployment of the stairs, but due from a hospital after a 24-hour assess- The incident occurred at 1225 to the geometric restrictions imposed by ment and treatment of minor injuries. local time on July 17, 2009, at London the retraction mechanism design, they The child had climbed the airstair Stansted Airport, the AAIB report do not extend to the fuselage side. to the upper platform followed by her said. The airplane was manufactured “In order to bridge the gap between mother, who was carrying a younger in 2005 and certificated to applicable the top of the handrails and the fuse- sibling and a carry-on bag. “Due to her European standards. lage, a manually extendable handrail is mother’s lack of a free hand, the child This integral airstair (Figure 1, p. 38) fitted to each of the integral rails. After
climbed the airstair unassisted, but primarily was used to facilitate routine deployment of the airstair, these are © Radu Dobrescu/Airliners.net
www.flightsafety.org | AeroSafetyWorld | September 2010 | 37 groundSafety
attention to pas- Forward Integral Airstair on Boeing 737s sengers boarding [or deplaning] with small children or [pas- sengers] with special needs.” The AAIB re- port cited a paragraph Forward entry door from this template Aft handrail for operators, which extended position says, in part, “Small Support strut children on airstairs Forward handrail should be attended by retracted position an adult or respon- sible person.”4 Exterior control for Forward lower handrail airstair extension/retraction Investigation of the 2009 incident, however, found no Aft lower handrail process in place for operators to receive amendments to these type-specific cabin safety recommenda- Airstair tions. “The flight (door in cocked position) attendant manual re- FAA = U.S. Federal Aviation Administration ceived by the operator Notes: The upper handrail extensions, when secured to the inside of the door opening, are designed to provide a with its first Boeing continuous support from the ground to the airplane cabin. However, an FAA special airworthiness information bulletin (SAIB NM-07-47) in September 2006 advised 737-series owners and operators of four occurrences in which, during the 737-800 was issued on process of disembarking or entering the airplane, unattended small children fell through or over the handrails or lost their 28 September 1998,” balance and fell from the airstair. the report said. Source: U.K. Air Accidents Investigation Branch; FAA Investigators Figure 1 noted that, at the time of the incident, imple- extended and secured to points in the a service bulletin developed by Boeing mentation of the most current airstair entry door frame. Each extendable rail Commercial Airplanes,2 and another safety improvements recommended by is supported by a strut extending from developed by Monogram Systems, the Boeing and the airstair manufacturer the side rail of the airstair.” manufacturer of the airstair.3 was incomplete. “The airstair … had “These bulletins required warning the warning placards on the risers and Previous Child Falls placards to be added to the risers of anti-slip material installed in accor- Four similar incidents involving small the airstair steps and the aircraft door dance with [the] Monogram Systems children had prompted the U.S. Federal apertures, together with the addition of [service bulletin], but the door aper- Aviation Administration (FAA) in anti-skid material to the top platform ture placards, detailed in [the] Boeing September 2007 to issue advisory infor- and the side rails,” the report said. “The [service bulletin], had not yet been mation to all current owners and opera- [Boeing bulletin] also highlighted the applied,” the report said. tors of 737s. This comprised a special fact that Boeing had revised the flight Small children require close su- airworthiness information bulletin,1 attendant manual for the 737 series of pervision because of limitations of the calling for the incorporation of the aircraft, to include a warning regarding geometry of the rails. “When deployed, latest safety advice and advances from the need for operators to pay particular the left and right extendable handrails
38 | flight safety foundation | AeroSafetyWorld | September 2010 groundSAFETY
are intended to provide protection ground staff provided assistance, ac- the possibility of a child falling against people falling sideways off the cording to the AAIB. through the gap between the upper section of the airstair,” the report “When portable ground-based steps extendable handrail and its upper said. “While these handrails appear to or the aircraft’s integral airstair were platform.” provide adequate protection for adults, used, an adult boarding or disembark- The report explained the analytical a gap exists between the handrail and ing with ‘carry-on’ baggage, which could basis of each safety recommendation. the airstair platform which is large not easily be placed over the shoulder, “The lack of an amendment service enough to allow a small child to pass and a small child, found themselves, in for the Boeing 737 flight attendant through it and fall onto the [ramp pave- certain situations, in a position where manual … applies to all of the Boeing ment] below.” neither hand was available to provide commercial aircraft product line,” the According to procedures in Ryanair’s support during the ascent or descent. AAIB noted. “In this case … the opera- safety equipment and procedures man- This situation was further complicated tor would have been aware that some ual (SEP), three of four flight attendants when an adult was accompanied by changes had been made to the manual are assigned to maintain positions by more than one small child and ‘carry- upon receipt of [the FAA special air- the forward and rear doors, and near on’ baggage, as some of the children had worthiness information bulletin].” overwing exits for the duration of to negotiate the steps with little assis- Investigators concluded that the boarding. “However, during boarding, tance from the adult.” absence of a barrier that specifically the ability of the cabin crewmember protects small children also should at the forward doors to identify those Mitigation Measures be addressed. “The gap between the passengers requiring assistance, while The AAIB said that Ryanair also extendable handrail and the upper they are ascending or descending the analyzed this incident and instituted platform of the Boeing 737 airstair airstair, is limited,” the report noted, measures to reduce the risk. “As a result, represents a hazard to small children citing a provision from the SEP, which the operator raised a modification which boarding or disembarking the aircraft,” says, “Passengers accompanying young introduces a roller‑tensioned, high- the report said. “Four previous events children should be instructed to hold visibility tape between the door aper- resulted in [amended guidance or their hands when descending the stairs ture and the extendable handrail strut,” safety bulletins that] do not provide and on the ramp.”5 The report did not the report said. “After approval by the physical protection against a child fall- mention the positioning of the flight relevant airworthiness authorities, this ing through the gap. The modification attendants in the 2009 incident. modification will be embodied on the proposed by the operator provides a operator’s fleet as a matter of priority.” significant visual cue to the lack of a Other Airlines The AAIB recommended that: rigid barrier in this area, but provides AAIB observers also looked beyond • “Boeing establish a process to only a limited physical protection the airline involved to assess super- inform the operators of all Boeing against falling.” vision of small children on the 737 commercial aircraft of changes forward integral airstair. “In 95 per- This article is based on AAIB Bulletin 8/2010, EI- to the relevant flight attendant cent of cases, during disembarkation, DLJ, EW/C2009/07/08, published in August 2010. manual; passengers traveling with several small Notes children and hand baggage received no • “Ryanair review their current pas- senger boarding and disembark- 1. FAA. Special Airworthiness Information assistance from either cabin crew or Bulletin NM-07-47. September 2007. ground staff,” the report said. “How- ing procedures so that assistance 2. Boeing. Service Bulletin 737-52-1157. ever, ground [staff] and cabin crew is made available to passengers provided assistance in 78 percent of accompanied by children, and 3. Monogram Systems. Service Bulletin cases when single passengers accom- those with special needs; [and,] 870700-52-2130. panied by small children were allowed • “Boeing review the design of 4. Boeing Commercial Airplanes. Boeing to pre-board the aircraft.” The 2009 the Boeing 737 forward airstair Flight Attendant Manual, page 7.10.34. pre-boarding incident was an excep- with the intention of adding a October 29, 2008. tion: Neither the cabin crew nor the removable barrier to minimize 5. Ryanair. SEP Manual, Section 2.4.13.5. www.flightsafety.org | AeroSafetyWorld | September 2010 | 39 FoundationFocus
Advancing the new BARS program Setting a Flight Safety Foundation Safety Flight
Left: Graham Rochat, Flight Safety Foundation BARS technicalN manager.ew Standard Right: Bob Godden, Executive Airlines quality manager (Essendon).
light Safety Foundation has begun individual aircraft operators,” said Brisbane, Australia, in August and delivering training courses that South African aviation safety special- September. More than 30 resource advance implementation of the ist, Mike Litson, founder and CEO company employees from companies Basic Aviation Risk Standard of Litson & Associates. In addition, including BHP Billiton, Harmony F(BARS) that will improve aviation the BARS audit will be much more Gold, MMG, Newcrest Mining and safety in the global resources sector, or comprehensive, conducted by aviation Newmont Mining were trained on in any organization around the globe safety auditors accredited by the Flight how to use the new standard to iden- that uses contracted aviation services Safety Foundation (FSF). tify possible threats and risks and to (ASW, 3/10, p.14). Litson hosted the first BARS minimize those threats. Lead aviation safety auditors from Auditor Accreditation course at his Additional courses will be held Australia, South Africa and the United well-equipped training facility in Cape in Africa, Australia, Canada, Guinea, Kingdom this month became the first Town, South Africa. During the two- Indonesia and South Africa in coming auditor group to complete the Founda- day course, 11 experienced auditors months.
tion’s new training program, qualifying received intensive training on how To find out more, contact the BARS program them to conduct BARS audits of avia- to apply the new risk-based auditing office: +61 1300 557 162 or [email protected] tion service providers. system to companies in the unique re- Aviation contractors have been sub- sources sector environment. “Every one The Flight Safety Foundation’s BARS jected to multiple audits every year to of my own aviation advisers attended program is the first focusing spe- satisfy the safety requirements of each this course and it made sense to show cifically on aviation safety for the company they serve in the resources my support to the BARS program by resources sector by creating: industry sector. The single BARS audit offering my facilities,” he said. • A new risk-based international will take the place of these multiple “Word of mouth about this course is aviation standard audits as other members of the BARS flying around our aviation community, • A new auditing program tailored to the standard program share the results. and it’s a privilege to be involved with • A range of aviation safety “The BARS auditing system will something the industry is so excited training programs ensure audits are carried out consis- and passionate about.” • Global safety data analysis tently across the industry and will The first two Aviation Coordina- program ultimately mean fewer audits for tor Courses were held in Perth and
40 | flight safety foundation | AeroSafetyWorld | September 2010 Strategicissues
Valid Concerns By Wayne Rosenkrans Auditors urge quicker upgrades of U.S. safety data analysis to discover national risk trends.
ethods for identifying unex- “A senior FAA official [said] that … model the impact of NextGen changes pected risks in the Next Gen- although safety assessments had been on the National Airspace System [NAS] eration Air Transportation conducted on individual NextGen tech- and manage any risks emerging from System (NextGen) should nologies, until the agency has finalized these changes.” beM enhanced without delay as part of [the National Level System Safety Assess- The International Civil Aviation implementing the safety management ment] modeling project, it cannot begin Organization, U.S. agencies responsible system (SMS) of the U.S. Federal Avia- systemwide assessments of the safety of for aviation safety and counterparts tion Administration (FAA), says an in- NextGen technologies and procedures in other countries — such as the dependent review. If upgrades to safety that are already being deployed, includ- Confidential Human Factors Incident data collection and analysis fall behind ing 700 new navigational procedures that Reporting Programme (CHIRP) in the pace of NextGen advances, says the had been deployed as of October 2009,” the United Kingdom — now consider report by the U.S. Government Account- the report said. “Because some NextGen data-driven analysis to be indispens- ability Office (GAO), national-level risk changes are already taking place, it is able in accident prevention by reveal- analyses could be based on insufficient urgent that FAA move with all deliberate ing accident/incident precursors and
J.A. Donoghue J.A. or untrustworthy information. speed to advance its analytical capability emerging risks. This especially includes
www.flightsafety.org | AeroSafetyWorld | September 2010 | 41 Strategicissues
data reported voluntarily by aviation Administration (NASA), the National voluntary reporting programs,” the professionals. Transportation Safety Board (NTSB) report said. “While FAA has some “As part of SMS, FAA plans to ana- and the Department of Agriculture information on reasons for nonpar- lyze data proactively … to model the (National Wildlife Strike Database), ticipation and has taken some steps to impact of proposed changes in proce- and interviews with 10 subject mat- promote greater participation, it lacks dures and technologies on the safety of ter specialists in aviation safety and/or carrier-specific information on why air the NAS [and to identify safety vulner- safety data collection and analysis. carriers are not participating.” abilities and mitigating measures],” the Safety specialists at the FAA have report noted. “Currently, FAA assesses contended that statistically valid samples Reliable Sources risks for specific NextGen procedures from subsets of all airlines and industry The report found a number of appropri- and technologies, but cannot model the sectors adequately reflect risks in the ate controls over data quality in the 13 risks across the NAS in a comprehen- entire NAS and enable effective risk databases, but for several of them cited sive manner. … FAA is also developing management. GAO reviewers disagreed, inadequate routine review of data by a plan for managing data under SMS, arguing for an expansion of data col- a manager before data are added to a but the plan does not fully address data, lection to better monitor safety trends database. Correcting this weakness is a analysis or staffing requirements.” in some sectors and urging tighter data critical aspect of ensuring that data are The GAO performance audit from quality standards (Table 1). “reliable (complete and accurate) and August 2008 through May 2010 com- “FAA has access to some voluntarily valid (measure what is intended),” the prised a review of 13 aviation safety reported data, which are important report said. Overall, the four government databases maintained by the FAA, for SMS, but not all [air] carriers and agencies’ oversight of their safety data the National Aeronautics and Space aviation personnel participate in FAA’s was consistent with GAO standards for
Data Quality Control for U.S. Aviation Safety Databases
Database Quality Characteristic AIDS ASRS FOQA ATOS NMACS NTSB OEDS PDS SDRS VDRP VPDS Wildlife Managers review data before they are entered into the data system. Reconciliations are performed to verify the data’s completeness. Data entry processes are designed to enhance accuracy. Procedures are in place to validate and edit data to help ensure that accurate data are entered into electronic system. Procedures are in place to help ensure that erroneous data are identified, reported and corrected.
Not present Present to some extent Fully present AIDS = FAA Accident/Incident Data System, 1978; ASAP = FAA-industry Aviation Safety Action Program, 1997; ASRS = NASA Aviation Safety Reporting System, 1987; ATOS = FAA Air Transportation Oversight System, 1998; FAA = U.S. Federal Aviation Administration; FOQA = FAA Flight Operational Quality Assurance Program, 1995; GAO = U.S. Government Accountability Office; NASA = U.S. National Aeronautics and Space Administration; NMACS = FAA Near Midair Collision System, 1987; NTSB - U.S. National Transportation Safety Board; OEDS = FAA Operational Error/Deviation System, 1985; SDRS = FAA Service Difficulty Reports, 1986; USDA = U.S. Department of Agriculture; VDRP = FAA Voluntary Disclosure Reporting Program, 1990; VPDS = FAA Vehicle Pedestrian Deviation System, 1988; Wildlife = FAA-USDA National Wildlife Strike Database, 1990 Note: Data controls for proprietary data generated by airline ASAPs were not assessed because they were not made available for review by the GAO. Data completeness refers to the accuracy with which data entered into a database have been compiled or processed, not to the scope of the data. Years indicate when the database was established.
Source: U.S. Government Accountability Office
Table 1
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identifying, reporting and correcting erroneous data. Practices examined included checks of reli- ability, including whether “data are complete and accurate, measure intended safety concerns, and are useful for their intended oversight purposes.” In addition to issuing policies and quality control standards for safety data processing, the FAA has used techniques such as cross- referencing internal and external databases to check reliability and validity, and facilitated communication among analysts from these gov- ernment agencies to identify, share and correct discrepancies, the report said. As an example of a NextGen side effect that should be identifiable through national-level data analysis, the report cited NextGen ap- proach procedures that enable increased rates of landings — designed to reduce airspace conges- tion and fuel consumption — but that also could J.A. Donoghue J.A. generate greater airport surface congestion and risk of taxiway collisions. Another GAO observation about NextGen Increased rates “FAA is in the process of designing tools concerned the FAA Aviation Safety Informa- that will allow it to model the changes,” the tion Analysis and Sharing (ASIAS) program — a of landings could report said. “To do so, it has begun to develop government-industry program that conducts generate greater a baseline of current conditions [from fusion of NAS-scale data fusion and analysis (ASW, 5/08, operational data] and then expects to analyze p. 25, and 8/09, p. 32) — which had not final- airport surface how NextGen changes will affect those condi- ized its draft plan for operations for a period tions, according to a senior FAA official.” ending in 2022, a time frame similar to that for congestion and NextGen implementation (ASW, 4/10, p. 30). SMS and ASIAS “While FAA has issued agencywide guidance risk of taxiway Some organizations within the FAA have attained on implementing SMS and has some efforts collisions. SMS initial operating capability or have made such as ASIAS under way, it does not have a way significant progress toward that status, but the to measure, or specific times to indicate, full GAO expressed concerns about the pace during implementation,” the report said. FAA officials the past two years. “FAA’s goal is for the Office of and GAO reviewers agreed that full SMS and Aviation Safety to have initial operating capabilities ASIAS implementation will take years, but dis- in place for SMS by the end of [September] 2010 agreed about how best to manage this process. … these initial operating capabilities include train- Both organizations also recognized that the ing employees and defining how to apply SMS to amount of time and work required for data analy- the agency’s overall oversight activities,” the report sis have been difficult to project. For automated said, noting that the FAA Air Traffic Organiza- high-volume searching, coding, integration, inter- tion issued an implementation plan, introduced a pretation and analysis of narrative data, the FAA manual that guides SMS-related daily activities of had to develop an ASIAS-specific text-mining its personnel and attained initial operating capabil- process. “FAA has efforts under way to address ity in March. The FAA Office of Airports and FAA two key [ASIAS] challenges: … Data are not coded Office of Aviation Safety, however, were at earlier to permit electronic integration, analysis and stages of the implementation process. sharing [and] data from two voluntary reporting
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programs lack identifying details needed details and without maintaining data accuracy include “the reporter’s experi- for some types of analysis, and … do not for longer periods, opportunities for ence, visibility conditions, the duration remain available for long-term analysis,” some analyses are limited.” of the event, and any trauma experi- the report said. Coding disparities in the One accepted workaround for this enced by the reporter,” the report added. original definitions, event identifiers and conflict of safety objectives is case- classifications also have complicated the by-case permission from the ASIAS Missing Denominator integration of quantitative and qualita- Executive Board, which represents For decades, the availability of exposure tive/narrative data. industry and government, for MITRE data to calculate rates of accident/incident to perform “a specific, defined analysis occurrence — such as number of fatal ASAPs and FOQA [directed study] and to use data with accidents per million departures — has Participants in aviation safety action the identifying details needed for that been a key to monitoring airline safety programs (ASAPs) and flight operation- particular analysis,” the report said. trends, the report said. “FAA’s ability to al quality assurance (FOQA) programs Similar problems surface in compar- monitor and manage risk for certain adhere to rules for maintaining confi- ing other sources with NASA’s Aviation industry sectors, such as general aviation, dentiality and trust through data de- Safety Reporting System (ASRS) reports. air ambulance operators and air cargo identification processes and, with a few “While FAA’s contractor loses access to carriers, is limited by incomplete data,” exceptions, protections against public ASAP reports after three years, about 62 the report said. “[FAA] does not collect disclosure or disciplinary action by the percent of ASAP reports appear in ASRS, actual flight activity data for smaller air FAA or an employer for operational er- along with other reports voluntarily sub- carriers that provide on-demand service, rors. The NTSB told GAO reviewers that mitted by industry personnel, according such as [air cargo,] air taxis and air ambu- — in numerous investigations of serious to a NASA official,” the report said. lances, and general aviation operators. … incidents and accidents — FOQA data The GAO also contrasted NASA’s “Without data on the number of alone had not revealed any precursor. As reluctance to comment on individual flights or flight hours, FAA and the air opportunities emerge for data integra- ASRS or ASAP reports with the CHIRP ambulance industry are unable to deter- tion, however, a conflict among safety practice of advisory board review and mine whether the increased number of objectives can arise. comment on lessons learned from accidents has resulted in an increased ac- This year, the MITRE Corp., which selected reports. “NASA noted that, in cident rate, or whether it is a reflection of aggregates and analyzes the data from the past, it had an ASRS advisory com- growth in the industry. … Lack of opera- 28 ASIAS-participant air carriers with mittee that had provided a forum for tions data for small cargo carriers makes FOQA programs and from 13 of these FAA and industry to discuss corrective it difficult for FAA to prioritize risks and carriers with ASAPs, began quarterly action,” the GAO report said. “The better target safety improvements and briefings of the ASIAS Executive Board agency acknowledged the need to re- oversight to the areas of highest risk.” on work in progress, including provi- establish this committee.” The report also cited new or reiter- sion of industry benchmarks enabling Reviewers found that despite adher- ated NTSB proposals for FAA safety comparisons of individual airline per- ing to data quality standards, processes data enhancement, including needs for formance to aggregate performance. In for intake of ASAP and ASRS reports “new approaches to data analysis rather total, 73 U.S. airlines have one or more have limited control over completeness than simply combining existing data ASAPs and 36 have FOQA programs. or accuracy of the content. “Voluntarily sources into an analysis program” and “Details of reported incidents are reported data are subjective and are mandatory reports from airlines on a redacted from ASAP and FOQA data not always accompanied by supporting wider scope of aircraft airworthiness before an FAA contractor analyzes documentation, such as statistics, mea- and maintenance-related events. the data,” the report noted. “These surements or other quantifiable infor- details include the date, time and flight mation related to the reported events,” This article is based on the May 2010 GAO report no. GAO-10-414, “Improved Data number, and the names of the carrier the report said. Distortions, omissions Quality and Analysis Capabilities Are Needed or individuals involved. … Additionally, and errors may not imply failures or as FAA Plans a Risk-based Approach to Safety ASAP and FOQA data are retained for bad intentions of the reporter, however. Oversight,” available at
44 | flight safety foundation | AeroSafetyWorld | September 2010 HelicopterSafety
The pilot flew the R44 low and slow on the Western Australia sightseeing flight. the Norm the
BY LINDA WERFELMAN he pilot of a Robinson Helicopter R44 or was not fully utilized by the pilot, resulting in Raven had deviated from the regular the sequential development of an uncommanded scenic tour route in a mountainous area of descent, overpitching,2 significant main rotor Western Australia and was flying slow and RPM decay, a high rate of descent and collision Tclose to the ground when the helicopter crashed, with terrain,” the report said. killing the pilot and all three passengers, the The accident helicopter was one of four R44s Australian Transport Safety Bureau (ATSB) says. that were flown on sightseeing flights from a The ATSB, in its final report on the accident, sub-base at the Purnululu Aircraft Landing Area identified the departure from the “regular scenic (ALA) at the southwestern tip of the Bungle flight track, speed and profile” as a contributing Bungle mountain range in Purnululu National safety factor in the Sept. 14, 2008, crash. Park, 250 km (135 nm) south of Kununurra, Other factors were that the “out-of-ground- Western Australia. effect1 hover performance of the helicopter was The morning of the accident, the helicopter likely to have been marginal” and that the “high was flown by other pilots on three sightseeing level of engine power required to sustain a hover flights. At the same time, the accident pilot flew Departure from
@ Chris Photography Sorensen in the local conditions either was not available another R44.
www.flightsafety.org | AeroSafetyWorld | September 2010 | 45 HelicopterSafety
Around 1230 local time, the pilot and his not consistent with the standard scenic flight three passengers boarded the accident helicopter parameters,” the report said. The last image was for what was to be an 18-minute flight. The pilot taken when the helicopter was about 80 m (262 designated a search and rescue time — SAR- ft) from a rock face and about 100 ft above the TIME, or the time at which search and rescue level of the accident site. was to begin if there was no contact from the pilot — of 1250. R44 Endorsement At 1250, when the helicopter had not returned The accident pilot received a commercial pilot to the ALA, other company pilots tried unsuccess- license in 2002. He flew sporadically for several fully to contact the helicopter by radio and then years, until he began refresher training with searched in another of the company’s helicopters. the operator in August 2007. That training The pilot who initiated the search saw smoke consisted of flight in an R44, and in operations northeast of the ALA, and when he flew toward it, in confined areas, power limitations, autorota- he found the wreckage of the accident helicopter. tion and “a check of the pilot’s understanding A digital camera recovered from the wreckage of overpitching.” In January 2008, he received contained images taken by one of the passengers an endorsement for R44s and was certified for that showed that around 1245, the helicopter left satisfactory completion of a flight review. the regular route and traveled south, toward an In May 2008, he began conducting scenic area of distinctive rock formations. flights in the Bungle Bungle area on a regular ba- “The helicopter’s speed and height, as sis, and at the time of the accident, he had accu- derived from this sequence of images, was mulated 477 flight hours in helicopters, including 346 hours in R44s. He held a Class 1 medical Intended Route of Accident Flight certificate, and there was no indication of any physiological Australia Piccaninny problem that might Gorge have contributed to the accident, the Deep Gorge report said. On July 14, 2008, he underwent a stan- The Domes dard 180-day flight check, including au- torotation, low-level maneuvering and confined-area train- Piccaninny Accident Creek ing, as well as ground Site training. The report Coalition on the flight check noted that “confined Purnululu areas need[ed] more
0 10 km @ Geoscience Australia ALA work,” but there were no details. ALA = aircraft landing area The helicopter was Source: Australian Transport Safety Bureau manufactured in 2006 Figure 1 in the United States
46 | flight safety foundation | AeroSafetyWorld | September 2010 HelicopterSafety
and registered the same year in Australia. Its total a number of pilots stated that they were gen- time in service was 1,533 hours. The engine — a erally trained to follow a specified route,” the Lycoming 0-540-FIB5 — was new when it was report said. “Altitude was varied during flight installed at the factory and was top-overhauled at to maintain a minimum of 500 ft above ground about 823 hours total time. level [AGL] while maintaining about 80 kt indi- A 100-hour inspection was conducted cated airspeed.” Aug. 20, 2008, about 76 hours before the ac- The operator said that pilots who flew over cident, and the last recorded maintenance was the Bungle Bungles were “selected, trained and Pilots who flew performed Aug. 29, when new bearings were checked to the standard required to safely con- installed in the main rotor hub, along with a duct those flights.” over the Bungle subsequent adjustment of system components. Another section of the operations manual Bungles were The pilot on the flight before the accident discussed aerial photography, describing it as an flight said that the helicopter had performed “extremely demanding” operation and noting 'selected, trained well. The helicopter apparently was refueled, that a pilot engaged in such a mission should with fuel from the operator’s fuel storage facility, have a “thorough understanding of the limita- and checked to the after that flight, but documentation was not tions of the helicopter when operating out of standard required available, the report said. ground effect at high gross weights, low indi- The helicopter’s weight for the accident flight cated airspeeds and out of wind.” to safely conduct was within limits. Australian Civil Aviation Safety Authority Weather at the accident site was described (CASA) standards, outlined in the Day VFR those flights.' as hot, cloudless and dry, with light winds. The Syllabus — Helicopters, do not discuss the risks nearest site for recorded hourly observations of an out-of-ground-effect (OGE) hover, or of was about 100 km (62 mi) to the southwest, avoiding, and recovering from, low-rotor RPM. where surface winds were from the southwest Nevertheless, the aeronautical knowledge syl- to southeast at less than 5 kt, with gusts to 10 labus says pilots should understand the power kt, and the temperature was 35 degrees C (95 available/power required curves, as well as over- degrees F). Moderate thermal turbulence was pitching. The flight training syllabus includes considered likely below 9,000 ft. “avoidance of the manufacturer’s height velocity The wreckage was found in a flat site at the (H-V) diagram avoid area in hovering flight”; base of a rocky, upsloping area. The helicopter confirmation of helicopter performance, includ- was “seriously damaged” by the impact and a ing power checks as applicable, when landing subsequent fire, the report said, noting that it in a confined area; [and] execution of limited had struck the ground upright, with the right power takeoff, approach and landing.” skid low and at a high vertical speed but little Neither the Flight Instructor’s Manual — or no forward speed. Helicopter, published by CASA and the Civil An examination of the engine revealed no Aviation Authority of New Zealand, nor the anomalies, other than damage from the impact civil aviation advisory publication about flight and the fire. reviews presented specific guidance about OGE hover, the report said. Specific Route The company operations manual allowed flight at Pilot Survey altitudes below 500 ft in specific circumstances — As part of the accident investigation, eight expe- but those circumstances did not include during rienced helicopter pilots were questioned about sightseeing flights over the Bungle Bungles. their understanding of slow OGE flight. “While the operations manual section “Overall,” the report said, “the participants regarding scenic flights over the Bungle Bungles did not perceive that there were significant did not provide specific operational parameters, deficiencies in the generic pre-license training www.flightsafety.org | AeroSafetyWorld | September 2010 | 47 HelicopterSafety
requirements. There was general agree- pilot “committed to a more difficult safety-reporting system for communi- ment … that pre-license training was maneuver than that intended by the cating operational requirements. ‘basic training’ and was conducted in operator for the scenic flight. Had CASA said after the accident that it a relatively benign environment that the operator been aware of the pilot’s would review initial and recurrent pilot was inherently limited in its capacity to intent, the informal requirement for the training requirements — action that the prepare pilots for all possible helicopter senior pilot at the operator’s Kununurra ATSB said “could be expected … [to] operating environments. … base to be involved in the tasking of a address the safety issue” identified in “There was also general agreement suitable pilot may have meant that the the accident report. that the Robinson R22 and R44 helicop- flight did not occur or that a different The ATSB also issued Safety ters, with their relatively low inertia rotor pilot was involved.” Advisory Notice SAN AO-2008-062- system, engine governor, throttle correla- The report noted that the U.S. SAN-098 to draw operators’ attention tion system and derated engines, were Federal Aviation Administration to “the potential lack of assurance different [from] other piston-engine heli- (FAA) has ordered additional pilot that informal operator supervisory copters. It was reported that pilots flying knowledge and safety training require- and experience-based policy, proce- the R22 and R44 were not always aware ments for pilots of R22s and R44s, dures and practices minimize the risk of the applicable engine power limits and specifically to address the “insidious of their pilots operating outside the did not always adhere to those limits.” and critical nature” of low main-rotor individual pilot’s level of competence. RPM; when the report was written, no Operators are encouraged to consider ‘Most Likely Scenario’ such requirements existed for flight the safety implications of this safety Investigators were unable to determine training in Australia. issue and take action where considered whether the engine was rotating at appropriate.” Safety Actions impact but concluded that the unsuit- This report is based on ATSB Transport Safety ability of the accident site for landing On Sept. 19, 2008, five days after the Report AO-2008-062, Collision With Terrain, 6 after an engine failure, along with accident, the operator’s chief executive km NE of Purnululu ALA, Western Australia, the availability of more suitable sites officer issued a memo to remind pilots 14 September 2008, VH-RIO, Robinson nearby, indicate that if there had been of the company’s policy about authori- Helicopter Company R44 Raven. an engine failure, it “had not occurred zation of flights and that “it was unnec- Notes from the cruise height and speed ap- essary to operate any helicopter within plicable to the anticipated scenic flight the height-velocity avoid area during 1. Flight in ground effect usually occurs profile.” routine charter and scenic flights,” the when a helicopter is less than one rotor diameter above the surface, the ATSB The report said it was most likely that, report said. They also were told not report said, citing the FAA’s Rotorcraft “at slow speed or the hover, the engine to operate below 50 kt while flying in Flying Handbook. At this height, helicop- power required exceeded the engine pow- cruise below 1,000 ft AGL on sightsee- ters require less power to hover because of er available or selected, with a consequent ing flights, and not to deviate from “the cushioning effect created by the main descent. The pilot probably responded published scenic flight paths, except in rotor downwash striking the ground.” instinctively by raising the collective lever, an emergency or “as deemed necessary Operations conducted above that height are said to be “out of ground effect.” In an which further increased main rotor drag by the pilot-in-command.” Any devia- R44, the rotor diameter is 33 ft (10 m). and therefore the power required, leading tion under those circumstances was to to main rotor RPM decay (overpitch- be reported to the chief pilot. 2. The report describes “overpitching” this ing), a low rotor RPM warning and an The operator also ordered check way: increased descent rate.” flights with all pilots before the start of If a pilot selects a high collective setting By departing from the usual scenic each tourist season, along with follow- that, in the prevailing conditions, produces flight profile, the pilot “negated the up check flights; took steps intended to rotor drag greater than the available engine power, the main rotor RPM will decrease operator’s risk control for those flights ensure that pilots were aware of Robin- below the governed RPM of between 101 not to be conducted below 500 ft above son Helicopter Co. Safety Notice SN-34, and 102 percent. That situation is termed ground level,” the report said, adding which discussed the hazards of low, overpitching, and can develop into a critical that, by slowing to an OGE hover, the slow flight; and established a Web‑based condition known as blade stall.
48 | flight safety foundation | AeroSafetyWorld | September 2010 DataLink
BY RICK DARBY Turnaround Story Risk also lurks between flights.
round operations accidents and margins, and short aircraft turnaround percent were associated with ground incidents were dominated by times are critical for airline efficiency. operations and the rest with foreign ob- one causal factor — failure to … In some circumstances, ground ject debris (FOD), the report says. FOD comply with clearances — ac- operations do not go as planned or as occurrences increased notably during cordingG to a study conducted by the required, resulting in safety occurrenc- the study period (Figure 1). Ground Australian Transport Safety Bureau es which are the focus of this report.” operations occurrences trended slightly (ATSB) of occurrences at Australian The number of ground operations down, with peaks in 2002 and 2006; airports, 1998–2008.1,2 The occurrences workers involved in airliner turnaround the report has no explanation for the occurred most frequently on taxiways, is usually larger than that of crewmem- increases in those years. at the gate and during pushback. bers for the flight. Their various tasks During the study period, there were Ground operations accidents and must be performed according to clear 282 ground operations occurrences. incidents — called “occurrences” by the rules and guidelines to avoid conflicting Those on a taxiway, at the gate or dur- ATSB — are rarely spectacular enough to with aircraft, including moving aircraft ing pushback accounted for 34 percent, make headlines in the popular press. Nev- other than those being serviced. 28 percent and 26 percent of the total, ertheless, they represent a risk significant Of the 398 ground occurrences respectively, for a combined 88 percent enough that Flight Safety Foundation reported in the study period, about 71 of occurrences. targeted them in its Ground Accident Prevention program. Based on data from Occurrences, Australian Airports, 1998–2008 the International Air Transport Associa- 50 tion, the Foundation estimates the injury Ground operations FOD rate at nine per 1,000 departures. Accord- 40 ing to the Boeing Statistical Summary of
Commercial Jet Aviation Accidents (ASW, 30 8/10, p. 48), two accidents claimed the lives of ground workers in 2009: On May 20 19, at Miami, a cargo loader fell from a Number of occurrences ladder to the ramp; on Dec. 21, a deicer 10 fell from the bucket to the ramp. 0 “Ground operations are potentially 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 one of the most dangerous areas of air- Year craft operation,” the report says. “They FOD = foreign object debris include any services necessary to man- Note: Airports are those serving high-capacity aircraft. age an aircraft’s arrival and departure Source: Australian Transport Safety Bureau from an airport. Commercial aviation generally operates on small profit Figure 1 www.flightsafety.org | AeroSafetyWorld | September 2010 | 49 DataLink
Six types of ground operations occurrences controller clearance (not a runway incursion),” represented about 75 percent of the total. “Fail- the report says (Figure 3). Such failures, the ure to comply with a clearance,” at 28 percent of report says, included using an incorrect taxi- the total, was most common type, representing way; failing to stop at a taxiway holding point; more than double the next highest type, “colli- failing to stay on the surface-movement control sion or contact with an aircraft by a vehicle,” 13 frequency; and failing to seek a clearance. percent of the total. “The occurrences where vehicles nearly col- More than three-quarters of the ground lided with aircraft involved a range of vehicles, operations occurrences had no “consequential including cars belonging to the Australian Cus- events,” the report says. About 20 percent of the toms and Border Protection Service, catering total ground operations occurrences were related trucks, tugs and fuel trucks,” the report says. to ground crew collision with a stationary aircraft, Near collisions between aircraft on the and about 2 percent involved aircraft collision with ground were “infrequent, but potentially seri- an object on the ground. Fewer than 1 percent ous,” the report says, adding that “separation required passenger standards apply to aircraft in the air, but there Ground Operations Occurrence Types, disembarkation. are no specific separation standards on taxiways Australian Airports, 1998–2008 The report ana- — much the same as cars on the road.” lyzes the categories of In those near collisions, “some aircraft were occurrences according taxiing at a high groundspeed, in one case esti- Pushback (26%) to whether they took mated to be 30 kt; there are no speed limits for Approaching gate (11%) place on taxiways, at taxiing aircraft.” Other (1%) or approaching the Gate occurrences, the second-most-frequent Taxiway (34%) gate, or during push- type of ground operations occurrences, were Gate (28%) back (Figure 2). analyzed according to three subcategories: ap- “About 77 percent proaching the gate, at the gate and pushback. of taxiway occurrenc- The most commonly reported subcategory Note: Airports are those serving high-capacity aircraft. es involved a devia- of approach-to-gate occurrences was “near- Source: Australian Transport Safety Bureau tion by vehicles from collision with aircraft by vehicle” (Figure 4). Figure 2 a surface movement “These occurrences required immediate brak- ing action by the flight crew or vehicle driver in order to avoid a collision,” the report says. Taxiway Occurrences, Australian Airports, 1998–2008 “Occasionally, cabin crew were injured dur- ing these events, as they were out of their seats Failure to comply (clearance) preparing for arrival; the act of sudden braking Near-collision with aircraft by vehicle threw them off balance.” Ground equipment/obstacle clearance The second-most commonly reported oc- Near-collision, both aircraft on ground currence in the approach-to-gate subcategory Other was “ground equipment/obstacle clearance.” Generally, this meant a vehicle operating outside 0 10 20 30 40 50 60 Number of occurrences its prescribed clearance area as an aircraft ap- proached the gate. Note: Airports are those serving high-capacity aircraft. Occurrences in the “Other” category Occurrences at the gate most often involved involved a vehicle that was parked in the instrument landing system critical area when weather was below minimums; vehicles on perimeter roads operating contrary to traffic actual collision or contact — rather than near- lights used to stop vehicles when aircraft land (two occurrences); and a large aircraft making collision — by a vehicle and an aircraft (Figure a 180-degree turn, damaging lighting and pavement. 5). The report says that this subcategory was Source: Australian Transport Safety Bureau probably under-reported, because the ATSB Figure 3 only learns of accidents and incidents while an
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aircraft is being prepared for takeoff or Approach-to-Gate Occurrences, Australian Airports, 1998–2008 before disembarkation of passengers and crewmembers. Near-collision with aircraft by vehicle “Damage occurred in 45 percent of reported occurrences where the aircraft Ground equipment/obstacle clearance was at the gate,” the report says. “Most Engine startup/shutdown — ramp personnel of the damage came from vehicles, but Collision/contact with aircraft by aircraft three occurrences involved ground Other equipment collisions and [another] 0 2 4 6 8 10 12 involved an aircraft rolling and striking Number of occurrences a terminal wall.” Notes: Airports are those serving high-capacity aircraft. Occurrences in the “Other” category involved Among vehicles colliding with disembarking passengers; flight crew taxi techniques; and ground crew approaching the aircraft engines aircraft at the gate, the most common before the aircraft had stopped. were cargo or container loaders; mobile Source: Australian Transport Safety Bureau stairs; and catering trucks (Table 1, p. Figure 4 52). Of collisions at the gate, “about 50 percent occurred as the vehicle or object was being driven up to, or away Gate Occurrences, Australian Airports, 1998–2008 from, a door,” the report says. “Approxi- mately 23 percent of vehicle or object Collision/contact with aircraft by aircraft collisions involved contact with a wing, Refueling horizontal stabilizer or engine. … Ground equipment/obstacle clearance “It is interesting to note that airlines Door access and opening using predominantly hand-push vehicles Other for loading and unloading of luggage 0 5 10 15 20 25 3530 and passengers appear to have fewer Number of occurrences ground operations occurrences involv- ing damage. Use of motorized vehicles Note: Airports are those serving high-capacity aircraft. “Other” occurrences involved wind forcing an aircraft away from the gate; an aircraft collision with infrastructure; operating a vehicle without a around aircraft cannot be totally elimi- clearance; and aircraft parking clearance and congestion. nated, as pallet container and catering Source: Australian Transport Safety Bureau trucks must continue to lift heavy items into the cargo hold of an aircraft.” Figure 5 Pushback occurrences, the third- report says. “A clear line of communi- with pushback clearance procedures; most frequently reported category in cation is required at all times between inadvertent aircraft door opening; and ground operations, were identified as flight and ground crew. With PPU [pow- collision with aircraft by a vehicle those occurring during the time between er push units] and tug towbar pushes, (Figure 6, p. 52). connection of a tug or PPU and the time a large amount of energy is exerted on Occurrences involving tug or PPU an aircraft taxies under its own power. the aircraft nose or main landing gear connections and breakages consisted “Commonly, pushback might involve up to provide enough inertia to move the of events such as pushback begun with to four ground personnel, including a aircraft. Sometimes these components the airbridge still connected; pushback tug or PPU driver, a dispatcher and pos- fail, and this poses a significant risk to begun without inserting the aircraft sible observers,” the report says. the tug unit and driver, as the driver is steering lockout pin; premature discon- Pushback involves a strict sequence. usually positioned under the aircraft.” nection, resulting in the aircraft rolling “This includes connecting the push unit Four subcategories dominated, in forward or backward; and using an [tug], releasing the aircraft brakes, push- total accounting for about 80 percent of incorrectly configured tug for the air- ing the aircraft back onto the taxiway pushback occurrences: tug or PPU con- craft, causing the tug roof to strike the and disconnecting the push unit,” the nection and breakage; failure to comply aircraft fuselage. www.flightsafety.org | AeroSafetyWorld | September 2010 | 51 DataLink
FOD occurrences, which increased handling equipment onto runways, of tools and equipment were found on from seven in 1998 to 26 in 2008 — taxiways and the airport aprons runway strips, taxiways and aprons, a 271 percent jump — were “most [ramps]. In the case of aircraft, the including screwdrivers, a 15-L [4-gal] frequently reported during the busiest physical stresses exerted during takeoff can of paint, spanners and wrenches, hours of operation at most airports in and landing place high loads and vibra- a torch [flashlight], wire, a headset Australia, between 7 a.m. and 7 p.m.,” tions on tires, engines (reverse thrust) and rags.” the report says. and landing gear components, which About 11 percent of reported FOD “FOD comes from many sources. can cause poorly secured components occurrences damaged airframes, wheels Material sometimes falls from aircraft, to loosen and separate.” or engines. Four FOD occurrences maintenance vehicles and aircraft The most common form of FOD occurred during takeoff, with one re- reported — about 25 percent of the sulting in engine ingestion of the FOD Vehicle Types Causing Damage, FOD occurrences — was aircraft com- and a return to the gate, and three tire Australian Airports, 1998–2008 ponents, the report says. blowouts entailing a rejected takeoff “In terms of high-capacity aircraft, and return to the gate. Vehicle Causing Damage Number Percent components making up the engine “FOD occurrences leading to air- Cargo or 8 24.2 reverse-thrust assemblies were most craft damage occurred not only on the container loader commonly reported and included runway strip, but on taxiways and the Mobile stairs 8 24.2 blocker doors, door assembly pins and aerodrome gate,” the report says. “Nine Catering truck 4 12.1 bolts, bushes, and plates,” the report of the 116 occurrences … occurred on Airbridge 3 9.1 Passenger lifter 3 9.1 says. “Less commonly reported FOD the aerodrome apron and 12 occurred Belt loader 3 9.1 items from aircraft were landing gear on taxiways. Examples of foreign ob- Tug 2 6.1 doors, de-laminated material from flaps jects found on aprons and taxiways in- Baggage trolley 1 1.3 and control surfaces, struts and landing cluded a box, paper and plastic sheets, Fuel truck 1 1.3 lights. Most of these components were which are all capable of being ingested Total 33 100.0 found on the runway strip rather than into an engine.” Note: Airports are those serving high-capacity on or near taxiways and airport aprons.” aircraft. Tools or equipment accounted for Notes Source: Australian Transport Safety Bureau about 19 percent of FOD occurrences. 1. ATSB. Ground Operations Occurrences at Table 1 “The reports showed [that] a variety Australian Airports 1998 to 2008. ATSB Transport Safety Report, Aviation Research and Analysis AR-2009-042. June 2010. Pushback Occurrences, Australian Airports, 1998–2008 Available via the Internet at
Source: Australian Transport Safety Bureau that — as a result of being in that location — can damage equipment or injure crew, Figure 6 passengers or airport personnel.”
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Inside Air France 447 An unofficial investigative team tries to reconstruct the fatal accident.
VIDEO This program is based on the tentative Documentary Speculation findings of its own Crash of Flight 447 unofficial investiga- Written and directed by Kenny Scott. To be broadcast in the United tive team, which did States on the Public Broadcasting System, Oct. 26, 2010. not have access to the he camera takes us inside the cockpit of Air recovered parts of the France (AF) Flight 447, an Airbus A330 A330 but was able to Tflying from Rio de Janeiro to Paris on June look at photographs of 1, 2009. It is night, 35,000 ft over the Atlantic the parts. Team members included Martin Ocean, three hours into the flight. One of the Alder, a captain and training pilot for Airbus pilots calmly makes a position report to Brazil airplanes; John Cox, a former airline captain air traffic control. who is now chief executive officer, Safety Oper- A thunderstorm appears on the weather ating Systems, and an AeroSafety World contrib- radar display. The captain illuminates the “fasten utor (“No Smoking in the Cockpit,” 1/09, p. 31); seat belt” sign for the passengers and issues a John K. Williams, a weather expert; Jim Wildey, brief announcement notifying them to expect a structural engineer; and Tony Cable, a former turbulence. He then plans a course deviation. So aviation accident investigator. far, everything is routine. After that, nothing is. A series of visual annunciations to the What the narrator calls “an incredible chain of pilots that began with “ADVISORY CABIN events” begins. VERTICAL SPEED” were transmitted auto- We are not, of course, peering into the actual matically by the A330’s datalink aircraft com- AF 447 cockpit on that night, but a dramatic munications addressing and reporting system re-creation in a flight simulation training device. (ACARS) and recorded. A cascade of system The illusion of being with the pilots on that failures followed. flight, which crashed into the ocean with a loss The team believes that the initial failure of all 228 people aboard, is intercut with analysis was due to the icing of all the pitot tubes, as of the event. preliminary BEA investigative reports and No final accident report has been issued speculation have suggested. Why could that by the French Bureau d’Enquêtes et d’Analyses have happened, since pitot tubes are heated to (BEA). The investigation has been hampered withstand cold and storms at altitude? They by the inability, so far, to recover the flight data suggest that the pitot tubes fell victim to su- recorder and the cockpit voice recorder from the percooled liquid water — “instant ice,” as one accident airplane. of them says. Their search of previous incident www.flightsafety.org | AEROSafetyWorld | September 2010 | 53 InfoScan
reports reveals 32 failed pitot tube events in control. … It has raised the question about A330s or A340s in the previous six years, whether the situation is actually being made including about one a week in the two months worse by the increasing automation, whereby preceding the AF 447 accident. crews don’t get a great deal of opportunity to Their accident scenario is based on informed manually fly the aircraft.” speculation and may not coincide with findings However, the narrator adds, “Without [re- of the eventual final report of the official investi- trieving] the ‘black’ boxes and their vital data, gating agencies. there can be no definitive proof.” The team speculates that the airplane en- The program’s production values are out- tered a powerful thunderstorm that was hidden standing, using computer graphics imagery to from their radar display by a nearer, smaller demonstrate pitot tube icing, control surface storm. Assuming the pitot tubes malfunctioned, changes, pitch and roll, and other characteris- there was no airspeed data for either the autopi- tics. The simulator re-creation of the heightened lot or the crewmembers to use. The automatic workload in the cockpit when one system after flight systems disengaged and the pilots took another failed — accompanied by audio alerts manual control. and flashing and multi-colored visual annu- “When things go very wrong, the last line of nicators — realistically conveys the extremely defense is the aviator,” Cox says. stressful flight deck environment. The simula- The pilots tried to maintain the necessary tor motion and hand-held camera movements pitch and engine power to keep the airplane mimic the heaving “office” the flight crew was from stalling, the team suggests, but in the working in once the crisis began. The pace of end they were defeated by the lack of critical the cutting between shots offers a visual ana- airspeed data. “If Flight 447 speeds up or slows logue of the increasing urgency that unfolded down by as little as 10 kt, it could suffer a … before the pilots. stall,” the narrator says. The crew’s attention An empathetic viewer cannot help experi- may also have been distracted from the thrust encing uncomfortable moments. settings by the many fault warnings they were — Rick Darby receiving. Cable finds support in the record of earlier REPORTS incidents for the theory that the thrust setting selected became unsafe. The narrator says, “In A Status Report From NTSB 10 previous incidents of pitot probe failure, the U.S. National Transportation Safety Board Annual Report to Congress: 2009 Annual Report crew fails to immediately control thrust. … In U.S. National Transportation Safety Board (NTSB). five cases, crews don’t take control of thrust Report no. NTSB/SPC-10/01. July 2010. 187 pp. [until] more than 60 seconds [have elapsed]. For Flight 447, that would mean rapid deceleration he NTSB issued 138 aviation safety recom- and the risk of a sudden stall.” mendations in 2009, the report says. Of The team surmises that inhibition of lift Tthose, as of the publication date, 42 recom- because of airflow detachment from the wings mendations were closed in “acceptable” status, resulted in a rapidly descending aircraft, possi- and 22 in “unacceptable” status. Responses to bly accompanied by a severe roll — “more like a the others are pending. fighter jet than a passenger airliner,” the narrator Issues that were added to the “Most Wanted says. “Most airline pilots have limited experience Safety Recommendations” for Aviation in dealing with this type of event [loss of control in February 2010 urge the U.S. Federal Aviation flight].” Administration to “improve oversight of pilot Cable says, “In recent years, the single proficiency” and “reduce accidents and inci- biggest cause of accidents has become loss of dents caused by human fatigue.”
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For pilot proficiency, the “issue areas” • “The Office of Aviation Safety [completed] include asking the FAA to evaluate prior flight the Colgan Air accident [ASW, 3/10, p. 20] check failures for pilot applicants before hiring, investigation in less than one year. It will and “provide training and additional over- be the first time in over 15 years that a sight that considers full performance histories major investigation with a public hearing for flight crewmembers demonstrating pilot has been completed in less than a year.” deficiencies.” The fatigue recommendations “address fatigue [risk] management systems, — Rick Darby which constitute a complement to, but not a WEB SITES substitute for, regulations to prevent fatigue.” In addition to the six major aviation ac- On Ice cident investigation launches and 178 accident “Recommendations for De-Icing/Anti-Icing investigation launches handled by regional Aeroplanes on the Ground,”
samples of quality assurance checklists and Transport Canada has provided James reports, and a glossary of terminology complete Reason’s checklist for scoring a company’s safety the recommendations document. culture. A sub-working group consisting of the AEA member airlines bmi, British Airways, Finnair, Lufthansa and SAS addressed training issues. The group prepared standardized train- ing guidelines in a separate document, “AEA Training Recommendations and Background Information for De-Icing/Anti-icing Aeroplanes on the Ground,” 7th edition, August 2010. The 195-page guide is available at
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Fumbled Numbers Calculations using the A340’s landing weight, rather than its takeoff weight, led to a ‘sluggish’ departure.
BY MARK LACAGNINA
The following information provides an aware- aboard, was flown to the destination without ness of problems in the hope that they can be further incident. Nevertheless, the AAIB deter- avoided in the future. The information is based mined that the flight crew’s faulty calculations on final reports by official investigative authori- and the aircraft’s sluggish departure constituted ties on aircraft accidents and incidents. a serious incident that occurred despite the aircraft operator’s “robust” standard operating JETS procedures (SOPs) for calculating and cross- checking takeoff performance. Late Change Disrupted Preflight “The operator used a system whereby the Airbus A340-600. No damage. No injuries. aircraft’s takeoff performance would be calcu- he pilot flying noticed that the A340’s ac- lated off-aircraft,” the report said. The system celeration was slower than it should have involved preflight transfer of data between the Tbeen for the takeoff from London Heathrow flight crew and a centralized computer via the Airport, but he did not believe that it was par- aircraft communications addressing and report- ticularly abnormal. “He described the rotation ing system (ACARS). As part of the procedure, as ‘slightly sluggish and nose heavy’ and noticed the crew would send the aircraft’s takeoff weight that after rotation, the aircraft settled at a speed to the computer, along with a request for a
below VLS [the lowest selectable speed providing takeoff data calculation, while completing the an appropriate margin above the stall speed], loadsheet and initializing the aircraft’s multi- which prompted him to reduce the aircraft pitch function control and display unit. attitude in order to accelerate,” said the report “The SOPs required the loadsheet proce- on the Dec. 12, 2009, incident by the U.K. Air dures to be led by the commander and checked Accidents Investigation Branch (AAIB). by the copilot, and the TODC procedures to be The climb rate, 500 to 600 fpm, also was led by the copilot and checked by the command- sluggish. “The flaps were retracted on schedule, er,” the report said. “Nine independent cross- and the aircraft continued its climb,” the report checks were built into the procedures, including said. “At no time was full takeoff thrust selected. a requirement for the actual takeoff weight to Later in the climb, the crew looked again at the be written on the TODC printout alongside TODC [takeoff data calculation] and realized the takeoff weight used for the calculation to their error.” They had used the estimated land- provide a gross error check.” ing weight of the aircraft, rather than its takeoff In this case, however, the flight crew’s weight, to calculate takeoff performance and preflight preparations were disrupted by a late reference speeds. change to the A340’s zero fuel weight, and the Following the sluggish departure, the A340, procedures involved in completing the load- which had 282 passengers and 16 crewmembers sheet and calculating takeoff performance were www.flightsafety.org | AEROSafetyWorld | September 2010 | 57 OnRecord
conducted out of order. The report said that the Tail Strike Prompts Turnaround disruption of the preflight procedures, plus time Boeing 737-800. Minor damage. No injuries. pressure on the crew, likely were factors when he flight crew felt a “bump” when the tail the crew inadvertently included the aircraft’s ex- skid assembly grazed the runway during pected landing weight of 236.0 tonnes (519,200 Trotation for takeoff from Dublin (Ireland) lb), rather than its actual takeoff weight of 322.5 Airport the morning of Sept. 11, 2008. They tonnes (709,500 lb), in their takeoff data calcula- completed the “After Takeoff” checklist, and the tion request. Noting that the expected landing commander transferred control to the copi- weight, 236.0 tonnes, was within the normal lot so that he could assess the situation. “This range of takeoff weights for the smaller A340- assessment took some time,” said the incident 300 model that the crew also flew, the report report by the Irish Air Accident Investigation said, “The operator considered that this might Unit. Noting that the crew continued the climb, have been why the crew was not alerted to the the report said that it would have been more error.” appropriate to level at a safe low altitude, in part The report also said that the cross-checks to prevent the cabin from pressurizing while conducted by the crew were not effective in de- troubleshooting the problem. tecting the error. Based on the erroneous takeoff The commander contacted a cabin ser- weight provided by the crew, the centralized vice attendant who confirmed that a tail strike
computer calculated a rotation speed, VR, of 143 had occurred. He then resumed control of the
kt and a takeoff safety speed, V2, of 151 kt. The aircraft, leveled at 12,000 ft and called for the correct values for the aircraft’s actual takeoff “Tailstrike on Takeoff” non-normal checklist,
weight were about 15 kt higher: 157 kt for VR which required depressurizing the cabin due
and 167 kt for V2. The flexible thrust setting to possible structural damage. “As the aircraft provided for the takeoff also was lower than it was not above 14,000 ft, the passenger oxygen should have been. system did not deploy automatically,” the report The operator subsequently initiated a review said. The cabin service supervisor told the flight of its loadsheet and takeoff performance cal- crew that the passenger oxygen masks had not culation procedures. However, the report said, deployed, and the crew attempted to deploy “Adding more cross-checks to the SOPs would the masks manually. However, three passenger The AAIB repeated probably complicate the procedures with no service units did not open and release the nine guarantee that a recurrence of a similar event masks they housed. recommendations for would be prevented. The pre-departure phase The flight crew declared an emergency and of a flight is a dynamic environment where time received clearance to return to Dublin. They takeoff performance pressure and interruptions can create conditions landed the 737 without further incident after being monitoring systems. where diligent crews can perform robust proce- airborne for 21 minutes. After a visual inspection dures incorrectly.” by airport fire services personnel, the aircraft was Based on its investigations of this incident taxied to a stand, where all 148 passengers dis- and a previous incident involving a takeoff per- embarked. One passenger requested and received formance calculation error (ASW, 12/09–1/10, medical assistance, but none of the passengers p. 58), the AAIB repeated recommendations required hospitalization, the report said. that the European Aviation Safety Agency Damage from the tail strike was confined develop specifications for takeoff performance to scrapes on the tail skid assembly shoe, and monitoring systems that would alert flight the aircraft remained serviceable. The report crews of inadequate performance for the aircraft noted that, because of their longer fuselages, the configuration and airport conditions, and that 737-800 and -900 are more susceptible to tail the agency require the systems aboard transport strikes than earlier models. Another factor that category aircraft. increased the tail strike risk was the aft loading
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of the incident aircraft. While the aircraft was who then performed unspecified maintenance. being prepared for the flight, the outbound pas- “After the maintenance was completed, the flight sengers had boarded through the rear doors and crew performed engine ground runs to satisfy had taken mostly rear seats while an inbound themselves of the serviceability status,” the passenger in a wheelchair was assisted in disem- report said. “All four engines started normally, barking through a front exit. The report noted, and the engine runs were done up to maximum however, that the aircraft was within center-of- takeoff power (MTOP) without experiencing gravity limits. any further abnormalities. … The captain also ‘According to the Investigators were unable to determine why simulated an approach and landing scenario by the three passenger service units (PSUs) had running the engines up to MTOP and selecting captain, it appeared failed to open. “The manufacturer has had few the TMS to synchronize but at the same time as though there reports of PSU compartment doors not deploy- also retarding the thrust levers. The TMS was ing correctly during decompression events,” assessed as operating normally.” was no fuel flow the report said. “Usually, these are confined to The aircraft was released to service, and 19 a single PSU. … One known cause is an incor- passengers boarded for the return flight to Cape to the engines.’ rectly stowed oxygen mask.” Noting that a PSU Town, 400 km (216 nm) east of George. En compartment door can be opened by insert- route, the captain noticed that the no. 2 engine ing a small pointed object into one of the holes TMS was not functioning properly. When the adjacent to the door-test stop, the report said thrust levers were set to flight idle on downwind that some passengers tried to open the doors by at Cape Town, the no. 2 engine high-pressure striking them with their fists. Cabin service spe- rotor speed (N2) stabilized at 50 percent, while cialists moved the affected passengers to seats the other three engines settled at the normal 60 with deployed oxygen masks. percent. When ground idle was selected shortly The report said that many passengers had after touchdown, all four engines flamed out. become anxious and upset during the incident. “The aircraft had enough momentum to roll “Depressurization normally produces a mist due forward on the runway and vacated onto a taxi- to condensation. This, coupled with the unusual way,” the report said. odor of the chemical oxygen generators func- Maintenance personnel advised the captain tioning, can be alarming to passengers.” to restart the engines and taxi the BAe 146 to the apron. “The captain restarted the engines Four-Engine Flameout on Landing and saw them spooling up to 17 percent, only,” British Aerospace 146-200. No damage. No injuries. the report said. “According to the captain, it fter the aircraft touched down on the run- appeared as though there was no fuel flow to the way at George, South Africa, the morning engines.” He shut them down and had the air- Aof March 19, 2009, the no. 1 engine flamed craft towed to the apron, where the passengers out and the no. 3 engine spooled down to a disembarked normally. “hung” state, in which high-pressure rotor speed Investigators found that another flight crew stabilized below the normal ground idle speed. had reported the TMS as faulty after a flight two The flight crew taxied the aircraft to the apron days earlier. Maintenance personnel decided to and noticed, after shut-down, that the thrust defer the defect and temporarily deactivate the modulation system (TMS) lights for the no. 1 TMS according to provisions of the minimum and no. 3 engines remained illuminated, which equipment list (MEL). They pulled the three was not normal, said the report by the South primary circuit breakers, as required to deac- African Civil Aviation Authority. tivate the system, but also pulled the four TMS The crew reported the problem with the actuator-centering circuit breakers, which was TMS — which trims, or synchronizes, engine specifically prohibited by the aircraft mainte- speeds — to company maintenance personnel, nance manual. www.flightsafety.org | AEROSafetyWorld | September 2010 | 59 OnRecord
Before the incident flight, the TMS computer runway and steered right in an unsuccessful and control-display unit were replaced, the attempt to avoid it. The airplane had deceler- three primary circuit breakers were reset, and ated to about 80 kt when its left wing struck the the deferred defect was cleared from the MEL. tractor, which was slightly left of the runway However, the four actuator-centering circuit centerline. About 10 ft (3 m) of the wing sepa- breakers were not reset during this maintenance rated during the collision. Neither the pilots nor or during the subsequent maintenance per- the tractor operator was injured. formed at George. As a result, when the TMS The report said that the probable cause disengaged automatically, as designed, during of the accident was “the air traffic controller’s final approach, any actuators that had been failure to properly monitor the runway envi- retracted by the system did not automatically ronment” and that a contributing factor was center, causing the engines to run down below “the tractor operator’s failure to scan the active normal speed when ground idle was selected. runway prior to crossing.” The report also noted that “Federal Aviation Collision With a Tractor Administration publications do not adequately Cessna Citation 550. Substantial damage. No injuries. address the need for ground vehicle operators to he airport traffic controller cleared the Cita- visually confirm that active runways/approaches tion flight crew to land when the airplane are clear prior to crossing [a runway] with air Twas about 8 nm (15 km) from the runway traffic control authorization.” at Reading, Pennsylvania, U.S., the afternoon of Aug. 3, 2008. The controller then cleared TURBOPROPS the operator of a tractor with retractable “bat- wing” mowing attachments to cross the 6,350-ft Prop Start Lock Overlooked (1,935-m) active runway at an intersection about Cessna 441. Substantial damage. No injuries. 2,600 ft (792 m) from the approach threshold, urface winds were variable at 3 kt when said the report by the U.S. National Transporta- the pilot initiated a takeoff from a 5,000-ft tion Safety Board (NTSB). S(1,524-m) runway at Thurgood Marshall The controller, who was coordinating both Airport in Baltimore the afternoon of Aug. 20, ground and local aircraft operations, then 2008. The pilot said that the airplane began turned his attention to an aircraft that was being drifting left as it accelerated, and he increased taxied to its hangar, and he did not see the Cita- power from the left engine to compensate. The tion touch down or the tractor begin crossing 441 continued drifting left, and the pilot rejected the runway from left to right, as viewed from the the takeoff when the left main landing gear approach end. rolled off the edge of the runway. As the tractor neared the intersection, the “The airplane continued to veer to the mowing attachment on its left side began to left, completely departed the paved surface drop. “The operator grabbed the control lever and struck an earthen mound in the grass,” to raise the wing to the ‘up’ position and looked the NTSB report said. “The nose landing gear to the left to ensure it was latched,” the report fractured, and the airplane came to rest approxi- said. “As he looked [away from the approach end mately 2,500 ft [762 m] beyond the start of the of the runway], the tractor proceeded onto the takeoff roll.” None of the four people aboard the runway.” The operator told investigators that he 441 was injured. saw a “white blur” as the tractor’s front window Examination of the airplane revealed that the was smashed. left propeller start lock had not been disengaged The Citation had touched down about 1,000 before takeoff. Start locks engage automatically ft (305 m) from the approach threshold. The when the engines are shut down and the propel- captain said that he saw the tractor enter the ler levers are moved to the reverse setting. They
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prevent the propeller blades from feathering 2 hydraulic system is pressurized during engine during shut-down and hold the blades in low start, which normally is performed during push- pitch to minimize propeller drag and resultant back, according to the report. high engine turbine temperatures during subse- After the incident, the company issued a bul- quent hot starts. letin instructing pilots to ensure that no one is The pilot had 2,485 flight hours, including near the nosewheel bay during engine start; the 1,473 hours in the 441. His inadvertent attempt to bulletin also instructed ground crewmembers to take off with the left propeller start lock engaged ensure that the forward nose gear doors are fully resulted in an asymmetric thrust condition. closed before disconnecting the tow bar. “Although there were no discrete annunciators to advise of start lock status, the airplane informa- Attendant Suffers Anxiety Attack tion manual provided means to recognize and Saab 340B. No damage. No injuries. correct when the start locks were not disengaged” he airplane was at 20,000 ft, en route with before taxi and takeoff, the report said. 30 passengers and three crewmembers from TDetroit to Marquette, Michigan, the night Gear Doors Snare Ground Crewman of July 30, 2009, when the flight crew heard Bombardier Q400. No damage. One minor injury. several knocks on the flight deck door. The s the aircraft was pushed back from the captain responded with an interphone call that stand at Isle of Man Airport the morning was answered by a passenger who said that the Aof Sept. 3, 2009, the commander did not flight attendant had become incoherent and was start the engines right away because air traffic performing “numerous unusual activities,” the control (ATC) had informed him that the depar- NTSB report said. ture would be delayed. Then, at the same time “The captain advised the passenger to assist the ground crew told the commander to engage the flight attendant to a seat and to stow the ser- the parking brake, ATC told him that there vice cart that was blocking the aisle,” the report would be no delay. said. He then told ATC that he was diverting “He confirmed that the brakes were set, the flight to Traverse City because of a medical cleared the ground crew to remove the tow emergency. bar and received clearance from the ground “Prior to landing, the captain coordinated crew supervisor to start the right engine,” the with a passenger to ensure that all passengers AAIB report said. “He instructed the copilot were seated and using their seat belts,” the report to start that engine, which caused the forward said. “The flight made an uneventful landing nosewheel undercarriage (landing gear) doors and was met by paramedics and local law en- The flight to close, trapping the ground crewman who forcement [personnel].” was attempting to remove the tow bar. … The Records of the flight attendant’s post- attendant had commander immediately shut down the right incident examination and treatment noted a become incoherent engine, pulled the landing gear door release diagnosis of “acute anxiety/delirium of un- handle and exercised the elevator to dissipate certain etiology [cause], resolved while in the and was performing the hydraulic pressure. The ground crewman emergency room.” The treatment records, as was able to release himself with the assistance well as a pre-employment medical-history ‘numerous unusual of his colleague and was taken to hospital with questionnaire, indicated no pre-existing medi- activities.’ minor injuries [to his right arm and chest].” cal or psychiatric conditions. The forward nose landing gear doors had “According to federal regulations, a single been opened — and left open, per normal flight attendant was required for the incident procedure before the first flight of the day — by flight,” the report said. “In addition, there are no company engineers who performed the preflight medical standards for flight attendants currently inspection. The doors remain open until the no. stipulated by federal regulations.” www.flightsafety.org | AEROSafetyWorld | September 2010 | 61 OnRecord
Nose Gear Jams in Wheel Well Worth, Texas, U.S., the morning of Nov. 17, De Havilland Dash 8-300. Substantial damage. No injuries. 2009. “Despite his application of full-up elevator hen the flight crew extended the land- to arrest the descent, the airplane continued to ing gear on approach to Philadelphia descend,” the NTSB report said. “The pilot was WInternational Airport the morning of forced to make a landing in an open field.” Nov. 16, 2008, they saw indications that the nose Examination of the airplane showed that landing gear was not properly configured for the pitch trim was in the full nose-down landing. They conducted a go-around and flew position and that the original trim switch had the Dash 8 to an area where they could trouble- recently been replaced during an overhaul of shoot the problem. the autopilot. “The switch wiring was not the “The first officer transferred airplane control original wiring and did not correspond to the to the captain and performed the alternate land- original color codes on the wires,” the report ing gear extension checklist,” the report said. said. “One of the wires was pinched and press- “However, the anomalous indications remained, ing on the switch wafer stack; according to a and the nose landing gear remained retracted.” representative of the manufacturer, [this] could The crew flew the airplane past the airport have resulted in an [electrical short and a] control tower, and controllers confirmed that the runaway trim condition.” nose gear doors were open but that the gear itself was not in sight. After several more attempts to Overrun on a Short, Wet Gravel Strip lower the gear in consultation with airline main- Cessna 207A. Substantial damage. Two minor injuries. tenance personnel, the crew landed the airplane. he pilot did not calculate the single-engine “During the landing, and after the airplane’s airplane’s weight and balance before at- main landing gear touched down, the captain Ttempting to depart from Kongiganak, held the nose of the airplane off the runway Alaska, U.S., for a scheduled commuter flight to until the slowest speed possible,” the report said. Bethel the afternoon of Aug. 22, 2008. He told “After the nose contacted the runway, the air- investigators that the tail struck the ground as he plane slid on it for about 525 ft [160 m] before was loading the five passengers and “numerous” coming to a stop. There was no fire. The [35] bags for the flight, but that the tail stayed off the passengers deplaned via the main cabin door ground after he and his “very large” front-seat and were taken to the terminal by a bus.” passenger boarded. Examination of the Dash 8 revealed that the “The pilot noted that [the airplane] was at nosewheel steering links had been overloaded and or near gross weight but didn’t have an exact had fractured, allowing the nosewheels to rotate weight of the airplane at the time he attempted and to become wedged in the wheel well during to take off,” the report said. He said that the the approach to Philadelphia. “Hardness testing Cessna accelerated slowly and decelerated satisfied the manufacturer’s minimum require- each time it encountered one of the numerous ments, and no determination could be made as to puddles on the wet, 1,885-ft (575-m) gravel when the overload occurred,” the report said. runway. “About 3/4 down the runway, the airplane PISTON AIRPLANES lifted off but would not climb,” the report said. “The airplane flew over the end of the runway Pinched Wire Causes Trim Runaway in ground effect … and began to sink. The pilot Piper Seneca II. Substantial damage. No injuries. stated that he added another 10 degrees of flap he pilot said that the Seneca pitched down to the 20 degrees he already had and pulled back rapidly when he used the electric pitch-trim on the control wheel to cushion the collision Tswitch on his control yoke to establish a with the tundra.” Two passengers sustained climb attitude shortly after taking off from Fort minor injuries in the crash.
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Vm c Roll Downs Air Tanker worn spherical bearing,” the report said. “It was Lockheed P2V-7. Destroyed. Three fatalities. probable that bearing wear outside of maintenance he Neptune had 2,070 gal (7,835 L) of re- manual limits existed but was not detected during tardant aboard when it took off from Reno, the most recent after-last-flight inspection.” TNevada, U.S., the afternoon of Sept. 1, 2008, to fight a wildfire. Witnesses on the ground saw Wasp Nests Block Fuel Flow a fireball emerge from the left auxiliary jet en- Bell 47G-2A. Substantial damage. No injuries. gine shortly after the landing gear was retracted he pilot topped off the fuel tanks before about 200 ft above the ground. The captain told departing from Rensselaer, Indiana, U.S., for the copilot, the pilot flying, “We got a fire over Ta personal flight to Greenville, Michigan, here.” The copilot replied that he was holding the afternoon of Aug. 11, 2009. The engine lost full right aileron. power about two hours into the flight, and the “At no point did either pilot call for the jet- pilot performed an autorotative landing in a tisoning of the retardant load, as required by com- field near Covert, Michigan. The tail boom was pany standard operating procedures, or verbally damaged when the tail rotor struck a wooden enunciate the jet engine fire emergency checklist,” post during the landing. the NTSB report said. “Recorded data showed The power loss had been caused by fuel that the airplane’s airspeed then decayed below the starvation, the NTSB report said. “Inspection
minimum air control speed [VMC].” The airplane of the helicopter revealed that the left fuel tank rolled steeply left and descended to the ground, was empty and the right fuel tank was full. The killing the pilots and the flight mechanic. right tank fuel vent was completely blocked by Examination of the air tanker revealed that a mud dauber debris, along with the remains of fatigue-induced fracture of the 11th-stage com- two mud daubers. The left fuel tank vent was pressor disk in the left jet engine had caused the partially blocked by mud dauber debris. Both compressor section to fail catastrophically. tanks feed to a central line which provides fuel to the engine.” HELICOPTERS Boulder Struck During Clearing Turn Tail Rotor Pitch Link Fails Aerospatiale AS 350-B2. Substantial damage. No injuries. Eurocopter AS 350-BA. Substantial damage. No injuries. fter dropping off six passengers at a heli- he pilot was returning to Rosehill, New South pad near the Colorado River and escorting Wales, after transporting six passengers to Athem to a trail head the morning of Aug. TFitzroy Falls the afternoon of Sept. 19, 2008, 27, 2009, the pilot restarted the engine to pick when he felt a minor vibration in the anti-torque up another load of passengers waiting at the pedals. “Approximately five minutes after the top of Grand Canyon, Arizona, U.S. “Boulders onset of the vibration, it became violent,” said had been situated around the perimeter of the the report by the Australian Transport Safety helipad by the operator to assist in marking Bureau. “The pilot entered autorotation, declared its location,” the NTSB report said. “The pilot a mayday and conducted a run-on landing on the stated that seconds after becoming airborne, and Casula High School oval [athletic field].” as he was maneuvering during a left clearing Examination of the helicopter revealed that a turn to depart the area, the helicopter’s tail rotor tail rotor pitch change link, which had accumu- impacted a perimeter boulder.” lated 2,130 hours of service, had failed, resulting The helicopter pitched nose-down and in lateral movement of the tail rotor and damage yawed left and right, shuddering violently. “The to the tail boom. “The pitch link had fractured pilot immediately descended from a hover and from fatigue cracking that was the result of stresses landed with the helicopter remaining upright,” induced in the link by excessive play in the heavily the report said. www.flightsafety.org | AEROSafetyWorld | September 2010 | 63 OnRecord
Preliminary Reports, July 2010 Date Location Aircraft Type Aircraft Damage Injuries July 3 Hong Kong, China Agusta–Bell A139 destroyed 13 NA The helicopter was ditched in Victoria Harbour after a tail rotor problem occurred on takeoff. No fatalities were reported. July 4 Alpine, Texas, U.S. Cessna 421B destroyed 5 fatal Dark night visual meteorological conditions (VMC) prevailed when the emergency medical services (EMS) airplane crashed in an open field shortly after takeoff. July 6 Orange, New South Wales, Australia Gippsland GA-8 Airvan destroyed 1 minor The cargo airplane crashed after clipping the top of a hangar on landing. July 7 Piedras Negras, Mexico Piper Cheyenne II destroyed 7 fatal The Cheyenne stalled and crashed during a flood-inspection flight. July 10 Tulsa, Oklahoma, U.S. Cessna 421A destroyed 3 fatal The airplane struck terrain on approach after its fuel supply was exhausted during a business flight. July 13 St. Ignace, Michigan, U.S. Beech 58 Baron destroyed 4 fatal, 1 serious The airplane crashed on a highway during a departure that followed two rejected takeoffs. July 15 Brac Island, Croatia Cessna Citation 550 substantial 5 none The Citation overran the 1,440-m (4,725-ft) runway on landing and struck a ditch. July 16 Chute-des-Passes, Quebec, Canada de Havilland Beaver destroyed 4 fatal, 1 serious, 1 none The floatplane struck a mountain in fog shortly after departing on a charter flight. July 17 Cairo, Egypt Boeing 747-300M substantial 22 none The flight crew rejected the takeoff after an uncontained failure of the no. 4 engine. July 18 Rankin Inlet, Nunavut, Canada Aero Commander 500S substantial 3 none The airplane crashed in a swamp after both engines lost power on takeoff. July 20 Kansas City, Missouri, U.S. Boeing 777-200 none 1 serious, 21 minor, 244 none The flight from Washington to Los Angeles was diverted to Denver after an encounter with severe turbulence at 34,000 ft. July 22 Kingfisher, Oklahoma, U.S. Eurocopter AS 350-B2 destroyed 2 fatal, 1 serious VMC prevailed when the helicopter struck terrain during an EMS positioning flight. July 22 Cleburne, Texas, U.S. Piper Aerostar 601P substantial 1 minor The pilot landed the Aerostar in a plowed field after both engines lost power on takeoff. July 23 Gahbühel, Austria Bell 204B destroyed 1 fatal The helicopter crashed while transporting an external load of concrete to a construction site. July 23 Elk Lake, Ontario, Canada Bell 206B destroyed 2 fatal The helicopter crashed after striking a communications tower. July 23 Ward Cove, Alaska, U.S. de Havilland Beaver substantial 1 fatal Instrument meteorological conditions prevailed when the cargo airplane struck terrain while holding for a special visual flight rules clearance into Ketchikan’s Class E airspace. July 24 La Grande, Quebec, Canada de Havilland Beaver destroyed 2 fatal, 3 serious The Beaver stalled and crashed after an engine problem occurred on takeoff. July 25 Chichibu, Japan Eurocopter AS 365-N3 destroyed 5 fatal, 2 none The EMS helicopter crashed after two crewmembers were lowered to the ground to assist mountain climbers. July 27 Riyadh, Saudi Arabia Boeing MD-11F destroyed 2 serious The MD-11 touched down hard and veered off the runway. Preliminary reports varied on whether the crew reported a cargo fire on approach or the fire broke out after the hard landing. July 27 Oshkosh, Wisconsin, U.S. Raytheon Premier I destroyed 2 serious The airplane struck terrain after it apparently stalled while being maneuvered to land. July 28 Conakry, Guinea Boeing 737-700 substantial 10 serious, 87 none The 737 overran the runway while landing in heavy rain. July 28 Islamabad, Pakistan Airbus A321-200 destroyed 152 fatal The A321 crashed while being positioned for a second approach in monsoon rains. July 28 Tucson, Arizona, U.S. Aerospatiale AS 350-B3 destroyed 3 fatal The helicopter descended rapidly and crashed on a street during an EMS positioning flight. July 31 Lytton, British Columbia, Canada Convair 580 destroyed 2 fatal The air tanker crashed during a forest fire-fighting mission. 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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